CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Expedited pre-service clinical appeal request process

Defines the process and form for requesting an expedited pre-service clinical appeal for commercial BCBSOK members when non-approval may seriously jeopardize health or cause severe unmanaged pain; applies to pre-service (not post-service) requests.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyExpedited pre-service clinical appeal request process

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRequest an expedited pre-service clinical appeal and fax the completed form with supporting medical records to the Appeals Department when denial may seriously jeopardize the member's health or cause severe uncontrolled pain.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2fax destinations for submitting appeals (standard and FEP)

1expedited pre-service clinical appeal form for commercial members

5+required data sections

Eligibility for Expedited Pre-Service Clinical Appeal

Eligibility criteria for expedited pre-service clinical appeal

Services eligible for expedited pre-service clinical appeal must meet ALL of the following:

ALL of the following

Satisfy the urgent nature description (the requested pre-service or ongoing treatment, if not approved, may seriously jeopardize the member's health or cause severe pain that cannot be managed without the requested care).
BCBSOK has determined the service to be medically unnecessary, experimental, investigational, or medically unproven.
The service has not yet taken place or is ongoing (pre-service); retrospective/post-service requests are excluded.
The service is not covered for clinical reasons or is not in the member's benefit plan.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyExpedited pre-service clinical appeal request process

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Provider or appellant must follow submission instructions (complete and fax the expedited pre-service clinical appeal form with supporting medical records to the Appeals Department).

Procedure Codes and Timing Requirements

procedure_codesmixed

CPT/HCPCS

Field provided to list relevant procedure codes (CPT/HCPCS) related to the appeal

Timing requirement for expedited pre-service clinical appeal

RequirementService must be pre-service or currently ongoing; post-service (retrospective) requests are not eligible

RationaleApplies when denial could seriously jeopardize health or cause severe unmanaged pain

BCBSOK determinationService may be determined medically unnecessary, experimental, investigational, or medically unproven

Coverage statusService may be not covered for clinical reasons or not in the member's benefit

When and How to Initiate an Expedited Appeal

Denial Risk

Expedited Pre-service Clinical Appeal Request Form (Commercial Networks Only)

An expedited pre-service clinical appeal may be requested when the member, an authorized representative, or the physician believes that denial or non-approval of a requested service could seriously jeopardize the member's health or would subject the member to severe pain that cannot be adequately managed without the requested care. This process applies only to pre-service (not yet provided) or ongoing services and does not apply to non-urgent, post-service, or retrospective requests. For FEP expedited appeals, use the FEP fax number below.

Must satisfy the urgent/serious jeopardy description above
Service has not yet taken place or is ongoing
Service was determined by BCBSOK to be medically unnecessary, experimental, investigational, or unproven, or is not covered for clinical reasons or not in benefit

Prior Authorization

Instructions

Once it has been determined that BCBSOK criteria for an expedited pre-service clinical appeal are met, follow these steps: 1. Complete the expedited pre-service clinical appeal form (use the Tab key to navigate fields). 2. Print the completed form and use it as a cover sheet. 3. Include supporting documentation such as medical records, office notes, and any other pertinent clinical information. 4. Fax the cover sheet, form, and supporting documentation to BCBSOK Appeals Department at 918-551-2011. For FEP expedited appeals, fax to 972-766-9776.

Key Definitions

Expedited pre-service clinical appeal — definition and scope

DefinitionAn appeal requested because non-approval of a requested pre-service or ongoing treatment may seriously jeopardize a member's health or cause severe pain that cannot be managed without the requested care.

Who may requestMember, authorized representative, or physician may initiate the expedited appeal when criteria met

ExclusionsDoes not apply to non-urgent or post-service (retrospective) requests

Eligibility checkService must also meet BCBSOK criteria (e.g., deemed medically unnecessary, experimental, investigational, or not in benefit) and be pre-service/ongoing