Services Performed by KePRO, the Quality Improvement Organization (QIO) for S.C. Medicaid


This bulletin is to notify you that the July 1, 2012 effective date to automatically reject claims that require an authorization number from KePRO, if the authorization number is not present on the claim or is invalid, has been delayed until August 1, 2012.  The delay is due to required detailed testing of the claims processing system which is necessary to minimize the potential for rejecting claims in error.  This policy affects Medicaid Fee-For-Service members including members enrolled in Medical Home Networks (MHNs).

Patients with Medicare are only required to obtain a PA if Medicare does not make a payment or the service is not covered by Medicare, and Medicaid then becomes primary.  Please note that Managed Care Organizations (MCOs) will continue to authorize services according to their specific plans for enrolled beneficiaries.  Case Managers and Service Coordinators for CLTC and DDSN home and community-based waiver programs will continue to authorize services for their waiver participants.

KePRO has conducted three web-based training sessions over the past week. We encourage you to visit their website at for additional information regarding the prior authorization process, required forms and documentation and training. 

Please review this bulletin carefully.  If you have any questions regarding the content or the prior authorization process, you should contact a KePRO representative at one of the following sources:

KePRO Customer Service Phone:    855-326-5219

KePRO Fax #                                                 855-300-0082

For Provider Issues email:        

These newly automated edits will not be paid if one of these conditions exists.

Edit 837           Service Requires Prior Authorization from the QIO.  No authorization number is on the claim or the authorization number is not on file for the member.

Edit 838           Service Requires Prior Authorization from the QIO and Prior Authorization on the claim is not valid. For example, the date of the service on the claim is not within the date range authorized by the QIO. 

Edit 839         Inpatient Admission Requires Prior Authorization from the QIO for claims with date of admission on or after June 15, 2012. No authorization number is on the claim or the authorization number is not on file for the member.

The following is a list of services performed by KePRO.  Please review your provider manuals at for complete policies and procedures, forms for submission of PA requests and for a list of procedure codes and services. 

Hospital Admissions:  All acute care hospital admissions, except deliveries and births, must be prior authorized.  Requests for emergency admissions must be made within 1 business day of the date of the admission.  If a second level consultant’s review is required, a determination will be made by the QIO within 2 business days of the initial request. 

Organ Transplants: Heart, Lung, Liver, Pancreas, Small Bowel and Multi-organ transplants require prior authorization from KePRO.  Authorization requests include the evaluation for the transplant and when applicable, the request to have the service performed in a certified transplant center that is either in SC or beyond the SC medical service area.  A copy of the Transplant Prior Authorization Request Form should accompany a letter from the attending physician.  For members enrolled in a Medicaid MCO, KePRO will authorize the transplant event which includes services performed 72 hours prior to the admission, the transplant surgery and 90 days after surgery.  The QIO will also authorize transplants for members enrolled in Medicare and/or private HMOs.

Surgical Justification:  The list of surgical procedures that will require a prior authorization is found on KePRO’s website and on SCDHHS’s website.  Surgeries that are performed in an inpatient hospital setting will require only one authorization number.  In the case of a hysterectomy, prior authorization must be obtained even if the surgery follows a delivery.  Providers should continue to use the Request for Surgical Justification for Hysterectomy Form and the Sterilization Consent Form with each request.  There is a 30 day wait period from the date the Consent Form is signed before the surgery is performed.  For urgent and emergent hysterectomy cases the 30 day wait is not required, however the reason for the emergency must be provided by the physician.  The claim will be reviewed retrospectively. 

Outpatient Therapy:For recipients age 21 and over, physical, occupational and speech therapies (PT/OT/ST) performed in an outpatient hospital setting must be prior authorized.  For claims with dates of service on or after June 1, 2012, hospital providers will be required to submit the Revenue Code and the applicable CPT procedure code as defined in the CPT reference guide for the specified therapy.  For therapy procedure codes defined in 15 minute sessions, SCDHHS will define 15 minutes as 1 unit of service.  Therapy sessions that are defined in 15 minute increments are limited to 4 units per date of service.

Durable Medical Equipment:  The following DME services require prior authorization from KePRO - Evaluation and pre-certification for Cranial Molding Orthotic Devices, Manual and Power (motorized) Wheel Chairs and wheel chair accessories.  KePRO will use nationally developed clinical rules and best practices for medical necessity determinations such as McKesson’s InterQual for Durable Medical Equipment.  Providers will continue to submit the Certificate of Medical Necessity along with the physician’s order.  Please refer to your DME provider manual for the list of codes that require PA from SCDHHS.  

Mental Health Therapy Services Rendered by a Physician:  Eligible Medicaid beneficiaries, regardless of age, are allowed 12 mental health visits per fiscal year (beginning July 1st through June 30th of each year).  Codes 90801, 90862, and 90882 will not be included in the 12 allowable mental health visits.  SCDHHS will allow for the review and prior authorization of additional therapy sessions.  The beneficiary’s physician must request prior authorization from KePRO, to exceed the 12 allowable therapy visits.  The prior authorization request must be submitted to the

QIO using the Physician’s Mental Health (PMH) Form along with supporting clinical documentation.  The PMH form will be available on July 1, 2012 and will be posted to the QIO’s website.

Physician Referred Rehabilitative Behavioral Health Services:Requests for prior authorization must be submitted using the revised forms located in the provider manual and must include the Medical Necessity Statement (MNS).  The PA request can come from the physician or the LIP by either fax, telephone or via the QIO’s web portal (all required fields must be completed).  The LIP will receive an authorization letter for approved services only.  The frequency (i.e. 2 x per week) will be up to the referring physician and rendering LIP to determine.  The QIO will no longer fax the MNS, LIP Authorization Form, LIPs Referral Form or applicable clinical documentation back to the LIP once submitted for approval.   Failure to complete and submit all required information and/or documentation may result in delay/denial of service authorizations.  Please refer to the policy manual for more specific information regarding changes.

Other Medical Review Services

Prepayment Reviews:  Current Medicaid services that include surgical pre-payment reviews such as Sterilizations, Abortions, ICF/MR Level of Care Reviews, Inpatient Psychiatric/Outpatient Community Rehabilitative Services will continue to require a review for medical necessity by the QIO.  Please refer to your Medicaid provider manual for policies related to these services.

KePRO will also be responsible for conducting a review of Utilization Review Plans for acute care hospitals, mental hospitals and Intermediate Care Facilities (ICFs).  The written plans must meet the requirements outlined in the Code of Federal Regulations at the following location: for acute care hospitals 42 CFR §456.100-145; for mental hospitals 42 CFR §456.200-245; for ICFs 42 CFR §456.400-438.  KePRO will contact each facility prior to June 30 of each year in preparation of their review. 

Again, we encourage you to visit KePRO’s website at for additional information regarding KePRO’s web based PA submission, upcoming trainings, forms and any new policies or procedural changes affecting Medicaid’s QIO process.

If you have any questions, comments or concerns regarding this bulletin, we encourage you to submit them to  Thank you for your continued support of the South Carolina Healthy Connections program.

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