CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

prior_authorization_requirements_list

A payer-level list describing services, settings, and categories that require prior authorization (pre-service medical necessity review) for Blue Cross Blue Shield - Oklahoma members, including inpatient admissions, selected outpatient services, behavioral health, specialty pharmacy/medical benefit drugs, and pharmacy benefit medications. The document directs providers to verify eligibility and submit clinical information and to use Availity or AIM where indicated.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policyprior_authorization_requirements_list

Policy CodePolicy N/A

Change TypeAdministrative update (no material changes)

Effective DateJan 1, 2023

Next Review Date

Key ActionSubmit prior authorization requests with appropriate clinical/medical record information via Availity Authorizations & Referrals or AIM as indicated and verify eligibility and benefits before requesting authorization.

POLICY UPDATE CHANGES

Document header shows 'Effective 01/01/2023 Updated 04/01/2023' indicating an update on 04/01/2023.

8Inpatient/Facility categories listed

7Outpatient service categories listed (AIM/BCBSOK)

8Other services requiring prior authorization

6Behavioral health outpatient services listed

Policy Summary

This document is a payer-level prior authorization requirements list for Blue Cross Blue Shield - Oklahoma (BCBSOK) describing services, settings, and categories that require prior authorization as a pre-service medical necessity review. Providers should verify eligibility and benefits before requesting authorization and submit clinical information to support medical necessity. Preauthorization is a review to determine medical necessity and is not a guarantee of coverage or payment; benefits and payment are determined at claim processing based on member eligibility and plan terms. Providers may submit prior authorization requests via Availity Authorizations & Referrals and should use AIM for the specified services where indicated. Effective date: 01/01/2023; Last review/updated: 04/01/2023.

Key Metadata

Effective Date2023-01-01

Last Review2023-04-01

Next Review

StatusCURRENT

SubjectPrior Authorization Requirements List

PayerBlue Cross Blue Shield - Oklahoma

Scope SummaryA payer-level list describing services, settings, and categories that require prior authorization (pre-service medical necessity review) for BCBSOK members, including inpatient admissions, selected outpatient services, behavioral health, specialty pharmacy/medical benefit drugs, and pharmacy benefit medications. Providers must verify eligibility, submit clinical information, and use Availity or AIM where indicated.

Services and Settings Requiring Prior Authorization

General Prior Authorization Requirement

Prior authorization is required as a pre-service medical necessity review for the services listed below. An eligibility and benefits inquiry should be completed first.

ALL of the following

Prior authorizations must be accompanied by appropriate clinical/medical record information except for routine vaginal or cesarean section deliveries.
Preauthorization is required for all inpatient services (medical/surgical facility admissions including transfers).

Required Provider Steps and Documentation

Prior Authorization

Prior Authorization required for listed services

Submit prior authorization requests with appropriate clinical/medical record information (except routine vaginal or cesarean deliveries). Verify eligibility and benefits before requesting authorization. Providers may submit prior authorization requests via Availity Authorizations & Referrals; route requests to AIM when indicated.

Availity Authorizations & Referrals
AIM (as indicated)

Documentation Required

Clinical documentation required

Requests must be accompanied by appropriate clinical/medical record information to support medical necessity, except for routine vaginal or cesarean section deliveries.

Referenced Code Lists

Codes not available / referenced but not listedmixed

No codes listed

Mental Health and Specialty Pharmacy procedure codes (external list)mixed

No codes listed

Definitions

Prior AuthorizationA pre-service medical necessity review to determine if a requested service or drug is medically necessary and covered under the member's health plan.

FI (Fully Insured)Fully Insured

ASO (Administrative Services Only)Administrative Services Only

Additional context: This is a system-level prior authorization requirements list that emphasizes completing an eligibility and benefits inquiry first to confirm membership and verify whether prior authorization is required. Prior authorization requests must be accompanied by appropriate clinical/medical record information (except routine vaginal or cesarean deliveries). Providers may submit prior authorization requests via Availity Authorizations & Referrals and should follow routing instructions to use AIM where applicable.

Document Revisions

2023-01-01effective

Policy effective date as shown in header: Effective 01/01/2023

2023-04-01clarified

Updated 04/01/2023; update appears administrative with no specific clinical policy statement changes identified