Effective Jan. 1, 2023, Blue Cross and Blue Shield of Oklahoma (BCBSOK) is changing the name of its longstanding preservice review, previously called predetermination, to recommended clinical review (RCR).
Here are a few things to know:
• Recommended clinical review is not a different process, and it will not generate a different result than a predetermination.
• Recommended clinical reviews are optional medical necessity reviews conducted before services are provided. Submitting a request prior to rendering services informs you of situations where a service may not be covered based upon medical necessity.
• The service will be subject to post-service review if a provider does not elect to use recommended clinical review.
• Submitting a recommended clinical review evaluates the medical necessity of a service but does not guarantee the service will be covered under the members' benefit plans. The terms of the member's plan control the available benefits.
Download our recommended clinical review (predetermination) form
Use our recommended clinical review (predetermination) form after Jan. 1, 2023. The form is located here on the Forms page in the Education and Reference page on our website.
For More Information
Learn more about our utilization management process, including prior authorization and recommended clinical review (predetermination in the Utilization Management section of our provider website. Follow our News and Updates page for future updates.