Removal of Prior Authorization and Service Limits for Certain DME Procedure Codes
The South Carolina Department of Health and Human Services (SCDHHS) recently conducted a review of specific categories of claims impacted by system changes that reinstated some requirements at the end of the COVID-19 federal public health emergency (PHE). This review process was described in Medicaid bulletin MB# 23-039.
Based on this additional review, SCDHHS has taken the following actions:
- Service/frequency limits have been removed for the following:
- B4087 (gastrostomy/jejunostomy tubes and extension tube sets);
- A7520 (tracheostomy/laryngectomy tubes); and,
- A7507 (filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system).
- Prior authorization requirements for B4103 [Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear liquids)] have been removed.
SCDHHS is also reminding providers of other instances where prior authorization is not required:
- Prior authorization is not required for pulse ox probes (A4606). The frequency for A4606 is six per month.
- Prior authorization requirements for claims submitted for HCPCS code B9998 (Enteral supplies not otherwise specified) for gastric tube buttons, tubing and Farrell bags have been removed, as announced in Medicaid bulletin MB# 23-039. There are no current frequency limits in place for these items. Please note that submission of a valid, signed prescription and a Medicaid Certificate of Medical Necessity (MCMN) is required as indicated in Medicaid bulletin MB# 23-003.
SCDHHS will review and reprocess all claims associated with these codes retroactive to May 11, 2023. Providers will receive updated claims processing information, where appropriate, on their regular remittance advices. Providers should continue to use these codes consistent with how they used them prior to May 11, 2023, until further notice. Services must continue to be rendered in accordance with the requirements, including those related to medical necessity, described in the Durable Medical Equipment Services provider manual.
Providers with questions about this change should contact 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. Any other questions related to claims that were denied as a result of the requirements that were previously in place for the identified procedure codes can be directed to MedicaidWaiver@scdhhs.gov.
Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.