Prior Authorization (an approval from BlueChoice HealthPlan Medicaid)
Your PCP will need to get an approval from us for some services to make sure they are covered. This means that both BlueChoice HealthPlan Medicaid and your PCP (or specialist) agree that the services are medically necessary.
“Medically necessary” means that the covered services or supplies you get are needed to find out what’s wrong with you and to best treat your illness, injury or disease. When a service is medically necessary and it is a covered benefit, BlueChoice HealthPlan Medicaid will pay for it as long as you are eligible.
Getting an approval will take no more than 14 calendar days, or if urgent, no more than 72 hours. See Part 5 of the August 2017 Evidence of Coverage (EOC) to see what BlueChoice HealthPlan Medicaid covers and to check service limits. Your PCP can tell you more about this.
We may ask your PCP why you need specialty care. We may not approve the service you or your PCP asks for. We will send you and your PCP a letter that tells you why we would not cover the service. The letter also will let you know how to appeal our decision.
If you have questions, you or your PCP may call the CCC number at the bottom of this page. You also may write to us at:
BlueChoice HealthPlan Medicaid
P.O. Box 100124
Columbia, SC 29202-3124
You do not need an approval from your PCP for these types of care:
- Family planning
- In-network OB/GYN services
- Emergency care
If you see a specialist or get specialty services from a provider out of the network before you get an approval from us, we will not pay for the services. If we deny a request to pay for specialty care, we will send you a letter that tells you why we denied it. The letter also will let you know how you can appeal the decision if you do not agree with the denial.
At times, the network may not have the type of doctor you need. You do not have to pay the cost to see a doctor outside your network if:
- Your PCP says you need the care of such a doctor.
- Your PCP tells you to see such a doctor and you get approval from us.