Sunday, July 14, 2024, 1:51 PM
Site: Healthy Connections Medicaid E-Learning
Course: Learning Resources (Learning Resources)
Glossary: Frequently Asked Questions
D

Does the Web Tool’s Lists feature allow you to save a beneficiary’s prior authorization in a field?

No, prior authorization may not be necessary for all services. There is a field for prior authorization.

Does Web Tool’s Status show whether it is approved to be paid?

Yes

E

Edit 150

Edit 953

Edit 989

Edit 990

F

For HIPP referral, who should you contact?

For HIPP referral, providers should contact the Medicaid Insurance Verification Services at 1-888-289-0709 option 5, option 4. The HIPP Fax is 803-462-2580.

H

How are MCO plans chosen for a beneficiary if they are auto-enrolled?

The plan is chosen based on the beneficiary’s needs, service area, and any needed specialists.

How are providers categorized by risk categories?

Three levels of screening (limited, moderate and high) are recognized for those provider types that are also recognized provider or supplier types under Medicare.  For those provider types that are not recognized under Medicare, SCDHHS has assessed the risk of fraud, waste and abuse using similar criteria to those used in Medicare.  See the list below for SCDHHS risk categories:

Limited Risk:

(State-regulated and State-licensed would generally be categorized as limited risk)

  • Physician or non-physician practitioners and medical groups or clinics (excluding Physical Therapists and Physical Therapists Groups)
  • Nursing Homes, Hospitals, Public and Private Community Mental Health Centers, Audiologists, Certified Nurse Midwife/Licensed Midwife, Certified Registered  Nurse Anesthetists, Anesthetist Assistants, CMS Parts A & B, Managed Care Organizations,  Licensed Marriage and Family Therapists, Licensed Professional Counselors, Licensed Independent Social Workers –Clinical Practice, Psychologists, Speech Therapists, Nurse Practitioners, Physician’s Assistants, Occupational Therapists, Physicians, Speech and Hearing Clinics, End Stage Renal Disease Clinics, DHEC Clinics, Federally Qualified Health Clinics, Federally Funded Health Clinics and Rural Health Centers, Ambulatory Surgical Centers, Diabetes Education Clinics, School Districts, Developmental Rehabilitation Clinics, Infusion Centers, Pediatric Aids Clinics, Maternal and Child Health Clinics, Dentists, Opticians, Optometrists, Podiatrist, Chiropractors, Pharmacy, Pharmacy Part D, Individual Transportation Providers, Contractual Transportation Providers , Transportation Broker,  X-Ray (not portable)

Moderate Risk:

(Highly dependent on Medicare, Medicaid and CHIP to pay salaries and other operating expenses and which are not subject to additional governmental or professional oversight and would be considered moderate risk)

  • Rehabilitative Behavioral Health Services,  Physical Therapists , Comprehensive Outpatient Rehabilitation Facilities (CORFs),  Hospice Providers, Community Long Term Care (individuals and groups), Independent Laboratories, X-Ray (portable), Ambulance and Helicopter Providers
  • Currently enrolled (revalidating Home Health Agencies)
  • Currently enrolled (revalidating DMEPOS)

 High Risk:

(Identified by the State as being especially vulnerable to improper payments and would be considered as high risk)

  • Proposed (newly enrolling) Home Health Agencies (HHAs), Suppliers of Durable Medical Equipment, Prosthetics, Orthothics and Supplies (DMEPOS)

How are split claims broken up?

A 10 in your CCN represents 8 lines; 20 is the next 8 lines, etc.