Public Notice of Final Action for Third-party Liability Changes Required in the Consolidated Appropriations Act of 2022
The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following actions regarding the third-party liability (TPL) requirements under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Effective on or after July 1, 2024, SCDHHS will amend the South Carolina Title XIX State Plan to come into compliance with the TPL requirements reflected in current state law. The applicable state statute is Section 43-7-465 of the S.C. Code that implements the following changes.
- Health insurers can no longer deny payment for an item or service rendered to a Medicaid member on the basis that the item or service did not receive prior authorization for the third-party payor. The health insurer must accept the authorization provided by the state that the item or service is covered under the State Plan.
- Health insurers are required to respond to a state inquiry regarding claim(s) submitted within 60 days of receiving the inquiry from the state.
Medicaid is generally the payor of last resort and only pays claims for covered items and services if there are no other liable third-party payors. Federal law generally requires health insurers and other third parties legally liable for health care services received by Medicaid members to pay for such services.
Based on the actions above, SCDHHS anticipates a budget impact of approximately $113,000 (total dollars) in increased recoveries.
Copies of this notice are available at each South Carolina Healthy Connections Medicaid county office and at www.scdhhs.gov for public review. Additional information regarding these actions is available upon request at the address cited below.
Any written comments submitted may be reviewed by the public at SCDHHS, Office of Health Programs, 1801 Main Street, Columbia, South Carolina, Monday through Friday between the hours of 9 a.m. and 5 p.m.