Effective with dates of service on or after October 1, 2012, the South Carolina Department of Health and Human Services (SCDHHS) will require prior authorization (PA) for the following services and medical record pre-payment review from our Quality Improvement Organization (QIO), KePRO.

Patients with Medicare as primary are only required to obtain a PA if Medicare does not make a payment or the service is not covered by Medicare and Medicaid then becomes primary. Managed Care Organizations will continue to authorize services according to their specific plans for enrolled beneficiaries (members). Case Managers and Service Coordinators for CLTC and DDSN home and community-based waiver programs will continue to authorize services for their waiver participants.


Hospice Services.  For Medicaid-only beneficiaries, the hospice provider must submit requests for prior authorization along with medical documentation.  All hospice services except General Inpatient (GIP) care will be prior authorized for up to six (6) months.  If a beneficiary is in need of hospice services beyond the initial six (6) months, the hospice provider must submit a new request to KePRO.  For GIP care a separate request must be submitted to KePRO along with documentation to support the need for such services. All requests must meet the medical necessity criteria for approval.  See Table 1 for Hospice Services that Require PA.

Home Health.  Requests for home health services that exceed the annual combined benefit limit of 50 visits per state fiscal year (July – June) must be authorized by KePRO.  KePRO will utilize evidence-based and nationally recognized criteria for evaluating and determining medical necessity for the type of services requested and the number of visits required to appropriately treat the beneficiary’s condition.  Providers are required to track and request the additional visits prior to the expiration of the combined limit.  Current SCDHHS policy can be reviewed on line in the Home Health Services Provider manual at  Table 2 lists the Home Health services that require PA.

Rehabilitative Therapy for Children.  Requests for therapy services for all children that exceed the fiscal year checkpoints for combined rehabilitative therapy services (105 hours or 350 units) must be submitted to KePRO for authorization.  The checkpoint will apply to private rehabilitative providers as well as to those performed in the outpatient hospital clinic.  KePRO will use InterQual’s Outpatient Rehabilitation criteria for medical necessity determinations.   Providers will be required to track and request the additional visits prior to the expiration of the combined limit.  Requests for therapy services may be submitted by the primary care physician or Physical, Occupational or Speech Therapist but must follow the guidelines outlined in the Provider Manual.  This policy does not apply to School-Based Rehabilitative Therapy Services provided under the Individuals with Disabilities Education Act (IDEA).

DME.  Effective immediately, requests for PA of DME codes that currently require prior authorization must be submitted to KePRO. This includes codes for the repair and/or replacement of DME products.  DME requests will be reviewed and a response provided within 15 days of the receipt of request.  Effective with dates of service on or after October 1, 2012 the following two codes will require a prior authorization request from KePRO. 

S8189 -Tracheostomy Supply, not otherwise classified

L0638 - Lumbar-sacral orthotic (SLO)


DME services provide therapeutic benefits or enables beneficiaries to perform certain tasks that they are unable to undertake otherwise due to certain medical conditions and/or illness.  Convenience and prevention items are not covered.  A provider’s medical record for each beneficiary must substantiate the need for services and must include all findings and information necessary to support medical necessity.

Responses to all PA requests will be faxed back to the provider with an approval or denial. Unless indicated through policy, all requests for PA will be returned to providers within 24 hours of receipt of the request.  Exceptions include a request for additional information, a physician’s review or DME services.  For PAs issued by SCDHHS that include dates of service after October 1, 2012, KePRO will issue a new prior authorization number and notify providers of the new number via fax.  Please contact KePRO if you do not receive notification of the new PA number by October 12, 2012.  

Please visit for additional information about KePRO’s web based PA submission. 




OB Ultrasound.  Claims for Obstetrical Ultrasounds that exceed the defined limits (currently 3 per pregnancy) will be reviewed by KePRO for medical necessity.  The complete policy for ultrasound can be reviewed in the Physicians Provider manual located at

All applicable forms for requests for prior authorizations will be posted to KePRO’s website.  Also posted are upcoming trainings, new policies or procedural changes affecting Medicaid’s QIO process and direct links to Medicaid policy manuals.  KePRO will be conducting web based training sessions for health care providers over the next few weeks.  Please visit the web site for training dates and times at  If you have questions or concerns with the above process, please contact KePRO at the following:


KePRO Customer Service Phone:                            855-326-5219

KePRO Fax #:                                                            855-300-0082

For Provider Issues email:                                

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