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.

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

How to Request Prior Authorization

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.

DME (in the home setting), 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 in the home setting, 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.