Autism Spectrum Disorder Services Interim Process – Phase Two

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Effective Feb. 1, 2016, the South Carolina Department of Health and Human Services (SCDHHS) will initiate an improved interim process by which its members are evaluated for and receive Autism Spectrum Disorder (ASD) services that are identified as medically necessary based on an Early and Periodic Screening Diagnosis and Treatment (EPSDT) encounter.

Healthy Connections Medicaid members 0 to 21 years of age are eligible to submit requests and be evaluated for ASD services, including members currently on the Pervasive Developmental Disorder (PDD) Waiver waiting list and those whose PDD Waiver services have expired.

Evaluation for Autism Services

Members must submit evaluation requests to the attention of Dr. Pete Liggett at SCDHHS, P.O. Box 8206, Columbia, SC 29202-4500 or autism@scdhhs.gov. Requests must include the following items and documents:

  • Healthy Connections Medicaid member identification (ID) number
  • Indication of when PDD waiver services will expire (applicable only if member is currently receiving PDD waiver services)
  • Results of an EPSDT visit that demonstrates the medical necessity for ASD services
  • Attestation by a doctor, developmental pediatrician or current ASD services provider with treatment recommendations (e.g., specific problem behaviors to be addressed), including recommended hours
  • 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 last medical visit, description of medical complications, etc.)
  • Speech and language therapy notes, if applicable (e.g., summary of last visit/progress review)
  • Family history, including, but not limited to, family history of ASD (e.g., maternal and paternal history and maternal and paternal grandparent history)
  • Past therapies profile sheet (e.g., therapy modalities, frequency, duration, outcome, etc.)
  • Genetic testing, if applicable
  • Prior Authorization or Denial Letter from member's primary insurance carrier

 

Autism Service Provision

Those providing services as part of this interim ASD process must meet the existing PDD Waiver provider qualifications. Claims may now be submitted via the SC Medicaid web-based claim submission tool: https://portal.scmedicaid.com/login

Any issues with claims submitted through the webtool should be addressed with the Provider Service Center (888) 289-0709. Until March 1, 2016, claims may also be mailed to: SC Medicaid Claims Receipt
PO Box 1412
Columbia, SC 29202-1412

Claims must not exceed the approved hours documented in the member's Medicaid Service Authorization. Only the following PDD Waiver procedure codes may be used for the interim ASD process, as CPT codes will not be accepted at this time:

Assessment: H2000 (annually)
Consultant: H0032 (hourly)
Lead: G0177 (hourly)
Line Therapy I: H0046 (hourly)
Line Therapy II: H0046U2 (hourly)

 

Providers will be paid PDD waiver rates for these services. Please remember that all Medicaid providers must follow Medicaid Third Party Liability (TPL) policy. TPL information can be found on the Healthy Connections Medicaid website, scdhhs.gov, on the "Training Opportunities" page under the "For Providers" tab.

As of March 1, 2016, claims will not be accepted via the interim manual billing process.

The South Carolina Department of Disabilities and Special Needs (DDSN) has developed an interim process interpreter services program that will be available through June 30, 2016, or until SCDHHS institutes the permanent State Plan autism service array, whichever comes first. This particular program is not affiliated with or a part of the PDD Program. The explicit purpose of this program is to enable children receiving ABA services through the interim process to have access to interpreter services. If interpretation services are needed, please contact Shamaiah Talley (stalley@ddsn.sc.gov ) at DDSN.

For questions regarding the interim process, please contact Lara Sheehi, Psy.D., at Lara.Sheehi@scdhhs.gov.

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

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