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We’ll Begin Removing Recommended Clinical Review as an Optional Medical Necessity Review, Effective Jan. 1, 2027
Act
by Dec 31, 2026
Effective date
Jan 1, 2027
Identified
Sep 17, 2026
Summary
Effective January 1, 2027, Blue Cross and Blue Shield of Texas will eliminate 'recommended clinical review' as an optional medical necessity review option for commercial members. Services that previously allowed recommended clinical review will require prior authorization instead. This change will be fully implemented by the end of 2027.
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What to do
by Dec 31, 2026 · 5 steps
01Billing team must audit all current workflows and identify services currently using 'recommended clinical review' as the review method.
02Beginning January 1, 2027: Transition all affected services to require prior authorization instead of recommended clinical review.
03Update billing software, encounter forms, and provider education materials to reflect that prior authorization is now mandatory for these services.
04Before submitting any claims for services previously using recommended clinical review, verify eligibility and benefits through Availity Essentials to confirm prior authorization requirements.
05Throughout 2027: Monitor system updates as BCBSTX phases out the recommended clinical review option entirely.
If missed: Failure to obtain prior authorization for affected services will result in claim denials.
Original notice
We’ll Begin Removing Recommended Clinical Review as an Optional Medical Necessity Review, Effective Jan. 1, 2027
bcbstx.com · Always check the source before changing claims.