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BLUE REVIEWSM

for Providers

October 2023

New BlueApprovRSM Tool Expedites Prior Authorization and Recommended Clinical Review for Some Medical/Surgical Services

Blue Cross and Blue Shield of Texas (BCBSTX) continues to streamline the Prior Authorization and Recommended Clinical Review (RCR) process to reduce your workload with BlueApprovR. Effective Sept. 11, 2023, this new tool in Availity® EssentialsLeaving Site Icon helps you expedite approvals for some medical and surgical services for many of our commercial members. 

BlueApprovR offers End-to-End Efficiencies 
Registered Availity Essentials users have free, 24/7 access to BlueApprovR to:

What if I am Prior Authorization Exempt? 
Providers with active prior authorization exemptions are encouraged to submit a notification through BlueApprovR for services or procedures for which you have a prior authorization exemption. You will also be able to submit recommended clinical reviews through BlueApprovR before moving forward with some services or procedures that are not on the required prior authorization list. Learn more here. 

Note: Your RCR submissions will follow the same path through BlueApprovR as prior authorization requests. Also, your RCR submission via BlueApprovR replaces the need to fax or to attach forms in Availity. 

Use BlueApprovR to request prior authorization for these types of care:

How to submit Prior Authorization and Recommended Clinical Review requests through Availity Essentials:

Other prior authorization request methods: 

Note: This new tool is currently not available for our Federal Employee Program® (FEP®), Employees Retirement System of Texas, Teachers Retirement System of Texas, or Medicare Advantage members. Please use your existing process for requesting prior authorization and recommended clinical review for these members. 

Don’t forget: Benefits will vary based on the service being rendered. Always check eligibility and benefits first for BCBSTX members to confirm if prior authorization is required. This step also will alert you if your request must be submitted through a vendor, rather than BCBSTX. 

Provider Resources 
Learn more about how to access and use BlueApprovR at our Provider Tools web page. 

For More Information
Continue to watch News and Updates for future program updates and training opportunities.

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

Avoid post-service medical necessity reviews and delays in claim processing by obtaining prior authorization before rendering services. If prior authorization is required, services performed without prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member. 

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. 

BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer. 

Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been prior authorized or is issued a recommended clinical review is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card.