Blue Cross Medicare Advantage^SM Plans

Blue Cross Medicare Advantage has two resources to help you care for our Medicare Advantage members during their annual wellness visits. These resources can help you document our members’ visits to more easily meet Medicare requirements.

• Our Medicare Advantage Annual Wellness Visit Guide  includes a visit checklist and information on Medicare coverage, coding tips, preventive services and closing gaps in care.
• Our Medicare Advantage Annual Wellness Visit Form  can be followed during our members’ wellness visits. It can be used as a fillable form or printed and completed by hand.

The guide and form are for your use only and do not need to be returned to us.

Blue Cross Medicare Advantage wants to help you avoid administrative claim denials. To prevent denials from occurring, a list of administrative claim denials that providers may receive has been created, along with tips on how to avoid them. Read more. 

Blue Cross Medicare Advantage^SM has contracted with eviCore healthcare (eviCore), an independent specialty medical benefits management company, to provide Utilization Management services for prior authorization requirements outlined below.

Effective Jan. 1, 2023, Blue Cross Medicare Advantage members will be subject to the prior authorization requirements set forth in this article. eviCore will manage prior authorization requests for the following specialized clinical services effective for dates of service on or after June 1, 2017:

• Radiology
• Medical Oncology
• Molecular Genetics
• Musculoskeletal
  • Joint Surgery
  • Spine Surgery
  • Interventional Pain
• Radiology Therapy
• Sleep
  
• Specialty Drug
   

Providers can contact eviCore using one of the following methods:

• The eviCore HealthCare Web Portal  will be available 24x7. After a one-time registration, you are able to initiate a case, check status, review guidelines, view authorizations/eligibility and more. The Web Portal is the quickest, most efficient way to obtain information.
• Providers can call toll-free at 855-252-1117 between 7 a.m. to 7 p.m. (local time) Monday through Friday.

The rendering provider must obtain prior authorization for services outlined in this notification, except for emergency care or urgent services. PCP referrals are not required if the specialty provider selected is in network.

Services performed without prior authorization and that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.

Availity's Authorizations tool will continue to be available for all other services that require prior authorization.

BCBSOK and eviCore will be providing additional information, including training opportunities, in the coming months. Please continue to Provider site and the BCBSOK Blue Review Newsletter for updates.

Please note that the fact that a service has been preauthorized/pre-certified 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.

* 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.

** Prior authorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Prior authorization of a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.

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 (BCBSOK) appreciates your interest in becoming a contracting provider with our Blue Cross Medicare Advantage PPO and HMO networks. We contract with physicians, facilities and other health care professionals to ensure that our members receive accessible, cost effective and quality health care services. To join the Blue Cross Medicare Advantage network, please fill out the Provider Onboarding Form located under the Network Participation tab/How to Join Our Networks.

All providers who contract with Blue Cross and Blue Shield of Oklahoma (BCBSOK) to provide Medicare Advantage services are expected to abide by the Centers for Medicare & Medicaid Services (CMS) rules for marketing when it involves BCBSOK or Blue Cross Medicare Advantage (HMO) or Blue Cross Medicare Advantage (PPO) products or benefits.

See the Medicare Marketing Guidelines on the CMS website.

As a Blue Cross Medicare Advantage^SM provider, you may have recently received an official message from the Centers for Medicare & Medicaid Services (CMS), identifying you as a provider who prescribes drugs for Medicare patients, but who is not currently enrolled in (or validly opted-out of) Medicare.

Sample Message for Providers who Prescribe Drugs for Medicare Patients 

Effective Jan. 1, 2017, changes affecting claims submissions for Medicare Advantage Plans will assist in streamlining claims processing and improve efficiencies of claims routing to our primary claims adjudicator. Read More 

• Blue Cross Medicare Advantage Prior Authorization List Effective 01/01/2025
• Blue Cross Medicare Advantage Prior Authorization List Effective 10/01/2024
• Blue Cross Medicare Advantage Prior Authorization List Effective 05/01/2024
• Blue Cross Medicare Advantage Prior Authorization List Effective 04/01/2024
• Blue Cross Medicare Advantage Prior Authorization List Effective 01/01/2024
• Blue Cross Medicare Advantage Prior Authorization List Effective 10/01/2023
• Blue Cross Medicare Advantage Prior Authorization List Effective 07/01/2023
• Blue Cross Medicare Advantage Prior Authorization List Effective 04/01/2023
• Blue Cross Medicare Advantage Prior Authorization List Effective 01/01/2023
• Blue Cross Medicare Advantage Prior Authorization List Effective 10/01/2022
• Blue Cross Medicare Advantage Prior Authorization List Effective 07/01/2022
• Blue Cross Medicare Advantage Prior Authorization List Effective 04/01/2022
• Cross Medicare Advantage Prior Authorization List Effective 1/1/2022

• Blue Cross Medicare Advantage Prior Authorization List Effective 1/1/2021

• Blue Cross Medicare Advantage Prior Authorization List Effective 9/1/2020

• Blue Cross Medicare Advantage Prior Authorization List Effective 1/1/2020
• Blue Cross Medicare Advantage Prior Authorization List Effective 1/1/2019

• 2022 Prior Authorization Guide Summary Effective 04/01/2022

• 2021 Prior Authorization Guide Summary Effective 1/1/2021

• 2020 Prior Authorization Guide Summary Effective 1/1/2020

• Blue Cross Medicare Advantage Prior Authorization Form (Faxable)

Blue Cross Medicare Advantage members can earn rewards for completing selected screenings, managing chronic conditions or seeing a physician for a physical.

Rewards and Incentives for Healthy Activities