How to Fill Out and Submit the BCBS SC Prior Authorization Form

The BCBS SC prior authorization form is submitted by your provider, almost always electronically through the Cohere Health portal that BlueCross BlueShield of South Carolina now uses for medical and behavioral health requests. Fax is the backup. Pharmacy drugs follow a separate track. Below is what the submission needs, where it goes, how long it takes, and what to do if it comes back denied.

What You Need Before Submitting

Most administrative denials happen because something was missing at submission, not because the care wasn’t justified. Have these in hand first:

Member ID number from the front of the BCBSSC insurance card.
Provider identifiers for the ordering provider, performing provider, and facility — each needs a Tax Identification Number (TIN) or 10-digit National Provider Identifier (NPI). The Cohere Health portal has a TIN search that pulls these automatically.
Procedure codes. CPT or HCPCS codes for the requested service. A CPT code is required for all outpatient authorizations. For inpatient services, a diagnosis code alone may be enough to start the request.
Diagnosis codes. ICD-10 codes explaining medical necessity.
Service type. Inpatient or outpatient; the portal asks upfront.
Clinical documentation. Office notes, lab results, imaging reports, or other records that support medical necessity.

Emergency room notifications do not require CPT codes and follow a faster, separate track.¹ These requirements come from the BCBSSC authorization workflow.²

Submitting Through the Cohere Health Portal

This is the fastest route and the one BCBSSC prefers. Providers sign in through My Insurance Manager at provider.bcbssc.com, and the system routes them into the Cohere Health application to complete the request.³

If your practice hasn’t used Cohere Health before, one administrator from the organization registers at coherehealth.com/provider/register and then manages user access for everyone else. Only one portal account per organization is needed, and any registered user can view authorizations submitted by anyone else under the same TIN, so a request doesn’t disappear when the submitter is out of the office. Support runs Monday through Friday, 8 a.m. to 5 p.m. EST at 888-787-0309 or bcbs-sc.support@coherehealth.com.¹

Cohere Health covers all BCBSSC plans and subsidiary health plans except Medicare Advantage, and it does not cover autism-related services. Members can log in to My Health Toolkit to check the status of a request, but the actual submission is handled on the provider side.⁴

Submitting by Fax

When the portal isn’t an option, the completed prior authorization form and supporting clinical documentation can be faxed. The right number matters; BCBSSC has flagged that many requests arrive at the wrong fax line, which delays everything.⁵

Medical services (non-Medicare Advantage): 803-264-6552.
Medicare Advantage: 813-751-3760, with the Preauthorization Request Form and supporting documentation.⁶

Send a separate fax for each patient. Bundling multiple patients into one transmission slows processing. If any part of the form is handwritten, print legibly so the scanning systems can read it.

Pharmacy Prior Authorization

Prescription drug requests do not go through Cohere Health. BCBSSC points providers to its “Prescribing Nonspecialty and Specialty Drugs” resources for pharmacy-specific guidance, and the submission channel depends on the plan.³

For Exchange plan members (group numbers starting with 61, 62, or 65), a change took effect April 1, 2026: BCBSSC now internally manages non-specialty drug prior authorization requests instead of routing them through OptumRx. The preferred submission method is CoverMyMeds (CMM), an electronic prior authorization portal. Phone submissions go to 1-833-494-2987 and fax to 1-803-462-5000.⁷

Which Services Need a Prior Authorization

Before filling out anything, confirm the service actually requires pre-approval under the specific plan. BCBSSC publishes a standard prior authorization list that it updates periodically and describes as “not all inclusive and is subject to change.”³ Categories that commonly require it:

Laboratory services: certain genetic tests and advanced lab panels.
Musculoskeletal care: joint surgeries, spinal procedures, related treatments.
Radiology: advanced imaging such as MRIs, CT scans, PET scans.
Radiation oncology: cancer radiation treatment plans.
Specialty medical drugs: infused or injected medications given in a clinical setting.
Non-specialty drugs: certain prescription medications under the pharmacy benefit.
Durable medical equipment: wheelchairs, CPAP machines, home infusion equipment.

