Blue Cross Blue Shield OK prior auth code update | OpenPayer
ModifiedBlue Cross Blue Shield - OklahomaPolicy N/A
Prior authorization CPT/HCPCS code list (managed services)
Governs which CPT/HCPCS codes and service categories may require prior authorization for Blue Cross and Blue Shield of Oklahoma networks (Blue Choice Preferred PPO, Blue Choice PPO, Blue Traditional) effective 1/1/2025 and updates through 2025; affects providers submitting claims and requesting prior authorization.
Policy Summary
PayerBlue Cross Blue Shield - Oklahoma
PolicyPrior authorization CPT/HCPCS code list (managed services)
Policy CodePolicy N/A
Change TypeAddition of site-of-care criteriamanagement assignments updated
Effective DateJan 1, 2025
Next Review DateN/A
Key ActionProviders must consult the searchable PDF and follow the 'Managed By' designation (Carelon or BCBSOK) to obtain prior authorization and confirm site-of-care requirements for listed codes.
Managed by assignments updated/indicated for many musculoskeletal, pain management, neurology, and radiology codes (Carelon or BCBSOK).
1/1/2025Effective date for codes
CarelonManagement entity
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~120+CPT/HCPCS codes listed (approx)
MultipleCodes with site-of-care update
04/01/202581195 effective date
Coverage Criteria and Medical Necessity
General prior authorization criteria
Covered when noted; prior authorization may be required for listed CPT/HCPCS codes—providers should consult the searchable file and the assigned manager for authorization processes and effective dates.
Prior authorization may be required for the CPT/HCPCS codes and service categories listed in this file; providers must consult the searchable PDF and follow the managing entity (Carelon or BCBSOK) for authorization processes and effective dates.
Code management and authorization notes
Codes shown are assigned a managing entity and, where indicated, require prior authorization through that manager.
ALL of the following
Managed By = Carelon: Codes listed with 'Managed By = Carelon' are subject to Carelon's utilization management and authorization processes (effective 01/01/2025).
Managed By = BCBSOK: Codes listed with 'Managed By = BCBSOK' are managed by Blue Cross and Blue Shield of Oklahoma; follow BCBSOK authorization processes where indicated.
Advanced imaging site-of-care criteria (summary)
Effective 01/01/2025 the medical necessity criteria for multiple advanced imaging CPT codes were updated to include site-of-care as an assessment factor.
For advanced imaging CPT codes listed in this file (for example 70450, 70460, 70470, 70480, 70481, 70482 and others), the medical necessity determination must include consideration of the site of care (update effective 01/01/2025).
Site-of-care addition to medical necessity criteria
Operational update summary: site-of-care attribute added to medical necessity criteria for many advanced imaging CPTs effective 01/01/2025.
Medical necessity criteria for the listed advanced imaging CPTs have been amended to include an explicit site-of-care consideration; this change is effective 01/01/2025 and applies to the codes enumerated in the advanced imaging sections (CT, MRI, CTA, MRA, PET/SPECT where noted).
Notations on coverage/management
Breast MRI codes: site-of-care addition and management assignment noted.
CPT codes 77046, 77047, 77048, 77049 and 77084: site of care has been added to the medical necessity criteria effective 01/01/2025; these codes are listed with Managed By = Carelon and providers should follow Carelon prior authorization/workflow requirements.
Code listing (informational)
Informational: code listings with managing entity assignments; per-code coverage criteria are not provided in this excerpt.
The document lists multiple CPT codes (examples include cardiac and pulmonary imaging codes such as 78472–78496 and molecular/genetic codes such as 81195, 81200, etc.) with Managed By = Carelon (effective 01/01/2025). No additional per-code medical necessity criteria are included in the excerpt beyond site-of-care additions noted elsewhere.
Codes and management — informational
Informational listing: molecular genetic lab testing codes and management assignments; explicit coverage criteria not included here.
Codes in the molecular genetic lab testing series (for example 81272–81349 shown) are listed with Service Category = Molecular Genetic Lab Testing and Managed By = Carelon effective 01/01/2025. This excerpt provides code descriptions and manager assignments but does not include detailed coverage rules for each code in this section.
Panel composition and test-level requirements
Panel composition and minimum-gene requirements for specified genomic test CPT codes (examples).
ALL of the following
81410: Panel must include sequencing of at least 9 genes (including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, MYLK).
81412: Panel must include sequencing of at least 9 genes (including ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, SMPD1).
81413: Panel must include sequencing of at least 10 genes (including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, SCN5A).
81418: Drug metabolism/pharmacogenomics panel must include at least 6 genes including CYP2C19, CYP2D6 and CYP2D6 duplication/deletion analysis.
Code-specific criteria and administration
Code-specific requirements, retirements, and management notes as listed in this document segment.
