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.
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.