Frequently Asked Questions


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Frequently Asked Questions

 

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REVALIDATION

When should I expect to receive my provider revalidation approval?

Once the provider revalidation process is complete and error free, provider revalidation approval will be emailed to the email address entered during the provider revalidation process within 30 days. Revalidation FAQs PDF


Where can I find additional information about the South Carolina Healthy Connections Medicaid provider revalidation process?

For additional information about the South Carolina Healthy Connections Medicaid provider revalidation process, please visit www.scdhhs.gov/revalidation or medicaidelearning.remote-learner.net. Revalidation FAQs PDF


Who is mandating the provider revalidation process?

This implementation is in response to directives in the standards established by Section 6401(a) of the Affordable Care Act (ACA) in which CMS requires all state Medicaid agencies to implement the provider enrollment, screening, and revalidation provisions of the Affordable Care Act. These regulations were published in the Federal Register, Vol. 76, February 2, 2011, and were effective March 25, 2011. Revalidation FAQs PDF


Will I need a site visit?

All moderate and high risk providers will need a site visit. The site visit must occur within 30 days from the date on the revalidation notification letter. Revalidation FAQs PDF


Will there be training available for the South Carolina Healthy Connections Medicaid provider revalidation process?

There will be webinars, e-learning opportunities, and classroom training sessions available. For information about dates, times and registration, please visit medicaidelearning.remote-learner.net. Revalidation FAQs PDF


SCREENING REQUIREMENTS

Can a billing provider be an ordering or referring provider as well?

Yes, as long as the provider is not designated as an ordering/referring provider exclusively. Future edits will prevent claims payment if an ordering/referring-only provider submits their NPI as a billing provider.


Can a provider be moved from one risk category to another?

Yes, providers can be reassigned from the “limited” or “moderate” categories due to:

  • Imposition of a payment suspension within the previous 10 years
  • A provider or supplier has been terminated or is otherwise precluded from billing Medicaid
  • Exclusion by the OIG
  • A provider or supplier has been excluded from any federal health care program
  • A provider or supplier has had billing privileges revoked by a Medicaid contractor within the previous 10 years
  • A provider or supplier has been subjected to a final adverse action (as defined in 42 CFR 424.502) within the past 10 years
  • Instances in which CMS lifts a temporary moratorium for a particular provider or supplier type and a provider or supplier that was prevented from enrolling based on the moratorium, applies for enrollment as a Medicaid provider or supplier at any time within 6 months from the date the moratorium was lifted.

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 can a provider check to see if the ordering/referring physician is enrolled with Medicaid?

 

 

On the SCDHHS website SCDHHS.gov, there is a searchable listing of Enrolled Providers under the For Providers tab. If the provider is not listed, then the provider is not currently enrolled with Medicaid. You may also contact the Provider Service Center at 1 (888) 289-0709, option 4 to verify the provider’s enrollment. 

 


How can I obtain more information regarding the new provider screening and other enrollment requirements?

A link to the Federal Register, Vol 76, No. 22, dated February 2, 2011, can be found on the SCDHHS website at SCDHHS.gov.



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