Recommended Clinical Review Request Form - Medical and Surgical

Sep 17, 2026

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Instructions outline how to submit a voluntary, written request for a Recommended Clinical Review to determine whether a proposed treatment or service is covered under a patient health benefit plan. The guidance defines urgent criteria, highlights required eligibility checks and preservice steps (such as prior authorization), and stresses that all fields and supporting documents must be legible. It specifies routing to the administering plan, submission order, photo handling via email, and fax or mailing addresses for standard and behavioral health cases, noting decisions are not payment guarantees.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Submitting a Recommended Clinical Review Request

Urgent criteria

Important reminders and required information

Submission methods and contact details

Instructions for Submitting REQUESTS FOR RECOMMENDED CLINICAL REVIEW A Recommended Clinical Review is not required. A Recommended Clinical Review is a voluntary, written request by a member or a provider to determine if a proposed treatment or service is covered under a patient’s health benefit plan. Recommended Clinical Review approvals and denials are usually based on our medical policies. Review our Blue Cross and Blue Shield of Texas medical policies or Federal Employee Program® (FEP®) medical policies and your FEP Benefit Brochure criteria. The provider and member will be notified when the decision on a Recommended Clinical Review has been reached. URGENT Definition is below and if not met the request will be re-classified from urgent to standard priority: • Waiting could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment, or • Waiting could seriously jeopardize the life, health or safety of the member or others, due to the member’s psychological function, or • In the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request. IMPORTANT RECOMMENDED CLINICAL REVIEW REMINDERS 1. Always confirm eligibility and benefits first. 2. You must also complete any other preservice requirements, such as prior authorization, if applicable and required. (For example, all inpatient admissions require prior authorization.) 3. All applicable fields are required. All information and documents provided must be legible. If all required or necessary information is not provided, this may cause a delay in the Recommended Clinical Review process. (Inquiries received without the member/patient’s group number, ID number, and date of birth cannot be completed and may be returned to you to supply this information.) Procedure (CPT)/HCPCS codes for requested services along with ICD10 diagnosis codes must be listed on the form. 4. You MUST submit the Recommended Clinical Review to the Blue Cross and Blue Shield Plan that issues or administers the patient’s health benefit plan which may not be the state where you are located. 5. Always place the completed Recommended Clinical Review Request Form on top of other supporting documents. Do not send in duplicate requests as this may delay the process. 6. Per Medical Policy, if photos are required for review, please email the photos to [photohandling@bcbsil.com. The](photohandling@bcbsil.com. The) body of the email should include the patient’s first and last name, Group number, Subscriber ID number and the patient’s date of birth. 7. A Recommended Clinical Review decision 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 contract or certificate of coverage applicable on the date services were rendered. Exceptions may apply. Regardless of any benefit determination, the final decision to proceed with any treatment or service is between the patient and the health care provider. 8. ONLY use this form for requests for Recommended Clinical Review. Do Not Use This Form To: 1) submit a claim for payment or request payment on a claim; 2) request an appeal; 3) confirm eligibility; 4) verify coverage; 5) request a guarantee of payment; 6) ask whether a service requires prior authorization; 7) request a referral to an out of network physician, facility or other healthcare provider. 9. Submission of documents as part of the Recommended Clinical Review process does not preclude the Blue Cross and Blue Shield Plan from seeking additional information or documents in relation to its review of other requests or matters. 10. Fax each completed Recommended Clinical Review Request Form to 888-579-7935. If unable to fax, you

FAQs

What is a Recommended Clinical Review and is it required?

A Recommended Clinical Review is a voluntary, written request used to determine whether a proposed treatment or service is covered under a patient’s health benefit plan. A Recommended Clinical Review approval or denial is based on medical policies.

When does a request qualify as URGENT?

A request is urgent only if waiting could seriously jeopardize the member’s life or health or ability to regain maximum function, or waiting could seriously jeopardize life, health, or safety due to psychological function, or without the care requested the member would face adverse health consequences according to a knowledgeable practitioner.

How should the Recommended Clinical Review be submitted and what routing is required?

Fax the completed form to the specified number, or mail it to the listed BCBSTX address. Submit to the Blue Cross and Blue Shield Plan that issues or administers the patient’s health benefit plan, and place the completed request form on top of supporting documents without sending duplicate requests.

Sep 17, 2026

Upload by Mia