Full Lift of Provider Enrollment Moratorium for Medicaid Targeted Case Management Services and Implementation of Prior Authorization Requirements

Effective July 1, 2024, the South Carolina Department of Health and Human Services (SCDHHS) will fully sunset the moratorium for new provider enrollment for Medicaid Targeted Case Management (MTCM) services providers. Fully sunsetting the moratorium, which has served as a valuable tool to protect against potential fraud, waste and abuse in this service area, will allow new MTCM services providers to enroll in the Healthy Connections Medicaid program in all remaining South Carolina counties where new provider enrollment is currently prohibited. This coincides with SCDHHS’ effort to fundamentally redesign the array of covered Medicaid behavioral health services. Through this redesign, SCDHHS will continue to work with stakeholders to increase access to quality behavioral health care for Healthy Connections Medicaid members while also appropriately safeguarding taxpayer funds.

Information on the moratorium, provider risk level categories and the initial steps taken to sunset the moratorium is available in Medicaid bulletin MB# 23-059, which was issued Nov. 27, 2023. MB# 23-059 also describes changes to provider enrollment and revalidation for private MTCM services providers. Please note in these requirements apply to all newly enrolling MTCM services providers. Providers may also review the enrollment criteria specific to private MTCM services providers in the MTCM Services provider manual and can find information on the provider enrollment process here on SCDHHS’ website.

MTCM Services Provider Manual Changes

In support of sunsetting the moratorium, the MTCM Services provider manual has been reorganized and updated for more current service needs. In addition to the changes announced in MB# 23-059, new changes will be added to the manual by July 1, 2024. These changes include:

• Updated provider qualifications
  • Training requirements will be enhanced to support expertise with target populations. Updated MTCM Services provider training resources will be released later this year.
• Updated program format
  • Guidance on MTCM components of monitoring and follow-up will be added.
• Addition of new MTCM forms which include the following:
  • Targeted Case Management Referral form
  • Targeted Case Management Brief Screening form

SCDHHS will hold training webinars to discuss the changes to the MTCM Services provider manual. Current and prospective MTCM services providers interested in learning more about these changes are encouraged to register for one of the webinars through the links included below.

• Friday, July 19, 2024, from 10:30 a.m.-12 p.m. https://scdhhs.webex.com/weblink/register/r32625777d09b93f3e4ba9c3c260e0c7d
• Tuesday, July 23, 2024, from 2 p.m.-3:30 p.m. https://scdhhs.webex.com/weblink/register/r8b7b712c022dc3a0a233239beef69c1f

Prior Authorization (PA)

Also effective July 1, 2024, PA requirements for MTCM services rendered by private providers will be added to the MTCM Services provider manual. Training will be conducted by SCDHHS’ quality improvement organization (QIO), Acentra Health, to provide further guidance on the PA process and the requirements for MTCM services providers.

For members beginning MTCM services on or after July 1, 2024, initial authorization will require submitting the following to the QIO for review:

• Targeted Case Management Referral form (and/or other additional referral information that describes the medical necessity);
• Targeted Case Management Brief Screening form (completed by the provider agency); and,
• Freedom of Choice form which is accessible here.

Upon approval, the provider will be authorized to provide the MTCM units necessary to complete the assessment and care plan within the 45-day period as defined by policy.

After completing the assessment and care plan, PA for additional services identified in the care plan will include submitting the following to the QIO:

• The assessment and care plan; and,
• Any additional information substantiating medical necessity, such as a recent hospital discharge or psychological report.

For members currently receiving MTCM services which began prior to July 1, 2024, PA will include the following steps:

• Prior to reaching the 180-day mark for the policy-required updates to the assessment and care plan, the provider must submit the current assessment, care plan and all service notes from the previous 30 days to the QIO for review.
• Any additional information substantiating medical necessity, such as a recent hospital discharge or psychological report, which supports the need for continued services shall be submitted to the QIO for review along with the information above.

Additional provider web-based training sessions on the PA process will be held by SCDHHS’ QIO. Dates for these training sessions and registration information will be announced through a future Medicaid bulletin.

State agency providers and entities acting on behalf of a state agency are not considered high-risk providers and therefore, are not subject to the PA requirements described in this bulletin. However, all other MTCM Services provider manual updates apply to all MTCM services providers.

Providers should direct questions related to this bulletin to the Provider Service Center (PSC). PSC representatives can be reached at (888) 289-0709 from 7:30 a.m.-5 p.m. Monday-Thursday and 8:30 a.m.-5 p.m. Friday. Providers can also submit an online inquiry at https://www.scdhhs.gov/providers/contact-provider-representative.

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

Print Version