Physicians

Physicians

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.
 

Patient Centered Medical Home (PCMH) Incentive Update

The South Carolina Department of Health and Human Services (SCDHHS) is informing all practices currently recognized by the National Committee for Quality Assurance (NCQA) as a patient-centered medical home (PCMH) or who have applied or are considering applying for PCMH certification that the following modifications are being made to its PCMH incentive program, effective July 1, 2017.

Monthly Prescription Limit

Effective with dates of service on or after July 1, 2017, the South Carolina Department of Health and Human Services (SCDHHS) will no longer limit the number of prescriptions available to Medicaid beneficiaries.

If you have any questions regarding this policy, please contact the Provider Service Center at (888) 289-0709.

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

Modification to Codes that require Filing to TPL

Effective for dates of service on or after July 1, 2017, and as required by 1902(a) (25) of the Social Security Act, the South Carolina Department of Health and Human Services (SCDHHS) will implement cost avoidance rules for the procedure codes reflected below. Service providers will be required to file claims to any liable third-party insurer before submitting a claim to SCDHHS for payment.

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:

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.

2017 Provider Revalidation: Physician Assistants

The South Carolina Department of Health and Human Services (SCDHHS) is beginning 2017 provider revalidation of physician assistants. The physician assistant revalidation process begins Jan. 20, 2017, and ends 5 p.m. Feb. 24, 2017.

Reimbursement Rate Update for Long Acting Reversible Contraceptives (LARCs)

Due to a recent increase in pricing of several Long Acting Reversible Contraceptives (LARCs), effective Jan. 1, 2017, the South Carolina Department of Health and Human Services (SCDHHS) has updated the reimbursement rates. Sales tax coverage has been included.

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.

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