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Notification of Updates to Medical Necessity Criteria
Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Oct 31, 2026
Summary
BlueCross BlueShield of South Carolina is transitioning from MCG Care Guidelines to InterQual Criteria for medical necessity determinations effective January 1, 2027. This change applies to commercial, Medicare Advantage, and Healthy Blue (Medicaid) members across all service categories including inpatient/outpatient procedures, behavioral health, DME, and medical benefit drugs. Prior authorization requirements and submission methods remain unchanged; only the underlying criteria used for medical necessity reviews will shift.
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What to do
by Jan 1, 2027 · 6 steps
01Billing and clinical staff should familiarize themselves with InterQual Criteria to ensure medical necessity determinations align with the new guidelines.
02Access InterQual Criteria through the provider transparency link on the BlueCross BlueShield of South Carolina website.
03Note that reviews opened before January 1, 2027, will continue under MCG Guidelines through completion; only services with dates of service on or after January 1, 2027, will use InterQual.
04Prior authorization submission methods are not changing.
05Contact your Provider Relations Consultant with questions regarding the transition.
06Verify current applicability with BlueCross BlueShield of South Carolina as the effective date approaches.
Original notice
Notification of Updates to Medical Necessity Criteria
southcarolinablues.com · Always check the source before changing claims.