What is a prior authorization and how do I request one?

A prior authorization is a process used by health insurance providers, including Blue Cross Blue Shield of South Carolina, to determine whether a specific treatment, medication, or service is medically necessary before it can be paid for by the insurance plan. This means that the healthcare provider must first submit a request to the insurance company, providing necessary details about the patient’s condition and the proposed treatment. The insurance company then reviews this information to decide if they will approve the request based on their policies and guidelines. To request a prior authorization, the healthcare provider typically initiates the process on behalf of the patient. They usually need to complete a specific form or provide detailed information through an online portal or by calling the insurance company's customer service line. It is important for the provider to include all necessary clinical information, such as medical history, diagnostic tests, and the rationale for the proposed treatment to support the request. Patients may want to discuss the need for a prior authorization with their healthcare provider, as the provider can guide them through the process. Patients can also find helpful information and resources about prior authorizations on the Blue Cross Blue Shield of South Carolina website, including the specific requirements and any potential appeals process if a request is denied.