Claims and Eligibility
This section presents an introduction to doing business with Blue Cross and Blue Shield of Oklahoma (BCBSOK), along with an overview of options and resources that may help you maximize administrative efficiencies in your office.
The pages in this section are designed to follow the claim cycle — from the moment a BCBSOK member walks into your office, through processing and payment for covered services you provide.
If you are not yet a contracted provider with BCBSOK, review the How to Join section under the Network Participation tab.
Check Member Identification
Check BCBSOK Medical Policies
Always consult the approved BCBSOK Medical Policies in the Standards and Requirements. Approved new or revised BCBSOK medical policies and their effective dates are posted on the BCBSOK website the first and fifteenth day of each month. These policies may impact your reimbursement and your patients’ benefits. You may view all active and pending policies, or view draft Medical Policies and provide comments.
Complete All Necessary Precertification Processes
Most HMO and PPO contracts require the member or provider to contact BCBSOK to receive precertification (also known as prior authorization.)
Prior authorization is the determination of the medical necessity and appropriateness of treatment as a required part of the Utilization Management process for certain covered services.
Please visit the Utilization Management page.
The fastest way to conduct business with BCBSOK throughout the entire claims process is via Electronic Data Interchange (EDI) – the computer-to-computer transmission of standardized information.
To prevent delays, billing errors and other potential setbacks, here are some valuable tips and information to help you manage and submit claims.
Ancillary providers include Independent Clinical Laboratory, Durable/Home Medical Equipment and Supplies and Specialty Pharmacy providers. File claims for these providers as follows:
- Independent Clinical Laboratory (Lab) - The Plan in whose state the specimen was drawn based on the location of the referring provider.
- Durable/Home Medical Equipment and Supplies (D/HME) - The Plan in whose state the equipment was shipped to or purchased at a retail store.
- Specialty Pharmacy - The Plan in whose state the Ordering Physician is located.
*If you contract with more than one Plan in a state for the same product type (i.e., PPO or Traditional), you may file the claim with either Plan.
After submitting a claim, you can check the status online via Availity Claim Status Tool or your preferred web vendor. By checking claim status, you can verify if your claim has been received, pended or finalized. Additionally, you can verify the descriptions for any claim denials.
Patient eligibility and benefits should be verified prior to every scheduled appointment.
- Claim Status Guide
- Inpatient Preauthorization Caller Guide
- Outpatient Preauthorization Caller Guide
- Checking Status of a Preauthorization Request
- Behavioral Health Inpatient Preauthorization IVR Caller Guide
- Behavioral Health Outpatient Preauthorization IVR Caller Guide
If you provide care to a Medicare Advantage Private Fee-for-Service (PFFS) member from an out-of-area Blue Cross and Blue Shield (BCBS) Plan, you may use the Web Finder Tool to view the Terms and Conditions of the member's plan.
In response to the COVID-19 pandemic, Blue Cross and Blue Shield of Oklahoma (BCBSOK) expanded access to telemedicine services to give our members greater access to care. The experience confirmed the importance of telemedicine in health care delivery. Members can access their medically necessary, covered benefits through providers who deliver services through telemedicine. Many of our members also have access to various telemedicine vendors, such as MDLIVE.
Utilization management review requirements and recommendations are in place to help ensure our members get the right care, at the right time, in the right setting. Learn about the types of utilization management reviews – prior authorization, predetermination and post-service review Learn More.