Prior Authorization
Please note, failure to obtain authorization may result in administrative claim denials. Oklahoma Complete Health providers are contractually prohibited from holding any member financially liable for any service administratively denied by Oklahoma Complete Health for the failure of the provider to obtain timely authorization.
Check to see if a pre-authorization is necessary by using our online tool.
Expand the links below to find out more information.
PCPs should coordinate all healthcare services for Oklahoma Complete Health members. Paper referrals are not required to direct a member to a specialist within our participating network of providers. All out of network services (excluding ER and family planning) require prior authorization. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient’s medical record.
Some services require prior authorization from Oklahoma Complete Health in order for reimbursement to be issued to the provider. Please use our Prior Authorization Prescreen tool to determine the services needing prior authorization.
Authorization requests may be submitted by secure web portal and should include all necessary clinical information. Urgent requests for prior authorization should be submitted as soon as the need is identified.
Oklahoma Complete Health’s Medical Management department hours of operation are Monday through Friday, 8 a.m. to 5 p.m. CDT (excluding holidays). Emergent and post-stabilization services do not require prior authorization.
We will determine most routine authorizations within 72 hours of receipt or as expeditiously as the Members’ health requires. All inpatient behavioral health PA requests will be determined within 24 hours.
All attempts are made to provide the most current information on the Pre-Auth Needed Tool. However, this does NOT guarantee payment. Payment of claims is dependent on eligibility, covered benefits, provider contracts, correct coding and billing practices. For specific details, please refer to the provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response
For Complex Imaging MRA, MRI, PET, and CT scan authorizations - click here
to access Evolent
For PT/OT/ST, Cardiac, MSK, IPM Pain Management authorizations - click here
to access Evolent
For Medical Oncology, Radiation Oncology, Cardiology authorizations - click
here to access Evolent (effective 6/1/2024)
Non-participating providers must submit Prior Authorization for all services.
For non-participating providers, Join Our Network.
Are Services being performed in the Emergency Department or Urgent Care Center or Family Planning services billed with a Contraceptive Management diagnosis?
| Types of Services | YES | NO |
|---|---|---|
| Is the member being admitted to an inpatient facility? | ||
| Is the member receiving hospice services? | ||
| Is the member receiving chiropractic services? |