New to helping someone in South Carolina?
You do not need a law degree to help someone fight a health insurance denial. Start by gathering three basic documents:
- Insurance card — shows which company administers the plan. Use the name and phone number on the card when you call or file paperwork.
- Denial letter or explanation of benefits (EOB) — the notice that says a service was denied, not paid, or needs approval first. Look for appeal instructions and a deadline.
- Summary of Benefits and Coverage (SBC) — helps you tell whether the fight is about medical necessity or whether the benefit exists at all.
Your first tasks: identify what type of plan this is (HealthCare.gov, job-based, Medicaid, Medicare) and write down the appeal deadline from the letter.
South Carolina law gives you an internal appeal with the insurer first in most cases, then a right to external review through an independent review organization (IRO) approved by the South Carolina Department of Insurance (SCDOI).
For steps that work in every state, read these general guides first, then return here for South Carolina rules:
What is different in South Carolina?
- HealthCare.gov: South Carolina uses the federal Marketplace at HealthCare.gov. Major 2026 carriers include BlueCross BlueShield of SC, Ambetter (Absolute Total Care), Molina, Select Health, UnitedHealthcare, and InStil Health (availability varies by county).
- Prior authorization: Ch. 38-70 utilization review — adverse notice within 5 business days; no PA for many preventive services; pending S.B. 531 would add 48 hr / 24 hr deadlines and gold carding.
- Internal appeals: Ch. 38-71 — typically 180 days to file; 30/60-day decisions; 72-hour urgent.
- External review: File with carrier within 60 days (SCDOI); IRO decision within 45 days standard / 72 hours expedited; binding on plan.
- Medicaid: MCO appeal first (60 days typical), then SCDHHS fair hearing (120 days from MCO resolution)—separate from commercial IRO review.
Who is in charge of your plan?
- SCDOI: External review, consumer help — doi.sc.gov. Consumer hotline: 800-768-3467 · 803-737-6180 · consumers@doi.sc.gov
- U.S. Department of Labor: Many self-funded employer plans.
- SCDHHS Appeals: Medicaid fair hearings — scdhhs.gov — file an appeal · 803-898-2600
- CMS: Medicare and Medicare Advantage.
After appeals are exhausted, see Regulator complaints.