Medicaid Targeted Case Management Service Review Process

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The South Carolina Department of Health and Human Services (SCDHHS) will implement a review process on Medicaid Targeted Case Management Services (MTCM) rendered by private providers of MTCM. Effective Nov. 1, 2015, SCDHHS will reimburse for no more than 24 units per calendar quarter per beneficiary unless medical necessity has been demonstrated and approved through the prior authorization process defined in the Oct. 1, 2015, edition of the MTCM Provider Manual. The 24-unit allowance applies to any combination of face to face or telephonic MTCM. For the October-December 2015 calendar quarter, payment for services incurred in October 2015 in excess of the 24-unit limit will not be retroactively denied due to this change.

Requests for targeted case management services in excess of 24 units per calendar quarter per beneficiary may be submitted directly to the SCDHHS for approval. The MTCM manual will include detailed instructions on the process to request additional units of service.

Please contact the Provider Service Center at (888) 289-0709 for any questions regarding the fee-for-service policies indicated in this bulletin.

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

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