Lab Prior Authorization

On July 22, 2015, BlueCross® BlueShield® of South Carolina announced that it will partner with Avalon Healthcare Solutions (Avalon) to administer a comprehensive suite of laboratory benefits management services to promote patients access to affordable, high quality health care. Effective January 1, 2016, BlueCross will require Avalon to precertify certain lab procedures when performed in an office, outpatient or independent lab location. Avalon is an independent company that provides benefit management services on behalf of BlueCross. Avalon relies on evidenced-based, clinically validated medical literature, published national health care guidelines, promulgated clinical protocols, the scientific and clinical expertise of its Clinical Advisory Board, and other resources as deemed appropriate by Avalon to develop its medical policies. These policies, further approved by client health plans, provide the foundation for medical necessity decision-making that promotes a member’s receipt of the right laboratory test at the right time and place. Avalon has developed a matrix in an effort to help you determine when you need to contact Avalon for prior authorization. This matrix is designed to assist you in submitting the appropriate code(s) to obtain the diagnostic information you require for your patient’s treatment plan.