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. 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 Recommended Clinical Review provided the services are medically necessary. Blue Cross and Blue Shield of Texas (BCBSTX) will review the request to determine if it meets approved medical policy, American Society of Addiction Medicine (ASAM) 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 Recommended Clinical Review 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 Recommended Clinical Review determines the proposed service does not meet medical necessity.
The Recommended Clinical Review option is available for inpatient services that do not require prior authorization for members in Fully Insured Plans (TDI on ID card) and certain Administrative Services Only (ASO) Groups1 effective Oct. 1, 2022.
Submitted claims for services not included as part of a request for Recommended Clinical Review, may be reviewed retrospectively.
Services Providers may Request Recommended Clinical Review
Refer to the Recommended Clinical Review Services List for Fully Insured & Certain Administrative Services Only (ASO) Groups for applicable services.
Submitting Recommended Clinical Reviews
Providers may submit a Recommended Clinical Review utilizing the same submission process as a prior authorization:
- Online using the Availity® Authorizations and Referrals tool
- Call the authorization number on the ID card.
You will be notified when an outcome has been reached.
1Applicable Administrative Services Only Groups
- BCS - Gannett Executives - Supplemental Plans - Group # 193211
- BCS - Tegna, Inc - Supplemental Plans - Group # 193219
- Speaking Rock Entertainment Center - Group # 290491
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