Recommended Clinical Review Option 

What is the Recommended Clinical Review Option

Providers will have the option of submitting a Recommended Clinical Review which are reviews for medical necessity before services are provided for both inpatient and outpatient services that are not on the prior authorization lists. 

These reviews are optional and inform the provider of situations where a service may be denied based upon medical necessity.

  • There is no penalty if a provider does not elect to use RCR provided the services are medically necessary.
  • The request will be reviewed to determine if it meets approved medical policy, American Society of Addiction Medicine or MCG Guidelines criteria before services are provided for medical and behavioral health services.
  • Once a decision has been made on the services reviewed as part of the RCR process, they will not be reviewed for Medical Necessity again on a retrospective basis. Providers will be notified of an adverse determination and have the opportunity to appeal if the RCR determines the proposed service does not meet medical necessity.
  • Submitted claims for services, not included as part of a request for RCR, may be reviewed retrospectively.

Eligibility and Benefits Reminder: An eligibility and benefits inquiry should be completed first to confirm membership, verify coverage and determine whether or not prior authorization (also known as preauthorization, pre-certification or pre-notification) is required and if no prior authorization can be submitted as an RCR.

Recommended Clinical Review Services

Refer to the Recommended Clinical Review Services Lists for applicable services and plans: 

Outpatient Services Code Lists

Below are lists of codes1 where outpatient RCR may be available (includes services effective  01/01/25):

Submitting Recommended Clinical Review Requests

Electronic options are preferred to help expedite your request.    

Inpatient Services:

Outpatient Services:

Services Managed by BCBSTX:

  • You will be notified when an outcome has been reached.

Services Managed by Carelon Medical Benefits Management:

1Applicable Non-ERISA Administrative Services Only (ASO) Groups

  • BCS - Tegna, Inc - Supplemental Plans - Group # 193219 (Non-ERISA)
  • Speaking Rock Entertainment Center - Group # 290491 (Non-ERISA)

1 The attached lists are for reference only and are not intended to be a substitute for checking benefits or medical policies. This list applies only to members who have health insurance through a BCBSTX Plan or who are covered by a group plan administered by BCBSTX. If your patient is covered under a different Blue Cross and Blue Shield Plan, please refer to the Medical Policies of that Plan.

2 Applicable Non-ERISA Administrative Services Only (ASO) Groups

  • BCS - Tegna, Inc - Supplemental Plans - Group # 193219 (Non-ERISA)
  • Speaking Rock Entertainment Center - Group # 290491 (Non-ERISA)

3 BlueApprovR is currently not applicable to the Federal Employee Program® (FEP®) or Teacher Retirement System plans. It will be applicable to the Empolyees Retirement System of Texas Effective 09/03/2024.

Related Resources

Recommended Clinical Review does not apply to requests for Texas Medicaid or Medicare Advantage members.

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