Prior Authorization

Always check benefits through the Voice Response Unit (VRU) or My Insurance ManagerSM to determine if prior authorization is required.

Prior authorization is a process used to determine if a requested service is medically necessary. Currently, Medicare Advantage requires prior authorization for these services.

Note: These requirements only apply to South Carolina members. For members who have other Blue® plans, please contact their home plan to verify the authorization requirements.

Services Requiring Universal Prior Authorization

  • All inpatient admissions — Inpatient admissions also require review if a continued stay is necessary.
    • Hospital inpatient
    • Rehabilitation facilities
    • Long term acute care
    • Skilled nursing facilities
  • Inpatient level of care for nonemergency surgery
  • Behavioral health services

Note: Behavioral health services are managed by Companion Benefit Alternatives (CBA), a separate company that offers behavioral health benefits on behalf of BlueCross BlueShield of South Carolina.

Codes That Require Prior Authorization

View the complete list of codes requiring prior authorization.

Medical Policies

You can review Medicare Advantage's medical policies for all the previously-mentioned services for more information.

Methods for Requesting Prior Authorization

Medical services

Behavioral health services

Laboratory services

DME (in the home setting), home health and home infusion services

Avalon’s Laboratory Network

Avalon also manages a network of labs. Our members pay less out of pocket when you use network labs rather than non-network labs. We urge you to use participating laboratories, when possible. 

Interested in enrolling in our lab network? Go to the Avalon website to get started.


Avalon Healthcare Solutions is an independent company that manages lab benefits on behalf of BlueCross BlueShield of South Carolina.

IHCS is an independent company that provides utilization management on behalf of BlueCross BlueShield of South Carolina.

Important Notice:

Beginning July 5, 2023, our Medicare Advantage plans will require prior authorization through Integrated Home Care Services (IHCS) for all durable medical equipment (DME) used in the home setting, home health and home infusion services. View the list of codes that will require prior authorization on this page. 

Complementary Content