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.


Before You Administer Treatment

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 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.
Please visit Preauthorization webpage under the Clinical Resources tab.



Electronic Commerce Solutions

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.

Learn more about Electronic Commerce Solutions.


Submitting Claims

To prevent delays, billing errors and other potential setbacks, here are some valuable tips and information to help you manage and submit claims.


Filing Ancillary 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.


Claim Status

After submitting a claim, you can check the status online via Availity Claim Research Tool (CRT) 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.

Learn more about Claim Status.


Eligibility and Benefits

Patient eligibility and benefits should be verified prior to every scheduled appointment.

Learn more about Eligibility and Benefits.


Interactive Voice Response (IVR) Caller Guides


Medicare Advantage Private Fee-for-Service Terms and Conditions

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.