We’ll Begin Removing Recommended Clinical Review as an Optional Medical Necessity Review, Effective Jan. 1, 2027
Sept. 16, 2026
To improve the efficiency of our utilization management program, we‘ll begin removing recommended clinical review as an optional review for our commercial members, starting Jan. 1, 2027.
What this means for you: Throughout 2027, we’ll reduce recommendations that you complete a recommended clinical review request. We expect to remove this option entirely from our utilization management processes by the end of 2027 for commercial members. Recommended clinical review isn’t an option for Medicare or Medicaid members.
With this change, services that previously requested recommended clinical review may require prior authorization.
How to confirm coverage during this transition: Always check eligibility and benefits through Availity® Essentials or your preferred vendor prior to rendering services. This step will determine prior authorization requirements and utilization management vendors, if applicable.
Learn how to submit a recommended clinical review.
Refer to the utilization management page for more information.
Checking eligibility and benefits information 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, including, but not limited to, exclusions and limitations applicable on the date services were rendered. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider. If you have any questions, call the number on the member’s ID card.
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 Blue Cross and Blue Shield of Oklahoma. BCBSOK makes no endorsement, representations or warranties regarding third-party vendors and the products and services they offer.