How to Request Prior Authorization or Recommended Clinical Review (Predetermination)

The following outlines the process for providers to submit prior authorization requests.

Services which may require Prior Authorization

  • Inpatient admissions (scheduled and/or nonemergent), certain outpatient services, emergent admissions/obstetric (request authorization within two (2) 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 preauthorization. Always check eligibility and benefits first, via the Availity® Provider Portal  or your preferred vendor, prior to rendering care and services.

For additional information, refer the Electronic Provider Access (EPA) FAQs  located in the right navigation menu.

Prior Authorization for an Extension of Approved Days
Should additional days of treatment be deemed necessary, it is the responsibility of the facility, treating physician or ancillary provider to request an extension in accordance with the BCBSOK participating provider agreement.

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 is not a guarantee of benefits. It is the responsibility of the rendering BCBSOK participating provider to verify eligibility and benefits prior to the date of service. Benefits can be verified via the Availity® Provider Portal or your preferred vendor; or by contacting the customer service number listed on the back of the member's ID card.

Prior Authorization Penalty
Failure to obtain preauthorization may result in a financial penalty. For more information, please refer to your BCBSOK participating provider agreement.

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

Services requiring prior authorization through Carelon Medical Benefits Management, formerly AIM Specialty Health®, (Effective Jan. 1, 2021)

Blue Cross and Blue Shield of Oklahoma (BCBSOK) has contracted with Carelon Medical Benefits Management to provide certain utilization management services. Carelon is an independent company that provides specialty medical benefits management for BCBSOK.

Benefits of the Carelon ProviderPortal:

  • Medical records for pre or post-service reviews are not necessary unless specifically requested by Carelon.
    • Do not submit medical records to BCBSOK for prior authorization or post-service reviews for the care categories managed by Carelon.
  • Carelon's ProviderPortal  offers self-service, smart clinical algorithms and in many instances real-time determinations
  • Check prior authorization status on the Carelon ProviderPortal
  • Increase payment certainty
  • Faster pre-service decision turnaround times than post service reviews

BCBSOK requires preauthorization (for medical necessity) through Carelon for:

  • Advanced imaging
  • Cardiology (only required for certain members)
  • Pain management
  • Joint and spine surgery
  • Radiation therapy
  • Genetic testing

Do you have an account with Carelon?
Make sure you have an account with Carelon. To create an account:

  • Access Carelon ProviderPortal , or
  • By Phone – Call the Carelon Contact Center at 1-800-859-5299 Monday through Friday, 6 a.m. to 6 p.m., CT; and 9 a,m. to noon, CT on weekends and holidays.

If you are already registered with Carelon you do not need to register again.

How to submit a prior authorization request through Carelon
Submit prior authorization requests to Carelon in one of the following ways:

  • Online – Submit requests via the Carelon ProviderPortal  24/7.
  • By Phone – Call the Carelon Contact Center at 1-800-859-5299 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®:

Prior authorization services through eviCore are only for Medicare AdvantageSM Plans.

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 and name/date of birth
  • Place of treatment
  • Provider NPI, name and address
  • Diagnosis code(s)
  • Procedure code(s) (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.”

The results are then sent to the provider. If you have questions about the response, call the number on the member’s ID card or the authorizing vendor.

Submitting Recommended Clinical Review (Predetermination) Requests

The following outlines the process providers should take to submit requests for recommended clinical review (predetermination). (Always verify eligibility and benefits first.)

Use BlueApprovR to request recommended clinical review to BCBSOK for some inpatient and/or outpatient, medical and surgical services and specialty pharmacy drugs. (Visit our BlueApprovR Provider Tools Page for instructions)

Step 1: Log in to Availity

Step 2: Select Claims & Payments from the navigation menu

Step 3: Select Attachments – New

Step 4: Within the tool, select Send Attachment then Predetermination Attachment

Step 5: Download and complete the Recommended Clinical Review (Predetermination) Request Form

Step 6: Complete the required data elements

Step 7: Upload the completed form and attach supporting documentation

Step 8: Select Send Attachment(s)

To request a Recommended Clinical Review (Predetermination) by fax and/or mail, please complete the Recommended Clinical Review (Predetermination) Request form.

All applicable fields are required. If any information is not provided, this may cause a delay in the Recommended Clinical Review (Predetermination) process

(Requests received without the member/patient's group number, ID number, and date of birth cannot be completed and may be returned.)

  1. Submit online or fax information for each patient separately.
  2. If faxing the request, always place the Recommended Clinical Review (Predetermination) Request form on top of other supporting documentation. Please include any additional comments if needed with supporting documentation.
  3. Do not send in duplicate requests, as this may delay the process.
  4. Per Medical Policy, if photos are required for review, the photos should be mailed to the address indicated on the Recommended Clinical Review (Predetermination) Request form and not faxed. Faxed photos are not legible and cannot be used to make a determination.
  5. Regarding major diagnostic tests, please include the patient's history, physical and any prior testing information.

 

The attached lists are for reference only and are not intended to be a substitute for benefit verification or BCBSOK's medical policies. All lists above apply only to members who have health insurance through a Blue Cross and Blue Shield of Oklahoma Plan 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 of that Plan.

eviCore is a trademark of eviCore healthcare, LLC, formerly known as CareCore, 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.

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