Prior Authorization



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This page provides a summary of pre-service requirements and recommendations for Blue Cross and Blue Shield of Oklahoma (BCBSOK) providers. Call the number on the back of the member's ID card if you have any questions.


Eligibility and Benefits Reminder: An eligibility and benefits inquiry should be completed first to confirm membership, verify coverage and determine whether or not pre-certification (also known as pre-notification or preauthorization) is required. This includes prior authorization for high-tech imaging services.




What is preauthorization?

Preauthorization is the determination of the medical necessity and appropriateness of treatment as a required part of the Utilization Management process for certain covered services. Failure to obtain these proper permissions may affect claim payment, subject to the terms and conditions of a Coverage Plan. A Preauthorization is not a guarantee of benefits or payment.


Services which may require preauthorization

  • Inpatient admissions (scheduled and/or non emergent), certain outpatient services, emergent admissions/obstetric, requests for extensions and Plan65 Members when their Medicare Part A benefits have been exhausted.
  • Other services may also require preauthorization. Please refer to the number on the back of the member's ID card to obtain Preauthorization requirements.

For additional information, refer to the Pre-Service Review for Out-of-Area Members tip sheet, located with other tip sheets under iEXCHANGE® on the Provider Tools page. You can also refer to the Electronic Provider Access (EPA) FAQs for additional information. For more information about iEXCHANGE, including how to register if you are not a current user or training opportunities, visit the Provider Tools page.


Who is responsible for preauthorization?

The facility, treating physician or ancillary provider is responsible for obtaining preauthorization for Blue Cross and Blue Shield card carrying members, in accordance with the BCBSOK participating provider agreement. Please refer to the number on the back of the member’s ID card for Preauthorization Requirements.


How to request preauthorization

For the convenience of our providers, Blue Cross and Blue Shield of Oklahoma providers may submit preauthorization requests via iEXCHANGE, a Web-based automated tool.  To learn more, visit Getting Started With iEXCHANGE.


Preauthorization may also be requested by calling the Preauthorization phone number listed on the back of the members ID card.


For more information regarding preauthorization requirements, please refer to your BCBSOK participating provider agreement.


Preauthorization for an Extension of Approved Days

Should additional days of treatment be deemed necessary, it is the responsibility of the facility, treating physician or ancillary provider to request an extension in accordance with the BCBSOK participating provider agreement.


Preauthorization vs benefits

Preauthorization is a determination of medical necessity for the delivery of services. An approved authorization of services by the Preauthorization process is not a guarantee of benefits. It is the responsibility of the rendering BCBSOK participating provider to verify eligibility and benefits prior to the date of service, to the extent practical. Benefits can be requested by contacting the customer service number listed on the back of the member's ID card.


Preauthorization Penalty

Failure to obtain preauthorization may result in a financial penalty. For more information, please refer to your BCBSOK participating provider agreement.



iEXCHANGE supports direct submissions and provides online approval of benefits for inpatient admissions, referrals and select outpatient services. iEXCHANGE is accessible to network physicians, professional providers and facilities within Oklahoma 24-hours-a-day, seven-days-a-week.


A Predetermination is a voluntary request that a provider may submit to BCBSOK to determine in advance whether a specific service is Medically Necessary. A Predetermination is not a guarantee of Benefits or a substitute for the Preauthorization process, when required.


Examples of services for which the provider may request a Predetermination include:

  • outpatient services
  • durable medical equipment
  • surgeries that might be considered cosmetic
  • possible experimental and investigational procedures/treatments

For your convenience, we have included a link to a list for codes where Predetermination may be available and is recommended PDF Document *. Please refer to BCBSOK's medical policies for medical necessity criteria.


The following provides links to specific lists* that include codes unlikely to be considered medically necessary and codes that would not be considered for Predetermination:

Steps for Requesting a Predetermination

  1. Always verify eligibility and Benefits first.
  2. To request a Predetermination, please complete the Predetermination Request form PDF Document. All applicable fields are required. If any information is not provided, this may cause a delay in the Predetermination process. (Requests received without the member/patient's group number, ID number, and date of birth cannot be completed and may be returned.)
  3. Fax information for each patient separately, using the fax number indicated on the form.
  4. Always place the Predetermination Request form on top of other supporting documentation. Please include any additional comments if needed with supporting documentation.
  5. Do not send in duplicate requests, as this may delay the process.
  6. Per Medical Policy, if photos are required for review, the photos should be mailed to the address indicated on the Predetermination Request form and not faxed. Faxed photos are not legible and cannot be used to make a determination.
  7. Regarding major diagnostic tests, please include the patient's history, physical and any prior testing information.


* The attached lists are for reference only and are not intended to be a substitute for benefit verification or BCBSOK's medical policies. All lists above apply only to members who have health insurance through a Blue Cross and Blue Shield of Oklahoma Plan or who are covered by a group plan administered by BCBSOK. If your patient is covered under a different Blue Cross and Blue Shield Plan, please refer to the Medical Policies of that Plan.


Blue Cross and Blue Shield of Oklahoma (BCBSOK) has contracted with eviCore healthcare (eviCore)* to provide certain utilization management services for outpatient molecular and genomic testing and outpatient radiation therapy. eviCore is an independent company that provides specialty medical benefits management for BCBSOK.

 

Preauthorization Requirements

BCBSOK requires preauthorization (for medical necessity) ** through eviCore for outpatient molecular and genomic testing and outpatient radiation therapy. Refer to the eviCore implementation site and select the BCBSOK health plan for the applicable CPT/HCPCS code list and radiation therapy physician worksheets.

 

Contact Information

eviCore preauthorization’s for outpatient molecular and genomic testing and outpatient radiation therapy can be obtained using one of the following methods:

  • The eviCore Healthcare Web Portal is available 24x7. After a one-time registration, you are able to initiate a case, check status, review guidelines, view authorizations/eligibility and more. The Web Portal is the quickest, most efficient way to obtain information.
  • Providers can call toll-free at 855-252-1117 between 7 a.m. to 7 p.m. (local time) Monday through Friday.
  • More specific program-related information can be found on the eviCore implementation site.

* eviCore is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of BCBSOK.

** Preauthorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Preauthorization of a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.

Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.