Sometimes, to receive benefits for certain services or prescription drugs, you or your provider must call BCBSOK before you receive treatment. This is known as prior authorization. It is also sometimes called preauthorization or preapproval. Note that this is different than getting a referral or a waiver to see a specialist. Sometimes, you may need to get a referral or a waiver to see a specialist and prior authorization to receive benefits for a service from that specialist. You can work with your doctor on determining when you need each.
When you or your provider contact BCBSOK with a prior authorization request, we will ask for some information regarding the care or treatment that is proposed. This may include the following:
- Information about your medical condition
- The proposed treatment plan
- The estimated length of stay (if you are being admitted)
During the prior authorization process, BCBSOK or a company on our behalf reviews the requested service or medication to see if the service or medication is medically necessary.
"Medically Necessary" is defined in your benefit booklet and generally refers to health care services that:
- are required to treat or manage a medical condition or symptom;
- are the most efficient and economical services that can safely be provided;
- follow generally accepted medical standards;
- are not considered experimental or investigational, except those described under your policy; and
- are not primarily for the convenience of you or your doctor.
The service or treatment must meet your plan's definition of medical necessity in order to be eligible for benefits under your plan. The prior authorization process is not a substitute for the medical advice of your health care provider. The final decision to receive any medical service or treatment is between you and your health care provider.
For more information on medical necessity, see your benefit booklet.
Learn about prior authorization
If you are unsure which health care services or medications need prior authorization, you can call the Customer Service number listed on your BCBSOK member ID card.
Remember, even if a service or medication is authorized, if the provider is out of network you will likely pay more out of pocket. Check Provider Finder® to ensure the provider is in your plan's network. Also, a determination that a service is authorized or medically necessary is not a guarantee of coverage. The applicable terms of your plan will control the benefits that you will receive.
For PPO members: Most PPO benefit plans require you or your provider to obtain benefit preapproval for inpatient hospital admissions (acute care, inpatient rehab, etc.). In addition, many PPO benefit plans require prior authorization for services such as skilled nursing visits and home infusion therapy. Make sure to consult the terms of your plan.
For HMO members: Contact your primary care provider (PCP) to coordinate your care. If you are seeking care from a specialist, ask your PCP to ensure that you have received any needed prior authorization.
For all members: If you or your doctor's request for prior authorization is denied, you have the right to appeal the decision. However, you may be responsible for the cost of that service or drug. You can learn more about the appeals process in the Why Was Payment for the Service I Received Denied? section. You can also refer to your benefits documents or call the Customer Service number listed on your BCBSOK member ID card.
There are services that do not require a Prior Authorization that may be subject to a post-service medical necessity review. There is an option to request a Recommended Clinical Review to determine if the service meets approved medical policy and/or level of care review criteria before services are provided to you.
To determine if a Recommended Clinical Review is available for a specific service, visit our website for the Recommended Clinical Review list which is updated when new services are added or when services are removed. You can also call the Customer Service number listed on your BCBSOK member ID card for more information.