Because plan designs vary, a service requiring prior authorization under one BCBSSC plan may not require it under another. Providers can verify for a specific member through the Voice Response Unit (VRU) or My Insurance Manager.³ Skipping the step when it was required means the plan can deny the claim entirely; the general exception is emergency care.⁸

Decision Timelines and Tracking

Expedited requests for urgent medical needs receive a decision within 72 hours.⁸ The portal has an urgent flag, and BCBSSC asks providers to use it only when the situation truly qualifies.² Standard turnaround times vary by plan; check the plan documents or call BCBSSC customer service for the specific window.

Providers track pending requests through the Cohere Health dashboard, which shows pending, under review, or finalized status. Members can track through My Health Toolkit. BCBSSC sends the final decision to both the provider and the member.

If the Request Is Denied

A medical-necessity denial doesn’t end the process. The treating physician can request a peer-to-peer discussion with a BCBSSC Medical Director before filing a formal appeal, and this is often the fastest way to reverse a denial because the Medical Director decides at the end of the call. The window is short:

Concurrent denials (care already in progress): request within 2 business days of the denial.
Pre-service denials (care not yet started): request within 5 business days of the denial notification, and before filing a formal appeal.

The treating physician completes the Peer to Peer Request Form, including new clinical information supporting medical necessity. Submit by fax to (803) 264-9175, by email to Peer.Medical@BCBSSC.com, or online through the Medical Forms Resource Center. BCBSSC makes two attempts to reach the provider at the date and time listed on the form; if none is listed, the call comes within one business day. A representative, nurse, or assistant who can retrieve the physician can take the call in the physician’s place. Peer-to-peer is not available for denials based on contract exclusions or exhausted benefits, and it doesn’t cover services managed by National Imaging Associates (NIA), OptumRx, or Caremark — those have their own review processes. Questions go to (803) 264-8114.⁹

If the denial still stands, you have 180 days from the date on your Explanation of Benefits (EOB) to file a written appeal. Call the customer service number on the front of your EOB first to confirm your appeal rights and get plan-specific instructions. The written appeal must include your name and Member ID, the patient’s name, the claim number from the EOB, the name of the person filing, and whether that person is the member, the patient, or an authorized representative. If someone other than the member files, a signed Designation of Authorized Representative to Appeal form must come with it. Mail to the address in the appeal rights section of the EOB. Urgent situations may qualify for expedited internal review; ask customer service when you call.¹⁰

If the internal appeal is also denied, South Carolina law allows an independent external review when the denial was based on medical necessity or on the treatment being considered experimental, the amount at stake is at least $500, and the internal appeal process has been exhausted. Standard requests must be submitted in writing within 60 days of the denial, with a signed Medical Records Release form; the Independent Review Organization (IRO) issues a decision within 45 days. Expedited external review, available when a physician certifies a serious condition requiring immediate treatment, must be requested within 15 days of the denial, and the IRO decides within three working days.¹¹

1
BlueCross BlueShield of South Carolina. Blue Cross Blue Shield of South Carolina Cohere Health FAQ
2
BlueCross BlueShield of South Carolina. Authorizations
3
BlueCross BlueShield of South Carolina. Prior Authorization
4
BlueCross BlueShield of South Carolina. My Health Toolkit
5
BlueCross BlueShield of South Carolina. Reminder: Requesting Prior Authorization for Medicare Advantage Members
6
BlueCross BlueShield of South Carolina. Prior Authorization – Medicare Advantage
7
BlueCross BlueShield of South Carolina. Update to Pharmacy Benefit Drug Prior Authorization Process for Exchange Members
8
BlueCross BlueShield of South Carolina. Referrals and Prior Authorization
9
BlueCross BlueShield of South Carolina. Peer to Peer Discussion Request Form
10
BlueCross BlueShield of South Carolina. Appeal a Denied Claim
11
Allied National. South Carolina External Claim Review Information Packet