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Clinical Review of Benefits

A clinical review of benefits is a review by medical staff to determine if the service you are requesting is appropriate for your medical needs. Clinical Reviews are done prior to services so that the patient will know in advance if the procedure is covered under their group benefit plan.* The Clinical review of benefits is dependent upon information submitted before the services are rendered. Payment is dependent upon the information submitted after the services are rendered.

Necessary Documents

To begin the review process, your health care provider will need to forward all information requested:

  1. Physician letter of medical necessity, which should include:
    • Description on any tissue to be removed
    • Height, weight and diets or programs used for attempted weight loss
  2. Patient evaluation and office notes, including but not limited to:
    • Health/family history form documenting allergies, risk factors, etc.
    • Chief complaint(s)/symptoms(s) as stated by the patient
    • Office notes for the past year with documentation and history of all prior treatments and therapies and patient response to them; description of treatment modalities/interventions that were not able to reduce pain or have been utilized; presenting symptoms and age of onset, if applicable. Office notes also should include any functional issues, prior treatment, including oral and topical medications, and documentation of degenerative changes.
    • Transport notes
    • Hospital evaluation
    • Procedure code(s), including expected duration of treatments and any proposed rehabilitation plan.
    • Pre-operative photos or X-rays, if applicable.
    • Any applicable report(s) such as ER, operative, sleep study, cancer staging, medical regimen, initial evaluation, Doppler study/duplex scan, diagnostic test, cat scan/X-ray, speech evaluation, visual field exam or scope.
    • Progress notes from time of injury and, if applicable, serial X-ray results and documentation of any previous failed fusion type.

Services Requiring Clinical Review

The following is a list of services requiring clinical review. Note that this is not an all-inclusive list. Should you have questions about this list, please contact the number on the back of your ID card.

  • Abdomioplasty
  • Blepharoplasty
  • Blepharoptosis
  • Botox
  • Brachytherapy
  • Breast MRI
  • Breast Reduction
  • Brow Ptosis Repair
  • Chelation Therapy
  • Dental Implants
  • Depo
  • Gastric Bypass
  • Growth Hormone
  • Lipectomy
  • Nasal Surgeries
  • Ostetomies
  • Panniculectomy
  • PET Scans
  • Sclerotherapy

Providers

Physicians can download a Recommended Clinical Review Request Form, and return form with applicable information to:

Fax each completed recommended clinical review request form to 1-888-579-7935. If unable to fax, you may mail your request to:

Blue Cross and Blue Shield of Texas 
P.O. Box 660044 
Dallas, TX 75266-0044

* Clinical review requests should be completed in 30 days or less, assuming all necessary information has been received. However, the review may take longer if additional information is requested. International Information: If translation is needed, time frame is 2–3 weeks. Quotations of benefits and/or the availability or extent of coverage are not a guarantee of payment. Payment is subject to actual information and charges submitted.