Effective Jan. 1, 2027, InterQual® Criteria will replace MCG Care Guidelines for medical necessity reviews across Commercial, Medicare Advantage, and Healthy Blue℠ plans.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
Effective Jan. 1, 2027, InterQual® Criteria will replace MCG Care Guidelines for medical necessity reviews across Commercial, Medicare Advantage, and Healthy Blue℠ plans.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
BlueCross BlueShield of South Carolina and BlueChoice Health Plan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
Effective Nov. 1, 2026, providers will have 90 days to appeal DRG downgrades, replacing the current 6-month appeal period.
Effective Dec. 1, 2026, Evolent will expand prior authorization management to include select interventional cardiovascular and physical medicine services.
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.
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.
PromptPA™ is a secure online prior authorization tool that enables providers to submit, track, and manage PA requests quickly and efficiently.
Effective Dec. 1, 2026: Prior authorization reviews for Marketplace medical specialty drugs will transition from MBMNow to Cohere Health, streamlining the review process.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
CMS approved updated IM and DND forms with improved readability and design. Providers must transition to the new versions by May 15, 2026.
Effective Aug. 1, 2026, BCBSSC will no longer separately reimburse potentially preventable inpatient readmissions within 30 days for related diagnoses.
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.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
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.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
BlueCross BlueShield of South Carolina will partner with Codoxo’s Provider Scope® to review coding patterns and provide education without practice changes.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
CMS issued an updated Medicare Outpatient Observation Notice (MOON) on Feb. 24, 2026, impacting BlueCross BlueShield of South Carolina Medicare Advantage plans.
Submit Continued Stay Reviews within seven days of the initial request to ensure uninterrupted care across inpatient, rehab, LTAC, and skilled nursing facilities.
As of Jan. 1, 2026, Lupron Depot moved from pharmacy to medical benefit coverage for State Health Plan members and must be billed medically.
BlueCross BlueShield of South Carolina will use Cotiviti for post‑payment reviews of select hospital claims for group and individual plans.
ClaimsXten™ (CXT) auditing expanded with a third phase effective March 2026, continuing to support accurate, compliant claims processing since 2019.
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 ensures accurate payment of high‑cost claims, applying review thresholds of $100K or $75K to protect payment integrity.
Starting April 1, 2026, BlueCross BlueShield of South Carolina will manage non‑specialty drug prior authorizations for Exchange members.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
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.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
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.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
Starting Jan. 1, 2026, Coupe Health offers self‑insured employers a simpler, more predictable healthcare option with upfront costs and high‑quality provider guidance.
As of June 9, 2025, all provider enrollment applications, agreements, and related documents can be completed using electronic signatures.
As of Oct. 1, 2025, GLP‑1 prescriptions for Type 2 diabetes must be written by authorized providers with diabetes care expertise.
Accurate provider demographic data helps keep directories up to date, ensuring members can easily find the right physicians and facilities for care.
October 2025 medical policy updates from BlueCross BlueShield of South Carolina, outlining new and revised policies, effective dates, and clinical guidance.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
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.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
Updates to GLP‑1 medication management ensure safe, FDA‑approved use, reduce off‑label demand, and protect access for members managing serious conditions.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
BlueExtend℠ is an ACA‑compliant plan offering coverage in select SC counties, using BlueEssentials in‑state and BlueCard PPO access when traveling.
BlueCross BlueShield of South Carolina uses evidence‑based medical policies to determine medical necessity; coverage depends on the member’s benefit plan.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan regularly update medical policies. Review the latest changes to stay informed on coverage decisions.
Correct coding is essential for clean claims, ensuring accurate payment, fewer denials, and faster, more timely claims processing.
