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.
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 *. 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:
- Codes that BCBSOK has determined to be not medically necessary per BCBSOK's medical policies . Please refer to BCBSOK's medical policies for more information.
- Codes that BCBSOK has determined to be Experimental/Investigational/Unproven (EIU) per BCBSOK's medical policies . Please refer to BCBSOK's medical policies for more information.
- Codes that are commonly not a benefit for BCBSOK Members . Predetermination is not available for services that are not a benefit or are subject to a benefit exclusion.
Steps for Requesting a Predetermination
- Always verify eligibility and Benefits first.
- To request a Predetermination, please complete the Predetermination Request form . 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.)
- Fax information for each patient separately, using the fax number indicated on the form.
- Always place the Predetermination Request form on top of other supporting documentation. Please include any additional comments if needed with supporting documentation.
- Do not send in duplicate requests, as this may delay the process.
- 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.
- 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 the following services on and after Oct. 3, 2016:
- Outpatient Molecular and Genomic Testing
- Outpatient Radiation Therapy
BCBSOK may require preauthorization (for medical necessity under the applicable benefit plan)** by eviCore for outpatient molecular and genomic testing and outpatient radiation therapy under the following benefit plan(s):
- All retail and fully insured small and large commercial groups.
Beginning Sept. 26, 2016, providers will be able to contact eviCore to request preauthorization for dates of service on and after Oct. 3, 2016, for outpatient molecular and genomic testing and outpatient radiation therapy.
Check this site regularly for updates that will include:
- Future webinars regarding registration to utilize eviCore
- eviCore web portal address you may bookmark
- eviCore contact information
For additional information:
- Contact your BCBSOK provider representatives for questions regarding eviCore
- Find specific program-related information on the eviCore implementation site
- See our recent News and Updates article
*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.