Transplant Services and Hospital Services Authorizations Policy Updates

Effective for dates of service on or after July 1, 2023, the South Carolina Department of Health and Human Services (SCDHHS) is announcing changes to the transplant services prior authorization policies and procedures described below. A clarification of hospital services authorizations for members with retroactive Medicaid eligibility policy is also described below.

Fee-for-Service (FFS) Corneal and Kidney Transplants

SCDHHS will no longer require prior authorizations for corneal or kidney transplants and their related services. Prior authorization requirements for all other transplants will remain in place. 

FFS and Managed Care Prior Authorizations for Transplant Services

SCDHHS’ contracted quality improvement organization (QIO), KEPRO, is responsible for issuing prior authorizations for transplant services for members in the FFS and managed care organization (MCO) programs. Consistent with current policy, MCOs will determine the medical necessity for the transplant services for MCO-enrolled members. The authorization determination letter will be issued by KEPRO. Providers with questions about prior authorizations for transplant services can contact KEPRO by email at atrezzoissues@kepro.com or by phone at (855) 326-5219.

The prior authorization for transplants issued by KEPRO will cover the transplant event and the pre- and post-transplant periods described below:

• Pre-transplant period – medically necessary services rendered in preparation for the transplant within 72 hours prior to the transplant event/surgery.
• Transplant event – surgery and services rendered through discharge. 
• Post-transplant period – medically necessary services from discharge up to 90 days post-discharge.

Medically necessary transplants and transplant-related services rendered for all transplant types (except corneal), during the pre-transplant and transplant event periods will be reimbursed by SCDHHS’ FFS Medicaid program, regardless of the Medicaid member’s enrollment status in FFS or an MCO. Post-transplant services for members enrolled in an MCO will be reimbursed by the MCO.

Billing providers will need to continue to comply with the transplant services policy in the Hospital Services provider manual. The agency’s transplant services policy will also be added to the Physicians Services provider manual. All policy changes and clarifications are referenced in the change control record of the Hospital Services and Physicians Services provider manuals. 

FFS Hospital Services Authorizations for Members with Retroactive Medicaid Eligibility

Hospital services occurring prior to a Medicaid member’s Medicaid eligibility determination do not require prior approval. However, for appropriate and timely claims processing of a claim in the case of retroactive eligibility, the provider must obtain an authorization number in support of a determination of medical necessity in accordance with the “Time Limit for Submitting Claims” section in the Provider Administrative and Billing manual. For members in the FFS Medicaid program, providers can contact KEPRO for authorization number requests and consideration for payment for services rendered to members with retroactive Medicaid eligibility. Providers can contact KEPRO at the email address and phone number listed above. For members enrolled in an MCO, providers must follow the member’s MCO process and procedures. The contact information for the MCOs is available here on SCDHHS’ website.

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: http://www.scdhhs.gov/contact-us.

Redesigned SCDHHS Website

SCDHHS is excited to announce the launch of the agency’s redesigned website. The agency’s URL will remain www.scdhhs.gov, but users will notice a new look and feel to the website. This includes several features that improve the overall usability and brings it in line with leading public agency website industry standards. Read more about the redesigned site here.

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

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