Requesting Predetermination of Medical Necessity

August 15, 2017

As a reminder, predetermination of medical necessity requests may be submitted electronically through iExchange®, which is accessible through the AvailityTM Web portal. Providers also may verify status and/or obtain online approvals for submitted predetermination requests via iExchange. This tool is designed to help save you time by reducing the amount of calls and written inquiries submitted. For providers who need to submit written predetermination requests should send the patient's medical documentation using the Predetermination Request Form.

Blue Cross and Blue Shield of Oklahoma (BCBSOK) is streamlining the predetermination of medical necessity review process to help facilitate more accurate processing of incoming requests. Beginning Dec. 1, 2017, written predetermination requests must be submitted using the Predetermination Request Form. If these written requests are sent to BCBSOK without the Predetermination Request Form starting Jan. 1, 2018, the inquiry will be returned to the submitting provider requesting that the predetermination be sent with the appropriate form. This form is available on our Provider website in the Education and Reference Center/Forms section at

Online verification of the patient's eligibility and benefits is strongly encouraged prior to submitting predetermination requests. A predetermination of medical necessity is not a guarantee of benefits. Real-time coverage status and benefit details may be obtained electronically through Availity, or your preferred web vendor.

To learn more about these and other electronic options, visit the Provider Tools section in our online Education and Reference Center. For personalized online training regarding electronic tools, contact our Provider Education Consultants at

Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized 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. If you have any questions, please call the number on the back of 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 BCBSOK. iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers. BCBSOK makes no endorsement, representations or warranties regarding any products or services offered by third party vendors such as Availity or Medecision. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.

Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.