Prior Authorization

Oklahoma Complete Health will need to approve some treatments and services before you receive them. Oklahoma Complete Health may also need to approve some treatments or services for you to continue receiving them. This is called prior authorization. For a list of services that require a prior authorization, please see the chart in the “Services Covered by Oklahoma Complete Health’s Network” section of the member handbook (PDF) on page 15.

Typically, your primary care provider (PCP) will submit the prior authorization to Oklahoma Complete Health for you through the provider portal. Asking for approval of a treatment or service is called a prior-authorization request. To get approval for these treatments or services:

• You or your doctor may call Member Services at 1-833-752-1665 (TTY: 711) to ask about prior authorization. However, all official prior authorization submissions must be done via our provider portal.

What Happens After We Get Your Prior Authorization Request?

The health plan has a review team to be sure you get the services we promise and that you need. Qualified health care professionals (such as doctors and nurses) are on the review team. Their job is to be sure that the treatment or service you asked for is covered by your plan and that it will help with your medical condition. They do this by checking your treatment plan against medically acceptable standards.

After we get your request, we will review it under either a standard or an expedited (faster) process. You or your doctor can ask for an expedited review if a delay will cause serious harm to your health. If your request for an expedited review is denied, we will tell you and your case will be handled under the standard review process. In all cases, we will review your request as fast as your medical condition requires us to do so but no later than described timeframes noted below.

We will tell you and your provider in writing if your request is approved or denied. We will also tell you the reason for the decision. We will explain what options you will have for an appeal when you don’t agree with our decision.

Any decision to deny a prior authorization request or to approve it for an amount that is less than requested is called an adverse benefit determination. These decisions will be made by a health care professional. You can request the specific medical standards, called clinical review criteria, used to make the decision for adverse benefit determinations related to medical necessity.

Prior Authorization and Timeframes

We will review your request for a prior authorization within the following timeframes:

• Standard review: We will make a decision about your request within 72 hours after we receive it.
• Expedited (fast track) review: We will decide about your request and you will hear from us within 24 hours.
• Inpatient Behavioral Health: We will make a decision about your request within 24 hours.

If additional information is needed to make the decision, the review could take up to an additional 14 days. If this happens, Oklahoma Complete Health will send you a written notice along with information on how to file an appeal on the extension.

In most cases, if you are receiving a service and a new request is made to keep receiving a service, we must tell you at least 10 days before we change the service if we decide to reduce, stop, or restrict the service.

If we approve a service and you have started to receive that service, we will not reduce, stop, or restrict the service during the approval period unless we determine the approval was based on information that was known to be false or wrong.

If we deny payment for a service, we will send a notice to you and your provider the day the payment is denied. These notices are not bills.