Physicians

Physicians

Changes to Administrative Review Procedures of Select Physician Administered Drugs

Effective March 1, 2020, the South Carolina Department of Health and Human Services (SCDHHS) will implement the changes described below for select physician-administered drugs.

SCDHHS contracts with a designated quality improvement organization, KEPRO, for utilization review and prior authorization services. Providers serving Medicaid fee-for-service beneficiaries must receive prior authorization from KEPRO for the following limited list of physician-administered drugs:

Non-Invasive Prenatal Screening

Effective on or after Feb. 1, 2020, the South Carolina Department of Health and Human Services (SCDHHS) will require prior authorization(PA) for Cell-free Fetal DNA Testing, commonly known as Non-Invasive Prenatal Screening (NIPS). PA forms should be submitted through Keystone Peer Review Organization (KePro), the agency's quality improvement organization.

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.
 

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.

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