The following outlines the process for providers to submit prior authorization requests.
Services that may require prior authorization:
- Inpatient admissions (scheduled and nonemergent)
- Certain outpatient services
- Emergent admissions/obstetric (request authorization within two 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 prior authorization. Always check eligibility and benefits first via Availity® Essentials or your preferred vendor prior to rendering care and services. See our prior authorization lists.
Prior Authorization for an Extension of Approved Days
If additional days of treatment are deemed necessary, it’s the responsibility of the facility, treating physician or ancillary provider to request an extension.
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 isn’t a guarantee of benefits. It’s the responsibility of the rendering participating provider to verify eligibility and benefits prior to the date of service. Check eligibility and benefits via Availity or your preferred vendor or call the customer service number on the member's ID card.
Prior Authorization Penalty
Failure to obtain prior authorization may result in a financial penalty. For more information, refer to your participating provider agreement with BCBSOK.
How to Submit a Prior Authorization
Step 1: Confirm if prior authorization is required using Availity 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:
Services requiring prior authorization through BCBSOK
- Submit your request using the Availity Authorizations & Referrals tool.
- Use the BlueApprovRSM integrated process through Availity Authorizations to request prior authorization for behavioral health services.
- Call the phone number on the member’s ID card.
Services requiring prior authorization through Carelon Medical Benefits Management
BCBSOK has contracted with Carelon to provide certain utilization management services for some of our members. Carelon is an independent company that provides specialty medical benefits management for BCBSOK.
BCBSOK requires prior authorization through Carelon for:
- Advanced imaging
- Cardiology (only required for certain members)
- Pain management
- Joint and spine surgery
- Radiation therapy
- Genetic testing
How to submit a prior authorization request through Carelon:
- Online – The Carelon ProviderPortal is available 24/7.
- By Phone – Call the Carelon 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.
Services requiring prior authorization through EviCore:
BCBSOK has contracted with EviCore healthcare to provide utilization management prior authorization services for proton beam therapy for Medicare Advantage members only.
Submit your prior authorization request for proton beam therapy to EviCore:
- Online – The EviCore Web Portal is available 24x7.
- By phone – Call EviCore toll-free at 855-252-1117, Monday through Friday, 7 a.m. to 7 p.m., except holidays
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, name and date of birth
- Place of treatment
- Provider‘s name, address and National Provider Identifier
- Diagnosis codes
- Procedure codes, 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.”
You’ll receive results once the review is completed. If you have questions about the response, call the number on the member’s ID card or the authorizing vendor.
Submitting Recommended Clinical Review Requests
The following outlines the process providers should take to submit requests for recommended clinical review. Submitting a request for recommended clinical review is optional and informs the provider of situations where a service could be denied based upon medical necessity, even though prior authorization isn’t required.
To submit your request online:
- Log in to Availity
- Select Claims & Payments from the navigation menu
- Select Attachments – New
- Within the tool, select Send Attachment, then Predetermination Attachment
- Download and complete the Recommended Clinical Review Request Form
- Complete the required data elements
- Upload the completed form and attach supporting documentation
- Select Send Attachments
To submit your request by fax or mail:
Complete the Recommended Clinical Review Request form and submit it following instructions on the form.
All applicable fields are required. If any information is missing, this may cause a delay in the review process.
Requests received without the member or patient's group number, ID number and date of birth cannot be completed and may be returned.
- Submit online or fax information for each patient separately.
- If faxing the request, always place the Recommended Clinical Review Request form on top of other supporting documentation. Please include any additional comments if needed with supporting documentation.
- Don’t send in duplicate requests, as this may delay the process.
- Per medical policy, if photos are required for review, the photos should be mailed to the address indicated on the Recommended Clinical Review Request form and not faxed. Faxed photos are not legible and cannot be used to make a determination.
- Regarding major diagnostic tests, include the patient's history, physical and any prior testing information.
The lists are for reference only and are not intended to be a substitute for benefit verification or medical policies for BCBSOK. All lists above apply only to members who have health insurance through BCBSOK 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 for that Plan.
EviCore healthcare is an independent company that provides utilization review for select health care services on behalf of BCBSOK.
Carelon Medical Benefits Management is an independent specialty medical benefits management company that provides utilization management services for BCBSOK.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSOK. BCBSOK makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.