Recommended Clinical Review

A recommended clinical review is a medical necessity review conducted before services are provided for our commercial members.

Submitting the request prior to rendering services is optional. It informs the provider and member of situations where a service may not be covered based upon medical necessity. Lists of services eligible for recommended clinical review are below.

About recommended clinical reviews

  • These reviews are optional and inform the provider of situations where a service may be denied based upon medical necessity.
  • There is no penalty if a provider doesn’t elect to use the recommended clinical review process if the services are medically necessary.
  • The review process helps confirm that the proposed services are in alignment with our medical policy, American Society of Addiction Medicine or MCG Guidelines criteria before services are provided.
  • Once a decision has been made on the services reviewed, they will not be reviewed for medical necessity again on a retrospective basis.
  • Providers will be notified of the outcome and will have the opportunity to appeal an adverse determination if the recommended clinical review determines the proposed service doesn’t meet medical necessity.
  • The recommended clinical review process isn’t available for Medicare or Medicaid members.

Submitted claims for services not included as part of a request for recommended clinical review may be reviewed retrospectively.

Check eligibility and benefits

Complete an eligibility and benefits inquiry to confirm membership, check coverage and determine prior authorization requirements. If no prior authorization is needed, you may submit a request for recommended clinical review.

Recommended clinical review services lists

Note: Providers may request medical necessity review of additional services even if they aren’t included on the recommended clinical review services list.

The following lists expired on Dec. 31, 2024:

Outpatient services code lists

Below are lists of codes for outpatient services eligible for recommended clinical review. The lists are for reference only and aren’t intended to substitute for checking benefits or medical policies.

Members of other Blues Plans

This information applies only to members of Blue Cross and Blue Shield of Texas 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.

Submitting recommended clinical review requests

Use electronic options for the quickest turnaround time:

For inpatient services, request a recommended clinical review through:

For outpatient services managed by BCBSTX, request a recommended clinical review by:

For outpatient services managed by Carelon Medical Benefits Management, request a recommended clinical review through Carelon:

  • Carelon customer service at 800-859-5299 (Monday-Friday, 6 a.m. to 6 p.m.; Saturdays, Sundays and holidays, 9 a.m. to noon)

Related resources

 

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX.

Carelon Medical Benefits Management is an independent company that has contracted with BCBSTX to provide utilization management services for members with coverage through BCBSTX.

BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.