Health Insurance Terms: What Is Recommended Clinical Review?

Health Insurance Terms: What Is Recommended Clinical Review?

Health Insurance Terms: What Is Recommended Clinical Review?

Sometimes, it seems like you need to bring a dictionary with you to the doctor’s office. Medical terms for the diagnosis of a condition or illness can be a mouthful. The names of prescription medicines don’t always roll off the tongue either. In fact, the lack of “simple speak” can make health care seem confusing at times.  

Even health insurance has its own lingo. For example, at some point you may be told a recommended clinical review is needed before you receive certain care.  

What is a recommended clinical review, you may wonder?

It involves a review of the proposed treatment by your insurer’s medical staff. During this review, the experts reviewing the clinical recommendation will decide if they agree that the treatment is right for your health needs. 

Recommended clinical reviews are done before you get care. You will know early if the treatment is covered by your health insurance plan. Approval depends on information your doctor sends to Blue Cross and Blue Shield of New Mexico (BCBSNM) medical staff.

You may think, “If my doctor tells me I need something, why does it need a second approval? Shouldn’t the doctor’s recommendation be enough?”

Often, it’s important to have a medical person who is very knowledgeable about every aspect of your coverage review the request. They may know of another treatment option that’s just as effective and covered under your plan.

Making sure your treatment is covered will save you money. Sometimes, your plan may require that your doctor show other treatments were tried first. For example, if you struggle with your weight, your doctor may recommend gastric bypass surgery. Before surgery is approved, your doctor may need to show that you have tried a medical weight loss plan first.

Here’s a breakdown of the way recommended clinical review works:

  • The doctor’s office will call BCBSNM to verify your benefits.
  • BCBSNM will decide if a recommended clinical review is needed and tell your doctor.
  • If it is needed, your doctor will send the required details explaining why you need the treatment.
  • BCBSNM medical staff will consider the request, make a decision and tell your doctor.

Here are some services that may need a recommended clinical review. Remember, the details can be different for every plan.

  • Botox
  • Breast MRI
  • Breast Reduction
  • Dental Implants
  • Growth Hormone
  • Nasal Surgery

Once a recommended clinical review is approved, you can continue with the service or buy the medicine covered by your health insurance plan. If it is denied, you can still choose to have the service or buy the medicine, but you will have to pay all the costs.

You can appeal the decision. An appeal gives you the chance to provide the medical review team with details you think will change their decision.

If you ever have questions about a recommended clinical review or anything else about your coverage, you can find answers one of three ways:

  • Visit our website
  • Call the number on your BCBSNM ID card
  • Drop your question in the comment area

Always remember to keep your personal information private. We offer a private message section if you need to provide specific details with your question.

Originally published 3/17/2015; Revised 2021, 2023