MedicaidPrior AuthMedium impact
Provider Letter 2025-04: RE: SoonerSelect Prior Authorization Process for Tonsillectomies and/or Adenoidectomies for Members Over Age 12 for Oklahoma Complete Health and Oklahoma Complete Health Children’s Specialty Program
Oklahoma SoonerCare·OK · ENT (Ear, Nose & Throat)·Prior Authorization
Effective date
Feb 1, 2025
We identified it
Jun 20, 2026
Summary
Oklahoma Complete Health (Medicaid) now requires prior authorization using InterQual criteria for tonsillectomies and/or adenoidectomies performed on members over age 12, effective February 1, 2025. This adds a new prior auth requirement that did not previously exist for these procedures in this age group.
Action Required
Immediately: Billing team must update prior authorization workflow to require approval from Oklahoma Complete Health before scheduling tonsillectomies and/or adenoidectomies for Medicaid members over age 12. Contact OCH at 833-752-1664 (standard) or 833-752-1665 (Children's Specialty Program) to obtain prior auth using InterQual criteria. Update scheduling protocols to verify member age and obtain approval before procedure dates. Claims will likely be denied without prior authorization.