Overview
This article houses some of our most frequently asked questions and their answers for Blue Cross Blue Shield of South Carolina specifically.
My previous experience submitting prior authorization requests to BlueCross BlueShield of South Carolina only required me to select the general type of request. Why do I now have to input procedure codes?
When submitting a prior authorization request through the Cohere portal, you are now required to input specific procedure codes for review and decision-making. This ensures greater accuracy and faster processing of your request, as the codes provide detailed information necessary for a thorough review.
I’m trying to submit a prior authorization request for a planned inpatient procedure/admission. Why is the Cohere portal requiring me to add a date range/length of stay (LOS) if the patient is not yet admitted?
Even though the patient has not yet been admitted, the request must be reviewed for the medical necessity of both the procedure and the anticipated duration of the patient’s stay. The requested length of stay (LOS) should reflect the number of days the provider expects the patient to remain admitted for services related to the procedure.
If you’re unsure of the required LOS for the procedure, you can initially request one day. Once the patient has been admitted, if additional days are needed, you can submit a Continued Stay Review (CSR) to request approval for an extended stay.
What happens if a request has a status of “pending review”?
If the Cohere portal is unable to auto-approve your authorization, it will be placed in a “pending review” status. This means that a team of BlueCross BlueShield of South Carolina physicians and nurses are reviewing your request against the appropriate guidelines.
An authorization can pend for many different reasons that require the clinical team to review in order for the final decision to be made.
If the clinical teams reviewing the authorization have any questions or need any additional information and/or documentation in order to decision the request, you will be contacted.
Once a decision has been made, the submitter will receive a letter from BlueCross BlueShield of South Carolina with the decision.
What happens if I try to submit a Medicare Advantage (MA) request?
Cohere is not delegated to process Medicare Advantage (MA) requests for BlueCross BlueShield of South Carolina. When attempting to submit an MA request you may receive the following message instructing you not to proceed.
Please submit your request to Medicare Advantage by contacting BlueCross BlueShield of South Carolina at:
Medical Services Phone: 855-843-2325
Behavioral Health Services Phone: 833-971-4075
Fax: 803-264-6552
How is my Healthy Blue request for an observation (short) stay processed through Cohere?
In most cases, observation stays do not require prior authorization. However, if an inpatient admission request is submitted and the diagnosis is not on the approved exception list (see below), you will see the following message suggesting that observation may be more appropriate.
If you proceed with the request for an admission, the request will pend and be sent to Healthy Blue to be reviewed manually.
If the service you are submitting for is one of the services listed below, you will not receive the above message and can proceed with your submission.
Are there any visibility restrictions with Behavioral Health authorizations?
To protect sensitive health information, authorizations related to behavioral health, substance abuse, or HIV/AIDS services are only fully visible and editable to the user who submitted them. Other users, including those from the same or different organizations, will have limited access to details such as status, tracking information, and submitter information. Click here for more details.
What Place of Service (POS) should I select when submitting requests for Intensive Outpatient (IOP) or Partial Hospitalization Program (PHP) services?
Both IOP and PHP services should be submitted as Outpatient. Currently, the only POS option available in the dropdown is Psychiatric Facility – Partial Hospitalization. This should be selected for both IOP and PHP, even though it may not perfectly reflect IOP.
If you’re submitting via fax, please clearly label IOP and PHP services and include CPT or Rev codes.
How to load solo provider information when submitting a request?
If you are submitting as a solo provider, you will need to follow the steps below:
Solo Providers will first enter the NPI number into the 'Ordering provider' box
Once the name is displaying, click on the check box for 'Performing or attending provider'
Once the name is displaying, click on 'Performing provider is a solo practitioner'
Users will then enter the following information: Facility NPI- solo providers NPI Number, Facility name-practice name, Address, City, State, Zip, optional for phone number and fax number to be included.
User should then take a moment to review and ensure all the information that has been entered is correct before clicking the 'Validate Address' box.
Important Notes:
If there is an issue with the information entered (ex. misspelling of street name) users will receive an error is not validated, user will not be able to move forward.
A manually entered Solo provider may display as network unknown in the Performing Facility.