Provider News

October 31, 2024

The following lists of drugs are intended to inform you of new, pending or revised criteria that has been adopted by Healthy Blue only. While these drugs are subject to prior authorization review, this list does not include the specific details surrounding the requirements.

Additionally, listed below are HCPCS codes that have recently been updated:

September 23, 2024

The following lists of drugs are intended to inform you of new, pending or revised criteria that has been adopted by Healthy Blue only. While these drugs are subject to prior authorization review, this list does not include the specific details surrounding the requirements.

Additionally, listed below are HCPCS codes that have recently been updated:

September 12, 2024

Coming soon, BlueCross BlueShield of South Carolina and BlueChoice® HealthPlan will be making changes to the prior authorization (PA) process. While you will still sign on through My Insurance Manager℠, the portal will route you to a new web-based application, powered by Cohere Health, that will enhance the efficiency of PA decisions.

These latest changes will only impact the authorizations managed by BlueCross and BlueChoice®. The prior authorization process for our third-party vendors like Evolent, Avalon Healthcare Solutions and Novologix will remain the same.

Benefits of the new process

• Accelerates and expands real-time approvals.
• Enables a more seamless provider experience.
• Decreases administrative efforts.
• Meets new CMS¹ and NCQA² requirements that shorten the time for PA decisions.

What the new process will do

• Verify member eligibility.
• Verify the provider’s network.
• Check prior authorization requirements, including medical record requirements.
• Verify procedure and diagnosis codes.
• Expand fast-track approvals and real-time responses.
• Align with our clinical policies.
• Allow for digital submission of medical records.

What you need to do

To get ready, be sure to register with Cohere Health to access the new web-based application before the implementation date. If you already have an account with Cohere Health, you do not need to create a new one. You can continue logging in as usual.

There are also available webinars and a beneficial learning center that will help prepare you for the coming changes. We encourage you to review these resources at your earliest convenience.

Lastly, if you have any additional questions, feel free to reach out to your dedicated Provider Relations Consultant, and they will be glad to assist you.

¹Centers for Medicare and Medicaid Services (CMS)

²National Committee for Quality Assurance (NCQA)

Evolent, Avalon Healthcare Solutions and Novologix are independent companies that manage utilization management services on behalf of BlueCross and BlueChoice® HealthPlan.
 

August 19, 2024

Per the direction of South Carolina Department of Health and Human Services (SCDHHS), the following changes will be made regarding COVID-19 resources effective 10/1/2024:

• COVID-19 over-the-counter (OTC) test kits will no longer be covered under the pharmacy benefit.
• COVID-19 tests will continue to be covered at a physician’s office or clinic.
• COVID-19 vaccines for beneficiaries 19 years of age and older will continue to be covered under both pharmacy and medical benefits.
• COVID-19 vaccines for beneficiaries under the age of 19 years will be covered under the Vaccines for Children (VFC) program.
   

August 5, 2024

To align with the State’s single preferred drug list (sPDL), prior authorizations are now required for all GLP-1 products.  This change may affect both current and new utilizers. Please see below for criteria provided by South Carolina Department of Health and Human Services.

Prior authorizations may be submitted by:
•    Phone: 844-410-6890
•    Fax: 844-512-9005
•    ePA

If you have further questions regarding this communication, please call Provider Services at 866-757-8286 or visit www.healthybluesc.com.

July 31, 2024

The following lists of drugs are intended to inform you of new, pending or revised criteria that has been adopted by Healthy Blue only. While these drugs are subject to prior authorization review, this list does not include the specific details surrounding the requirements.

Additionally, listed below are HCPCS codes that have recently been updated:

June 7, 2024

As a health care provider, it is important to understand cultural differences and how they can impact the care patients receive. Having the knowledge, resources and tools to offer culturally competent care is vital, and Healthy Blue is here to help you achieve this goal.

Did you know that a person’s culture can influence:

• Where and how care is accessed and how symptoms are described.
• Expectations of care and treatment options.
• Adherence to care recommendations.

Offering culturally appropriate care incorporates different skills and knowledge, such as:

• Recognizing cultural factors that shape personal and professional behavior.
• Developing an understanding of others’ needs and values.
• Producing appropriate treatment plans.
• Understanding the use of language support services to support effective communication.

For more information, please review the provider manual or visit the Improving Patient Experiences page of the website.
 

Jun. 7, 2024

Due to the pandemic, we have conducted our annual trainings virtually for the last four years. We are excited to announce that this year's Annual Provider Training will be in-person. Now that we are back under the BlueChoice umbrella we have a lot of beneficial information and updates to share.

