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Precertification

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.

 

  • General Precertification

    General Precertification

    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. Access the user guide here

    Precertification and Referral Guide - Learn how to submit a referral or precertification request through My Insurance ManagerSM and determine which services we can automatically authorize. 

    You can also submit requests using the Prior Authorization for Services/Procedures Form.

    Ancillary Services – BlueChoice HealthPlan directly manages prior authorizations, claims and network management processes for ancillary services, including:
    •    Durable Medical Equipment (DME) 
    •    Hemophilia management 
    •    Home health services 
    •    Home infusion therapy 
    •    Orthotics and prosthetics 
    •    Oxygen and respiratory equipment 
    •    Home physical therapy 
    •    Home occupational therapy 
    •    Home speech therapy 
    •    Private duty nursing 
    •    Hospice 

    Please use the Prior Authorization Request for Ancillary Services Form. 

  • Services Managed by NIA Magellan Healthcare Inc.

    Services Managed by NIA Magellan Healthcare Inc.

    NIA Magellan is an independent company that provides utilization management services on behalf of BlueChoice. Magellan manages precertification for advanced radiology, musculoskeletal care, radiation oncology and nuclear cardiology. 

    • Radiology Services 
    • Musculoskeletal Care Management Program 
    • Radiation Oncology Program 
    • Nuclear Cardiology 

     

    Radiology Services

    Beginning January 1, 2015, some groups will require National Imaging Associates (NIA) precertification for radiation oncology services when performed and billed in an outpatient or office location. Check out these FAQs. NIA is an independent company that provides precertification services for certain imaging services on behalf of BlueCross® BlueShield® of South Carolina and BlueChoice HealthPlan.

    Musculoskeletal Care

    Beginning May 1, 2016, some groups will require National Imaging Associates (NIA) Magellan Healthcare Inc. precertification for interventional pain management-spine services when performed and billed in an outpatient or office location. NIA Magellan Healthcare Inc. is an independent company that provides utilization management services on behalf of BlueChoice HealthPlan. We also require prior authorization for lumbar and cervical spine surgery in an inpatient and/or outpatient location. 

    Here are NIA Magellan Healthcare Inc.’s reference materials about this musculoskeletal care management program:

    MSK Group Prefixes Requiring NIA MSK Precertification MSK Interventional Pain Management Checklist MSK Interventional Pain Management Frequently Asked Questions MSK Provider Announcement Letter MSK Quick Reference Guide for Order Physicians/Surgeons MSK Spine Surgery Checklist MSK Spine Surgeries Frequently Asked Questions MSK Utilization Review Matrix MSK presentation RadMD Pain Management Injection Quick Start Guide RadMD Pain Management Surgery Quick Start Guide 

    Radiation Oncology Program

    Beginning January 1, 2015, some groups will require National Imaging Associates (NIA) precertification for radiation oncology services when performed and billed in an outpatient or office location. NIA is an independent company that provides precertification services for certain imaging services on behalf of BlueCross® BlueShield® of South Carolina and BlueChoice HealthPlan.

    Here are National Imaging Associates' reference materials about this radiation oncology program:

    Radiation Oncology Reference Guide Radiation Oncology Frequently Asked Questions (FAQ)  Radiation Oncology Claims Review Matrix Radiation Oncology Solutions Presentation Radiation Therapy Treatment Notification Form 

    Nuclear Cardiology

    Effective Nov. 1, 2016, BlueCross BlueShield of South Carolina and BlueChoice HealthPlan 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.

     

  • Laboratory Precertification

    Laboratory Precertification

    Effective Jan. 1, 2016, BlueCross BlueShield of South Carolina 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®. Please check this page frequently for new information.

    What Physicians Need to Know About Avalon
    Beginning Jan. 1, 2016, we will introduce a program that will improve the quality and reduce the cost of laboratory services our members receive. Note that with this new program, certain lab procedures when performed in an office, outpatient or independent lab location will require precertification.

