09/12/2022
Blue Cross and Blue Shield of Texas (BCBSTX) is removing some inpatient services from requiring prior authorization, effective Oct. 1, 2022, for fully insured plans (TDI on ID card) and certain commercial groups. This does not impact the Employees Retirement System of Texas (ERS) or Teacher Retirement System of Texas (TRS) at this time.
What’s Changing: Effective Oct. 1, 2022, the following inpatient services will no longer require a prior authorization:
- Elective Acute (Medical, Hospice, Maternity, Surgical, Transplant)
- Elective Post-Acute (LTAC, Rehab, SNF)
- All Behavioral Health Elective Inpatient (Rehab and Residential Treatment Center)
All of our systems will be updated to reflect these changes on or before Oct. 1, 2022.
Instead of a required prior authorization, providers will have the option of submitting a Recommended Clinical Review. Recommended Clinical Reviews 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. You can find a list of services for which Recommended Clinical Review is available on the Recommended Clinical Review page.
- Unlike a required prior authorization, there is no penalty if a provider does not elect to use Recommended Clinical Review but the service will be subject to retrospective review.
- BCBSTX will review Recommended Clinical Review requests to determine if the planned service 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.
Recommended Clinical Reviews are not required prior authorizations. As a result, a provider is not eligible for an exemption with respect to these services and Recommended Clinical Reviews are not considered when a provider’s required prior authorization exemption approval rating is calculated. Review the BCBSTX Prior Authorization Exemption page for more information.
Be sure to check eligibility and benefits via Availity® Essentials or your preferred electronic vendor prior to rendering services. This process will also notify you, if the service requires prior authorization or is eligible for Recommended Clinical Review for your member. A Recommended Clinical Review can be submitted utilizing Availity Authorizations and Referrals or by calling the number on the member’s ID card.
More Information
Visit the Utilization Management page on our provider website for more information on our revised Prior Authorization Lists reflecting the removal of services that no longer require a prior authorization and what services are eligible for Recommended Clinical Review.
Watch News and Updates for more information.
This does not apply to BCBSTX Medicare and Medicaid Government Programs.
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. BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.