We are offering eight in-person sessions at four different locations. Each location will have two sessions: 9 a.m. to noon and 1 p.m. to 4 p.m. To plan accordingly, the dates and locations are as follows:

Oct. 2, 2024
Embassy Suites by Hilton Greenville Golf Resort & Conference Center
670 Verdae Blvd.
Greenville, SC 29607

Oct. 8, 2024
Richland Two Institute of Innovation (R2i2)
763 Fashion Drive
Columbia, SC 29229

Oct. 15, 2024
Southern Institute of Manufacturing and Technology (SIMT)
1951 Pisgah Road
Florence, SC 29501

Oct. 21, 2024
Trident Technical College (Building 920, Salon F)
7000 Rivers Ave.
Charleston, SC 29406

The topics will be the same during both sessions, so please feel free to choose the session that works best for you.

Register today so you do not miss out. We look forward to having you!

Jun. 4, 2024

The following lists of drugs are intended to inform you of new, pending or revised criteria that has been adopted by Healthy Blue only. While these drugs are subject to prior authorization review, this list does not include the specific details surrounding the requirements.

Additionally, please review the following lists of HCPCS codes that have recent updates:

*Only applies to Secukinumab IV Soln 125 mg/5ml

Jun. 4, 2024

As you know, after Healthy Blue transitioned under BlueChoice HealthPlan, there were several new tools implemented, while some of the previous tools were no longer available. One of the tools that went away was the Prior Authorization Lookup Tool.

The Prior Authorization Lookup Tool was a feature that allowed providers to enter a CPT or HCPCS code to verify the prior authorization requirements for outpatient services. After entering the code, the results would pull in the matter of seconds.

That said, we are pleased to share with you that the Prior Authorization Lookup Tool is coming back, effective July 1, 2024. The tool will function as it previously did and will still be for outpatient services only.

In addition to checking the authorization requirements, we encourage you to always verify eligibility and benefits before rendering services. This will ensure you know whether a member has coverage for a specific service. You can verify eligibility and benefits through My Insurance Manager℠ or by calling Provider Service at 866-757-8286.

If you have any questions about this announcement, feel free to contact your dedicated consultant, and they will gladly assist you.

May 30, 2024

Effective Jul. 1, 2024, Healthy Blue will transition to a SCDHHS single preferred drug list for all providers. In addition to the drug list change, no pharmacy copays will apply for Healthy Blue members.

If you have any additional questions, please reach out to Provider Education at Provider.Education@bcbssc.com or by contacting your dedicated consultant directly.      
 

Apr. 17, 2024

For dates of service on or after March 1, 2024, SCDHHS reimburses for the following laboratory services:

• Oncotype DX® Breast Cancer Assay
• Neuropharmagen Genomic Test

Physicians Services provider manual and the Community Mental Health Services provider manual have been updated by SCDHHS to outline the coverage of these laboratory services. 

Use the following procedure codes, limitations and criteria when billing for these test as certain criteria must be met for services to be reimbursed:


 

If you have any questions regarding this bulletin, please contact Provider Education at Provider.Education@bcbssc.com.

Mar. 11, 2024

My Provider Enrollment Portal (MyPEP) is our provider enrollment portal that offers a web-based solution for providers who are credentialed or are interested in credentialing with BlueCross BlueShield of South Carolina and Healthy Blue to complete the enrollment process. Since its launch in 2022, continuous upgrades and enhancements have improved the portal’s performance to ensure applications meet the necessary requirements for completion.

At times, providers unknowingly submit applications that include errors or have incomplete sections. This results in the application being returned to the provider for corrections. When this happens, the provider must go into the portal and make the necessary corrections, as handwritten corrections cannot be accepted. The signature and date fields are the only fields that should be handwritten.

When corrections are made in the portal, the system tracks the corrections and applies them to the appropriate fields. The system will then generate the corrected document(s) for the case. The corrected document(s) will require signatures, initials and dates to be updated based on the changes.  

Going forward, if an application is returned for corrections, be sure to complete them inside the portal to avoid any potential delays. If applications are received with handwritten corrections, they will be returned.

For questions regarding this bulletin, please contact Provider Education at 803-264-4730 or Provider.Education@bcbssc.com.    

Feb. 16, 2024

Beginning March 18, 2024, Healthy Blue℠ will begin working with ProgenyHealth^®. ProgenyHealth specializes in neonatal care management services and their program will enhance services to our members.

With this program, ProgenyHealth’s neonatologists, pediatricians and neonatal nurse care managers will collaborate closely with our members, as well as attending physicians and nurses. This approach promotes healthy outcomes for Healthy Blue’s premature and medically complex newborns.

