Utilization Management Update Including Change to Recommended Clinical Review Effective Sept. 1, 2024, for ERS Plans 


What’s Changing

Blue Cross and Blue Shield of Texas will be making the following changes effective Sept. 1, 2024, for the Employee Retirement System of Texas (ERS) medical plans, including HealthSelect of Texas® and Consumer Directed HealthSelectSM:

  • Moving all services previously requiring prior authorization, as well as other certain services needing medical necessity review, to Recommended Clinical Review (RCR).  
    • RCR allows providers to submit requests for medical necessity review before the services are provided. RCR will replace post-service review for medical necessity when an RCR is completed. This includes concurrent reviews.
    • RCR is an optional medical necessity review conducted before services are provided. Submitting a request prior to rendering services informs you of situations where a service may not be covered based upon medical necessity or other plan rules. 
  • Carelon Medical Benefits Management will handle RCR for the following services:
    • Advanced Imaging (such as CT scan, nuclear stress test, MRI, PET scan with the exception of MRI of the breast)/cardiology imaging
    • Musculoskeletal (Joint/Spine), pain
    • Genetic/molecular testing
    • Radiation (oncology) therapy for cancer
    • Medical oncology specialty drugs and supportive care

Important: Medical necessity does not guarantee payment. Eligibility and other plan requirements must be met. You can access the HealthSelect of Texas and Consumer Directed HealthSelect documents at: https://healthselect.bcbstx.com/medical-benefits.

Coming soon: Refer to the updated ERS RCR Services List for the most current services applicable for an RCR and how to submit the requests.

Note: Providers may continue to request medical necessity review of additional services even when not included on the RCR Services List.

Effective Sept. 1, 2024, providers submitting RCR requests for services for ERS participants will have the option of submitting the request electronically via BlueApprovRSM or the Availity® Authorization & Referrals tool.

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.

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.