What is the Recommended Clinical Review Option
Providers will have the option of submitting a Recommended Clinical Review (RCR) which are reviews for medical necessity before services are provided for both inpatient and outpatient services that are not on the prior authorization lists. Note - previously for outpatient services this was referred to as Predetermination of Benefits.
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.
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 a Recommended Clinical Review.
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.
- Refer to the Recommended Clinical Review Services List for Fully Insured & Certain Administrative Services Only (ASO) Groups for applicable services.
- 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.
Effective Jan. 1, 2023, Predetermination of Benefits for outpatient services is now referred to as the Recommended Clinical Review Option. The process to submit the Recommended Clinical Review for outpatient services is the same as the previous Predetermination of Benefits process.
Outpatient Procedure Code Lists
Below are lists of codes2 where outpatient Recommended Clinical Review may be available:
- 2023 Recommended Clinical Review, Post Service Review and Non-Covered Procedure Code List for Fully Insured Accounts
- 2023 Recommended Clinical Review, Post Service Review and Non-Covered Procedure Code List for Non-ERISA Accounts
- 2023 Recommended Clinical Review, Post Service Review and Non-Covered Procedure Code List for Administrative Services (ASO) Only Accounts
Submitting Outpatient Recommended Clinical Review Requests
- Online:Use the Availity Attachments tool to quickly submit recommended clinical review (predetermination) 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 Recommended Clinical Reviews (or Predetermination of Benefits requests submitted prior to 1/1/23).
You will be notified when an outcome has been reached.
Reminder: Submit your prior authorization requests with the appropriate documentation and level of urgency. An urgent or expedited request is appropriate when treatment that, when delayed:
- could seriously jeopardize the life and health of the member or the member’s ability to regain maximum function.
- would subject the member to severe pain that cannot be adequately managed without the requested care or treatment
- would subject the member to adverse health consequences without the care or treatment that is the subject of the request
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
2The attached lists are for reference only and are not intended to be a substitute for checking benefits or Blue Cross and Blue Shield of Texas' (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.
Recommended Clinical Review does not apply to requests for Texas Medicaid or Medicare Advantage members.
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BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.