Benefits of partnering with ProgenyHealth include:

• The support of a team who understands the complexity and stress of managing infants in the neonatal intensive care unit (NICU) and will collaborate with you to achieve the best outcomes.
• A collaborative and proactive approach to care management that supports timely and safe discharge to home.
• A company that believes in sharing best practices and works with NICUs nationwide to improve the health outcomes of our next generation.

In the program, families will have dedicated care managers who will provide support and education, while having access to an “on-call” staff member 24/7. For our hospitals, ProgenyHealth will serve as a liaison for Healthy Blue providing inpatient review services and assisting with the discharge planning process to ensure a smooth transition to the home setting.

What you need to do:

For all newborns delivered by a Healthy Blue mother, you must contact ProgenyHealth directly at 888-832-2006 to notify them of the infant’s admission to the NICU or the Special Care Nursery (SCN). You can also fax the request to ProgenyHealth’s secure fax number: 877-471-0549. All admission, concurrent, transfers, and discharge reviews should be sent to ProgenyHealth beginning March 18, 2024. ProgenyHealth will follow Healthy Blue timeframes for determinations and notifications.

If you have any questions regarding this bulletin, please contact Provider Education at Provider.Education@bcbssc.com or 803-264-4730.
 

Feb. 1, 2024

On Jan. 1, 2024, Healthy Blue transitioned from Elevance to BlueChoice HealthPlan. With this change, new processes were implemented to get eligibility, benefits, authorizations and claims. My Insurance Manager (MIM) on www.HealthyBlueSC.com is the preferred method to get this information. However, there are other options available:  

Submitting claims:

For dates of services on or before Dec 31, 2023, you must:
•    Submit your claims through your clearinghouse with the payor ID 00403 and have the claims routed directly to Availity, or
•    Submit your claims with the payor id 00403 directly to Elevance’s front end Availity, or
•    Key your claims through the Availity portal.

_{Note: If you submit a claim for dates of service 1/1/2024 or after with payor ID 00403 to Availity you will get a denial.}  

For dates of service on and after Jan 1, 2024, you must:
•    Submit your claims through your clearinghouse with the payor ID 00403 and have them routed to BlueChoice, or
•    Submit your claims with the payor ID 00403 directly to BlueCross BlueShield of South Carolina’s front end, Electronic Data Interchange Gateway (EDIG). If you are not currently connected to EDIG, contact them at EDIG.Support@palmettogba.com to get set up for claim submissions, or
•    Key your claim in MIM.

_{Note: If you submit a claim for dates of service 12/31/2023 or before with payor ID 00403 to BlueCross BlueShield of South Carolina’s front end, Electronic Data Interchange Gateway (EDIG) you will get a denial.}

Eligibility and Benefits:

For dates of services on or before Dec 31, 2023, you must:

•    Call Provider Service at 866-757-8286, press 1 for eligibility, claims or benefits, and then press 1 to be routed to an Elevance agent.

For dates of service on and after Jan 1, 2024, you must:

•    Use MIM or 
•    Call Provider Services at 866-757-8286 and press 1 for eligibility, claims or benefits and you will be routed to a BlueChoice Healthy Blue agent.
_{Note: Availity will not provide 2024 eligibility or benefits for Healthy Blue members.}

Jan. 12, 2024

With the changes that went into effect as of January 1, 2024, you may have noticed a reassignment in the PCP listed on the member’s ID card. During the process to create the new 2024 ID card for some of our Healthy Blue members, the incorrect PCP was listed. We are in the process of sending impacted members new cards. Please continue to see our members. We will process your claims accordingly.

Thank you for your patience while we work to provide a quick resolution. 
 

Dec. 29, 2023

With the 2024 Healthy Blue transition under BlueChoice HealthPlan, it is important to know how to handle prior authorization requests and inquiries. For dates of service on and after Jan. 1, 2024, use the following Utilization Management (UM) contact information:

• Phone: 866-757-8286
• Medical UM Fax: 800-823-5520
• Behavioral Health UM Fax: 803-870-6506

We look forward to continuing serving you in the new year.

Sept. 18, 2023

Healthy Blue takes pride in offering the best service to our members. As a value-added benefit to our members, we will waive copays for medical services in 2024. This change will reduce barriers to care for our members and will improve their overall experience.

Note: Pharmacy copays will still apply.

Sept. 18, 2023

My Remit Manager (MRM) is free to providers enrolled with BlueCross^® BlueShield^® of South Carolina who receive electronic payments. It accepts 835 files from all commercial BlueCross plans and works independently of your claims management system or clearinghouse.