ALL of the following
81434: Hereditary retinal disorders panel must include sequencing of at least 15 specified genes (examples listed in the code description).
81435: Hereditary colon cancer disorders panel must include sequencing of at least 10 specified genes (examples listed in the code description).
81436: Duplication/deletion analysis panel (81436) listed with Retire Effective 04/01/2025.
Management note: many molecular/genetic codes are Managed By = Carelon; select codes or other service categories may be Managed By = BCBSOK as noted per code. Follow the manager indicated for authorization routing.
Code additions/updates — informational listing
Informational listing of additional codes and management assignments; no explicit coverage decision text in this excerpt.
Additional HCPCS/CPT entries (including U-codes and other molecular/genetic or imaging-related codes such as 0045U, 0046U, 0047U, and echocardiography codes) are listed with their managing entity (primarily Carelon) and effective date 01/01/2025. The excerpt does not provide per-code medical necessity rules beyond those noted elsewhere (site-of-care additions and panel composition requirements).
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis; interrogation for copy number and LOH.
81349
Cytogenomic (Genome-Wide) Analysis for Constitutional Chromosomal Abnormalities; low-pass sequencing analysis.
Selected molecular/genomic CPT codes with required gene panel contents where specifiedCPTCovered
81343
Ppp2R2B gene analysis to detect expanded alleles (example Spinocerebellar Ataxia)
81415
Exome sequence analysis
81418
Drug metabolism (pharmacogenomics) genomic sequence panel must include at least CYP2C19, CYP2D6 and CYP2D6 duplication/deletion analysis
81432
Hereditary breast cancer-related genomic sequence panel must include at least BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, TP53
81439
Hereditary cardiomyopathy genomic sequence panel must include sequencing of at least 5 cardiomyopathy-related genes
Selected molecular genetic panel codesCPTCovered
81434
Hereditary Retinal Disorders genomic sequence analysis panel (must include sequencing of at least 15 specified genes)
81435
Hereditary Colon Cancer Disorders genomic sequence analysis panel (must include sequencing of at least 10 specified genes)
81436
Hereditary Colon Cancer Disorders duplication/deletion analysis panel (must include analysis of at least 5 specified genes); Retire Effective 04/01/2025
Large genomic panels and mitochondrial testingCPTCovered
81460
Whole mitochondrial genome sequence analysis with heteroplasmy detection
81455
Solid organ or hematolymphoid neoplasm 51+ gene genomic sequence analysis panel (DNA or combined DNA/RNA)
mRNA gene expression profiling assaysCPTCovered
81518
Oncology (Breast) mRNA gene expression profiling by RT-PCR of 11 genes
81519
Oncology (Breast) mRNA gene expression profiling by RT-PCR of 21 genes
81525
Oncology (Colon) mRNA gene expression profiling by RT-PCR of 12 genes
Cardiology echocardiography codesCPTCovered
93306
Transthoracic echocardiography complete with spectral and color flow Doppler
93350
Echocardiography transthoracic during rest and cardiovascular stress test with interpretation and report
93320
Doppler echocardiography pulsed/continuous wave with spectral display
Cardiology echocardiography codesCPTCovered
93350
Echocardiography transthoracic real-time with image documentation (2D) includes M-mode; includes stress testing interpretation and report
93351
As 93350, including continuous ECG monitoring with supervision
93352
Use of echocardiographic contrast agent during stress echocardiography (add-on)
Advanced imaging and selected molecular test codesmixed
0042T
Cerebral perfusion analysis using CT with contrast including post-processing parametric maps
0045U
mRNA gene expression profiling for breast DCIS (12 genes) — recurrence score
0055U
Cell-free DNA PCR assay of 96 DNA target sequences for heart transplant (plasma)
examples of molecular genetic/U-codes in this excerptmixed
0129U
Hereditary Breast Cancer-Related Disorders genomic sequence and deletion/duplication panel (Atm, Brca1, Brca2, Cdh1, Chek2, Palb2, Pten, Tp53)
Oncology (Breast) mRNA gene expression profiling by NGS of 101 genes — triple negative breast cancer subtype
0211U
Oncology (Pan-Tumor) DNA and RNA by NGS FFPE — report includes SNVs, CNAs, TMB, MSI with therapy association
0239U
Targeted genomic sequence analysis panel — cell-free DNA of 311+ genes
0250U
Oncology (Solid Organ Neoplasm) targeted genomic DNA analysis of 505 genes including MSI and TMB
0266U
Tissue-specific gene expression by whole-transcriptome NGS — reported as presence/absence of splicing or expression changes
0272U
Hematology (Genetic Bleeding Disorders) genomic sequence analysis of 60 genes and duplication/deletion of PLAU
inv-42: Advanced imaging effective date
Effective date09/01/2025
Provider Actions and Authorization Routing
Prior Authorization
Provider Actions and Authorization Routing
Prior Authorization and management routing: Several CPT/HCPCS codes across service categories are assigned a managing entity (Carelon or BCBSOK) effective 01/01/2025. Providers must route prior authorization requests and utilization management activities to the manager listed for the specific code. When a code is listed as Managed By = Carelon, prior authorization and review are handled by Carelon; when Managed By = BCBSOK, route authorization to Blue Cross and Blue Shield of Oklahoma.
