Clinical Guidelines

How Do We Use Clinical Guidelines to Make Decisions for Prior Authorizations?

BlueCross BlueShield of South Carolina uses Medicare national coverage determinations (NCDs), local coverage determinations (LCDs), best clinical practices and internal medical policies to make sure that you get the best health care.

Doctors use evidence-based clinical guidelines to make sure you get the health care you need. All criteria used are based on scientific and medical research.

Our clinical team applies clinical guidelines to make sure you are getting safe and necessary care. There are no rewards to deny or promote care.

Always talk to your doctor about your health questions or concerns. You also can check with your doctor if you have questions about prior authorizations or medical policies. 

To review NCDs and LCDs:

  1. Go to MCD Search (cms.gov).
  2. Enter the NCD/LCD number or service in the search bar.
  3. Select South Carolina as the state.
  4. Read the disclaimer and accept the terms and conditions.

MCG Guidelines

BlueCross BlueShield of South Carolina uses MCG Care Guidelines to review the medical necessity of requests covered by Medicare Advantage plans. MCG guidelines are proprietary, and BlueCross is not able to distribute them without MCG's permission. MCG has provided a tool that allows BlueCross members, prospective members and providers to view relevant MCG guidelines.

By following these instructions, you can access the MCG Care Guidelines on your web browser, but you will not be able to print or copy them:

  1. Access the MCG Care Guidelines.
  2. Read the disclaimer and accept the terms and conditions.
  3. Complete the user information form.
  4. Complete the verification process to continue.
  5. Select the arrow icon.
  6. Select the guidelines you wish to view.

Need to review a care guideline but don't have a guideline code? If you do not have a guideline code, you can search the whole list of MCG Care Guidelines.
 

Disclaimer

Last Updated: August 21, 2024

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BlueCross BlueShield of South Carolina is a Medicare Advantage PPO plan with a Medicare contract. BlueCross Rx Value is a stand-alone prescription drug plan with a Medicare contract. Enrollment in BlueCross Total, BlueCross Total Value, BlueCross Blue Basic, or BlueCross Rx Value depends on contract renewal. 

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. 

Out-of-network/non-contracted providers are under no obligation to treat BlueCross BlueShield of South Carolina Medicare members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call Customer Service or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. 

BlueCross BlueShield of South Carolina does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in our health plans, when we enroll members or provide benefits. Free language interpretation services are available for those who cannot read or speak English.