What You Need to Know About Precertifications and Referrals
PRE-CERTIFICATION/REFERRAL USER GUIDE
What You Need to Know About
Precertifications and Referrals
1
PRE-CERTIFICATION/REFERRAL USER GUIDE
Here at BlueCross BlueShield of South Carolina and BlueChoice HealthPlan, we always look for ways to
streamline our precertification and referral process. Therefore, we have made it easy for you to
request precertifications online for many inpatient and outpatient services or to request a referral.
We have designed this guide so you will know the services that will be automatically authorized
through My Insurance ManagerSM.
This guide also details which services will pend further review when you request authorizations
through My Insurance Manager. A pended authorization is review of information from the
precertification request, along with any supporting documentation to determine medical necessity of
the treatment.
Finally, we have added those referrals that are automatically approved for all BlueChoice? members
when performed on the web regardless of the specific diagnosis or procedure code(s).
If you have questions or need additional information about precertifications or referrals, please
contact your provider advocate.
Before we review the procedures that will be automatically authorized through My Insurance
Manager, let¡¯s review the procedures for which we may not grant an instant precertification or
referral.
1. Your patient¡¯s benefit plan does NOT require precertification for a particular service. In this
instance, you do not need to get a precertification and will not receive a precertification
number, if requested.
2. The group requires ALL of their precertifications to pend for further review.
3. The service requires precertification through another entity (like National Imaging Associates or
NIA). If services require precertification through NIA, you will be prompted to contact them for
precertification. NIA is an independent company that authorizes certain radiology procedures
on behalf of BlueCross and BlueChoice.
4. You use the customized feature. Unlisted services or services authorized through the
customized authorization feature in My Insurance Manager will always pend for clinical review.
Please note: This guide is for training purposes only. This is not a guarantee of payment. Non-payment
of premiums and other contractual limitations may result in denial of benefits or refunds.
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PRE-CERTIFICATION/REFERRAL USER GUIDE
BlueCross BlueShield of South Carolina Automatic Authorizations for
INPATIENT HOSPITAL PROCEDURES
If your service contains this criteria, you will receive an automatic authorization number when you
request precertification through My Insurance Manager.
ABDOMINAL AORTIC ANEURYSM
APPENDECTOMY/NOT
PERFORATED
BREAST RECONSTRC-GRAFT/FLAP
CAROTID ENDARTERECTOMY
DISKECTOMY
FRACTURE-OPEN REDUCTION
MASTECTOMY, RADICAL
(NEOPLASM)
NEPHRECTOMY
PTCA
THORACOTOMY/MINOR, MAJOR
TOTAL KNEE
ANTERIOR CERVICAL
DECOMPRESSION
APPENDECTOMY/RUPTURED
C-SECTION, BCBSSC
COLECTOMY
EXPLORATORY LAPAROTOMY
HEART STENT PLACEMENT
MASTECTOMY, SIMPLE
(NEOPLASM)
PELVIC BONE FX (OPEN)
SALPINGECTOMY/TUBAL PREG
THYROIDECTOMY, PARTIAL
TURP
AORTIC VALVE REPLACEMENT
ARTHRODESIS-CERVICAL, THORACIC,
LUMBAR
CABG
CRANIOTOMY
FRACTURE-CLOSED REDUCTION
HYDROCEPHALUS, VP SHUNT
MITRAL VALVE
REPLACEMENT/REPAIR
PROSTATECTOMY
SPLENECTOMY
TOTAL HIP
BlueCross BlueShield of South Carolina Automatic Authorizations for
OUTPATIENT FACILITY PROCEDURES
If your service contains this criteria, you will receive an automatic authorization number when you
request precertification through My Insurance Manager.
ANGIOGRAM
ARTHROSCOPY, KNEE
BREAST BIOPSY
BUNIONECTOMY
CARPAL TUNNEL RELEASE
COLONOSCOPY
CT OF EXTREMITY
CT OF PELVIS
D&C
EGD
ENDOSCOPIC SINUS SURGERY
EXCISION RECTAL TUMOR
HAMMER TOE REPAIR
HERNIA REPAIR-INGUINAL
LAP CHOLECYSTECTOMY
MAMMOGRAM
MRA UPPER EXT W/WO CONTRAST
ARTERIOGRAM
ARTHROSCOPY, ROTATOR CUFF
BREAST RECONSTRUCT-TISSUE
EXPANSION
CARDIAC CATH
CATARACT EXTRACTION
COLPOSCOPY
CT OF HEAT/NECK
CT SCAN
DIAGNOSTIC LAPAROSCOPY
EGD, COLONOSCOPY,
FLEXSIGMOID COMBO
ESOPHAGOSCOPY
GASTROSCOPY
HEMORRHOIDECTOMY
HYSTEROSCOPY
LARYNGOSCOPY
MRA OF ABDOMEN
MRI OF SHOULDER
ARTHROGRAM
ARTHROSCOPY, SHOULDER
BRONCHOSCOPY
CARDIAC STRESS TEST
CIRCUMCISION
CT OF ABDOMEN
CT OF SPINE
CYSTOSCOPY
ECHO
ENDOMETRIAL ABLATION
ETHMOIDECTOMY
GROSHONG CATHETER PLACEMENT
HERNIA REPAIR-IN/INC/UMB
INCISION WITH DRAINAGE
LITHOTRIPSY
MRA OF HEAD
MRD OF ABDOMEN
3
PRE-CERTIFICATION/REFERRAL USER GUIDE
BlueCross BlueShield of South Carolina Automatic Authorizations for
OUTPATIENT FACILITY PROCEDURES (continued)
If your service contains this criteria, you will receive an automatic authorization number when you
request precertification through My Insurance Manager.
