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    v1.0.28
    OpenPayerPolicy UpdatesPost-Acute & Facility CareBlue Cross Blue Shield TX elective inpatient revie…
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    CurrentBlue Cross Blue Shield - TexasPolicy N/A

    Optional Recommended Clinical Review for Elective Inpatient Services

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    Describes an optional pre-service clinical review process for elective inpatient admissions for fully insured and certain ASO groups and lists facility types and behavioral health settings eligible for submission. Affects providers submitting authorization requests to Blue Cross Blue Shield of Texas.

    Policy Summary
    PayerBlue Cross Blue Shield - Texas
    PolicyOptional Recommended Clinical Review for Elective Inpatient Services
    Policy CodePolicy N/A
    Change TypeInformational — no material changes
    Effective DateJan 1, 2024
    Next Review DateN/A
    Key ActionProviders may submit an optional Recommended Clinical Review prior to service completion using the Availity Authorizations and Referrals tool or by phone using the number on the member ID card.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Elective inpatienteligible service types
    6settings named
    MCG/BCBSTX/ASAM

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    guidelines referenced

    Optional Recommended Clinical Review — Eligible Admissions

    Elective Inpatient Admissions Eligible for Optional Review

    Optional Recommended Clinical Review may be submitted for the following elective inpatient admissions:

    Eligible elective inpatient settings: Includes acute care hospital (medical/surgical, maternity, transplant), hospice care, long term acute care/sub-acute, rehabilitation facility, skilled nursing facility, residential treatment center, and inpatient behavioral health/chemical dependency admissions.

    Providers may submit an optional Recommended Clinical Review prior to service completion using the Availity Authorizations and Referrals tool or by phone using the number on the member ID card.

    Optional Recommended Clinical Review may be submitted for elective inpatient admissions, including acute care hospital (medical/surgical, maternity, transplant), hospice care, long term acute care/sub-acute (LTAC), rehabilitation facility, skilled nursing facility, residential treatment centers, and inpatient behavioral health/chemical dependency admissions. Providers may use the Availity Authorizations and Referrals tool or call the number on the member ID card to submit these reviews.

    The policy does not list specific conditions that are automatically not medically necessary. It states that Recommended Clinical Review is an optional pre-service medical necessity review intended to reduce situations where services may be denied retrospectively for medical necessity. Submitting a Recommended Clinical Review can help limit retrospective denial risk, but the document does not define explicit not-medically-necessary diagnoses or scenarios.

    Coding and Effective Dates

    No specific codes listed in policymixed
    No codes listed
    Effective dates
    Screening criteria effective date10/01/2022
    Policy effective date01/01/2024
    Applicable accounts noteApplies to fully insured and certain ASO groups (see policy for list).

    How Providers Should Submit and Risks

    Prior Authorization

    Optional pre-service review for elective inpatient admissions — which admissions/providers may submit

    Recommended Clinical Review is an optional pre-service medical necessity review for elective inpatient admissions for fully insured and certain ASO groups (effective 01/01/2024). Submitting a Recommended Clinical Review before the service is performed can reduce the risk that the admission is retrospectively denied for lack of medical necessity.

    • Optional for fully insured & certain ASO groups only
    • Helps limit retrospective medical necessity denials
    Note

    Which elective inpatient admissions are eligible for Recommended Clinical Review

    Providers may submit an optional Recommended Clinical Review for elective inpatient services including the listed facility types below. Use this review to confirm medical necessity before admission.

    • Acute care hospital (medical, surgical, transplant, maternity, hospice)

    Purpose of Recommended Clinical Review

    Recommended Clinical Review is an optional pre-service medical necessity review performed before services are completed to help limit retrospective medical necessity denials. The screening criteria used to assess admissions reference external guidance such as MCG Care Guidelines, BCBSTX Medical Policies, ASAM Criteria, and applicable Texas DOI standards.