    Why Did BlueChoice Make This Change?
    The cost of health care is rising for everyone and we have an obligation to ensure that our members receive the highest quality of care at the most affordable cost. Laboratory medicine is continuing to become increasingly complex. As technology improves, the cost and utilization of these services increase. This program will assist us in ensuring appropriate testing for our members at the lowest out-of-pocket cost

    How Does This Program Affect You?
    We are dedicated to ensuring your patients receive the highest quality laboratory testing at the most reasonable cost. We can only accomplish this if we effectively manage the network of laboratory providers and if your practice accesses the laboratories that have been accredited for participation in the health plan.

    Sometimes patients may need a specialized test. BlueChoice has considered this issue and has included specialty labs and centers of excellence within the network of laboratory providers. The centers of excellence are staffed by qualified clinical pathologists and genetic counselors prepared to answer your inquiries both before and after you perform testing.

    We do not qualify all laboratories. If an out-of-network laboratory services you or you have outpatient testing performed by a hospital, your patients’ out-of-pocket cost may be significant. To ensure the lowest cost to your patients, please send BlueCross and BlueChoice members’ testing to in-network laboratories only.

    Avalon has developed a Lab Procedure Authorization matrix in an effort to help you determine when you need to contact Avalon for precertification. You can submit requests for precertification by fax or by phone. Avalon will promptly review your request and provide a timely, written decision.

    Please note that Avalon doesn't manage services in an emergency room or hospital inpatient setting. This change does not alter the available member benefits, but using these participating providers will result in a lower out-of-pocket cost for your BlueCross- and BlueChoice-covered patients.

    How Do You Contact Avalon?
    You can send prior authorization requests to Avalon by completing the Preauthorization Request Form, by calling 844-227-5769 or by faxing 888-791-2181.

    Which Laboratories are In-network?
    View a comprehensive list of the independent laboratories that are in-network. You can also use our Doctor & Hospital Finder to find participating labs. 

    What Other Resources are Available to Assist Me in Learning More About Avalon? 
    Here are reference materials about Avalon:

  • Specialty Medical Drug Prior Authorization

    Specialty Medical Drug Prior Authorization

    BlueCross® BlueShield® of South Carolina and BlueChoice HealthPlan require prior authorization for some specialty drugs billed under the medical benefit. Also, the medical benefit does not cover certain self-administered specialty drugs. 

    Drug costs continue to rise, and specialty drugs are contributing significantly to that trend. BlueChoice® has managed specialty drugs under the pharmacy benefit for several years, through prior authorization (PA), preferred drug strategies and, more recently, drug exclusions. We have also begun to manage specialty drugs under the medical benefit. Here are the current programs under the Specialty Medical Benefit Management (SMBM) strategy:

    • Prior Authorization: Some medical (injectable/infusible) specialty drugs will require prior authorization through the CVS/caremark online prior authorization tool, Novologix, an industry-leading software system that assists in managing drugs reimbursed under the medical benefit. CVS/caremark is an independent company that administers pharmacy benefits on behalf of BlueCross and BlueChoice. This tool is a web-based application available with single sign-on access through My Insurance ManagerSM
    • Self-administered Drugs: Certain self-administered drugs that were covered under the member’s medical benefit will only be covered under their pharmacy benefit. The pharmacy benefit will continue to cover these drugs. Hematologists, oncologists, nephrologists and rheumatologists may continue to bill these drugs under the medical benefit.

    Which drugs are included on the medical prior authorization and self-administered drug lists?

    Please see the two lists:

    While these lists may change at any time, we expect to make changes quarterly.

    Note: Prior authorizations for medical specialty drugs have always been a requirement for BlueChoice members. The attached is a comprehensive list that includes additional medical specialty drugs that require prior authorizations.

    What other resources are available to assist me in learning more about prior authorizations for specialty medical drugs?

    Here are reference materials about prior authorizations for specialty medical drugs: