Prior Authorization

Prior authorization is also called preauthorization, prior approval or precertification. It is important to understand what prior authorization means. It means the service has been determined to be medically appropriate for the patient’s condition. A prior authorization does not guarantee that we will pay benefits.

You must get prior authorization for certain categories of benefits. A failure to get prior authorization may result in benefits being denied. We will make our final benefit determination when we process your claims. Even when a service is preauthorized, we review each claim to make sure:

The patient is a member under the policy at the time service is provided.
The service is a covered service. Policy limitations or exclusions may apply.
The service provided was medically necessary as defined by your policy, including appropriateness, health care setting, level of care and effectiveness.

A prior authorization may only be for a specific period of time or number of visits or treatments. If you have any questions about this, please contact Member Services.

If your request for prior authorization of services is denied, you can request further review. Please contact Member Services for additional information. Prior authorization denials are considered denied claims for purposes of appeals and grievances.

Network providers in South Carolina will be familiar with the requirement to get prior authorization and will get the necessary approvals. If a network provider in South Carolina does not get prior authorization, it cannot bill you for services performed that would have been covered under the policy or any penalties applied.

The following items require prior authorization for benefits to be covered:

All inpatient admissions, except for emergency admissions: For emergency admissions, you or someone acting on your behalf must notify BlueChoice HealthPlan no later than 24 hours after the admission or the next working day, whichever is later.
Continued inpatient admissions
Outpatient facility admissions, except for emergency admissions: For emergency admissions, you or someone acting on your behalf must notify BlueChoice no later than 24 hours after the admission or the next working day, whichever is later.
All inpatient, outpatient/office psychological testing, intensive outpatient and partial hospitalization programs, repetitive transcranial magnetic stimulation (rTMS) and electroconvulsive therapy and certain prescription drugs for behavioral health disorders
Dental services to sound natural teeth related to accidental injury after initial visit
Genetic counseling
Habilitation services
Home health services
Hospice services
Covered transplants, which must be obtained at Blue Distinction^® Centers for Transplants
Durable medical equipment (DME) that has a purchase price or rental cost of $250 or more (Any supplies used with DME must be authorized every 90 days.)
Virtual colonoscopies, subject to medical management guidelines
Procedures and treatment of varicose veins
Services, supplies, or charges for a covered multidisciplinary pain management program, regardless of the state of location of the provider
Prescription drugs as listed in the prescription drug list
Cardiac rehabilitation
Pulmonary rehabilitation
Dialysis
Radiation oncology
Injectable/infusible chemotherapy
Treatment of hemophilia
Advanced radiology
Nuclear cardiology
Musculoskeletal care
Home infusion therapy
Home occupational therapy
Home physical therapy
Home speech therapy
Biofeedback