Blue Cross Medicare Advantage Contact and Tip sheet Form

Outpatient Specialty Prior Authorization Blue Cross and Blue Shield of Oklahoma (BCBSOK) Prior Authorizations Prior Authorization Requirements – www.eviCore.com/healthplan/bcbsokm Web Portal – www.eviCore.com • Request prior authorizations and check case status online 24/7 • Upload clinical documents and use pause/start feature to complete initiated cases Call Center – 855-252-1117 (toll free) • Business Hours: Monday – Friday 6 a.m. to 6 p.m. (CT); Saturday and Sunday, 9 a.m. to noon • Request prior authorizations and check case status • Discuss questions re: prior authorizations and case decisions • Change facility or CPT® Code(s) on an existing case Peer to Peer or Provider to Provider Consultation – 855-252-1117 (toll free) • Urgent requests only • Standard requests – www.eviCore.com Prior Authorization Requirements – bcbsok.com/provider/network/bma.html • Review inpatient and outpatient services requiring prior authorization through BCBSOK • Obtain Prior Authorization Code List and Prior Authorization Form Medicare Advantage – 877-774-8592 (toll free) • Business hours: Monday – Friday 8 a.m. to 8 p.m. (CT) • Check eligibility and benefits, or check online through Availity® – availity.com • Request prior authorization information • Request peer to peer or provider to provider consultation Online – availity.com • Submit an electronic 278 transaction, 24/7, through Availity or your preferred vendor portal Medical Policy – bcbsok.com/provider/standards/ • Review active and pending policies and policy updates Appeals Pre-service Appeals Process (Administered by BCBSOK) Submit your request and supporting documentation by mail or fax. BCBSOK will administer the pre-service appeals process for denied or partially denied benefit
prior authorization requests that are submitted through eviCore or BCBSOK. When submitting
a pre-service appeal, always follow the directions included within the denial letter. Mailing Address: Blue Cross Medicare AdvantageSM C/O Appeals and Grievances PO Box 4288 Scranton, PA 18505 Fax: 855-674-9185 For expedited appeals, call: • Individual plans: 877-774-8592 (toll free)
• Employer plans: 877-299-1008 (toll free)
• TTY: 711 Claims Claims Filing (Administered by BCBSOK) – bcbsok.com/provider/claims Submit electronic claims (837 transactions): • Via Availity or your preferred vendor portal • Use BCBSOK Electronic Payer ID – 66006 Mail paper claims to: Blue Cross Medicare Advantage C/O Claims Department PO Box 3686 Scranton, PA 18505 Phone: 877-774-8592 (toll free) Fax: 855-674-9192 Claims Reminders • Utilize the HCFA form for all claims submissions • Complete field number “17” on the CMS claims form • Add the authorization number to “Box 23” Support eviCore Provider Services – 800-646-0418 (toll free) • Select option 1 to request case status, authorization, clinical review or a determination letter • Select option 2 for Web Portal registration questions • Select option 4 to speak with a representative or to request an authorization be resent to the health plan eviCore Client Services – clientservices@evicore.com • Report eligibility/other issues experienced during authorization case creation • Request training on program processes Training and Reference Information – www.eviCore.com/healthplan/bcbsokm • Provider Overview Tutorials, FAQs and Quick Reference Guide • Clinical Guidelines and CPT Code information Network Consultant: Email: OklahomaMedicareAdvantageNetwork@bcbsok.com
Training and Reference Information – bcbsok.com/provider/network/bma.html • Access Medicare Advantage forms, tips and tools • Sign up for Availity webinar training at bcbsok.com/provider/training Blue ReviewSM – bcbsok.com/provider/news • Sign up to receive monthly newsletter by email Medicare Advantage Prior Authorization Contact Sheet for Providers This guide is intended to be used for quick reference and may not contain all the necessary information. For detailed information, please email OklahomaMedicareAdvantageNetwork@bcbsok.com. eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for Blue Cross and Blue Shield of Oklahoma. Availity is a trademark of Availity, L.L.C., 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 any products or services offered by third party vendors such as eviCore and Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. CPT copyright 2019 American Medical Association (AMA). All rights reserved. CPT® is a registered trademark of the AMA.

Prior Authorization Checklist Please have the following when requesting prior authorization: Patient/Member ▫ First, middle and last name ▫ Date of birth ▫ Gender ▫ Address ▫ Home and cellphone numbers ▫ Health plan, member and group ID numbers Ordering Provider and Facility/Site ▫ Name ▫ Primary specialty ▫ Tax identification number (TIN) ▫ National provider identifier (NPI)
▫ Phone and fax numbers ▫ Office contact and email address Procedure ▫ Valid CPT codes Diagnosis ▫ Diagnosis, if known or rule out ▫ Valid ICD-10 codes ▫ Date of last visit Clinical Information ▫ Primary reason for the service request ▫ Date of the first office visit with any physician for the current condition ▫ Date of the most recent office visit for the current condition ▫ Current symptoms ▫ Length of physician-directed treatment or observation for the current condition ▫ How symptoms have changed with physician-directed treatment or observation
since onset of the current condition ▫ What conditions have been found by a medical professional on a physical exam
performed for the current condition ▫ Any other conditions present in the medical history Submitter ▫ Ordering physician, facility or other Prior Authorization Forms For specialized outpatient services, check eviCore Clinical Worksheets for more details about specific service areas
and clinical solutions: www.eviCore.com/provider/online-forms BCBSOK Medicare Advantage form: bcbsok.com/pdf/forms/bmapriorauth_form.pdf Expedited Review Call 877-774-8592 for urgent service after hours, weekends and holidays. Avoid Administrative Claim Denials Call 877-774-8592 or fax 855-874-4711 to obtain:
• Referrals for out-of-plan or out-of-network providers before a patient receives care • Inpatient notification for post-stabilization care after an ER admission (report within one business day) • Prior authorization for the services, drugs and devices listed on bcbsok.com/provider/network/bma.html

• Click “eviCore Prior Authorization Program” for specialized outpatient services
• For other services, click “Prior Authorization Requirements” Check Claim Status Online At availity.com, the Availity Claim Research Tool provides the equivalent of an Explanation of Benefits (EOB),
  including line-item breakdowns. Member Rewards At BlueRewardsOK.com, Medicare Advantage members can sign up to earn rewards for completing selected screenings, managing chronic conditions or seeing a physician for a physical. Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of Oklahoma, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 611153.0920 Medicare Advantage Quick Tips for Providers