December 1, 2021
What’s Changing?
As we announced in October 2021, beginning Jan. 1, 2022, Blue Cross and Blue Shield of Oklahoma (BCBSOK) will implement new Clinical Reimbursement Policies as part of our Medical Policies for a new claims program with Avalon Healthcare Solutions. This will affect certain outpatient laboratory services provided to some of our Fully Insured commercial members. This program does not apply to Federal Employee Program (FEP) and Administrative Only Services (ASO) members.
The new program will:
- Help ensure our members get the right care at the right time and in the right setting
- Better prepare you to submit claims that support and reflect high quality, affordable care delivery to our members
Note: Look for our new and revised Clinical Reimbursement Policies (BCBSOK Clinical Reimbursement Policies) effective Jan. 1, 2022, related to certain laboratory services, tests and procedures.
Avalon’s Laboratory Benefit Manager Drives High Quality Care
- Includes a review of claims post-service and pre-payment for outpatient laboratory claims for Dates-of-service on or after Jan. 1, 2022; performed in an outpatient setting (typically office, hospital outpatient, or independent laboratory)
- Excludes Laboratory services provided in emergency room, hospital observation and hospital inpatient settings. Member contract benefits and clinical criteria still apply.
Provider Resources
Self-service Trial Claim Advice Tool via Availity® available 24/7
Beginning Jan. 1, 2022, you can get free access to the Avalon’s Trial Claim Advice Tool by registering at Availity.com, which allows you to input laboratory procedure and diagnosis codes to see, before submitting a claim, the potential outcome of your claim.
- The Trial Claim Advice Tool does not guarantee approval, coverage, or reimbursement of services
- Responses consider information entered through the tool for the date of service entered and historical claims finalized through the previous business day
- Decision and Description information available on the Provider Claim Summary and 835 Remittance Advice with links to Medical Polices with Reimbursement Guidelines
Training
General Training sessions, open to all Providers, are as follows;
| Dec. 7, 2021 from 2 to 3 pm CST | Dec. 15, 2021 from 11 to Noon CST |
| Dec. 28, 2021 from 11 to Noon CST | Jan. 5, 2022 from 11 to Noon CST |
*Targeted Training for Providers with the greatest impact are scheduled for December and January. Watch for an invitation from your Network Management Representative.
Avalon Health Solutions (Avalon) is an independent company that provide claims management services for members with coverage through BCBSOK. BCBSOK makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Avalon. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. 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 any products or services provided by third party vendors such as Availity.
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. Blue Cross and Blue Shield of Oklahoma, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.