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Additional Benefit Preauthorization Requirements for 2018

Posted November 1, 2017 (Updated Feb.23, 2018)

*After receiving feedback from the provider community about the new benefit preauthorization requirements that went into effect January 1, 2018, BCBSOK is removing certain codes from the preauthorization requirements listed below, effective Feb. 23, 2018. To access the updated list of codes, please visit the Prior Authorization page on the BCBSOK provider website.

We appreciate your feedback and your continued participation in BCBSOK’s networks.

Beginning Jan.1, 2018, Blue Cross and Blue Shield of Oklahoma (BCBSOK) will require preauthorization through BCBSOK or eviCore for certain procedures.

These new preauthorization requirements will apply to the fully insured members with Blue Choice PPOSM, Blue Advantage PPOSM, Blue Preferred PPOSM, BlueOptions PPOSM, Blue TraditionalSM and Blue Lincs HMO plans.

Check eligibility through AvailityTM or your preferred web vendor prior to rendering services. This step will help you determine if preauthorization is required. Remember, providers should ask to see the member''s ID card for current information and a photo ID to guard against medical identity theft.

To obtain benefit preauthorization through BCBSOK, you may continue to use iExchange®. This online tool is accessible to physicians, professional providers and facilities contracted with BCBSOK. For more information or to set up a new account, refer to the iExchange page in the Provider Tools section of our Provider website.

As a reminder, services performed without preauthorization that do not meet medical necessity criteria may be denied as not medically necessary.

The new additional 2018 Preauthorization Requirements are listed below:

Cardiology

  • Lipid Apheresis

Musculoskeletal

   Interventional Pain Management

  • Percutaneous and Implanted Nerve Stimulation and Neuromodulation
  • Surgical Deactivation of Headache Trigger Sites
  • Occipital Nerve Stimulation
  • Spinal Cord Stimulation

   Orthopedic

  • Orthopedic Applications of Stem-Cell Therapy
  • Functional Neuromuscular Electrical Stimulation (FNMES)
  • Femoroacetabular Impingement (FAI) Syndrome
  • Meniscal Allografts and Other Meniscal Implants
  • Autologous Chondrocyte Implantation (ACI) for Focal Articular Cartilage Lesions
  • Artificial Intervertebral Disc
  • Lumbar Spinal Fusion

Neurology

  • Sacral Nerve Neuromodulation/Stimulation
  • Vagus Nerve Stimulation (VNS)
  • Deep Brain Stimulation

Ear, Nose and Throat

  • Nasal and Sinus Surgery
  • Bone Conduction Hearing Aids
  • Cochlear Implant

Outpatient Surgery

  • Orthognathic Surgery (Face Reconstruction)
  • Mastopexy (Breast Lift)
  • Reduction Mammaplasty (Breast Reduction)

Gastroenterology

  • Gastric Electrical Stimulation (GES)

Wound Care

  • Hyperbaric Oxygen (HBO2) Therapy

In addition, BCBSOK will provide health advocacy solutions for self-funded Large Groups administered by BCBSOK.

health advocacy solutions is an innovative product that takes a holistic, high-touch, tailored approach to enriching a member's health care journey and reducing health care costs. There are dedicated health advocacy solutions Health Advocates who will deliver personalized communication and educational resources to help members make informed decisions concerning their health care. Participation in this product will be indicated on the back of the member's ID card.

health advocacy solutions may have some specific preauthorization requirements. Please verify eligibility and benefits to determine if preauthorization is required through Availity, BCBSOK or eviCore.

Our goal is to provide our members with access to quality, cost-effective health care. If you have any questions, please contact your Provider Network Representative.

The new 2018 Preauthorization Requirements for health advocacy solutions are listed below:

Please note that a member penalty may also apply based on the benefit plan if preauthorization is not obtained.

  Primary

  • Molecular and Genomic Testing (eviCore)
  • Radiation Therapy (eviCore)
  • Advanced Radiology Imaging (Notification Only – eviCore)

  Advanced

  • Molecular and Genomic Testing (eviCore)
  • Radiation Therapy (eviCore)
  • Advanced Radiology Imaging (eviCore)

  Premier

  • Molecular and Genomic Testing (eviCore)
  • Radiation Therapy (eviCore)
  • Advanced Radiology Imaging (eviCore)
  • Cardiology
  • Ear Nose and Throat
  • Gastroenterology
  • Musculoskeletal
  • Neurology
  • Outpatient Surgery
    • Orthognathic Surgery
    • Mastopexy
    • Reduction Mammaplasty
    • Bunionectomy
    • Cardiac Catherization
    • Carpal Tunnel Repair
    • Inguinal Hernia Repair
    • Lithotripsy
  • Specialty Pharmacy
  • Wound Care


Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized or predetermined for benefits 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. If you have questions, contact the number on the member's ID card.

iExchange is a trademark of Medecision, Inc., a separate company that provides collaborative health care management solutions for payers and providers. BCBSOK makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity and Medecision. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.