08/21/2024
As announced on May 31, effective for dates of services on or after Sept. 1, 2024, Blue Cross and Blue Shield of Texas (BCBSTX) is removing all prior authorization requirements for the Employee Retirement System of Texas (ERS) medical plans, including HealthSelect of Texas® and Consumer Directed HealthSelectSM:
Recommended Clinical Reviews
Services previously requiring prior authorization, as well as other certain services needing medical necessity review, can be submitted as a Recommended Clinical Review (RCR) prior to rendering services.
Submitting an RCR request prior to rendering services informs you of situations where a service may not be covered based upon medical necessity or other plan rules. RCR will replace post-service review for medical necessity when an RCR is completed.
Refer to the ERS RCR List for services that are available for RCR as well as determining whether you should submit the request to medical management at BCBSTX or Carelon Medical Benefits Management.
Providers submitting RCR requests for services managed by BCBSTX for ERS participants will have the option of submitting the request electronically via Availity® Authorization & Referrals tool or effective Sept. 3, 2024, via BlueApprovRSM
Note: Providers may continue to request medical necessity review of additional services even when not included on the RCR Services List.
NICU Notification Change
ProgenyHealth will be delegated for all neonatal intensive care unit (NICU) admissions and concurrent reviews as of Sept. 1, 2024. Providers have the option to notify ProgenyHealth pre-service to ensure medical necessity, level of care and other plan requirements are met prior to submitting claims.
Providers can notify ProgenyHealth for NICU admissions and concurrent care via fax at (855) 732-8182. ProgenyHealth will perform utilization management and discharge planning throughout the inpatient stay.
ProgenyHealth is hosting a webinar on Aug. 29, 2024 at 12:00 PM. Register here.
More Information
Be sure to check eligibility and benefits and confirm if a service is eligible for RCR through Availity® Essentials or your preferred vendor.
Learn more about ERS processes, including RCR on the Utilization Management section of our provider website. Follow our News and Updates page for future updates.
Carelon Medical Benefits Management is an independent company that has contracted with BCBSTX to provide utilization management services for members with coverage through BCBSTX.
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.
ProgenyHealth is an independent company that has contracted with Blue Cross and Blue Shield of Texas to provide NICU utilization and case management for HealthSelect of Texas® and Consumer Directed HealthSelectSM plans.
BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity or Carelon Medical Benefits Management.
Please note that checking eligibility and benefits and/or the fact that a service or treatment has been approved for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card.