Update to Pediatric Inpatient Rehabilitation Services
Effective for dates of service on or after July 1, 2023, the South Carolina Department of Health and Human Services (SCDHHS) will reimburse for medically necessary pediatric inpatient rehabilitation services that are delivered in a qualified inpatient rehabilitation unit or facility. This change applies to services rendered under the Medicaid State Plan to Healthy Connections Medicaid members 21 years of age and younger.
Pediatric inpatient rehabilitation services are designed to provide comprehensive, individually tailored care plans to meet the physical, developmental, social, psychological, and educational needs of the patient and the patient’s family. These services must be performed in an inpatient rehabilitation unit or facility that complies with any applicable state and federal laws, rules, and regulations and the appropriate accreditation standards.
Prior Authorization Requirements
Pediatric inpatient rehabilitation services will require prior authorization before the patient is transferred from an inpatient stay to the inpatient rehabilitation unit or facility.
- For Healthy Connections Medicaid members enrolled in the fee-for-service (FFS) program, prior authorizations will be issued by the contracted Quality Improvement Organization (QIO). Providers with questions about prior authorizations for members enrolled in the FFS Medicaid program can contact SCDHHS’ QIO, KEPRO, by phone at +1 (855) 326-5219 or email at firstname.lastname@example.org. Providers can also submit documents to KEPRO by fax at (855) 300-0082.
- For members enrolled in a managed care organization (MCO), prior authorizations will be issued by the member’s MCO. MCO’s prior authorization phone numbers are available here on SCDHHS’ website.
Reimbursement for Services
- Facility inpatient rehabilitation services for FFS Medicaid members will be reimbursed based on a per-diem rate of $1,200.
- Professional services will be reimbursed separately following the policies and billing guidance in the Physician Services and Private Rehabilitative Therapy Services provider manuals.
Billing providers must comply with the pediatric inpatient rehabilitation services policy, including clinical criteria, medical necessity, and documentation requirements, which is detailed in the Hospital Services Provider manual. All policy changes are referenced in the Hospital Services Provider manual’s Change Control Record (CCR).
Questions about this bulletin may be directed to the Provider Service Center (PSC) at: (888) 289-0709 or through an online inquiry at: http://www.scdhhs.gov/contact-us. The PSC’s hours of operation are 7:30 a.m. – 5 p.m. Monday – Thursday and 8:30 a.m. – 5 p.m. Friday.