MRI OF EXTREMITY
MYELOGRAM
ORTHOPEDIC BONE PROCEDURE
EXCISION PILONIDAL CYST
SPHINCTEROTOMY, ANAL
MRI OF HEAD/NECK
MYRINGOTOMY
ORTHOPEDIC MUSCLE PROCEDURE
PORTA CATH, INSERTION
STRABISMUS
T&A
TURBINECTOMY
ULTRASOUND/GRAVID UTERUS
WOUND CLOSURE
THORACENTESIS
TYMPANOSTOMY
ULTRASOUND/HEAT & NECK
MRI OF SPINE
NERVE BLOCK
ORTHOPEDIC NERVE PROCEDURE
RADIATION/OUTPATIENT
SURGICAL TREATMENT, ANAL
FISTULA
TRIGGER FINGER RELEASE
ULTRASOUND/BREAST & LUNG
ULTRASOUND/HEART
BlueCross BlueShield of South Carolina Automatic Authorizations for
NON-PROCEDURE INPATIENT HOSPITAL
If your service contains this criteria, you will receive an automatic authorization number when you
request precertification through My Insurance Manager.
ACUTE RENAL FAILURE
ASTHMA
CARDIAC ARREST
CHEMOTHERAPY/LOS 3 DAYS
CHEST PAIN - R/O MI
CNS BLEED
CONGESTIVE HEART FAILURE
CVA-CONFIRMED
DRUG OVERDOSE
GASTRITIS
HEPATIC ENCEPHALOPATHY
MENINGITIS (CONFIRMED)
OTITIS MEDIA
PLEURAL EFFUSION
PULMONARY EMBOLISM
R/O MENINGITIS
RSV PNEUMONIA (PEDS)
SEPSIS
SICKLE CELL CRISIS
TIA
ACUTE RESPIRATORY FAILURE
ATRIAL FIBRILLATION
CARDIAC ARRHYTHMIA
CHEMOTHERAPY/LOS 5 DAYS
CHOLECYSTITIS
COLITIS
COPD
DIVERTICULITIS
DVT
GASTROENTERITIS
HYPERTENSIVE CRISIS
NEUTROPENIA
PANCREATITIS
PNEUMONIA
PYELONEPHRITIS
R/O SMALL BOWEL OBSTRUCT
SALPINGECTOMY/TUBAL PREG
SEVERE ANEMIA, PANCYTOPENIA
SINUSITIS
VAGINAL DELIVERY, BLUECROSS
ASCITES (INTRACTABLE)
BPH
CELLULITIS
CHEMOTHERAPY/LOS 7 DAYS
CHRONIC RENAL FAILURE
CONFIRMED MI
CROHN'S DISEASE
DKA
DVT (REGIME LEVINOX)
GI BLEED
INTESTINAL OBSTRUCTION
OSTEOMYELITIS
PELVIC BONE FX-CLOSED
PNEUMOTHORAX
PYELONEPHRITIS CHRONIC
RENAL CALCULI
SEIZURES (NEW ONSET)
SHORTNESS OF BREATH
SYNCOPE
4
PRE-CERTIFICATION/REFERRAL USER GUIDE
BlueCross BlueShield of South Carolina Automatic Authorizations
NON-PROCEDURE OUTPATIENT FACILITY
If your service contains this criteria, you will receive an automatic authorization number when you
request precertification through My Insurance Manager.
BONE SCAN
CHEST X-RAY
EEG
LAB CBC
LAB PT/INR
SLEEP STUDIES
X-RAY EXTREMITIES
CARDIOVERSION
DOPPLER STUDIES
EKG
LAB METABOLIC PANEL
LAB URINALYSIS
THYROID/PARA THYROID SCAN
X-RAY HEAD/NECK
CHEMOTHERAPY/OUTPATIENT
DUPLEX SCAN
EMG
LAB PSA
LUMBAR PUNCTURE
X-RAY ABD
BlueCross BlueShield of South Carolina Automatic Authorizations
NON-PROCEDURE HOME
If your service contains this criteria, you will receive an automatic authorization number when you
request precertification through My Insurance Manager.
AFO, PREFABRICATED
CANE
DIABETIC SHOES/INSERTS
LIFTS
PEAK FLOW METER
UPPER LIMB ORTHOSIS
WALKING BOOT, PNEUMATIC
WRIST/HAND/FINGER ORTHOSIS
BREAST PROSTHESIS
COMPRESSION SUPPORT HOSE
(ANTI-EMB)
GLUCOMETER
MASTECTOMY BRAS
PHOTOTHERAPY
VAGINAL DELIVERY, STATE
WHEELCHAIR PURCHASE
C-SECTION, STATE
DCPM WALKER
INSERTS/ORTHOTICS
NEBULIZER WITH COMPRESSOR
PREGNANCY NOTIFICATION,
BLUECROSS
WALKING BOOT, NON-PNEUMATIC
WHEELCHAIR RENTAL
Now that we have covered the services that are automatically authorized through My Insurance
Manager, let¡¯s take a look at the services that will pend when you submit a customized request in My
Insurance Manager.
Remember, unlisted services or services you submit through the customized authorization feature in
My Insurance Manager will always pend for clinical review. You will not receive an automatic
authorization when you use this option. Also, you do not need to submit any additional medical
information for the procedure (unless we ask you to provide it). Please remember to use the Provider
Web Note field to add all pertinent medical information to warrant the requested authorization.
Here are services that will pend when you request an authorization.
5
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