NICU Utilization Management Update Effective Sept. 1, 2024, for ERS Plans 


What’s Changing

Effective Sept. 1, 2024, ProgenyHealth® is delegated for all neonatal intensive care unit (NICU) admissions and concurrent reviews for the Employees Retirement System of Texas (ERS) Plans. 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. 

ProgenyHealth for NICU Key Points

BCBSTX encourages providers to request Recommended Clinical Review (RCR) for all NICU admissions and concurrent reviews. 

  • ProgenyHealth’s NICU UM program coordinates and monitors the appropriateness, cost-effectiveness and efficiency of the care being provided in the NICU while maximizing the quality of health care and services provided to the participant.
  • Each family is matched with a ProgenyHealth case manager who provides support up to the first year of the newborn’s life. Case managers connect with families to assess needs, optimize care and collaborate with hospital staff to support the baby’s transition from the hospital to home.
  • ProgenyHealth ensures continued care with the family’s pediatrician by reducing unnecessary emergency department visits and unplanned readmissions and provides any additional mental or physical health needs.
  • Providers are encouraged to notify ProgenyHealth directly of admissions via Sfax at 1 (855)732-8182. ProgenyHealth’s clinical staff will coordinate with providers to perform utilization management and discharge planning throughout the inpatient stay.  

More Information

Be sure to check eligibility and benefits through Availity® Essentials or your preferred vendor.

Watch for updates about ERS’ RCR processes on the ERS Tools page and News and Updates on our provider website.

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 third-party vendors and the products and services offered by them.

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 participant’s benefit plan applicable on the date services were rendered. If you have questions, contact the number on the participant’s ID card.