New Medicaid Quality Improvement Organization (QIO)

 

Effective March 1, 2012, the South Carolina Department of Health and Human Services (SCDHHS) began implementation of a contract with the Keystone Peer Review Organization, Inc. (KePRO), to serve as the new Quality Improvement Organization with an operational date of June 1, 2012.

 

KePRO has over 25 years of experience performing utilization reviews for Medicaid populations in several states.  The following chart provides a list of current and new services that will be performed by KePRO.  Please note that Managed Care Organizations will continue to prior authorize services according to their specific plans for enrolled beneficiaries (or members).

 

Current Prior Authorizations and Review Services

Organ Transplants

Surgical Procedure Codes

DME – Cranial Molding, Orthotic Devices and Power / Manual Wheelchairs and Accessories

Mental Health Counseling Services

Surgical Prepayment Reviews

Sterilizations

Abortions

Level of Care Reviews for Intermediate Care Facilities for the Mentally Retarded

Outpatient Community Rehabilitative Services

Freestanding Inpatient Psychiatric Services

New Prior Authorizations and Review Services

Inpatient Admissions (All DRGs Excluding Births and Deliveries)

Outpatient Clinic Physical Therapy/ Occupational Therapy/ Speech Therapy for adults over age 21

Utilization Review Plans for Acute Care Hospitals, Mental Hospitals and ICFs

 

A second Medicaid Bulletin will be released that will include a schedule for provider/facility training sessions.  Subsequent bulletins will include instructions for transitioning services currently performed by Alliant Health and SCDHHS to KePRO, contact information for each review type and updates or changes to current SCDHHS program policies.  Until such time, please continue to submit your requests for prior approvals to Alliant Health and SCDHHS. 

 

If you have any questions, comments or concerns, please direct them to comments@scdhhs.gov. For information about KePRO’s organization please visit their website at www.KePRO.com. Thank you for your continued support in the South Carolina Healthy Connections program. 

 

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