Preauthorization

Medi-Call Treatment Pre-Certification

Before you have certain treatment or care, you may need to call us for pre-certification. Please call us before you receive these services, or 48 hours after an emergency. If you don't, you'll have to pay $200! And the costs you have for your treatment will not go towards your out-of-pocket limit. Just call Medi-Call at 803-699-3337 or toll free 800-925-9724.

Procedures that require pre-certification:

  • All hospital admissions.
  • Pregnancy (must call within 12 weeks or there will be an additional $200 penalty).
  • Any non-emergency surgery (e.g., septoplasty, hysterectomy or sclerotherapy) you have in a hospital, free-standing clinic or ambulatory surgical center.
  • All admissions for obstetrical and sick newborn services.
  • Hospitalizations that are longer than the length of stay that Medi-Call previously authorized.
  • Chemotherapy or radiation therapy.
  • In vitro fertilization for you or your spouse.
  • Extended care services, such as hospice, home health care, skilled nursing facility or durable medical equipment.
  • Any medical treatment involving inpatient rehabilitative services and extended care.
  • Organ transplant, bone marrow transplant or other stem cell rescue or tissue transplant that are covered in your health plan.
  • A pre-certification request for any procedure that may potentially be considered cosmetic in nature (e.g., blepharoplasty, reduction mammoplasty, TMJ or other jaw surgery, etc.), must be received in writing by Medi-Call seven days before surgery.

To check claims status, view an explanation of benefits (EOB), check eligibility and benefits and much more, log in to My Health Toolkit®.

Advanced Radiology Preauthorization

South Carolina network physicians, radiology (imaging) centers and outpatient hospital radiology centers will be responsible for requesting advanced radiology preauthorization from National Imaging Associates (NIA). NIA is an independent company that handles preauthorization for certain imaging services on behalf of BlueCross.

If a subscriber or a covered family member is scheduled to receive a CT, MRI, MRA or PET scan from an out-of-network provider in South Carolina, it is the subscriber's responsibility to make sure the provider calls for preauthorization. A subscriber can begin the process by calling NIA at 866-500-7664. The subscriber should be able to give NIA the name and phone number of the imaging center or the physician who will provide the radiology service.

NIA will make a decision about non-emergency preauthorization requests within two business days of receiving the request from the provider. If the situation is urgent, NIA will make a decision within one business day of receiving the request from the provider. The process may take longer, however, if NIA needs additional clinical information.

Doctors can get more information by calling 800-444-4311. To request preauthorization online, providers can go to NIA's website, www.RadMD.com. They can also call NIA at 866-500-7664, Monday through Friday, from 8 a.m. to 8 p.m., ET.

Subscribers can check the status of preauthorization requests online through My Health Toolkit.

What Are the Penalties for Not Calling?

If a South Carolina network physician or radiology center does not request preauthorization, BlueCross will not pay the provider. The provider cannot bill the subscriber for the service.

If a subscriber or a covered family member receives advanced radiology services from an out-of-network provider in South Carolina or from any provider outside South Carolina without preauthorization, BlueCross will not pay the provider. The subscriber will be responsible for the entire bill.

Specialty Medication Preauthorization

Specialty medications are prescription drugs that are used to treat complex or chronic medical conditions. These might include cancer, rheumatoid arthritis, multiple sclerosis and hepatitis. Specialty drugs may be physician-administered or self-injected. For a list of medications that require prior authorizations, click here.

For most specialty medications, a doctor must request prior authorization. Doctors can access the preauthorization system by signing in to My Insurance Manager℠. Or they can request prior authorization by calling 866-284-9229 or faxing 844-851-0882.

Additionally, beginning October 1, 2018, some of these drugs will only be approved for administration in certain settings, or sites of care. These may include an infusion suite or even the member’s home with the help of a home-health nurse. For these drugs, a prior authorization will only be granted for the drug in an approved place of service. For a list of drugs subject to site of care requirements, click here.

A typical prior authorization is valid for up to one year. This may vary based on the medication and its dosing schedule. The doctor will receive an expiration notification by mail or fax at least 60 days before the prior authorization expires.

If you have questions, please contact BlueCross customer service at 800-868-2520.