Avalon: Claim Editor

Avalon: Claim Editor

6/7/2016

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan works with Avalon Healthcare Solutions to administer a comprehensive suite of laboratory benefit management services. Avalon is an independent company that provides benefit management services on behalf of BlueCross and BlueChoice®. We do this to further the plans’ practices of maintaining access to high-quality health care for members. The Avalon program is part of BlueCross’ and BlueChoice’s efforts to provide leadership in South Carolina. We strive to meet the national Triple Aim of better care for individuals, better overall population health and lower costs of care.

We are entering into our third phase of implementing the Avalon program. Prior communications provided you with information about Avalon’s clinically-driven approach. It combines the best in clinical research with scalable, reliable technology solutions to enhance the administration of medical policy. BlueCross and Avalon began the program implementation in phases:

  • Phase 1 – Nov. 1, 2015: Avalon expanded BlueCross’ network of laboratory providers including expansion of toxicology and genetic testing laboratories. You can access any network provider through our provider directories, however, a complete list of Avalon network providers can be found here on the BlueCross and BlueChoice websites.
  • Phase 2 – Jan. 1, 2016: Avalon deployed prior authorization for 137 AMA CPT and HCPCS codes as defined in the Avalon Lab Authorization Matrix. Prior authorization requests may be sent to Avalon by calling 844-227-5769 or by faxing 888-791-2181.
  • Phase 3 – May 1, 2016: BlueCross and Avalon enhanced the suite of services and began deployment of the claim editing technology with dates of service on or after May 1, 2016. The Avalon claim editing technology is designed to provide consistent application of BlueCross medical policy.
    We develop these medical policies using current evidenced-based scientific literature nationally recognized experts vetted in the field of laboratory medicine. 

  • The medical policies are available on the BlueCross and BlueChoice websites.

When fully deployed, the claim editing technology will impact reimbursement for testing utilization outside of medical policy. It would be prudent to ensure the lab tests you order are within policy guidelines. In-network laboratories will be educated prior to full deployment in regards to the policies and claim editor effect through provider outreach, webinars and alerts on remittance advices. Continue to use in-network laboratory resources to ensure your patients are receiving the highest quality care at the lowest out-of-pocket cost.

Contact Us:

We are all working together to deliver the best possible health care to the communities we serve. By promoting the most effective patient treatments, we can improve clinical outcomes while optimizing cost and affordability. Please look for further communications about Avalon by visiting our websites at www.SouthCarolinaBlues.com and www.BlueChoiceSC.com. Should you have specific questions, please contact Provider Relations and Education by emailing provider.education@bcbssc.com or by calling 803-264-4730. You may also contact Avalon at 855-895-1676 for additional information.