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Coverage Decisions & Appeals

Coverage decisions are decisions we make about whether a service is covered by the plan and the amount, if any, we are required to pay for the service. Coverage decisions are also called organization determinations. If you are not satisfied with the outcome of a coverage decision, you can appeal the decision by requesting a plan reconsideration. Learn more about coverage decisions and reconsiderations, and filing grievances. Call a customer service representative to get an aggregate number of grievances and appeals filed with BlueCross Total.

To request a coverage decision or reconsideration:

You can name another person to act as your “representative” and ask for a coverage decision or reconsideration on your behalf, such as a friend, relative, doctor or other prescriber. To have a representative act on your behalf, both you and the representative must sign the Appointment of Representative form.

More Important Information

How to Contact Us

To Enroll: 1-800-930-2836 (TTY 711). Calls to this number are answered by a licensed insurance agent
Already a Member: Call our Customer Service representatives at 1-855-204-2744 between 8 a.m. – 8 p.m. (Eastern Time), seven days a week.
AddressMedicare Advantage, BlueCross BlueShield of South Carolina, P.O. Box 100191, Columbia, SC 29202-3191
Provider Services: 1-855-209-7267
Prior Authorization Fax: 1-803-264-6552
Mental Health: 1-800-868-1032

BlueCross BlueShield of South Carolina is a Medicare Advantage PPO and HMO plan with a Medicare contract. BlueCross Essential, Rx Value and BlueCross Rx Plus are stand-alone prescription drug plans with a Medicare contract. Enrollment in BlueCross Total, BlueCross Total Value, BlueCross Blue Basic, BlueCross Secure, BlueCross Essential, BlueCross Rx Value or BlueCross Rx Plus 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. Read our Non-Discrimination Statement and Foreign Language Access policy.