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Notification of Updates to Medical Necessity Criteria

Oct. 29, 2026

BlueCross BlueShield of South Carolina is committed to ensuring that our medical necessity criteria remain evidence-based, clinically appropriate, and aligned with current standards of care.

Effective Jan. 1, 2027, we will use InterQual Criteria in place of MCG Care Guidelines for medical necessity review of commercial, Medicare Advantage, and Healthy Blue℠ members.

The InterQual® Criteria portfolio provides evidence-based clinical decision support designed to help ensure members receive the right care, at the right level of care, and in the most appropriate setting. Criteria are developed through a rigorous evidence review process and are regularly updated to reflect current standards of care and emerging clinical evidence.

Effective date

InterQual will apply to services with a date of service on or after Jan. 1, 2027. Reviews opened before Jan. 1, 2027, will continue under MCG through completion.

Services affected 

  • Inpatient diagnostic, surgical, and other therapeutic services and procedures
  • Outpatient diagnostic, surgical, and other therapeutic services and procedures
  • Behavioral health services and procedures, both inpatient and outpatient
  • Durable medical equipment
  • Drugs billed under the medical benefit, including Part B medications 
  • All other services and procedures requiring medical necessity determination
  • Surgical procedures

When InterQual is used

InterQual will be used when an internal clinical policy is not available for the service being authorized. Where an internal policy exists, that policy continues to apply.  

  • For Medicare Advantage members, Medicare coverage rules continue to apply first.  
  • For Healthy Blue members, Medicaid coverage rules continue to apply first.

What is not changing

Prior authorization requirements and submission methods are not changing. Only the criteria used to determine medical necessity are changing.

How to access the criteria

InterQual Criteria will be available on our website through the InterQual transparency link. 

Questions

If you have questions regarding these updates, please contact your Provider Relations Consultant.

 

Healthy Blue is offered by BlueChoice® HealthPlan of South Carolina. BlueChoice® HealthPlan of South Carolina is an independent licensee of the Blue Cross Blue Shield Association.