Sunday, July 14, 2024, 12:46 PM
Site: Healthy Connections Medicaid E-Learning
Course: Learning Resources (Learning Resources)
Glossary: Frequently Asked Questions

What are some of the new provider screening and enrollment guidelines?

  • Enhanced provider screening and enrollment based on risk categories (limited, moderate and high) for fraud, waste and abuse for each provider type as assigned by CMS and the SCDHHS.
  • Background checks and unannounced pre and post enrollment site visits.  Fingerprint-based criminal history records checks.   At the present time, the criminal background checks and fingerprinting are not required. 
  • Updated Disclosure of Ownership and Controlling Interest Statements
  • Enrollment of ordering/referring providers 
  • Suspension of provider Medicaid payments in cases of credible allegations of fraud
  • Denial of enrollment and/or termination of a provider from the Medicaid program “for cause”.  This is defined as the revocation of Medicaid billing privileges for specific reasons such as denial/termination from the Medicare program, denial/termination from other state Medicaid and Children’s Health Insurance Programs, or other reasons based on credible allegations of fraud, integrity or quality.
  • Implementation of a temporary moratorium on new provider enrollments, when instructed by CMS, to protect against high risk of fraud and abuse
  • Revalidation of enrolled providers at least every five years, with the exception of DME providers, who need to revalidate every three years.

What do I need to do to prepare for a site visit?

You will receive a site visit form with this information after your site visit has been scheduled. Revalidation FAQs PDF

What do I need to do to prepare for revalidation?

It is highly recommended that you make sure your primary practice location address and provider type are current with South Carolina Healthy Connections Medicaid. It is your responsibility to ensure that your information is current.

To update your address, please fax or mail a letter requesting an address change to MCCS Provider Enrollment on company letterhead. The Provider Enrollment fax number is (803) 870-9022. The address is Medicaid Provider Enrollment, P.O. Box 8809, Columbia, SC 29202-8809. The letter should include the provider’s legacy and NPI numbers, as well as the new address, along with the provider’s or an authorized person’s signature and a contact person’s name and telephone number in case there are any questions. To update info other than an address, please go to and select “FAQ Guide” for instructions on how to update information in your profile.

Revalidation FAQs PDF

What do you do if a beneficiary is out of visit counts?

When checking eligibility, you will see what visit counts they have left. You can request more from your representative or treat them as a self pay.

What do you do if monies are sent to the patient?

Change them to self pay after or before service completion.

What do you do if you contact a Primary Care Provider and they have no record of a patient?

If this were to happen, you would need to contact the Managed Care Organization directly.

What form needs to be completed for access to the Web Tool?

The trading partner agreement form needs to be completed.

What happens if my DHHS Form 181, CRCF 01 or IPC form is not received on time or is not received at all?

No changes will be made regarding beneficiaries’ income, IPC/CRCF status, etc., for the current billing month if change forms are not received by MCCS. However, changes can be made during the next month’s billing process.

What happens if someone in your office initiates a refund with the 205 and an adjustment, how do you get it back?

The program area would have to research the adjustment to return funds.

What happens if the NF or ICF/MR* accepts a hospice resident while Medicaid eligibility is pending and it is later determined that the resident is not eligible? Who is responsible for room and board payment to the NF or ICF/MR?

The hospice is responsible for the room and board amount.

It is imperative that the hospice social worker continues to pursue eligibility for the resident to decrease the financial risk in the event the resident is ultimately not eligible for nursing facility benefits. 

*Nursing Facility (NF) or Intermediate Care Facility (ICF) / Mental Retardation (MR)