    Screening Criteria Sources

    Screening criteria sources
    Primary clinical guidelineMCG Care Guidelines (MCG)
    Payer medical policiesBCBSTX Medical Policies (MP)
    Substance use criteriaAmerican Society of Addiction Medicine (ASAM) Criteria
    State standards for TexasTexas Department of Insurance Standards for Reasonable Cost Control and Utilization Review for Chemical Dependency Treatment Centers
    Vendor guideline (where applicable)Magellan Healthcare Guidelines (for certain plans served by Magellan)

    Settings Eligible for Recommended Clinical Review

    SNF | LTACH | IRF | acute care hospital | hospice | residential

    Admission settings: Acute care hospital (medical/surgical, maternity, transplant), hospice care, long term acute care/sub-acute, rehabilitation facility, skilled nursing facility, residential treatment center, and inpatient behavioral health/chemical dependency admissions are eligible for optional Recommended Clinical Review.

    Submission is optional and intended to assess medical necessity prior to service completion.

    Continued Stay Screening

    Continued stay criteria

    Referenced guidelines for continued stay or screening: MCG Care Guidelines, BCBSTX Medical Policies, ASAM Criteria, and Texas DOI standards are cited as screening/criteria sources for behavioral health and chemical dependency admissions.

    Specific continued-stay criteria are determined by the referenced clinical guidelines and payer medical policies.

    Discharge Screening

    Discharge decisions are not specified within this policy; instead, the document directs that screening and continued-stay assessments rely on referenced clinical guidelines. Screening criteria sources include MCG Care Guidelines, BCBSTX Medical Policies, ASAM Criteria, and applicable Texas Department of Insurance standards, which inform ongoing utilization review and applicable discharge planning criteria.

    Policy Dates and Revision Notes

    2024-01-01policy_effectiveLatest

    Policy became effective on January 1, 2024.

    2022-10-01screening_criteria_effective

    Recommended Clinical Review screening criteria became effective on October 1, 2022.

    Policy Summary
    PayerBlue Cross Blue Shield - Texas
    PolicyOptional Recommended Clinical Review for Elective Inpatient Services
    Policy CodePolicy N/A
    Change TypeInformational — no material changes
    Effective DateJan 1, 2024
    Next Review DateN/A
    Key ActionProviders may submit an optional Recommended Clinical Review prior to service completion using the Availity Authorizations and Referrals tool or by phone using the number on the member ID card.
    SourceLink
    On This Page
    Optional Recommended Clinical Review — Eligible AdmissionsCoding and Effective DatesHow Providers Should Submit and RisksPurpose of Recommended Clinical ReviewScreening Criteria SourcesSettings Eligible for Recommended Clinical ReviewContinued Stay ScreeningDischarge ScreeningPolicy Dates and Revision Notes
  1. Long-term acute care / Sub-acute care
  2. Rehabilitation facility
  3. Skilled nursing facility
  4. Hospice care
  5. Residential treatment center (RTC) and inpatient behavioral health/chemical dependency admissions
    6. Note

    How to submit — Availity Authorizations and Referrals portal submission instructions

    Submit Recommended Clinical Reviews via the Availity Authorizations and Referrals portal or by calling the member services number on the back of the member's ID card. For additional guidance and resources, see Utilization Management on the Blue Cross Blue Shield of Texas provider website.

    • Availity Authorizations and Referrals portal — create an authorization request and select Recommended Clinical Review where available
    • Provider Services telephone number on member ID card
    Denial Risk

    Retrospective medical necessity denial risk — benefit of Recommended Clinical Review

    If you do not obtain a Recommended Clinical Review prior to an elective inpatient admission, the service remains subject to retrospective medical necessity review and may be denied after the fact. To minimize claim denials and potential financial liability to the provider or member, consider using the optional pre-service Recommended Clinical Review.

    • Retrospective medical necessity denial risk if no pre-service review is obtained
    • Optional Recommended Clinical Review reduces likelihood of post-service denials