CurrentBlue Cross Blue Shield - TexasPolicy N/A

Ers Rcr Services 2025

This document describes Blue Cross Blue Shield of Texas's Recommended Clinical Review (optional pre-service medical necessity review) process, lists elective inpatient and outpatient services for which providers may submit RCRs, vendor-specific submission channels, and reference guidelines. It governs optional RCR submission procedures beginning 2025-01-01.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyErs Rcr Services 2025

Policy CodePolicy N/A

Change TypeInformational

Effective DateJan 1, 2025

Next Review Date

Key ActionProviders may submit an optional Recommended Clinical Review prior to service completion to limit retrospective denials for medical necessity; submission is optional (not mandatory) for listed elective services.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — policy provides informational guidance on optional Recommended Clinical Review (RCR) processes and eligible services.

7Inpatient categories

13Outpatient examples

1Vendor NICU notif.

Recommended Clinical Review (RCR) - Policy Summary

Scope: This document describes Blue Cross Blue Shield of Texas's Recommended Clinical Review (RCR) — an optional pre-service medical necessity review process that providers may request before services are completed to help limit retrospective denials based on medical necessity. The policy lists elective inpatient and outpatient services for which providers may submit RCRs, identifies vendor-specific submission channels, references applicable clinical guidelines, and governs optional RCR submission procedures effective 01/01/2025.

Background: A Recommended Clinical Review (RCR) is defined as “an optional review for medical necessity which occurs before services are completed for a covered service to help limit situations where a service may be denied retrospectively.” Vendors involved in managing RCR submissions and notifications include BCBSTX (Availity Authorizations and Referrals or phone number on member ID), Carelon (Carelon ProviderPortal or phone 1-800-859-5299), and ProgenyHealth (NICU admission notifications via Sfax 1-855-732-8182).

Eligible Services for Recommended Clinical Review (RCR)

Providers can submit an optional RCR for the following elective inpatient and outpatient services:

Elective Inpatient Medical/Surgical Facility Admissions Including Transfers

Acute Care/Hospital Hospice, Maternity, Medical, Surgical, Transplant
Hospice Care
Long Term Acute Care/Sub-acute
Rehabilitation Facility
Skilled Nursing Facility

Inpatient NICU

Inpatient NICU managed by ProgenyHealth

Elective Behavioral Health and Chemical Dependency Facility Admissions

Inpatient Rehab
Residential Treatment Center

Outpatient Medical/Surgical Services managed by Carelon

Advanced Imaging / Radiology, Cardiology
Molecular Genetic Lab Testing
Musculoskeletal - Joint, Spine Surgery, Musculoskeletal - Pain
Radiation Therapy / Radiation Oncology

Select Outpatient Services managed by BCBSTX

Cardiology - Lipid Apheresis
Ear, Nose and Throat
Gastroenterology
Neurology
Outpatient Surgery (Breast, Deactivation of Headache Triggers, Jaw)
Pain Management
Sleep Studies

Mental Health and Substance Use Disorder Services (Outpatient)

Applied Behavior Analysis
Intensive Outpatient Treatment
Partial Hospitalization
Psychological Testing/Neuropsychological Testing
Repetitive Transcranial Magnetic Stimulation

Specialty Pharmacy / Provider-Administered Drug Therapies (Medical Benefit)

Medical Oncology & Supportive Care (through Carelon) - medical necessity review for oncology drugs supported by an oncology diagnosis
Provider Administered Drug Therapies - medical necessity review for therapy only

Submission is optional and informational: Providers may choose to submit an RCR prior to service completion; it is not mandatory. The listed services map to vendor-managed categories (for example, select outpatient services managed by BCBSTX, outpatient medical/surgical services managed by Carelon, and NICU admissions managed by ProgenyHealth) as reflected in the policy’s criteria_group.

Submission Requirements and Vendor Channels

Documentation Required

Optional Recommended Clinical Review submission

Providers may submit an optional Recommended Clinical Review (RCR) prior to service completion to help limit retrospective denials based on medical necessity. Submission is optional (not mandatory) for the elective services listed in the policy.

Prior Authorization

Submission channels by vendor

Use the vendor-specific channels below to submit Recommended Clinical Reviews or notifications for eligible services.

Availity Authorizations & Referrals tool or phone (number on member ID) for BCBSTX-managed elective services
Carelon ProviderPortal or phone 1-800-859-5299 for Carelon-managed outpatient services
ProgenyHealth NICU notifications via Sfax 1-855-732-8182

Documentation Required

Reference guidelines to support RCR

Medical necessity reviews reference established guidelines and standards to support Recommended Clinical Review determinations.

MCG Care Guidelines
BCBSTX Medical Policies
American Society of Addiction Medicine Criteria
Texas Department of Insurance standards where applicable

Background and Definitions

Recommended Clinical Review (RCR) is an optional pre-service review for medical necessity that occurs before services are completed for a covered service to help limit situations where services may be denied retrospectively. The policy identifies elective inpatient and outpatient service categories for which providers may submit an RCR (including elective inpatient medical/surgical facility admissions, inpatient NICU managed by ProgenyHealth, elective behavioral health admissions, select outpatient services managed by Carelon, and select outpatient services managed by BCBSTX), and it specifies vendor-specific submission channels and referenced guidelines to support medical necessity review.

Definition

Recommended Clinical Review (RCR)An optional review for medical necessity which occurs before services are completed for a Covered Service to help limit situations where a service may be denied retrospectively.