Effective 01/01/2025: manager listed per CPT/HCPCS code must be followed for authorization routing.
Prior Authorization required through Carelon for specified codes (e.g., 27412 and many others managed by Carelon).
Musculoskeletal Joint/Spine arthroscopy (partial list) managed by Carelon: 29805, 29806, 29807, 29819–29826, 29805–29826 series as listed.
BCBSOK-managed outpatient jaw and ENT/outpatient surgery codes (selection): Jaw/outpatient surgery codes managed by BCBSOK include 21085, 21110, 21125, 21127, 21141–21151, 21154, 30130, 30140, 30400, 30410, 30420, 30430, 30435, 30450 (and others in the outpatient jaw/ENT lists).
Definitions and Interpretive Notes
inv-77: Managed By definition
Definition: 'Managed By'Denotes the utilization management organization responsible for review (e.g., Carelon or BCBSOK).
ImplicationProviders should follow the authorization/process requirements of the manager indicated for each code.
Source fileThis list is provided as the prior authorization code roster effective January 1, 2025
inv-78: Searchable file instruction
Searchable PDFReference file provided as a searchable PDF; providers instructed to use Ctrl+F to search codes or descriptions.
Effective dateEffective 1/1/2025 (updated April 2025)
Policy Summary
PayerBlue Cross Blue Shield - Oklahoma
PolicyPrior authorization CPT/HCPCS code list (managed services)
Policy CodePolicy N/A
Change TypeAddition of site-of-care criteriamanagement assignments updated
Effective DateJan 1, 2025
Next Review DateN/A
Key ActionProviders must consult the searchable PDF and follow the 'Managed By' designation (Carelon or BCBSOK) to obtain prior authorization and confirm site-of-care requirements for listed codes.
(Operational) Some panel codes show retirement or other status changes effective 04/01/2025; providers should reference the effective/retirement dates in the searchable file when requesting authorization.
Notes81195 is listed under Molecular Genetic Lab Testing with the update to add the 04/01/2025 effective date
Managed ByCarelon
inv-50: Minimum genes for specified panels (examples)
Minimum genes required (examples)81410: sequencing of at least 9 genes; 81412: at least 9 genes; 81413: at least 10 genes; 81418: at least 6 genes; 81430: at least 60 genes
ContextThese minimum gene count requirements apply to specified genomic sequence analysis panels as listed in the code descriptions
ApplicabilityMultiple CPT panel codes include explicit minimum gene counts in their descriptions
Managed ByCarelon
Radiation and transplant sample codes: Radiation therapy and transplant-related codes have manager assignments—examples include 31643, 32701 (Carelon); transplant codes 32851–32854, 33935, 33945 (BCBSOK).
PET/SPECT imaging and nuclear medicine codes managed by Carelon: 78814–78816 (PET/CT whole body/limited), 78830–78832 (SPECT CT tomographic), 78491–78492 (PET myocardial), and related nuclear imaging codes (78579–78582, 78597–78598).
Advanced imaging site-of-care note: For several advanced imaging CPTs (e.g., 70336, 71260–71271, 71275, 71550–71551, 77046–77049, 76391) the update effective 01/01/2025 adds site-of-care to the medical necessity criteria; these codes are managed by Carelon.
Molecular genetic lab testing roster (partial) managed by Carelon: numerous single- and panel-based PLA/ CPT-equivalent codes are managed by Carelon (examples: 81120–81121, 81162–81164, 81188–81195, 81200–81201, 81272–81277, 81343–81349, 81434–81437, 81551, 81554, 81558, 81595, and U/ M-series codes 0001U, 0004M, 0005U, 0006M, 0007M, 0120U, 0129U–0132U, etc.).
BCBSOK-managed miscellaneous codes: examples include neurostimulator implant/analysis codes 64561, 64581 (neurology sacral neurostimulators managed by BCBSOK) and 95980, and wound care/hyperbaric attendance 99183 (managed by BCBSOK).
Operational instruction: Consolidate code-specific routing—check the searchable prior authorization code list PDF for full code-to-manager mapping; follow the manager indicated for each CPT/HCPCS code to determine where to submit prior authorization requests.
Do not duplicate: This callout consolidates manager assignments and key examples; refer to the code list for complete entries and to the BCBSOK Medical Policy Website for medical policy details.
