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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 Prior Authorization Prescreen tool.

Expand the links below to find out more information.

As the Medical Home, PCMHs 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. PCMHs 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.

Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date or as soon as the need for service is identified.

Authorization requests may be submitted by fax, phone or secure web portal and should include all necessary clinical information. Urgent requests for prior authorization should be called in 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). After normal business hours, we have after hours service available to answer questions and intake requests for prior authorization. Emergent and post-stabilization services do not require prior authorization. Urgent/emergent admissions require notification within one (1) business day following the admit date.

We will process most routine authorizations within 72 hours of receipt. If we need additional clinical information or the case needs to be reviewed by the Medical Director it may take up to 14 calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email, or secure web portal.

Last Updated: 05/06/2021