Medical Clinics

Medical Clinics

Adding Developmental Pediatricians to the Comprehensive Diagnostic Assessment

The South Carolina Department of Health and Human Services will be amending its autism spectrum disorder (ASD) manual to include additional providers that will be allowed to complete the comprehensive psychological assessment/testing report to determine if Medicaid beneficiaries meet medical necessity criteria for ASD services.

Medication Assisted Treatment Services via Telemedicine

Effective for dates of service on or after Jan. 1, 2018, and pursuant to South Carolina Budget Proviso 117.135, Section A, the South Carolina Department of Health and Human Services (SCDHHS) will accept Act 301 Behavioral Health Centers (301 Centers) as approved referring sites for Medication Assisted Treatment (MAT) services rendered via telemedicine consultation.

Over-The-Counter Aspirin Coverage

The American College of Obstetricians and Gynecologists (ACOG) has issued updated recommendations regarding low-dose aspirin and the prevention of preeclampsia. The South Carolina Department of Health and Human Services (SCDHHS) issues this alert to remind providers that over-the-counter (OTC) aspirin is covered by the agency when a valid prescription is authorized by a licensed practitioner. Providers are advised to follow the ACOG recommendations only if this therapy is appropriate for their patient.
 

Tobacco Cessation Coverage

Effective with dates of service on or after July 1, 2017, the South Carolina Department of Health and Human Services (SCDHHS) is enhancing tobacco cessation coverage for full-benefit Medicaid beneficiaries to align with recommendations from the Centers for Disease Control and Prevention (CDC) and the American Lung Association (ALA). This update applies to both the fee-for-service and managed care Medicaid benefits.

The following medications will be available without prior authorization or co-payment when prescribed by a Medicaid provider:

Therapeutic Child Care (TCC) Requirements

Effective with dates of service on or after July 1, 2017, the South Carolina Department of Health and Human Services (SCDHHS) will allow therapeutic child care (TCC) providers to fulfill the requirement of parallel work with the primary caregiver by rendering family psychotherapy twice per month in conjunction with the TCC service. Family psychotherapy services provided to meet this requirement must be rendered within the stated frequency limits as outlined in the Rehabilitative Behavioral Health Services manual.

Coverage for Centering Pregnancy Group Prenatal Care

Effective July 1, 2017, the South Carolina Department of Health and Human Services (SCDHHS) will update coverage for CenteringPregnancy group prenatal care services.

Prior Authorization (PA) for Physician-Administered Drugs

Effective with dates of service on or after Nov. 1, 2016, the following physician-administered medications will require prior authorization (PA) to ensure that use is consistent with the medication’s indication(s) and appropriate clinical guidelines.

 

HCPCS Code                       Medication Name

J3262                                     Actemra

                J0800                                     Acthar HP

                J0717                                     Cimzia

Pediatric Screening (CPT) 96127

Effective Nov. 1, 2016, the South Carolina Department of Health and Human Services (SCDHHS) will limit payment for Current Procedural Terminology (CPT) code 96127 to a maximum of two units per date of service. This is consistent with the National Correct Coding Initiative (NCCI) Medically Unlikely Edit (MUE) limit for this service. This bulletin supersedes previous SCDHHS guidance, provided March 31, 2015, indicating that a maximum of four units are payable per date of service for CPT code 96127.

Modification to Codes that Require Filing to TPL

The list of Current Procedural Terminology (CPT) codes below require Third Party Liability (TPL) billing before the claim is submitted to SCDHHS for payment. As a reminder, claims that do not bill TPL first will receive a 150 edit (TPL cover verified/filing not indicated on claim). Providers should follow resolution steps as outline in the SCDHHS Physicians, Laboratories and Other Medical Professionals policy manual.

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