Prior Authorization

Our plans require prior authorization for certain procedures and services. Always verify benefits to determine whether prior authorization is required. Note: Some plans may use third-party vendors for utilization management.

The prior authorization process allows us to confirm in advance whether requested services meet coverage criteria under the member’s health plan. In many cases, decisions are issued immediately. When additional review is needed, determinations are based on:

• Medical policies
• Recognized clinical guidelines
• BlueCard^® requirements for out of area members
• The terms of the member’s benefit plan

Some requests may require additional clinical documentation to support medical necessity.

A standard prior authorization list is available as a reference for services that commonly require review. This list is not all inclusive and is subject to change.

Medical and Behavioral Health Requests

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 (excluding autism) to a secure web-based application powered by Cohere Health. This platform helps streamline submissions and expand opportunities for real-time approvals.

Autism services are excluded from this process. Continue to submit CBA autism PA requests to autismsupport@companiongroup.com.

Please note: Cohere does not make clinical decisions. All clinical decisions are made by the health plan.

Specialty Medical Drug Requests

To determine which medical specialty drugs require prior authorization under the Specialty Medical Benefit Management program, review the Medical Drug List.

Some infused specialty medications commonly administered in a hospital setting can be safely provided in alternative sites of care, such as the patient’s home, a physician’s office, or an infusion suite. Drugs with site-of-care requirements may be approved only in designated settings or when the patient is under 18 years of age.

Prior authorization requests for specialty drugs are submitted through My Insurance Manager. When a request is identified as a specialty drug, you will be routed to MBMNow to complete the submission.

Nonspecialty Medication Requests

Our pharmacy benefit manager has partnered with CoverMyMeds to offer free electronic prior authorization (ePA) services to all providers and their staff. This helps prescribers and pharmacies quickly find, complete and submit prior authorization (PA) requests.

You can use CoverMyMeds to:

• Submit the request electronically.
• Quickly find the correct PA request form for your patient’s plan.
• Receive real-time plan specific clinical guideline questions (where applicable).
• Complete PA requests started by pharmacies.
• Easily manage follow-ups for all your requests and patients.
• Check status of ePA requests submitted.

To get started all you need to do is register for a free account or log into your existing CoverMyMeds account. Create an account by selecting Get Started and filling out all the required information.

Our pharmacy benefit manager also accepts prior authorizations via phone and fax.

• Commercial plans
  • Phone: 855-811-2218
  • Fax: 844-403-1029 (Commercial Prior Authorization Fax Form)
• Exchange plans
  • Phone: 833-494-2987
  • Fax: 803-462-5000 (Exchange Prior Authorization Fax Form)
• Part D
  • Phone: 855-540-5951
  • Fax: 844-403-1028 (Part D Prior Authorization Fax Form)

Laboratory Requests

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.

Radiation Oncology, Radiology and Musculoskeletal Requests

Our health plans require prior authorization for certain radiation oncology, radiology, and musculoskeletal (interventional pain management and spine) services when performed in an outpatient or office setting. We partner with Evolent to manage these prior authorization requests.

Review the following lists to determine if prior authorization is required:

• Interventional Pain Management Utilization Review Matrix
• Spine Surgery Utilization Review Matrix
• Radiology Utilization Review Matrix
• Radiation Oncology Utilization Review Matrix

Requests can be submitted online through www.RadMD.com, which links to a third party website. Please note that Evolent is solely responsible for the content and privacy practices of its site.

BlueCard Requests

Use the BlueCard Authorization/Medical Policy tool to verify authorization requirements for out‑of‑state members. You will be directed to the member’s Home plan website. Please note that content on other plan websites is maintained by the member’s Home plan and not BlueCross BlueShield of South Carolina.

To use the tool:

• Select the type of request.
• Enter the three-character prefix of the member’s ID number.
• Select Submit.

Cohere Health, MBMNow, CoverMyMeds, Avalon Healthcare and Evolent are independent companies that assists BlueCross BlueShield of South Carolina with utilization management.