Blue cross blue shield of south carolina prior authorization form

Prior authorization lookup tool

Table of Contents Show

How to submit a request for prior authorization
Prior authorization information
Prior authorization forms
Participating specialty care health care professionals/providers
Nonparticipating health care professionals/providers
Please note:
To determine coverage of a particular service or procedure for a specific member:
To request authorizations:
Provider tools & resources
Interested in becoming a provider in the Healthy Blue network?
Provider forms
Healthy Blue Training Academy
Policies, Manuals and Guides
Learn about Availity
Prior authorizations
Behavioral health
Provider tools & resources
Interested in becoming a provider in the Healthy Blue network?

Providers are responsible for obtaining prior authorization. Providers may not bill members for services that require prior authorization and the authorization was not obtained, resulting in denial of the claim. Prior authorization requirements are inclusive of secondary claims.

Authorization is not a guarantee of payment. Other limitations or requirements may apply.

How to submit a request for prior authorization

Online: NaviNet Provider Portal https://navinet.navimedix.com > Pre-Authorization Management
By phone: 1-888-559-1010 (toll-free) or 1-843-764-1988 in Charleston
Fax: Prior Authorization Request Form to 1-866-368-4562

Prior authorization information

Prior authorization information grid (PDF)
Services requiring prior authorization
Provider Portal Participant Guide (PDF)

Prior authorization forms

General prior authorization form

Looking for pharmacy prior authorization forms?

Referrals

Participating specialty care health care professionals/providers

Select Health encourages members to seek referral from their primary care provider (PCP) for specialty care when such care is necessary. Prior authorization from Select Health is not required for participating plan specialists for office visits. Some services offered at the participating specialist’s office may require prior authorization.

Participating specialists are advised to contact Medical Services prior to delivering a service if in doubt. For coordination and continuity of care, the specialty care physician is strongly urged to communicate all findings and any needs for follow-up care back to the PCP via a consultation record.

Nonparticipating health care professionals/providers

PCPs and plan participating specialists may refer members to a nonparticipating plan specialist if there is not a participating specialist in a particular field.

However, plan health care professionals/providers who want to refer members to any nonparticipating health care professional/provider must contact Select Health’s Medical Services department for prior authorization.

Please verify benefit coverage prior to rendering services. Inpatient services and nonparticipating providers always require prior authorization.

Please note:

This tool is for outpatient services only.
Inpatient services and nonparticipating providers always require prior authorization.
This tool does not reflect benefits coverage* nor does it include an exhaustive listing of all noncovered services (i.e., experimental procedures, cosmetic surgery, etc.)— refer to your Provider Manual for coverage/limitations.

*Services may be listed as requiring prior authorization that may not be covered benefits for a particular member. Please verify benefit coverage prior to rendering services.

To determine coverage of a particular service or procedure for a specific member:

Access eligibility and benefits information on Availity
Use the Prior Authorization Lookup Tool within Availity or
Call Provider Services at 1-844-594-5072.

To request authorizations:

From the Availity home page, select Patient Registration from the top navigation.
Select Auth/Referral Inquiry or Authorizations.

Provider tools & resources

Log in to Availity
Learn about Availity
Prior authorization lookup tool
Prior authorization requirements
Claims overview
Member eligibility and pharmacy overview

Policies, Manuals and Guides
Referrals
Forms
Healthy Blue Training Academy
Pharmacy information
Electronic Data Interchange (EDI)

Interested in becoming a provider in the Healthy Blue network?

We look forward to working with you to provide quality services to our members.

We are committed to supporting you in providing quality care and services to Healthy Blue members. Here you will find frequently used forms, PDFs, provider manuals and guides, prior authorization information, practice policies, and support for delivering benefits to Healthy Blue members.

Provider forms

Provider forms are located in our online library for easy access.

Healthy Blue Training Academy

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) offers training and tutorials to support providers in continuing their education. Presentations, videos and other training documentation will be added as they become available.

Policies, Manuals and Guides

The Healthy Blue policies, manuals and guides provide key administrative information including the Quality Improvement program, the Utilization Management program, quality standards for participation, claims appeals, reimbursement and administration policies.

Learn about Availity

Many of the tools you need — such as eligibility and benefits inquiry, claims submission, claims status inquiry, and authorizations — can now be accessed by logging into your account on the Availity Portal.

Prior authorizations

Blue Cross NC makes determinations based on selected inpatient or outpatient medical services including surgeries, major diagnostic procedures and referrals to validate medical necessity.

Behavioral health

The behavioral health provider network for Healthy Blue members includes psychiatrists, psychologists, social workers, psychiatric nurses, and other mental health and employee assistance health care professionals. Our facility network includes hospital inpatient units, residential treatment centers, partial hospitalization programs, and intensive outpatient services and programs.