You can use MRM to:

• View ERA information by file and see all details. You can opt to view ANSI-specific details or view information in a conventional format. 
• View information categorized by check number or by patient. 
• Print individual remits for a single patient. 
• Print remits for selected patients. You can print individual or group remits.

MRM is available through My Insurance Manager^SM. You can also access MRM externally. Both options will provide the same information, but the appearance and functionalities will be different.

If you have questions or wish to sign up, contact our electronic data interchange (EDI) team at EDI.Services@bcbssc.com. 

BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross Blue Shield Association.
 

Sept. 18, 2023

My Insurance Manager^SM (MIM) is a unique online tool for providers. Once you sign up, you can log in to:

• Check benefits and eligibility in real time.
• Request prior authorization.
• Submit and track claims.
• Get remittance information.
• Send us a secure message through the “Ask Provider Services” feature.
• And much more!

You can even talk with a provider services representative online through STATchat. This fast free service is available if you have further questions about claims status, eligibility or prior authorization.

Note: MIM is not available during weekly maintenance on Sunday evenings from 5 p.m. to midnight.

Aug. 4, 2023

BlueCross^® BlueShield^® of South Carolina’s provider enrollment process has undergone a transformation with the implementation of My Provider Enrollment Portal (MyPEP), which is our web-based solution for credentialed providers or those interested in credentialing with BlueCross to complete the enrollment process.

Since its implementation in 2022, continuous upgrades and enhancements have improved the portal’s performance. One of the enhancements was the addition of the automated notifications for missing items. While this process is not new, we had not enacted this process in MyPEP to date. Due to recent timeliness regulations from South Carolina Department of Health and Human Services and other entities, it is now necessary for us to implement this process.

What this means for you:

If we receive an application but it has missing items, we will send an automated notification every seven days, with a 21-day maximum. The notification goes to the contact email address listed on the application and will include which items are missing. Once we receive the missing information, we will review the application and the additional notifications will stop.

If we do not receive the missing items within 21 days, the case will be placed into a “Canceled — Incomplete Submission” status. Once in this status, we cannot reopen the application, and the provider must submit a new application.

For questions on this bulletin, please contact the Provider Education team at Provider.Education@bcbssc.com or 803-264-4730.

BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross Blue Shield Association.

July 12, 2023

My Provider Enrollment Portal is our provider enrollment portal that offers a web-based solution for providers who are credentialed or are interested in credentialing with BlueCross^® BlueShield^® of South Carolina to complete the enrollment process. Since its launch in 2022, continuous upgrades and enhancements have improved the portal’s performance to ensure applications meet the necessary requirements for completion.

At times, providers unknowingly submit applications that include errors or have incomplete sections. This results in the application being returned to the provider for corrections. When this happens, the provider must go into the portal and make the necessary corrections, as handwritten corrections cannot be accepted. The signature and date fields are the only fields that should be handwritten.

When corrections are made in the portal, the system tracks the corrections and applies them to the appropriate fields. The system will then generate the corrected document(s) for the case. The corrected document(s) will require signatures, initials and dates to be updated based on the changes.  

Going forward, if an application is returned for corrections, be sure to complete them inside the portal to avoid any potential delays. If applications are received with handwritten corrections, they will be returned.

For questions regarding this bulletin, please contact Provider Education at 803-264-4730 or Provider.Education@bcbssc.com.

BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross Blue Shield Association.

May 22, 2023

Provider demographic data can change frequently throughout the year and in our networks. To ensure our members know where to find the right physicians or facilities for the care they need, it is vital that we validate the accuracy of their contact information regularly.

As a reminder, on Jan. 1, 2022, the Consolidated Appropriations Act (CAA) required providers to verify or update their demographic data at least every 90 days. If more than 90 days has passed since the provider’s last validation, we must suppress them from our directories.

Use M.D. Checkup, located in My Insurance Manager℠ (MIM), to validate your demographic data. Validations are determined based on the number of days since the provider’s last validation. To perform the validation, do the following:

1. Log into MIM.
2. In the purple box labeled “Provider Validation,” select Validate Now.
3. For each location with a status of “Verification Required,” select View & Edit.
4. Review and edit (if needed) the information, then select Verify.

To update suppressed locations due to missing the 90-day validation period, do the following:

1. Log into MIM.
2. In the purple box labeled “Provider Validation,” select Validate Now.
3. For each location with a status of “Suppressed from Directories,” select View & Edit.
4. Review and edit (if needed) the information, then select Verify.

We receive the provider’s data automatically once validated in MIM and update our directories.

If you have any questions about this bulletin, please contact Provider Education at Provider.Education@bcbssc.com or call 803-264-4730.