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You can request that your provider submit clinical information for clinical review before you receive care and services. This is called recommended clinical review. Recommended clinical review involves a review of the proposed treatment and relevant clinical information by the BCBSTX clinical staff. The experts reviewing your provider%u2019s request determine if the recommended treatment is right for your health needs.We recommend reviews are done before you get care. You%u2019ll know early if the treatment is covered by TRS-ActiveCare.It%u2019s important to have a clinical person who understands every aspect of your coverage review the request. They may know of another treatment option that%u2019s just as effective and covered under your plan. Making sure your treatment is covered will save you money. Here%u2019s a breakdown of the way recommended clinical review works:%u2022 The provider%u2019s office will call BCBSTX to verify your benefits.%u2022 BCBSTX will advise your provider if a recommended clinical review is suggested for your requested service or care.%u2022 Your provider may submit a recommended clinical review with clinical information explaining why you need the treatment.%u2022 BCBSTX clinical staff will consider the request, review clinical information and tell your provider and you the outcome of the review.Services that may need recommended clinical reviewElective inpatient medical and surgical facility admissions, including transfers:%u2022 acute care, hospital hospice, maternity, medical, surgical, transplant%u2022 hospice care%u2022 long-term acute and sub-acute care%u2022 rehabilitation facility%u2022 skilled nursing facilityElective behavioral health and chemical dependency facility admissions:%u2022 inpatient rehabilitation %u2022 residential treatment centerOutpatient medical and surgical services:%u2022 advanced imaging/radiology, cardiology%u2022 molecular genetic lab testing %u2022 joint, spine, or other musculoskeletal issues%u2022 radiation therapy/radiation oncology %u2022 sleep%u2022 cardiology %u2013 lipid apheresis%u2022 ear, nose and throat%u2022 gastroenterology%u2022 neurology%u2022 outpatient surgery (breast, deactivation of headache triggers, jaw)%u2022 pain management%u2022 sleep studies%u2022 wound care%u2022 home health services including but not limited to home private duty nursing, home infusion therapy and PT/OT/ST%u2022 home hemodialysis%u2022 home hospice%u2022 home infusion therapy%u2022 non-emergent air ambulance%u2022 transplant services, transplant evaluations and transplants%u2022 durable medical equipment greater than $5,000%u2022 outpatient PT/OT/STMental health and substance use disorder outpatient services:%u2022 applied behavior analysis%u2022 intensive outpatient treatment%u2022 partial hospitalization%u2022 psychological and neuropsychological testing%u2022 transcranial magnetic stimulationSpecialty pharmacy medications covered by medical benefits:%u2022 infusion site of care%u2022 medical oncology and supportive care %u2022 provider administered drug therapies Call a PHG at 1-866-355-5999 anytime if you need help with recommended clinical review.RECOMMENDED CLINICAL REVIEW34 www.bcbstx.com/trsactivecare