Other Medical Professionals

Other Medical Professionals

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.

Reimbursement Rate Update for Long Acting Reversible Contraceptives (LARCs)


The South Carolina Department of Health and Human Services (SCDHHS) has confirmed that the state tax exemption for physician administered injectable drugs (South Carolina Sales and Use Tax Act, 12-36-2120 (80)) does not apply to intrauterine devices or contraceptive implants. To ensure continued access to these products, SCDHHS has updated the reimbursement rates indicated below, effective July 1, 2016.




Previous Rate

August P&T Committee Meeting Postponed

The South Carolina Department of Health and Human Services (SCDHHS) Pharmacy and Therapeutics (P&T) Committee meeting scheduled for Aug. 3, 2016, is postponed until September.

SCDHHS is evaluating the potential impact of new product approvals in the medication classes that are scheduled to be considered. Postponing this meeting will allow time for a more thorough assessment of these new products. The date of the rescheduled meeting will be posted on the SCDHHS and Magellan websites as soon as it is scheduled.

2016: Last Chance to Begin Participation in the South Carolina Medicaid Electronic Health Records Incentive Program

In recent years, the South Carolina Department of Health and Human Services (SCDHHS) has worked to support the increase of eligible providers' adoption and use of Certified Electronic Health Record Technology (CEHRT) and health information exchange (HIE) through the South Carolina Medicaid Electronic Health Records (EHR) Incentive Program. This program provides incentive payments to eligible professionals (EP) and eligible hospitals (EH) as they adopt, implement, upgrade (AIU) or demonstrate meaningful use (MU) of CEHRT.

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.

Two May Meetings for SC P&T Committee


In addition to the regularly scheduled South Carolina Pharmacy and Therapeutics (P & T) Committee meeting May 4, 2016, there will be a second SC P&T Committee meeting held Wednesday, May 18, 2016. The meeting location and time will remain the same:

South Carolina Medicaid Pharmacy and Therapeutics Committee Meeting

Location: South Carolina Pharmacy Association (SCPhA) Office
1350 Browning Road, Columbia, SC 29210
Wednesday, May 18, 2016, 4 p.m.

Meaningful Use Modifications Webinar

The South Carolina Department of Health and Human Services (SCDHHS) will host a live webinar Thursday, Feb. 11, from 2-3 p.m. on the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs' meaningful use modifications for program years 2015 and 2016.

Rescind Physical Medicine and Therapy Policy Update; Medicaid Bulletin #14-001 Released Feb. 6, 2014

Effective immediately the South Carolina Department of Health and Human Services (SCDHHS) is rescinding the policy, bulletin 14-001 released Feb. 6, 2014, that allowed services delivered to recipients 21 years and over in place of service (62) Outpatient Rehabilitation Facility. Beneficiaries will continue to receive outpatient physical, occupational and speech therapies (PT/OT/SP) services in an outpatient hospital, clinic or office setting.

Physician Assistant Enrollment

All licensed Physician Assistants (PAs) providing services to Healthy Connections beneficiaries must be enrolled as providers with the South Carolina Department of Health and Human Services (SCDHHS). PAs providing services to Medicaid Managed Care enrolled members must also be enrolled and credentialed with the member's Managed Care Organization (MCO).

Pursuant to 42 CFR Part 455, Subpart E, all providers who refer or order items or services covered by the Medicaid program must be enrolled as described above.


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