What is prior authorization?
Prior authorization (PA) means the health plan must approve certain care before it will cover it. Providers often submit requests for you, but you still have rights if PA is denied or delayed.
Overview: Prior authorizations. South Carolina-only details below.
Confirm plan type: South Carolina: Start Here.
South Carolina PA rules
South Carolina regulates utilization review and prior authorization primarily through Title 38, Chapter 70 (private review agents) and the Health Carrier External Review Act in Chapter 38-71. These laws generally do not apply to Medicare, typical self-funded ERISA plans, or many federal programs.
Current law (Ch. 38-70)
- Private review agents must be certified by SCDOI before conducting utilization review in South Carolina
- Adverse determination notice must be provided within 5 business days of the utilization review decision (§ 38-70-20)
- Review agents must maintain a representative accessible at least 40 hours per week during business hours
- No prior authorizationfor USPSTF A/B preventive services, ACIP-recommended immunizations, and mandated women's preventive screenings
Federal deadlines (many Marketplace and group plans)
Federally regulated plans often follow CMS timing: 72 hours for urgent PA and 7 calendar days for standard requests—check your plan documents.
Pending reform (S.B. 531, 2025 session)
The Patients' Right to Transparency and Timely Access to Healthcare Services Act (S.B. 531) was introduced in 2025 and, if enacted, would require:
- 48 hours for non-urgent PA / 24 hours for urgent PA after receipt of necessary information
- Gold carding: providers with 90%+ approval rates exempt from PA for that service for 12 months
- Chronic-condition PA protections, step therapy exceptions, and continuity of care on plan changes
As of mid-2026, S.B. 531 remained in committee—not yet enacted law.
Medicaid PA
Medicaid prescription PA often requires a decision within 24 hours, with limited 72-hour emergency drug supplies while authorization is pending (state Medicaid rules).
Where to look up PA rules
Check your plan materials and the carrier's provider or member portal first.
Carrier links: South Carolina prior auth & internal appeals links.
Medicaid
Medicaid managed care follows federal and state utilization management rules. Denials use MCO appeal and fair hearing paths—see South Carolina internal appeals.
If PA is denied
Appeal the adverse determination using your plan's internal process under Chapter 38-71, then external review if needed.
Urgent care
Mark requests urgent when delay would seriously jeopardize life or health. Federal rules often require a response within 72 hours; pending S.B. 531 would require 24 hours under state law if enacted.
You may request expedited internal and external appeals in qualifying urgent situations.