News Bulletins

Important Update: DRG Audit Appeal Timeline Changes

September 28, 2026 | Claims

Effective Nov. 1, 2026, providers will have 90 days to appeal DRG downgrades, replacing the current 6-month appeal period.

Evolent Prior Authorization Management Expanding toInclude Interventional Cardiovascular and Physical Medicine Services — Effective Dec. 1, 2026

September 28, 2026 | Authorizations

Effective Dec. 1, 2026, Evolent will expand prior authorization management to include select interventional cardiovascular and physical medicine services.

2026 July Medical Policy Updates

September 23, 2026 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

Prior Authorization Management for Medical Specialty Drugs Is Changing

September 23, 2026 | Authorizations

Effective Dec. 1, 2026: Prior authorization reviews for Marketplace medical specialty drugs will transition from MBMNow to Cohere Health, streamlining the review process.

New Prior Authorization Submission Tool Available – PromptPA™

September 23, 2026 | Authorizations

PromptPA™ is a secure online prior authorization tool that enables providers to submit, track, and manage PA requests quickly and efficiently.

2026 June Medical Policy Updates

September 23, 2026 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

Commercial GLP-1 Coverage Updates for Expanded FDA-Approved Indications

September 23, 2026 | Pharmacy

Commercial GLP-1 coverage update: Wegovy may be covered for FDA-approved MACE and MASH indications; Zepbound for OSA remains excluded under weight-loss benefit exclusions.

Musculoskeletal and Joint Surgery Prior Authorizations Moving to Evolent

September 17, 2026 | Authorizations

BlueCross BlueShield of South Carolina is committed to keeping you informed of updates that may impact your administrative processes. Please review the important information below regarding an upcoming change to prior authorization (PA) management.

Reminder: BlueExtend Plan

August 17, 2026 | Benefits and Eligibility

BlueExtend℠ is an ACA‑compliant plan offering coverage in select SC counties, using BlueEssentials in‑state and BlueCard PPO access when traveling.

2026 May Medical Policy Updates

August 13, 2026 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

Reminder: High Dollar Pre-payment Review Process

August 13, 2026 | Claims

High Dollar Pre‑Payment Review ensures accurate payment of high‑cost claims, applying review thresholds of $100K or $75K to protect payment integrity.

Updated Medicare Important Message (IM) and Detailed Notice of Discharge (DND) Forms

July 16, 2026 | Medicare Advantage

CMS approved updated IM and DND forms with improved readability and design. Providers must transition to the new versions by May 15, 2026.

Notice to South Carolina Providers: Inpatient Readmission Payment Policy Updates

July 10, 2026 | Claims

Effective Aug. 1, 2026, BCBSSC will no longer separately reimburse potentially preventable inpatient readmissions within 30 days for related diagnoses.

Important Update – Prior Authorization for DME & Home Health Services

June 4, 2026 | Authorizations

Effective Aug. 1, 2026, DME and Home Health services for BCBSSC small group and individual plans (prefixes 61, 62, 64, 65) require IHCS prior authorization.

Prior Authorization Transition from HealthHelp to Evolent — Effective July 1, 2026

May 12, 2026 | Authorizations

BlueCross will move prior authorization for some services to Evolent for certain Exchange plans on July 1, 2026. Check which plans and services are affected and how to submit requests.

2026 April Medical Policy Updates

April 29, 2026 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

New Provider Coding Education Program, Provider Scope

April 3, 2026 | Claims

BlueCross BlueShield of South Carolina will partner with Codoxo’s Provider Scope® to review coding patterns and provide education without practice changes.

2026 March Medical Policy Updates

April 3, 2026 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

Importance of Submitting Continued Stay Reviews in Cohere Health

March 25, 2026 | Authorizations

Submit Continued Stay Reviews within seven days of the initial request to ensure uninterrupted care across inpatient, rehab, LTAC, and skilled nursing facilities.

Updated MOON Notice and Requirement for Medicare Advantage

March 25, 2026 | Medicare Advantage

CMS issued an updated Medicare Outpatient Observation Notice (MOON) on Feb. 24, 2026, impacting BlueCross BlueShield of South Carolina Medicare Advantage plans.

