Policy Changes to the Referral/Authorization Process

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Effective with dates of service on or after July 1, 2014, the South Carolina Department of Health and Human Services (SCDHHS) will implement policy changes to the Referral and Authorization process for acquiring Rehabilitative Behavioral Health Services (RBHS) and Inpatient Psychiatric Services for Children Under 21. These changes are being made in an effort to increase beneficiary access to medically necessary services and to increase efficiency of the current referral and authorization process for behavioral health services.

The SCDHHS Referral/Authorization Form 254 and Form 257 will no longer be required in order to authorize and bill for RBHS and Inpatient Psychiatric Services for Children Under 21 respectively, with dates of service on or after July 1, 2014.

Medicaid enrolled providers may receive self referrals and/or referrals from another Medicaid enrolled provider or state agency. In order to receive Medicaid reimbursement, all services must be determined medically necessary by a physician or other Licensed Practitioner of the Healing Arts as defined by the SCDHHS.

Providers of Inpatient Psychiatric Services for Children Under 21 (Psychiatric Residential Treatment Facilities) must continue to obtain a Certificate of Need and a CALOCUS (Child and Adolescent Level of Care Utilization System) evaluation indicating need for this level of service. Providers must also continue to request prior authorization and receive approval for Psychiatric Residential Treatment Facility placement from the SCDHHS designated Quality Improvement Organization (KEPRO). KEPRO will continue to review the submissions pursuant to the Interqual Criteria for Inpatient psychiatric placement.

Regional trainings have been scheduled May 14-30, 2014 for all impacted providers. This training will provide an overview of the policy changes and answer any additional provider questions.

Providers may register for the training through the South Carolina Medicaid Provider Education Website, http://medicaidelearning.com, or by calling the South Carolina Provider Outreach at 1-888-289-0709.

If you have any questions regarding this bulletin, please contact the Division of Behavioral Health at (803).898-2565. Thank you for your continued supportof the South Carolina Healthy Connections Medicaid Program.

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