Claims and Eligibility

Blue Cross and Blue Shield of Oklahoma has been working closely with doctors to improve the health care system and meet customers' health care delivery needs for more than 70 years. We aim to consistently provide the quality technology, services and information that can help improve all transactions and communication with health care professionals.

Before You Administer Treatment

Check Member Identification

Check BCBSOK Medical Policies

Always consult the approved BCBSOK Medical Policies in the Standards and Requirements section of our Web site when considering care for BCBSOK members. These Medical Policies serve as guidelines for health care benefit coverage decisions, which may vary according to the different products and benefit plans offered by BCBSOK.

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) for inpatient hospital admissions, including acute care, inpatient rehab, skilled nursing, long-term acute care, inpatient hospice, and coordinated health care such as skilled nursing visits, IV medication, etc. The precertification process may be completed by calling the number on the back of the member's ID card; or you may call our Medical Services Department at 800-672-2378. Upon verification of eligibility and benefits, you will be advised if precertification is required.

Please note the fact that a guideline is available for any given treatment or that a service has been precertified is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member's eligibility and the terms of the member's certificate of coverage applicable on the date services were rendered.

Electronic Commerce Solutions

Say goodbye to paper shuffle and say hello to increased operational efficiencies and improved turnaround on payments. BCBSOK is your source for e commerce transactions.

Learn more about Electronic Commerce Solutions.

Filing Ancillary Claims

Ancillary providers should submit claims as follows:

Independent Clinical Laboratory (Lab)

  • The Plan in whose state* the specimen was drawn.

Durable/Home Medical Equipment and Supplies (DME)

  • 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

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.

Physicians' Advisory Committee (PAC)

PAC is a forum for open dialogue on issues related to the relationships and interactions between and among Physicians, their patients and the Blue Plans.

Learn more about PAC.

Submitting Claims

At Blue Cross and Blue Shield of Oklahoma, we are committed to fast and efficient claim processing. In order to prevent delays, billing errors and other potential setbacks, we’ve put together valuable tips and information to help you manage and submit claims.

Thomas-Love Settlement Provision 7.8(d)

We are committed to promoting cooperation and communication with physicians. In compliance with our settlement agreement, the following Thomas-Love provisional updates and information are available to providers.

  • Significant edits [As of 12/23/10] 
  • Health Care Service Corporation (HCSC) Adverse Denial Rate — Calendar Year 2010
    • HCSC operates Blue Cross and Blue Shield plans in Illinois, New Mexico, Oklahoma, and Texas. As a whole, the corporation has received 8,353 appeals for Adverse Determinations that have been sent for external review. Of that total, 22.0 percent have been overturned. [Posted 01/18/11]