Our utilization management program helps ensure our members get the right care, at the right time, in the right setting. Our preservice review process, including prior authorization or optional recommended clinical reviews use evidence-based clinical standards of care to help determine whether a benefit may be covered under the member’s health plan.
Where to begin
Before rendering care or services, always check eligibility and benefits first, via Availity® Essentials or your preferred web vendor. In addition to verifying membership and coverage status, this step returns information on prior authorization requirements and utilization management vendors, if applicable.
Note: If you do not get prior authorization for services and drugs on our prior authorization lists the service or drug may not be considered medically necessary and you may be responsible.
Simplifying the complex
Member benefits and review requirements and recommendations may vary based on services rendered and individual/group policy elections.
Our utilization management website explains the various review types needed or suggested when you’re providing care for Blue Cross and Blue Shield of Oklahoma members. You can find “how to” direction and vendor profiles as well as prior authorization and recommended clinical review code lists.
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 third party vendors and the products and services they offer.