Encourage Annual Eye Exams and Statin Therapy Adherence for Members With Diabetes

We track Healthcare Effectiveness Data and Information Set (HEDIS^®) measures from the National Committee for Quality Assurance related to diabetes care to identify and close gaps in care.

Updates To Behavioral Health Substance Abuse Criteria for Utilization Management

Effective Jan. 1, 2027, we’ll refer to the American Society of Addiction Medicine’s Criteria 4.0 in our medical necessity reviews of services rendered to adolescents.

Reminder: Diagnosis‑Related Group Dictates Reimbursement for Inpatient Acute Care in Oklahoma for Our Commercial Members

Once initial medical necessity is approved, you do not need to continue to submit additional clinical information related to the stay.

See Prior Authorization Changes for Some Commercial and Government Program Members

We’ve updated prior authorization requirements for some commercial members and government plans to reflect new, replaced or removed codes.

Explore Learning Opportunities

We offer free webinars and workshops for providers who participate in our networks. View the schedule and sign up for training sessions, including webinars on coding for chronic obstructive pulmonary disease and coding for chronic kidney disease.

Reminder: Digital Access to Medicare Advantage Prior Authorization Decision Letters

Beginning Dec. 11, 2026, prior authorization approval letters for Medicare Advantage members will no longer be mailed via the U.S. Postal Service. You can view and securely download prior authorization decision letters for these members through the Provider Correspondence Viewer in Availity^® Essentials.

Blue Cross Medicare Advantage (HMO)^SM Members Transitioning to HealthSpring^SM Plan for 2027

During this year’s Medicare Annual Enrollment Period, we’re transitioning our current Medicare Advantage HMO members to a plan offered by insurer HealthSpring for 2027.

Keep Your Record ID Active To Prevent Network Termination

If you haven’t filed a claim with your billing or rendering National Provider Identifier and Tax ID number with a date of service within 24 months, we may cancel your corresponding record ID, and you may be terminated from our networks. Learn how to keep your record ID active with us.

Looking for Help?

Do you know the fastest way to get a response on prior authorizations? Are you aware of the latest pharmacy drug updates, or do you have a claims question? You can find many answers on our provider website, including:

• The latest updates

• Details about tools to streamline billing and processes

• Tips for newly contracted providers

Contact Your Provider Relations Representative

If you have a question and can’t find an answer, our provider representatives are here to help. Email us or call 800‑722‑3730 and select Option 2 for network.

Changes Coming to the Medical Drug Benefit Program

Effective Jan. 1, 2027, we will update coverage for specific prescription drugs administered by a health care provider in a clinical setting.

Review Pharmacy Program Quarterly Updates – Part 2

We’ve made changes to our drug lists and utilization management program. Learn about these and other pharmacy program updates.

Take Note of Provider Reference Manual Updates

Our Commercial Provider Reference Manual is updated. Changes to the manual include, but aren’t limited to, the following section: Authorizations. Please review it for all changes.

Learn About Updates to Reimbursement Policies

We regularly add and modify reimbursement policies, formerly known as clinical payment and coding policies, as part of our ongoing policy review. See which policies were updated.

Review Active and Pending Medical Policies

Approved new or revised medical policies and their effective dates are usually posted on our website the first and 15th of each month. You can view all active and pending policies, as well as draft medical policies, and provide comments on draft policies. These policies may impact your reimbursement and your patients’ benefits.