Blue Cross Medicare AdvantageSM Plans



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The Blue Cross Medicare Advantage plans offer all the coverage of Original Medicare – plus additional benefits not covered by Original Medicare or most Medicare Supplement insurance plans, including built-in prescription drug coverage and extra health and wellness options. Blue Cross and Blue Shield of Oklahoma (BCBSOK) offers both individual and group Medicare Advantage plans.

  • The Blue Cross Medicare Advantage (HMO) plan offers health coverage to Medicare beneficiaries who reside in the greater Oklahoma City area, which includes the following counties: Canadian, Cleveland, Grady, Lincoln, Logan, McClain, Oklahoma and Pottawatomie.

Our strong brand recognition and our historical relationship with Medicare makes Blue Cross and Blue Shield of Oklahoma (BCBSOK) an excellent choice for Medicare-eligible individuals. We maintain and monitor a network of participating providers including physicians, hospitals, skilled nursing facilities, ancillary providers, and other health care providers through which members obtain covered services.

 

Our retiree group Medicare plans are:

  • Blue Cross Group Medicare Advantage (PPO)SM
  • Blue Cross Group Medicare Advantage Open Access (PPO)SM
  • Blue Cross Group MedicareRx (PDP)SM

BlueSecureSM is a supplemental medical plan that helps cover some costs beyond what is covered by Original Medicare.

 

Out-of-network Note: If you see Medicare members or accept Medicare assignment and are willing to bill BCBSOK, you may treat members of Blue Cross Group Medicare Advantage Open Access (PPO) and BlueSecure as an out-of-network provider. Out-of-network providers will be paid the Medicare-allowed amount less any member cost-sharing. In-network providers will be paid at their contracted rate.

 

BlueSecure members also can see providers who accept Medicare assignment.




Blue Cross Medicare Advantage has two resources to help you care for our Medicare Advantage members during their annual wellness visits. These resources can help you document our members’ visits to more easily meet Medicare requirements.

The guide and form are for your use only and do not need to be returned to us.


Blue Cross Medicare Advantage wants to help you avoid administrative claim denials. To prevent denials from occurring, a list of administrative claim denials that providers may receive has been created, along with tips on how to avoid them. Read more


Blue Cross Medicare AdvantageSM has contracted with eviCore healthcare (eviCore), an independent specialty medical benefits management company, to provide Utilization Management services for prior authorization requirements outlined below.


Effective June 1, 2017, Blue Cross Medicare Advantage members will be subject to the prior authorization requirements set forth in this article. eviCore will manage prior authorization requests for the following specialized clinical services effective for dates of service on or after June 1, 2017:


  • Outpatient Molecular Genetics
  • Outpatient Radiation Therapy
  • Musculoskeletal
    • Chiropractic
    • Physical and Occupational Therapy
    • Speech Therapy
    • Spine Surgery (Outpatient/Inpatient)
    • Spine Lumbar Fusion (Outpatient/Inpatient)
    • Interventional Pain
  • Outpatient Cardiology & Radiology
    • Abdomen Imaging
    • Cardiac Imaging
    • Chest Imaging
    • Head Imaging
    • Musculoskeletal
    • Neck Imaging
    • Obstetrical Ultrasound Imaging
    • Oncology Imaging
    • Pelvis Imaging
    • Peripheral Nerve Disorders (Pnd) Imaging
    • Peripheral Vascular Disease (Pvd) Imaging
    • Spine Imaging
  • Outpatient Medical Oncology
  • Outpatient Sleep Program
  • Outpatient Specialty Drug

The Blue Cross Medicare Advantage Preauthorization Requirements List PDF Document has been updated to include the services listed above that require preauthorization through eviCore, for dates of service on or after June 1, 2017.


Providers can contact eviCore using one of the following methods:

  • The eviCore HealthCare Web Portal Learn more about third-party links will be available 24x7. After a one-time registration, you are able to initiate a case, check status, review guidelines, view authorizations/eligibility and more. The Web Portal is the quickest, most efficient way to obtain information.
  • Providers can call toll-free at 855-252-1117 between 7 a.m. to 7 p.m. (local time) Monday through Friday.

The rendering provider must obtain prior authorization for services outlined in this notification, except for emergency care or urgent services. PCP referrals are not required if the specialty provider selected is in network.


Services performed without prior authorization and that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.


iExchange® services will continue to be available for all other services that require prior authorization.


BCBSOK and eviCore will be providing additional information, including training opportunities, in the coming months. Please continue to visit the bcbsok.com/provider site and the BCBSOK Blue Review Newsletter for updates.


Please note that the fact that a service has been preauthorized/pre-certified 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.


* eviCore is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of BCBSOK.

** Prior authorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Prior authorization of a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.

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 (BCBSOK) appreciates your interest in becoming a contracting provider with our Blue Cross Medicare Advantage PPO and HMO networks. We contract with physicians, facilities and other health care professionals to ensure that our members receive accessible, cost effective and quality health care services. To join the Blue Cross Medicare Advantage network, please fill out the Provider Onboarding Form located under the Network Participation tab/How to Join Our Networks.


Medicare Marketing Guidelines 


All providers who contract with Blue Cross and Blue Shield of Oklahoma (BCBSOK) to provide Medicare Advantage services are expected to abide by the Centers for Medicare & Medicaid Services (CMS) rules for marketing when it involves BCBSOK or Blue Cross Medicare Advantage (HMO) or Blue Cross Medicare Advantage(PPO) products or benefits.


As a Blue Cross Medicare AdvantageSM provider, you may have recently received an official message from the Centers for Medicare & Medicaid Services (CMS), identifying you as a provider who prescribes drugs for Medicare patients, but who is not currently enrolled in (or validly opted-out of) Medicare.

Sample Message for Providers who Prescribe Drugs for Medicare Patients  


Effective Jan. 1, 2017, changes affecting claims submissions for Medicare Advantage Plans will assist in streamlining claims processing and improve efficiencies of claims routing to our primary claims adjudicator. Read More PDF Document


Blue Cross Medicare Advantage members can earn rewards for completing selected screenings, managing chronic conditions or seeing a physician for a physical.


Rewards and Incentives for Healthly Activities Effective 1/1/2018 PDF Document

Plans provided by Blue Cross and Blue Shield of Oklahoma, which refers to a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC) (PPO plans), and also to GHS Health Maintenance Organization, Inc. d/b/a BlueLincs HMO (BlueLincs) (HMO and HMO-POS plans) and GHS Managed Health Care Plans, Inc. (GHS-MHC) (HMO and HMO-POS plans). HCSC, GHS-MHC, and BlueLincs are Independent Licensees of the Blue Cross and Blue Shield Association. HCSC, GHS-MHC and BlueLincs are Medicare Advantage organizations with a Medicare contract. Enrollment in HCSC’s, GHS-MHC’s and BlueLincs’ plans depends on contract renewal.

Prescription drug plan provided by Blue Cross and Blue Shield of Oklahoma, which refers to HCSC Insurance Services Company (HISC), an Independent Licensee of the Blue Cross and Blue Shield Association. A Medicare-approved Part D sponsor. Enrollment in HISC’s plan depends on contract renewal