Medicare Advantage Prior Authorization

Our Medicare Advantage plans require prior authorization for certain procedures and services. Always verify benefits to determine whether prior authorization is required.

Note: These requirements only apply to South Carolina members. For members who have other Blue^® plans, please contact their home plan to verify the authorization requirements.

Services Requiring Universal Prior Authorization

No matter what, the following services will always require prior authorization.

• All inpatient admissions — Inpatient admissions also require review if a continued stay is necessary.
  • Hospital inpatient
  • Rehabilitation facilities
  • Long term acute care
  • Skilled nursing facilities
• Inpatient level of care for nonemergency surgery
• Behavioral health services

Codes That Require Prior Authorization

Our Medicare Advantage plan also has specific codes that require prior authorization. View the complete list of codes to ensure you get the necessary approvals before rendering services.

Note: This list is not all inclusive and is subject to change. It is a guide that includes the most commonly requested services requiring a medical review. We encourage you to review Medicare Advantage's medical policies for more information.

How to Request Prior Authorization

Medical and Behavioral Health Services

We are committed to making the prior authorization process fast, efficient, and accurate. Prior authorization requests are submitted through My Insurance Manager℠, which routes medical and behavioral health requests to a secure web based application powered by Cohere Health. This platform helps streamline submissions and expand opportunities for real time approvals.

Laboratory Services

Avalon conducts pre-service coverage reviews for select laboratory services performed in a physician’s office, independent laboratory, or outpatient setting. Services provided in inpatient or emergency room settings are not reviewed by Avalon, and you must follow the processes for medical service requests.

To determine which services require review, refer to the most current Avalon Prior Authorization List. Prior authorization requests can be submitted through Avalon’s Prior Authorization System (PAS) portal on their website. If you do not have a PAS account, you may request one by sending an email to Avalon-PAS-Help@AvalonHCS.com and include the following information:

• Lab or Practice name
• Your full name and email address
• Office phone number
• Supervisor's name and email address
• Individual NPI number(s) (Avalon does not accept group NPIs; list them in an Excel sheet if necessary).

Alternatively, you may complete the Avalon Preauthorization Request Form and fax it, along with any supporting documentation, to 813-751-3760. Avalon will review your request and issue a timely written determination.

Durable Medical Equipment, Home Health and Home Infusion Services

Integrated Home Care Services (IHCS) manages the coordination and provision of durable medical equipment, home health and home infusion services.

• Phone: 844-215-4264
• Fax: 844-215-4265
  • Include the Intake Coversheet when submitting your request.
  • Include the Oxygen Prescription Coversheet when submitting oxygen requests.

Avalon Healthcare Solutions and IHCS are independent companies that assist with utilization management on behalf of BlueCross BlueShield of South Carolina.