« Back to News List

Provider Financial Responsibility for Prior Authorization

May 21, 2014

BlueCard® is a national program that enables members of a Blue Plan to get health care services while traveling or living in another Blue Plan's service area. Currently, the responsibility for getting precertification is the member’s for inpatient facility services. 
Effective July 1, 2014, you will be responsible for getting prior authorization for inpatient facility services for out-of-area members. The member will not be responsible when prior authorization is required but not received for inpatient services. BlueCard members will now be treated the same as local BlueCross Plan members.
Failure to get necessary prior authorizations will result in claim penalties or denials. Here’s what you should know:

  • We base the amount of the penalty on your contract and applicable pricing methods.
  • The member’s Plan will continue to determine which services require prior authorization.
  • The member will not be responsible and cannot be balance-billed, unless the member has signed a written consent to be billed prior to rendering the service. Members are liable for services denied as not medically necessary.

You must also:

  • Notify the member’s Plan within 48 hours when a change or modification to the original prior authorization occurs.
  • Get prior authorization for emergency and/or urgent inpatient admissions within 72 hours.

Contact information to get prior authorization for a member’s Plan is on the identification card. You can also verify authorization requirements by:

  • Using the Electronic Provider Access (EPA) tool available through My Insurance ManagerSM at www.SouthCarolinaBlues.com. With EPA, you can gain access to a BlueCard member’s Plan, through a secure routing mechanism and have access to initiate prior authorization requests. Note: The availability of EPA will vary depending on the capabilities of each member’s Plan.
  • Submitting an ANSI 278 electronic transaction to BlueCross or calling 800-676-BLUE.

Thank you for your attention to this policy change. We encourage you to share this message with everyone in your office.
Please contact Provider Education for information about this bulletin at provider.education@bcbssc.com or by calling 803-264-4730.

« Back to News List