Oklahoma Precertification Requirements
What is precertification?
Preadmission Certification (precertification) and Admission Certification are processes used to review certain ancillary services, hospital admissions and certain outpatient services to determine that services are medically necessary.
When is precertification required?
Admission certification is required for all emergency and obstetric admissions. Preadmission certification (precertification) is required for all other inpatient admissions. In addition, specific outpatient services require precertification. All covered behavioral health services (inpatient, partial hospitalization and outpatient) require preauthorization. You can identify members who require precertification by checking the member ID card. The back of the ID card will indicate the appropriate precertification phone number.
Ambulatory Surgical Centers (ASC)
Effective February 1, 2012, BCBSOK no longer requires preauthorization for ASCs. However, services provided to BlueLincs HMO members may require preauthorization.
Blue Plan65 Select and BlueTraditional members
Blue Plan65 Select members require preauthorization when their Medicare Part A benefits have been exhausted. In addition, it is recommended that providers obtain preauthorization for Blue Plan65 members when their Medicare Part A benefits are exhausted.
BlueTraditional members may require preauthorization. Please call the phone number on the back of the member's ID card to obtain Preauthorization requirements.
Who is responsible for precertification?
The provider or treating physician bears the primary responsibility for obtaining precertification. Calls will be accepted from the admitting facility or member. For BlueCard members, precertification is the responsibility of the member.
How to request precertification
To the extent practical, precertification should be obtained at least five (5) days in advance of an admission or certain ancillary services. Please refer to the Quick Reference Guide for the appropriate phone numbers. Precertification must always be obtained prior to the actual admission and/or treatment. Admission certification for obstetric and emergency admission must be obtained within 48 hours of the actual admission or certain ancillary services. After you have completed the request for precertification and all relevant clinical information has been obtained, we will respond by telephone with a determination within the timeframe provided by law. Written notification of the determination will be sent within the timeframe provided by law to the physician, hospital (if applicable) or ancillary provider and the member.
For the convenience of our providers, Blue Cross and Blue Shield of Oklahoma offers iEXCHANGE, a Web-based automated preauthorization. Learn more about our iEXCHANGE tool.
If a precertified admission is expected to extend beyond Blue Cross and Blue Shield of Oklahoma assigned length of stay, the admission is subject to concurrent review and must be recertified. Recertification must be completed on or before the last day of the assigned stay. The recertification process is the same as precertification.
Precertification does not guarantee payment for services rendered
Precertification will only determine if a service is medically necessary. Precertification does not determine if the member is enrolled or if the service is a benefit for the member. You may call the Provider Inquiry Unit (PIU) to confirm current member enrollment and general benefit coverage. A member’s coverage may be subject to waivers, pre-existing conditions, limitations, exclusions and other membership stipulations, or subject to cancellation retroactive to the effective date (e.g., in the event of fraud, misrepresentation or non-payment of dues), even though such coverage may have been previously confirmed in good faith by Blue Cross and Blue Shield of Oklahoma.
Special note: physicians and ambulatory surgical centers
When a patient is sent to an Ambulatory Surgical Center (ASC) for treatment, it is important to provide accurate diagnosis and procedure codes. The ASC relies on the accuracy of these codes. The Blue Cross and Blue Shield of Oklahoma contract with Ambulatory Surgical Centers requires precertification for specific procedures. ASC claims may be reviewed or denied for a discrepancy between the precertified service and the subsequently submitted claim code.
Failure to precertify
Please refer to your contractual agreement(s) with Blue Cross and Blue Shield of Oklahoma for information regarding provider penalties.
iEXCHANGE supports direct submissions and provides online approval of benefits for inpatient admissions, referrals and select outpatient services. iEXCHANGE is accessible to network physicians, professional providers and facilities within Oklahoma 24-hours-a-day, seven-days-a-week.