Autism Spectrum Disorder Services Interim Process
The South Carolina Department of Health and Human Services (SCDHHS) has established an interim process by which Healthy Connections Medicaid members can access Autism Spectrum Disorder (ASD) services that are identified as medically necessary based on an Early and Periodic Screening Diagnosis and Treatment (EPSDT) encounter.
Members 0-21 years old are eligible to submit requests for ASD services, including members currently on the Pervasive Developmental Disorder (PDD) Waiver waiting list as well as those whose PDD Waiver services have expired.
Families can submit requests to the attention of Pete Liggett, Ph.D., at SCDHHS, P.O. Box 8206, Columbia, SC 29202-4500 or firstname.lastname@example.org with the following documents:
- Results of an EPSDT visit that demonstrate the medical necessity for ASD services
- An attestation by a doctor, developmental pediatrician or current provider with treatment recommendations (e.g., specific problem behaviors to be addressed), including recommended hours
- A comprehensive assessment report that confirms the presence of ASD
- The report must include developmental history, a detailed description of observed behavior, and results from standardized ASD diagnostic tools, as applicable. The diagnostic assessment must have been performed by a qualified examiner with training in the assessment of children and youth with ASD.
- Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) or (DSM-5) diagnostic profile, to establish proof of met criteria
- Checklist for Autism in Toddlers (CHAT) or Modified-CHAT assessment form, if applicable
- Medical profile (e.g., summary of pediatric visits and/or medically complex history)
- Speech and language therapy notes, if applicable
- Family history (including, but not limited to, family history of ASD)
- Past therapies profile sheet (e.g., therapy modalities, duration, outcome, etc.)
- Genetic testing, if applicable
- Prior Authorization or Denial Letter from beneficiary's primary insurance carrier, if applicable
Those providing services during this interim ASD process must meet the existing PDD Waiver provider qualifications.
Providers must enroll as Healthy Connections Medicaid Vendors via this site: http://procurement.sc.gov/PS/vendor/PS-vendor-registration.phtm.
Claims must be submitted to the SCDHHS Division of Behavioral Health to the attention of Gabriele Jefferson, J-9, 1801 Main St., Columbia, SC 29201 or email@example.com. Claims must include a completed 1500 form (instructions for completion of 1500 form can be found in provider manuals) and a primary payer Explanation of Benefits (EOB), if applicable. Claims must include member's name, Healthy Connections Medicaid Number, date(s) of services, number of hours, as well as aggregate cost of services. Only the following PDD Waiver procedure codes will be used for the interim ASD process:
- Consultant: H0032
- Lead: G0177
- Line Therapy I: H0046
- Line Therapy II: H0046 OU2
Please note that PDD waiver rates for these services will be paid to providers during this interim ASD process.
For questions regarding the 1500 form, please contact the Provider Service Center at 1 (888) 289-0709.
For questions regarding the interim process please contact Lara Sheehi, Psy.D., at Lara.Sheehi@scdhhs.gov.
Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.