Precertification

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

Precertification Requirements

There are some services that routinely require precertification or admission certification for BlueCross BlueShield of South Carolina. Other services require precertification due to the member's contract benefits, type of service, etc. To determine if a service may require precertification, review our precertification requirements.

Please note:
While some groups require precertification for all of the services listed, others only require precertification for a portion of the outpatient services listed or none at all. Precertification requirements may vary from group to group or by health plan.

Medical Forms Resource Center

The Medical Form Resource Center (MFRC) is an online tool created to allow you to submit your precertification requests for some services electronically. The system is fast and easy to use and ensures accuracy. It also cuts down on follow up calls as all the required information is outlined on the form. The user-friendly format provides an alternative to using My Insurance Manager for precertification for services that pend approval and offers many benefits.

Initial Precertification Requests

We require you to submit initial precertification requests for certain services.

BlueCard® Precertification/Medical Policies

To access precertification/preauthorization and medical policy information for other Blue Plans, use the BlueCard Precertification tool. You will need the patient’s prefix from his or her member ID card. Learn how you can initiate precertification for out-of-state members of other Blue Plans.

Lab Precertification

Effective Jan. 1, 2016, BlueCross and BlueChoice® HealthPlan of South Carolina will 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®. Review the laboratory precertification information to learn more.

Musculoskeletal Care Management (MSK) Program

BlueCross requires prior authorization from NIA Magellan Healthcare Inc. for two components of non-emergent MSK services: outpatient interventional spine pain management, and  inpatient and outpatient lumbar and cervical spine surgeries. NIA is an independent company that provides utilization management services on behalf of BlueCross. Review the MSK program information to learn more.

Nuclear Cardiology

Effective Nov. 1, 2016, BlueCross and BlueChoice require precertification for nuclear cardiology services through National Imaging Associates (NIA). NIA is an independent company that handles precertification for certain nuclear cardiology services on behalf of BlueCross and BlueChoice. This precertification requirement is only applicable to BlueCross and BlueChoice Exchange members receiving nuclear cardiology services. Review the specific procedures in the utilization matrix.

Precertification Forms

Avalon Preauthorization Request Form – Complete this form to request prior authorizations for specific lab services.

Precertification Request – Complete this form to request precertification for a specific procedure/service. If the determination of this review will influence the decision to proceed with treatment, we recommend that you do not schedule treatment until we issue the final decision.

Radiology Precertification

BlueCross requires some groups to get precertification for certain advanced imaging services through National Imaging Associates (NIA). NIA is an independent company that handles precertification for certain imaging services on behalf of BlueCross. Review the radiology precertification information to learn more.

Radiation Oncology Program

BlueCross requires NIA precertification for many radiation oncology services when you perform and bill them in an outpatient or office location. Review the radiation oncology program information to learn more.

Specialty Medical Drugs

Effective June 1, 2016, BlueCross and BlueChoice will require prior authorization for some specialty drugs billed under the medical benefit. Also, the medical benefit will no longer cover certain self-administered specialty drugs. Review the prior authorizations specialty medical drugs information to learn more. 

    Submit a Precertification Online

    Learn how to submit precertification requests online using My Insurance ManagerSM. You can submit requests for BlueCross and the State Health Plan.

    Submit Clinical Attachments Online

    Learn how to submit clinical attachments for pending precertification requests online. You can submit requests for BlueCross and the State Health Plan. 

    Documentation to Include for Precertification

    Some services require additional documentation in order to review a precertification request. Find out what clinical information to submit for specific services and procedures.

     BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association.