11/30/2023
Effective March 1, 2024, Blue Cross and Blue Shield of Texas (BCBSTX) is moving certain inpatient services from prior authorization to the Recommended Clinical Review Option (RCR) for Teacher Retirement System of Texas (TRS) participants.
RCR will be available for:
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
Elective Behavioral Health and Chemical Dependency Facility Admissions:
- Inpatient
- Residential Treatment Center (RTC)
Key Points
Refer to the Availity Attachments: Submit Recommended Clinical Review Requests Online.
RCR requests are optional medical necessity reviews conducted before services are provided. Submitting a request prior to rendering services informs you of situations where a service may not be covered based upon medical necessity.
Claims for services for which the RCR option is available will be subject to retrospective review if a provider elects not to submit a request for RCR.
Submitting a recommended clinical review evaluates the medical necessity of a service but does not guarantee the service will be covered under the participant’s benefit plans. The terms of the participant’s plan control the available benefits.
RCR Process
RCR requests can be submitted using Availity Authorization and Referrals tool or by calling the authorization number on the back of the participant’s ID card.
For More Information
Learn more about our utilization management process, including prior authorization and recommended clinical review in the Utilization Management section of our provider website. Follow our News and Updates page for future updates.
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.
BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association