Updates to Reimbursement Process for Organ Transplants and Managed Care Organizations (MCOs)
The South Carolina Department of Health and Human Services (SCDHHS) is announcing changes to the reimbursement process for organ transplant services for Healthy Connections Medicaid members who are enrolled in an MCO. Effective for services on or after Feb. 1, 2024, SCDHHS will shift reimbursement responsibility for pre-transplant periods and transplant events to MCOs. This shift is referred to as a “carve-in.” MCOs will reimburse providers for all services associated with medically necessary organ transplants and transplant-related services for Medicaid members enrolled in their MCO. This announcement does not change services covered for Healthy Connections Medicaid members.
This is a change from the current reimbursement process for services rendered to Medicaid members who are enrolled in an MCO. This change in reimbursement process does not apply to Medicaid members who are not enrolled in an MCO. However, prior to Feb. 1, 2024, medically necessary transplants and transplant-related services rendered during the pre-transplant period and transplant event for all transplant types (except corneal) are prior authorized and reimbursed through the fee-for-service (FFS) program regardless of a member's enrollment status in FFS or an MCO.
Updates to the Hospital Services and Physicians Services provider manuals reflecting these changes will be available on the SCDHHS website on Feb. 1, 2024.
For Healthy Connections Medicaid members who are enrolled in an MCO, providers should contact the member’s MCO for prior authorization of services provided during the pre-transplant periods and the transplant event. MCO’s contact information can be found on the SCDHHS website here.
Providers may 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.
Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.