Updates on Lupron Depot Injections for State Health Plan Members

March 11, 2026 | Benefits and Eligibility

As of Jan. 1, 2026, Lupron Depot moved from pharmacy to medical benefit coverage for State Health Plan members and must be billed medically.

New Phase Added to ClaimsXten

March 9, 2026 | Claims

ClaimsXten™ (CXT) auditing expanded with a third phase effective March 2026, continuing to support accurate, compliant claims processing since 2019.

Upcoming Post-payment Review Process Changes for Group and Individual Plans

March 9, 2026 | Claims

BlueCross BlueShield of South Carolina will use Cotiviti for post‑payment reviews of select hospital claims for group and individual plans.

2026 February Medical Policy Updates

March 4, 2026 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

Update to Pharmacy Benefit Drug Prior Authorization Process for Exchange Members

February 5, 2026 | Authorizations, Pharmacy

Starting April 1, 2026, BlueCross BlueShield of South Carolina will manage non‑specialty drug prior authorizations for Exchange members.

2026 January Medical Policy Updates

February 3, 2026 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

New Year, Same 90-Day Validation Requirements

January 6, 2026 | Other

Providers must verify or update demographic data every 90 days per CAA to remain in BlueCross BlueShield of SC directories and ensure accurate member access.

2025 December Medical Policy Updates

December 29, 2025 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

High Dollar Pre-payment Review Update for Group and Individual Plans

December 11, 2025 | Claims

Beginning Jan. 1, 2026, HDPR applies to Group and Individual claims of $75,000 or more, ensuring accurate payment and protecting against fraud and waste.

2025 November Medical Policy Updates

December 3, 2025 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

Introducing Coupe Health

December 2, 2025 | Other

Starting Jan. 1, 2026, Coupe Health offers self‑insured employers a simpler, more predictable healthcare option with upfront costs and high‑quality provider guidance.

Important Reminders for the E-sign Process for Provider Enrollment Applications

November 25, 2025 | Provider Enrollment

As of June 9, 2025, all provider enrollment applications, agreements, and related documents can be completed using electronic signatures.

Important Updates for GLP-1 Provider Taxonomy Edits

November 14, 2025 | Pharmacy

As of Oct. 1, 2025, GLP‑1 prescriptions for Type 2 diabetes must be written by authorized providers with diabetes care expertise.

Don't Forget Your 90-day Validations

November 14, 2025 | Provider Enrollment

Accurate provider demographic data helps keep directories up to date, ensuring members can easily find the right physicians and facilities for care.

2025 October Medical Policy Updates

October 31, 2025 | Medical Policies

October 2025 medical policy updates from BlueCross BlueShield of South Carolina, outlining new and revised policies, effective dates, and clinical guidance.

2025 September Medical Policy Updates

September 26, 2025 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

2025 August Medical Policy Updates

August 28, 2025 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

The New E-signing Process for Provider Enrollment Documents

August 15, 2025 | Provider Enrollment

BlueCross BlueShield of South Carolina launched My Provider Enrollment Portal 2.0 on June 9, 2025, adding e‑signatures and process improvements for easier enrollment.

2025 July Medical Policy Updates

July 29, 2025 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

2025 June Medical Policy Updates

July 14, 2025 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

2025 May Medical Policy Updates

June 9, 2025 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

Reminder: GLP-1 Utilization Management

May 9, 2025 | Authorizations

Updates to GLP‑1 medication management ensure safe, FDA‑approved use, reduce off‑label demand, and protect access for members managing serious conditions.

2025 April Medical Policy Updates

April 25, 2025 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

2025 March Medical Policy Updates

March 31, 2025 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

2025 February Medical Policy Updates

February 27, 2025 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

Have You Checked our Medical Policies?

January 31, 2025 | Medical Policies

BlueCross BlueShield of South Carolina uses evidence‑based medical policies to determine medical necessity; coverage depends on the member’s benefit plan.

2025 January Medical Policy Updates

January 30, 2025 | Medical Policies

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.

Reminder: Importance of Correct Coding

January 27, 2025 | Claims

Correct coding is essential for clean claims, ensuring accurate payment, fewer denials, and faster, more timely claims processing.