CurrentBlue Cross Blue Shield - TexasPolicy N/A

Recommended Clinical Review (RCR) for elective services

Governs optional Recommended Clinical Reviews for elective inpatient and select outpatient services for Blue Cross Blue Shield of Texas (BCBSTX) TRS and TRS ASO plans; informs providers how to submit pre-service medical necessity reviews and which services are eligible.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyRecommended Clinical Review (RCR) for elective services

Policy CodePolicy N/A

Change TypeNo material change

Effective Date09/01/2024

Next Review DateN/A

Key ActionProviders may submit an optional Recommended Clinical Review (pre-service medical necessity review) for specified elective inpatient admissions and selected outpatient services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

09/01/2024policy dates

TRS / TRS ASOplan applicability

>$5,000DME threshold

Carelon reviewsspecialty routing

Recommended Clinical Review Coverage Criteria

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Outpatient RCR (TRS ASO Plans / Selected BCBSTX services)

Select outpatient Recommended Clinical Review — providers may submit RCR for the following outpatient services (applies to TRS ASO plans; management may be BCBSTX or Carelon depending on service):

Carelon-managed outpatient services: Advanced Imaging/Radiology; Cardiology; Molecular Genetic Lab Testing; Musculoskeletal (Joint, Spine Surgery, Musculoskeletal - Pain); Radiation Therapy/Radiation Oncology; Sleep

These outpatient services are routed to Carelon for RCR

BCBSTX-managed outpatient services: Cardiology - Lipid Apheresis; Ear, Nose and Throat; Gastroenterology; Neurology; Outpatient Surgery (Breast, Deactivation of Headache Triggers, Jaw); Pain Management; Wound Care; Home Health Services (including home private duty nursing, home infusion therapy, PT/OT/ST); Home Hemodialysis; Home Hospice; Home Infusion Therapy; Non-Emergent Air Ambulance (through 5/22/25); Medical Transportation (through Alacura effective 5/23/25); Transplant Services and Evaluations; Durable Medical Equipment >$5,000; Outpatient Physical Therapy/Occupational Therapy/Speech Therapy

List is illustrative ('including but not limited to')

Behavioral health outpatient services: Applied Behavior Analysis; Intensive Outpatient Treatment; Partial Hospitalization; Psychological/Neuropsychological Testing; Repetitive Transcranial Magnetic Stimulation

Mental health and substance use disorder outpatient RCR services

Specialty pharmacy and infusion-related reviews: Infusion site of care reviews; Medical Oncology & Supportive Care reviews through Carelon; Provider-administered drug therapies medical necessity review for therapy

Specialty pharmacy medications covered by medical benefits

Elective behavioral health and chemical dependency inpatient admissions are listed separately from other inpatient Recommended Clinical Review settings. Covered facility types for these elective admissions include Inpatient Rehabilitation and Residential Treatment Centers, which providers may submit a Recommended Clinical Review for when clinically appropriate.

Listing these behavioral health and substance use disorder inpatient settings separately clarifies that RCR applies across inpatient facility types and ensures providers consider pre-service review to reduce the risk of retrospective medical necessity denials for these episodes of care.

Provider Submission Actions and Notices

Prior Authorization

Optional Recommended Clinical Review (pre-service) — elective inpatient admissions

Providers may submit an optional Recommended Clinical Review (RCR) as a pre-service medical necessity review for specified elective inpatient admissions to help limit retrospective medical necessity denials. Eligible inpatient settings include acute care/hospital hospice, maternity, medical, surgical, transplant admissions, hospice care, long term acute care/sub-acute, rehabilitation facility, and skilled nursing facility (including transfers).

RCR is optional and occurs before the service is completed.
Applies to elective inpatient services across TRS Plans.

Step Therapy

Specialty pharmacy and infusion reviews routed and scoped

Medical necessity reviews for specialty pharmacy medications covered by medical benefits include review of therapy and the infusion site of care; medical oncology and supportive care reviews are routed through Carelon when supported by an oncology diagnosis. Provider-administered drug therapies are reviewed for medical necessity of the therapy only.

Infusion site of care — medical necessity review for therapy and place of infusion.
Medical Oncology & Supportive Care reviews through Carelon for oncology-supported drugs.
Provider-administered drug therapies — therapy medical necessity review only.

Documentation Required

Submission channels for Recommended Clinical Review

Submit Recommended Clinical Review requests for BCBSTX-managed outpatient services using the Availity Authorizations and Referrals tool or by calling the phone number on the back of the participant ID card. For outpatient services managed by Carelon, submit online via Carelon ProviderPortal or call 1-800-859-5299.

Use Availity Authorizations and Referrals for BCBSTX-managed outpatient RCR submissions.
Use Carelon ProviderPortal or phone 1-800-859-5299 for Carelon-managed outpatient RCR submissions.

Denial Risk

Retrospective denial risk for lack of medical necessity

Services may be denied retrospectively if determined not medically necessary; submitting an optional pre-service Recommended Clinical Review can help limit the risk of retrospective denials for covered services.

RCR is an optional pre-service review intended to reduce situations where services are later denied for medical necessity.

Definitions

Recommended Clinical Review (RCR) — definition

DefinitionAn optional pre-service medical necessity review submitted before services are completed for a Covered Service to help limit retrospective denials for lack of medical necessity.

When to submitFor elective inpatient admissions across TRS Plans and for specified outpatient services where RCR is indicated (submission is optional but recommended to reduce retrospective denial risk).

How to submitUse Availity Authorizations and Referrals or the phone number on the participant ID card for BCBSTX-managed outpatient/ inpatient services; use Carelon ProviderPortal or phone 1-800-859-5299 for outpatient services managed by Carelon.

TRS ASO Plans

Plan typeTRS ASO (Administrative Services Only) Plans

ID card identifierNo 'TDI' printed on the participant ID card differentiates TRS ASO Plans

ScopeOutpatient Recommended Clinical Review applies to TRS ASO Plans only; certain outpatient services are eligible for optional RCR under these plans.

Background

A Recommended Clinical Review (RCR) is an optional, pre-service medical necessity review intended to evaluate elective services before they are performed. RCR is offered to help limit situations where services may be denied retrospectively for lack of medical necessity and to give providers an opportunity for pre-service confirmation of coverage.

RCR for inpatient services applies across TRS Plans and may be submitted for elective admissions (including transfers) to settings such as acute care/hospital hospice, maternity, medical, surgical, transplant, long-term acute care/sub-acute, rehabilitation facilities, skilled nursing facilities, and the behavioral health/chemical dependency facilities listed separately. For selected outpatient services, RCR applies to TRS ASO Plans and certain services are routed to either BCBSTX or Carelon depending on the service.

Because RCR is voluntary, providers retain discretion to submit a review when they believe pre-service confirmation will reduce the chance of a retrospective denial or help coordinate care planning and site-of-service decisions.

OpenPayer

Recommended Clinical Review (RCR) for elective services

Recommended Clinical Review Coverage Criteria

Coding and Thresholds

Provider Submission Actions and Notices

Definitions

Background