Recommended Clinical Review Option

What is the Recommended Clinical Review Option

Providers will have the option of submitting a Recommended Clinical Review which are reviews for medical necessity before services are provided for both inpatient and outpatient services that are not on the prior authorization lists.

These reviews are optional and inform the provider of situations where a service will be denied based upon medical necessity.

There is no penalty if a provider does not elect to use RCR provided the services are medically necessary.
BCBSTX will review the request to determine if it meets approved medical policy, American Society of Addiction Medicine or MCG Guidelines criteria before services are provided for medical and behavioral health services.
Once a decision has been made on the services reviewed as part of the RCR process, they will not be reviewed for Medical Necessity again on a retrospective basis. Providers will be notified of an adverse determination and have the opportunity to appeal if the RCR determines the proposed service does not meet medical necessity.

Eligibility and Benefits Reminder: An eligibility and benefits inquiry should be completed first to confirm membership, verify coverage and determine whether or not prior authorization (also known as preauthorization, pre-certification or pre-notification) is required and if no prior authorization can be submitted as an RCR.

Inpatient Services

The RCR option is available for inpatient services that do not require prior authorization for members in Fully Insured Plans (TDI on ID card) and certain ASO Groups¹. Effective March 1, 2024, the Teacher Retirement System of Texas is moving to RCR for certain inpatient services.

Submitted claims for services not included as part of a request for RCR, may be reviewed retrospectively.

Refer to the Recommended Clinical Review Services List for Fully Insured & Certain ASO Groups for applicable services.

Recommended Clinical Review Services List for Fully Insured & Certain Administrative Services Only Groups Effective 01/01/2024
Recommended Clinical Review Services List for Fully Insured & Certain Administrative Services Only Groups Effective 01/01/2023

Submitting Inpatient Recommended Clinical Review Requests

Providers may submit an RCR:
- Online using the Availity^® Authorizations and Referrals tool
- By calling the authorization number on the ID card.
You will be notified when an outcome has been reached.

Outpatient Services Code Lists

Below are lists of codes² where outpatient RCR may be available:

Submitting Outpatient Recommended Clinical Review Requests

Online:Use the Availity Attachments tool to quickly submit RCR requests to BCBSTX via the Availity Portal. For navigation tips, see our user guide. Electronic options are preferred to help expedite your request.

Fax or Mail: Complete the Recommended Clinical Review Form and fax to BCBSTX using the appropriate fax number listed on the form or mail to P.O. Box 660044, Dallas, TX 75266-0044. The form also may be used to request review of a previously denied RCR requests.

You will be notified when an outcome has been reached.

¹Applicable Non-ERISA Administrative Services Only (ASO) Groups

BCS - Tegna, Inc - Supplemental Plans - Group # 193219 (Non-ERISA)
Speaking Rock Entertainment Center - Group # 290491 (Non-ERISA)
Teacher Retirement System of Texas (Effective March 1, 2024)

²The attached lists are for reference only and are not intended to be a substitute for checking benefits or BCBSTX medical policies. This list applies only to members who have health insurance through a BCBSTX Plan or who are covered by a group plan administered by BCBSTX. If your patient is covered under a different Blue Cross and Blue Shield Plan, please refer to the Medical Policies of that Plan.

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