Removal of Prior Authorization Requirement for DME Procedure Code B9998
The South Carolina Department of Health and Human Services (SCDHHS) was recently made aware that system changes put in place at the end of the COVID-19 federal public health emergency (PHE) have led to claims being denied for DME procedure code B9998 (enteral supplies not otherwise classified). During the federal PHE, SCDHHS created temporary policy flexibilities related to DME. In Medicaid bulletin MB# 23-003, the agency announced it would reinstate most limits for specific categories that existed prior to the federal PHE including prior authorization (PA) requirements and quantity. After receiving feedback from family members of impacted Healthy Connections Medicaid members and providers, SCDHHS conducted a review of claims. As a result, SCDHHS will remove the PA requirement for procedure code B9998 effective for dates of service on or after May 11, 2023.
The agency has made this decision after determining the reinstatement of this PA requirement had the unintended consequence of limiting the ability for members to receive necessary supplies. Providers should continue to use code B9998 consistent with how they used it prior to May 11, 2023, until further notice.
SCDHHS will review and reprocess all claims associated with this code retroactive to May 11, 2023. Providers will receive updated claims processing information, where appropriate, on their regular remittance advices.
SCDHHS will contact impacted Healthy Connections Medicaid providers to further explain these changes. In addition, the agency will evaluate other changes made related to the end of the federal PHE. This review will identify any other actions needed to ensure the unwinding of temporary flexibilities instituted during the PHE does not have a negative impact on medically necessary services or provider reimbursement for covered services.
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 PA requirement that was previously in place for procedure code B9998 can be directed to MedicaidWaiver@scdhhs.gov.