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Autism Spectrum Disorder Services Interim Process – Phase Two

Effective Feb. 1, 2016, the South Carolina Department of Health and Human Services (SCDHHS) will initiate an improved interim process by which its members are evaluated for and receive Autism Spectrum Disorder (ASD) services that are identified as medically necessary based on an Early and Periodic Screening Diagnosis and Treatment (EPSDT) encounter.

Healthy Connections Prime Passive Enrollment Scheduled to Begin April 2016; Seniors in South Carolina now have a new health care option


Healthy Connections Prime is a new program for South Carolina seniors age 65 and older with Medicare and Medicaid. This demonstration program is jointly administered by the Centers for Medicare and Medicaid Services (CMS) and the South Carolina Department of Health and Human Services (SCDHHS) and is designed to integrate all the services of Medicare, Medicare Part D and Medicaid under a single Medicare-Medicaid plan. In South Carolina these Medicare-Medicaid plans are offered by Coordinated and Integrated Care Organizations (CICO).

Topical Fluoride Varnish Change In a Primary Care Setting

The South Carolina Department of Health and Human Services (SCDHHS) is notifying all providers of an update in coding related to the application of fluoride varnish in a primary care setting (excluding Convenient Care Clinics). Effective for dates of service on or after July 1, 2015, trained staff in a primary care setting must begin billing Current Procedural Terminology (CPT) code 99188 on the CMS-1500 form when applying fluoride varnish. This code replaces the American Dental Association (ADA) code of D1206 when the service is provided in a primary care setting.

Hepatitis C Virus (HCV) Pharmacy Benefit Carve Out

Effective with dates of service on or after July 1, 2015, the South Carolina Department of Health and Human Services (SCDHHS) will carve out coverage for medications used to treat Hepatitis C Virus (HCV) from the Managed Care Organization (MCO) benefit. Pharmacy claims for these medications for Medicaid members enrolled in a Medicaid Managed Care Organization (MCO) will be covered through the Fee-For-Service (FFS) pharmacy program. All FFS coverage rules, prior authorization requirements and preferred drug classifications will apply.

Medical Assessment of all OSS Residents



Effective October 1, 2014, SCDHHS will begin to conduct medical assessments of Optional State Supplementation (OSS) residents.  These medical assessments will be required of all residents within the program.  The assessments will be in the form of a survey.  Please note that the new medical assessment policy will not affect any resident’s standing within the program.  To learn more about the new assessment policy please review the OSS Provider Manual on the South Carolina Department of Health and Human Serviceswebsite.

Correction Regarding The Medicaid Targeted Case Management Providers Notice Posted June 26, 2014

The notice that was posted regarding Medicaid Targeted Case Management (MTCM) providers on June 26, 2014, pertaining to Medicaid Targeted Case Management was intended only for  newly enrolled private providers of MTCM. The intent was to advise newly enrolled private providers of MTCM of potential policy changes reflecting “conflict free” care management. Below is the updated correspondence distributed to newly enrolled private providers of MTCM. We apologize for any inconvenience. 

South Carolina Medicaid Preferred Drug List

The following revisions to the Preferred Drug List (PDL) are effective with dates of service on or after August 1, 2014. 


Quality Improvement Organization (QIO) Updates


KEPRO's, the QIO, primary role is to prior authorize (PA) select Medicaid services including, but not limited to inpatient admissions, therapy services for adults and children and Durable Medical Equipment (DME).  Effective April 1, 2014, the number of days required for providers to submit requests to the QIO as well as response times for the QIO to render determinations have been changed or revised as indicated below.

Referrals for Medicaid Targeted Case Management


Medicaid Targeted Case Management (MTCM) is an available Medicaid covered service that helps individuals in gaining access to doctors, social services, educational resources, jobs and other services.  Anyone who is Medicaid eligible and meets one of the following categories may qualify for MTCM:


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