Jan. 23, 2023

On Oct. 5, 2022, it was announced that BlueCross BlueShield of South Carolina’s Medicare Advantage plans would soon require prior authorization for additional molecular diagnostic testing services through Avalon Healthcare Solutions. This implementation is now in effect as of Jan. 23, 2023.

Prior authorization requests include a clinical review for medical necessity using the following guidelines from the Centers for Medicare & Medicaid Services (CMS):

• National coverage determinations (NCD)
• Local coverage determinations (LCD)
• Local coverage articles (LCA)
• And other nationally accepted guidelines

Medicare Advantage follows Milliman clinical guidelines (MCG) where no CMS guidance applies.

View the list of CPT codes that require prior authorization. Note: This list is a general reference and may not be all inclusive.

The following options are available to request prior authorization.

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

For questions, please contact the Medicare Advantage team at 855-204-2744.

CMS is an independent organization that offers health information you might find helpful. 

Avalon is an independent company that provides laboratory network management on behalf of BlueCross BlueShield of South Carolina.