Always check benefits through the Voice Response Unit (VRU) or My Insurance Manager^SM 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

No matter what, the following services will always require 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

Codes That Require Prior Authorization

Our Medicare Advantage plan also has specific codes that require prior authorization. View the complete list of codes to ensure you get the necessary approvals before rendering services.

This list is not all inclusive and is subject to change. It is a guide that includes the most commonly requested services requiring a medical review.

You can review Medicare Advantage's medical policies for more information.

How to Request Prior Authorization

Effective 12/19/2025, the My Insurance Manager website will redirect you to the Cohere platform. 

When you request prior authorization (PA) from us, we want the process to be fast, easy and accurate. We use the Cohere Health platform to provide you with a powerful tool to accelerate the PA process and expand real-time approvals.

You will still sign-on through My Insurance Manager so you can begin the process for medical services, but the portal will route you to the new web-based application, powered by Cohere Health, to enhance the efficiency of PA decisions.

This applies to medical and behavioral health services.

Note: All clinical decisions are made by BlueCross BlueShield of South Carolina.
 

Medical and Behavioral Health Services

• My Insurance Manager
• Medical Services Phone: 855-843-2325
• Behavioral Health Services Phone: 833-971-4075
• Fax: 803-264-6552

Laboratory Services

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.

• PAS Portal — This is Avalon's prior authorization system (PAS). If you do not have an account, request one here.
• Phone: 844-227-5769
• Fax: 813-751-3760 — Submit the Preauthorization Request Form along with supporting documentation.

Durable Medical Equipment, Home Health and Home Infusion Services

On July 5, 2023, our Medicare Advantage plans began working with Integrated Home Care Services (IHCS) for the coordination and provision of durable medical equipment, home health and home infusion services.

• Phone: 844-215-4264
• Fax: 844-215-4265
  • Include the Intake Coversheet when submitting your request.
  • Include the Oxygen Prescription Coversheet when submitting oxygen requests.