Prior authorization requirements
Determine how to submit authorization requests and what services require prior authorization.
Submit prior authorization requests
Wellpoint South Carolina, Inc. accepts prior authorization requests via through Availity or, if you prefer paper submissions, via phone or fax.
Please visit our Forms page for all prior authorization forms.
To request or check the status of a prior authorization request or decision for a particular plan member, log in to Availity and select Patient Registration and select Authorizations & Referrals.
ICR tool
Our ICR tool via Availity* is the preferred method for submitting prior authorization requests for physical health, offering a streamlined and efficient experience for providers requesting inpatient and outpatient medical services for our members. Additionally, providers can use this tool to make inquiries on previously submitted requests, regardless of how they were sent (phone, fax, Interactive Care [ICR] Reviewer or other online tool).
To request or check the status of a prior authorization request or decision for a particular plan member, access our ICR tool via Availity. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate.
Need more assistance with authorization?
Check out our Prior authorization lookup tool to determine prior authorization requirements or refer to your Provider manual for assistance.
Behavioral health
Please submit all prior authorization requests through our preferred method at Availity.com.
Services billed with the following revenue codes always require prior authorization:
- 0240–0249 — All-inclusive ancillary psychiatric
- 0901, 0905–0907, 0913, 0917 — Behavioral health treatment services
- 0944–0945 — Other therapeutic services
- 0961 — Psychiatric professional fees
Pharmacy
Services billed with the following revenue codes always require prior authorization:
- 0632 — Pharmacy multiple sources
Formulary
Please refer to the South Carolina Medicare formulary when prescribing for Medicare members. For more information please refer to your South Carolina Medicare provider manual.
South Carolina Medicare formulary
For prescriber prior authorization providers can call the pharmacy help desk.
Pharmacy Help Desk: 1-833-377-4266
Elective services
Elective services provided by or arranged at nonparticipating facilities always require prior authorization.
Interested in becoming a provider in the Wellpoint network?
We look forward to working with you to provide quality service for our members.