Addition of New Covered Autism Spectrum Disorder Services
UPDATE: The bulletin that was originally distributed included an incorrect service limit for procedure code 97152. Effective July 1, 2024, the service limit for procedure code 97152 will be 21 units/day.
Effective for dates of service on or after July 1, 2024, the South Carolina Department of Health and Human Services (SCDHHS) will add coverage of additional autism spectrum disorder (ASD) services. This coverage expansion applies to full-benefit South Carolina Healthy Connections Medicaid members. The new covered services announced in this bulletin will be added to the ASD Services provider manual and ASD fee schedule available on SCDHHS' website by July 1, 2024. SCDHHS is making these changes to support greater access to ASD services, enhance the state's provider network and ensure services are delivered effectively. The addition of these services will complete the available service array for Healthy Connections Medicaid members for ASD services.
Reimbursement Rates for New ASD Services
Reimbursement rates for the additional ASD services described in this bulletin are included in the table below.
| Code | Description | Provider Type | Rate per Unit |
|---|---|---|---|
| 97152 | Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient. | Registered Behavior Therapist (RBT) | $20.50 per 15 min. unit
Service limit: 21 units/day |
| 97157 | Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers. | Board-certified Behavior Analyst (BCBA) | $13.31 per 15 min. unit
Service limit: 16 units/day |
| 0362T | Behavior identification supporting assessment, administered by two or more technicians, face-to-face with a patient, requiring the following components:
| BCBA, Board-certified Associate Behavior Analyst (BCaBA), RBT | $27.95 per 15 min. unit
Service limit: 16 units/day
Based on total time elapsed, not total time per each technician; service is billed by the physician or other qualified health care professional directing the session. |
| 0373T | Adaptive behavior treatment with protocol modification, administered by two or more technicians, face-to-face with a patient, requiring the following components:
| BCBA, BCaBA, RBT | $30 per 15 min. unit
Service limit: 32 units/day
Based on total time elapsed, not total time per each technician; service is billed by the physician or other qualified health care professional directing the session. |
South Carolina's Healthy Connections Medicaid managed care organizations (MCOs) are responsible for the authorizations, coverage and reimbursement related to the services described in this bulletin for Healthy Connections Medicaid members who are enrolled in an MCO.
Providers should direct any questions related to this bulletin to the Provider Service Center (PSC) at (888) 289-0709 or to behavioralhealth004@scdhhs.gov. The PSC's hours of operations are 7:30 a.m.-5 p.m. Monday-Thursday and 8:30 a.m.-5 p.m. Friday.
Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.