Prior Authorization

Need to request a prior authorization but don't know where to start? We've put together some information to better serve you when requesting prior authorization. Our goal is to make the prior authorization process fast, easy and accurate.

  • General Prior Authorization

    General Precertification

    When you request prior authorization (PA) from us, we want the process to be fast, easy and accurate. We now use the Cohere Health platform to provide you with a powerful tool to accelerate the PA process and expand real-time approvals.

    You will still sign on through My Insurance Manager so you can begin the process for medical services, but the portal will route you to the new web-based application, powered by Cohere Health, to enhance efficiency of PA decisions.

    Note: All clinical decisions are made by BlueChoice HealthPlan.

    For behavioral health services, use the Forms Resource Center to being the prior authorization process.

    Cohere Health offers prior authorization services on behalf of BlueChoice HealthPlan.

  • Services Managed by Evolent

    Services Managed by Evolent

    Evolent is an independent company that provides utilization management services on behalf of BlueChoice HealthPlan. Evolent manages precertification for advanced radiology, musculoskeletal care, radiation oncology and nuclear cardiology, as well as certain imaging services. 

    • Radiology Services
    • Musculoskeletal Care Management Program
    • Radiation Oncology Program
    • Nuclear Cardiology 

     

    Radiology Services

    Visit RadMD, the secure webpage of Evolent. You can also view their radiology policies. Please select "BlueChoice HealthPlan" followed by the study desired. (These links lead to third party sites. Those companies are solely responsible for the contents and privacy policies on their sites.)

    RadMD, one of the services Evolent provides, allows contracting health care providers to enter authorization requests via the internet.

    Refer to the BlueChoice® Radiology Utilization Matrix for specific procedures that require authorization.

    View the Cardiac Services Checklist and Cardiac Services Tip Sheet to learn more about prior authorization requirements.

    Musculoskeletal Care

    As of May 1, 2016, some groups require Evolent precertification for interventional pain management spine services when performed and billed in an outpatient or office location. We also require prior authorization for lumbar and cervical spine surgery in an inpatient and/or outpatient location. 

    Here are Evolent's reference materials about this musculoskeletal (MSK) care management program:

    Radiation Oncology Program

    As of January 1, 2015, some groups require Evolent precertification for radiation oncology services when performed and billed in an outpatient or office location. 

    Here are Evolent's reference materials about this radiation oncology program:

    Nuclear Cardiology

    As of November 1, 2016, BlueCross BlueShield of South Carolina and BlueChoice HealthPlan require precertification for nuclear cardiology services through Evolent. This precertification requirement is only applicable to BlueCross and BlueChoice Exchange members receiving nuclear cardiology services. Review the specific procedures in the utilization matrix.

    BlueCross® BlueShield® of South Carolina is an independent licensee of the Blue Cross Blue Shield Association. 

     

  • Laboratory Prior Authorization

    Laboratory Prior Authorization

    Effective January 1, 2016, BlueCross® BlueShield® of South Carolina and BlueChoice HealthPlan of South Carolina require Avalon Healthcare Solutions to precertify certain lab procedures when performed in an office, outpatient or independent lab location. Avalon is an independent company that provides benefit management services on behalf of BlueCross and BlueChoice®. Please check this page frequently for new information.

    What Physicians Need to Know About Avalon
    January 1, 2016, we introduced a program that will improve the quality and reduce the cost of laboratory services our members receive. Note that with this new program, certain lab procedures when performed in an office, outpatient or independent lab location will require prior authorization.

    Why Did BlueChoice Make This Change?
    The cost of health care is rising for everyone and we have an obligation to ensure that our members receive the highest quality of care at the most affordable cost. Laboratory medicine is continuing to become increasingly complex. As technology improves, the cost and utilization of these services increase. This program will assist us in ensuring appropriate testing for our members at the lowest out-of-pocket cost

    How Does This Program Affect You?
    We are dedicated to ensuring your patients receive the highest quality laboratory testing at the most reasonable cost. We can only accomplish this if we effectively manage the network of laboratory providers and if your practice accesses the laboratories that have been accredited for participation in the health plan.

    Sometimes patients may need a specialized test. BlueChoice has considered this issue and has included specialty labs and centers of excellence within the network of laboratory providers. The centers of excellence are staffed by qualified clinical pathologists and genetic counselors prepared to answer your inquiries both before and after you perform testing.

    We do not qualify all laboratories. If an out-of-network laboratory services you or you have outpatient testing performed by a hospital, your patients’ out-of-pocket cost may be significant. To ensure the lowest cost to your patients, please send BlueCross and BlueChoice members’ testing to in-network laboratories only.

    Avalon has developed a Lab Procedure Authorization matrix in an effort to help you determine when you need to contact Avalon for prior authorization. You can submit requests for prior authorization by fax, phone or the web tool. Avalon will promptly review your request and provide a timely, written decision.

    Please note that Avalon doesn't manage services in an emergency room or hospital inpatient setting. This change does not alter the available member benefits, but using these participating providers will result in a lower out-of-pocket cost for your BlueCross- and BlueChoice-covered patients.

    How Do You Contact Avalon?
    You can send prior authorization requests to Avalon by completing the Preauthorization Request Form, by calling 844-227-5769 or by faxing 888-791-2181.

    Which Laboratories are In-network?
    View a comprehensive list of the independent laboratories that are in-network. You can also use our Doctor & Hospital Finder to find participating labs. 

    What Other Resources are Available to Assist Me in Learning More About Avalon? 
    Here are reference materials about Avalon:

     

    BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross Blue Shield Association. 

  • Specialty Medical Drug Prior Authorization

    Specialty medications often are covered under the medical benefit. They can be costly for our members, and not all plans cover them the same way. That’s why it’s important to review whether the use of these medications meets coverage criteria before a specialty drug is provided. 

    The program also includes requirements for self-administered drugs and site-of-care that may impact coverage, which is important to know if you provide these types of medications. 

    Medical Specialty Drugs

    To find out which medical specialty drugs require prior authorization under the Specialty Medical Benefit Management (SMBM) program, view the Medical Drug List. 

    Note: Some infused specialty medications commonly administered in the hospital setting can be safely provided at home, in a physician’s office or in an infusion suite. Drugs with a site-of-care requirement may only be approved in certain sites of care or if the patient is under 18 years of age.

    Self-Administered Drugs

    Certain self-administered drugs aren’t covered under the medical benefit. The drugs on the Self-Administered Drug List must be billed under the pharmacy benefit. There are some exceptions. Hematologists, oncologists, nephrologists and rheumatologists may continue to bill for these drugs under the medical benefit. Additionally, some member benefit plans may be exempt. 

    We make changes to all of our drug lists from time to time. Updates usually occur quarterly but can happen at any time. 

    Note: Prior authorizations for medical specialty drugs have always been a requirement for BlueChoice HealthPlan members.