Action for providersUse the PDF search box (CTRL+F) to locate procedure codes or descriptions for authorization guidance.
Meaning: 'Managed By'Indicates the organization responsible for authorization/management of the listed CPT code (e.g., Carelon or BCBSOK).
ExamplesMany musculoskeletal and molecular genetic codes in the file show 'Managed By = Carelon'; select outpatient jaw and other codes show 'Managed By = BCBSOK'.
Provider actionRoute prior authorization requests to the manager shown for the specific code.
inv-80: 'List Separately' billing note
Billing note'List Separately In Addition To Code For Primary Procedure' indicates the code is billed in addition to the primary procedure code.
Examples in fileSeveral allograft/autograft and stereotactic radiosurgery codes include 'List Separately' annotations.
Provider actionBill the add-on code separately in addition to the primary procedure when indicated.
inv-81: Managed By = Carelon
Managed By = CarelonIndicates the listed codes are managed by Carelon for utilization review and authorization
ScopeApplied across numerous procedural, imaging, and molecular genetic codes in the file
Provider actionSubmit prior authorization requests through Carelon for codes marked as managed by Carelon.
inv-82: Prior Authorization requirement
Prior Authorization requiredPrior Authorization required through Carelon (example: CPT 27412).
Example code27412 (Autologous Chondrocyte Implantation Knee) is noted as requiring prior authorization via Carelon.
Provider actionObtain prior authorization from Carelon before performing the service to ensure coverage.
inv-83: Managed By — entity responsibility
Definition: 'Managed By'Indicates the entity responsible for management/authorization/review of the listed CPT code (e.g., Carelon or BCBSOK).
ExamplesMany shoulder arthroscopy codes in the file are marked 'Managed By = Carelon'.
Provider actionFollow the manager's authorization process for codes marked accordingly.
inv-84: 'Managed By' occurrences
Occurrence'Managed By' label appears throughout the document to indicate the managing entity for each code listing.
ImplicationProviders must check the manager listed for the specific CPT/HCPCS code to determine authorization routing.
Examples61797–61799 stereotactic radiosurgery codes show 'Managed By = Carelon'.
inv-85: Service Category
Service Category label'Service Category' appears in code listings to group codes (e.g., Musculoskeletal Pain).
UseHelps providers identify clinical category and manager assignment for listed codes.
Example62320–62323 labeled as Musculoskeletal Pain and managed by Carelon.
inv-87: Site-of-care addition definition
Definition: 'site of care addition'Addition of site of care to the medical necessity criteria for listed imaging services
Effective dateEffective 01/01/2025 for affected codes
Examples70336; chest CT codes 71260–71275; breast MRI 77046–77049 include this update.
inv-88: Site-of-care — medical necessity attribute
Site of careAn attribute added to the medical necessity criteria for listed imaging services; reviewers must consider place of service when assessing necessity.
Effective dateEffective 01/01/2025 for codes with this update
ExamplesMultiple chest CT, breast MRI, and other advanced imaging CPT codes in the file are updated to include site-of-care criteria.
inv-89: Managed By = Carelon (definition/interpretation)
Managed By = Carelon (interpretation)Indicates utilization management for the listed codes is performed by Carelon.
Example codes77046–77049, 77084 (breast MRI codes) are listed with Managed By = Carelon.
Provider actionSubmit authorization requests per Carelon processes for codes so marked.
inv-91: Site-of-care impact on medical necessity
Addition meaningAddition of site of care to medical necessity criteria means reviewers will consider place of service as part of medical necessity determinations.
Effective dateEffective 01/01/2025 for the updated imaging codes
ImpactMay affect authorization approvals depending on the service location.
inv-93: PET with concurrently acquired CT
PET with concurrent CTPET with concurrently acquired CT indicates CT used for attenuation correction and anatomical localization.
ExamplesCodes 78814–78816 listed with this description and managed by Carelon.
Provider noteBilling and authorization should reflect PET with concurrent CT where applicable.
inv-95: CGH microarray
CGH microarrayComparative Genomic Hybridization (CGH) Microarray Analysis for copy number variants.
Example code81228 listed as CGH microarray and managed by Carelon.
Use caseInterrogation of genomic regions for copy number variants.
inv-96: STR comparative analysis
STR comparative analysisShort tandem repeat (STR) comparative analysis for donor/recipient or zygosity testing.
Example code81265 and 81266 describe STR comparative analyses and are managed by Carelon.
Billing note81266 may be billed separately in addition to primary procedure where applicable.
inv-98: Service Category = Molecular Genetic Lab Testing
Service Category: Molecular Genetic Lab TestingCodes in the 81272–81349 and 81400–81456 ranges are labeled 'Molecular Genetic Lab Testing'.
Managed ByCarelon for the majority of these entries
ActionRefer molecular/genetic codes to Carelon for utilization management where indicated.