Utilization Management

Prior Authorization and Predetermination

This page provides a summary of pre-service requirements and recommendations for Blue Cross and Blue Shield of Oklahoma (BCBSOK) members. The following information is for BCBSOK members only.

For more information on additional Blue Cross and Blue Shields members refer to the following links:

Eligibility and Benefits Reminder: An eligibility and benefits inquiry should be completed first to confirm membership, verify coverage and determine whether or not prior authorization (also known as preauthorization, pre-certification or pre-notification) is required.

Clinical Information Notice
Reminder:
Requests for authorization must in all cases be accompanied by appropriate clinical/medical record information except for routine vaginal or cesarean section deliveries. Please submit clinical/medical record information for routine deliveries only upon request. This will assist in faster, more efficient processing of authorizations for those deliveries and eliminate unnecessary work for you and your organization.

Utilization Management

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

How to Request Prior Authorization or Predetermination

Review the process to submit requests for prior authorizations and predeterminations. Learn More

Prior Authorization and Post-Service Review Lists

Download the lists of services and/or procedure codes that may require prior authorization or post-service reviews. Learn More



Utilization Management

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.

What is Utilization Management Review

A utilization management review helps determine the medical necessity and appropriateness of treatment for certain services.

Utilization management includes:

  • Prior Authorization
  • Predeterminations
  • Post-service reviews

What is 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. Failure to obtain these proper permissions may affect claim payment, subject to the terms and conditions of a Coverage Plan. A Prior Authorization is not a guarantee of benefits or payment. Go here to learn how to submit prior authorization requests.

Who Requests Prior Authorization

The facility, treating physician or ancillary provider is responsible for obtaining prior authorization for Blue Cross and Blue Shield card carrying members, in accordance with the BCBSOK participating provider agreement. Please refer to the number on the member’s ID card for prior authorization requirements. Information for members is on our member site.

Most out-of-network services require utilization management review. If the provider or member does not get prior authorization for out-of-network services, the claim may be denied. Emergency services are an exception.

Why Obtain a Prior Authorization

If you do not get prior approval via the prior authorization process for services and drugs on our prior authorization lists:

  • The service or drug may not be considered medically necessary, and the BCBSOK participating provider will be responsible.
  • We may conduct a post-service utilization management review, which may include requesting medical records and review of claims for consistency with:
    • Medical policies
    • State and federal requirements
    • Member’s benefits
    • Other clinical guidelines
  • Treating Medicare members, if you don’t get a prior authorization for a service or drug on our prior authorization list, we won’t reimburse you, and you cannot bill our member for that service or drug.

What is Predetermination

The purpose of a Predetermination request is to determine whether a specific service, including services that may be considered Experimental/Investigational/Unproven, is Medically Necessary. BCBSOK recommends submitting a predetermination request if it is unclear if the service meets BCBSOK Medical Policy criteria.

Predeterminations are:

  • Voluntary utilization management reviews
  • Not a substitute for the Preauthorization process
  • Submitting a predetermination does not guarantee services will be covered under the members’ benefit plan

Why Obtain a Predetermination

  • If you’re unsure about coverage or medical necessity criteria
  • May eliminate the need for a post-service review

What is Post-Service Utilization Management Review

A post-service utilization management review occurs after the service has been rendered. During a post-service utilization management review, we review clinical documentation to determine whether a service or drug was medically necessary and covered under the member’s benefit plan. We may ask you for the information we do not have.

We may also conduct a post-service utilization management review if you do not obtain a required prior authorization before the services were rendered. If the service required a prior authorization for a Medicare member, the claim will be denied with no post-service review.




How to Request Prior Authorization, Predetermination

The following outlines the process for providers to submit prior authorization requests.

Services which may require Prior Authorization

  • Inpatient admissions (scheduled and/or nonemergent), certain outpatient services, emergent admissions/obstetric (request authorization within two (2) business days of the admission), requests for extensions and Plan65 Members when their Medicare Part A benefits have been exhausted.
  • Other services may also require preauthorization. Always check eligibility and benefits first, via the Availity® Provider Portal Learn more about third-party links or your preferred vendor, prior to rendering care and services.

For additional information, refer the Electronic Provider Access (EPA) FAQs PDF Document located in the right navigation menu.

Prior Authorization 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.

Prior Authorization vs benefits
Prior Authorization is a determination of medical necessity for the delivery of services. An approved authorization of services by the Prior Authorization 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. Benefits can be verified via the Availity® Provider Portal Learn more about third-party links or your preferred vendor; or by contacting the customer service number listed on the back of the member's ID card.

Prior Authorization Penalty
Failure to obtain preauthorization may result in a financial penalty. For more information, please refer to your BCBSOK participating provider agreement.

