05/31/2024
What’s Changing
Effective Sept. 1, 2024, Blue Cross and Blue Shield of Texas will be moving prior authorization to Recommended Clinical Review Option for outpatient services for Teacher Retirement System of Texas participants as indicated below:
- Outpatient Services previously requiring PA by BCBSTX moving to RCR: (As a reminder, inpatient services were changed to RCR effective 03/01/2024)
- 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 but not limited to home private duty nursing (PDN), home infusion therapy (HIT)
- Home Hemodialysis
- Home Hospice
- Non-Emergent Air Ambulance
- Transplant Services, Transplant Evaluations and Transplants
- Durable Medical Equipment > $5000 applicable to medical necessity review per benefit language (less than $5000 medical necessity review not needed)
- Outpatient Physical Therapy/Occupational Therapy/Speech Therapy
- Mental Health and Substance Use Disorder Services
- Applied Behavior Analysis
- Electroconvulsive Therapy
- Intensive Outpatient Treatment
- Partial Hospitalization
- Psychological Testing/Neuropsychological Testing
- Repetitive Transcranial Magnetic Stimulation
- Specialty Pharmacy Medications that are covered by Medical Benefits
- Infusion Site of Care
- Medical Oncology & Supportive Care (through Carelon)
- Provider Administered Drug Therapies
- Carelon Medical Benefits Management will handle RCR for the following services:
- Advanced Imaging / Radiology
- Cardiology
- Molecular Genetic Lab Testing
- Musculoskeletal - Joint, Spine Surgery, Musculoskeletal - Pain
- Radiation Therapy / Radiation Oncology
- Sleep
Providers are encouraged to submit an RCR for services that previously required prior authorization to prevent post service medical necessity reviews. Refer to the RCR page for a list of applicable services.
Recommended Clinical Review Key Points
- 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.
- 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.
- 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.
For More Information
Refer to the RCR page for information on RCR services and how to submit requests for services managed by BCBSTX or Carelon.
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.
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