Prior Authorization Metrics

2025 Prior Authorization Metrics Process 

We share information each year to explain how our prior authorization (PA) process works. These metrics are numbers we gather to show how many PA requests we approve or deny. They also show how long decisions take and what happens when you appeal or ask for a review of a decision.

Services that need prior authorization

Some medical services and equipment need prior authorization. This means your doctor must get consent from us before you receive a service. This helps make sure everything is covered under your plan.

How we report prior authorization metrics

The metrics shown here combine data for all medical items and services that need consent before you get care. This does not include drugs. 

Standard prior authorization requests

Standard requests are for care that is not urgent. We review and decide most requests within normal time frames. Sometimes, we deny a request and later approve it after an appeal. Other times, we need more time to decide. When this happens, we may extend the review period for up to 7 days. Federal rules allow this. 

This table shows how many standard prior authorization requests we approved or denied in 2025. It also shows requests approved after an appeal or after an extended review. 

Standard prior authorizationPercentage
Requests approved98.86%
Requests denied1.14%
Requests approved after appeal52%

Expedited prior authorization requests

Expedited requests are for urgent medical needs. We review these requests in 72 hours. We may not report appeal or extended review data for these requests. Reporting this information is optional.

This table shows how many expedited prior authorization requests we approved or denied in 2025.

Expedited prior authorizationPercentage
Requests approved99.65%
Requests denied0.35%

Time to decision

This table shows how long decisions take. Time starts when we get the request and ends when we make a decision.

Prior authorization requestsAverage DaysMedian Days
Standard1.791
Expedited1.040

Disclaimer

Last Updated: March 26, 2026

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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.