How to Submit a Prior Authorizations

Step 1: Confirm if prior authorization is required using Availity® Learn more about third-party links or your preferred vendor. This will determine if prior authorization will be obtained through us or a dedicated vendor.

Step 2: If prior authorization is required:



Blue Cross and Blue Shield of Oklahoma (BCBSOK) has contracted with AIM Specialty Health® (AIM) to provide certain utilization management services. AIM is an independent company that provides specialty medical benefits management for BCBSOK.

Benefits of the AIM ProviderPortal:

  • Medical records for pre or post-service reviews are not necessary unless specifically requested by AIM.
    • Do not submit medical records to BCBSOK for prior authorization or post-service reviews for the care categories managed by AIM.
  • AIM’s ProviderPortal Learn more about third-party links offers self-service, smart clinical algorithms and in many instances real-time determinations
  • Check prior authorization status on the AIM ProviderPortal
  • Increase payment certainty
  • Faster pre-service decision turnaround times than post service reviews

BCBSOK requires preauthorization (for medical necessity) through AIM for:

  • Advanced imaging
  • Cardiology (only required for certain members)
  • Pain management
  • Joint and spine surgery
  • Radiation therapy
  • Genetic testing

Do you have an account with AIM?
Make sure you have an account with AIM. To create an account:

  • Access AIM ProviderPortal Learn more about third-party links, or
  • By Phone – Call the AIM Contact Center at 800-859-5299 Monday through Friday, 6 a.m. to 6 p.m., CT; and 9 a,m. to noon, CT on weekends and holidays.

If you are already registered with AIM you do not need to register again.


How to submit a prior authorization request through AIM
Submit prior authorization requests to AIM in one of the following ways:

  • Online – Submit requests via the AIM ProviderPortal Learn more about third-party links 24/7.
  • By Phone – Call the AIM Contact Center at 800-859-5299 Monday through Friday, 6 a.m. to 6 p.m., CT; and 9 a.m. to noon, CT on weekends and holidays.

Prior authorization services through eviCore are only for Medicare AdvantageSM Plans.

Step 3: Provide the following information:

  • Patient’s medical or behavioral health condition
  • Proposed treatment plan
  • Date of service, estimated length of stay (if the patient is being admitted)
  • Patient ID and name/date of birth
  • Place of treatment
  • Provider NPI, name and address
  • Diagnosis code(s)
  • Procedure code(s) (if applicable)

Step 4: After the request is submitted, the service or drug is reviewed to determine if it:

  • Is covered by the health plan, and
  • Meets the health plan’s definition of “medically necessary.”

The results are then sent to the provider. If you have questions about the response, call the number on the member’s ID card or the authorizing vendor.



The following outlines the process providers should take to submit requests for predetermination. (Always verify eligibility and benefits first.)

Step 1: Log in to Availity Learn more about third-party links

Step 2: Select Claims & Payments from the navigation menu

Step 3: Select Attachments – New

Step 4: Within the tool, select Send Attachment then Predetermination Attachment

Step 5: Download and complete the Predetermination Request Form

Step 6: Complete the required data elements

Step 7: Upload the completed form and attach supporting documentation

Step 8: Select Send Attachment(s)

To request a Predetermination by fax and/or mail, please complete the Predetermination Request form PDF Document.

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.)

  1. Submit online or fax information for each patient separately.
  2. If faxing the request, always place the Predetermination Request form on top of other supporting documentation. Please include any additional comments if needed with supporting documentation.
  3. Do not send in duplicate requests, as this may delay the process.
  4. 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.
  5. Regarding major diagnostic tests, please include the patient's history, physical and any prior testing information.

Prior Authorizations Lists

The procedures or services on these lists may require prior authorization by BCBSOK, eviCore Healthcare® (for Blue Cross Medicare AdvantageSM Members) or AIM Specialty Health® (AIM) for some commercial members. These lists are not exhaustive and are not necessarily covered under the member benefits contract. Lists are updated quarterly to comply with AMA and CMS guidelines.

Consult Availity® Learn more about third-party links or your preferred vendor for eligibility and benefits.

2021 Commercial Code Look Up Excel Document

Fully Insured, ASO and HMO Plans

Specialty Pharmacy Infusion Site of Care Benefit Prior Authorization Drug List

For Blue Cross Medicare Advantage Prior Authorization Requirement and Procedure Code List visit the Blue Cross Medicare Advantage page.


Predetermination, Post-Service Review and Non-Covered Code List

2021 Prior Authorization Requirements - Summary of Services PDF Document



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.

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.

AIM Specialty Health (AIM) is an operating subsidiary of Anthem, Inc., an independent specialty medical benefits management company that provides utilization management services for BCBSOK.

Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSOK. Blue Cross and Blue Shield of Oklahoma, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association