Frequently Asked Questions
Frequently Asked Questions
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:
Explain the Medicaid application fee and how much is it?
For 2015, SCDHHS must collect a $553 application fee from business organizations and entities that are enrolling in South Carolina Medicaid with an Employee Identification Number (EIN). [Note: $542 for 2014.] The fee is to be used to cover the cost of program integrity efforts including the cost of screening associated with provider enrollment processes. This fee can vary from year to year based on adjustments made pursuant to the Consumer Price Index for Urban Areas (CIP-U). The application fee will be imposed on business organizations and entities that are enrolling in South Carolina Medicaid that are: (1) initially enrolling, (2) adding a practice location and (3) revalidating enrollment information at least every five years (with the exception of DME providers, who must revalidate every three years). Providers that are EXEMPT from the application fee are: individual physicians or non-physician practitioners.
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:
(State-regulated and State-licensed would generally be categorized as limited 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)
(Identified by the State as being especially vulnerable to improper payments and would be considered as high risk)
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?
If I am currently enrolled in Medicare or with Medicaid in another state, will I have to go through the entire enrollment and screening process and pay another application fee to enroll in South Carolina Medicaid?
For 2015, SCDHHS must collect a $553 application fee prior to executing a provider agreement whether upon an initial enrollment, reactivation, revalidation or an enrollment to add a new practice location. [Note: $542 for 2014.] The provider enrollment application fee is applicable to providers that the Centers for Medicare & Medicaid Services (CMS) has identified as institutional providers. South Carolina Healthy Connections Medicaid recognizes and enrolls the following institutional providers: Ambulatory Surgery Centers, Community Mental Health Centers; Comprehensive Outpatient Rehabilitation Facilities; Durable Medical Equipment, End Stage Renal Disease Facilities; Federally Qualified Health Centers; Home Health Agencies; Hospices; Hospitals, Acute Inpatient Facilities, Inpatient Psychiatric Facilities, Inpatient Rehabilitation Facilities, Independent Clinical Laboratories; Skilled Nursing Facilities and Rural Health Clinics.
The fee is to be used to cover the cost of program integrity efforts including the cost of screening associated with provider enrollment processes. This fee can vary from year to year based on adjustments made pursuant to the Consumer Price Index for Urban Areas (CIP-U). A provider will be exempt from the fee if they have submitted and received approval for a Hardship Waiver request or they can demonstrate they are enrolled or have paid the application fee to Medicare and/or another state’s Medicaid or CHIP for the same enrollment location jurisdiction. A different enrollment jurisdiction means “a new enrollment with an address different from a currently enrolled location.” Individual physicians (sole proprietors enrolling with an EIN and Social Security Number (SSN) are considered individuals), non-physician practitioners and non-physician practitioner organizations are exempted from paying the enrollment application fee.
What are some of the new provider screening and enrollment guidelines?
What is a Temporary Moratorium?
A temporary moratorium is the imposition of a hold or freeze on the enrollment of new or initial Medicaid providers and suppliers of a particular provider type or the establishment of new practice locations of a particular provider type in a specific geographic area for a period of six months. CMS may extend a temporary moratorium in six month increments. The announcement of a moratorium will be reported in the Federal Register.
When will the new screening and enrollment guidelines be implemented?
Although indicated in a May 9, 2012 Medicaid Bulletin and letter to State Agencies this would be implemented by August 1, 2012, due to delays a new implementation date will be targeted and communicated to providers in future bulletins. Prior to implementation, provider outreach activities will focus on communication of the new policies and other related information. New screening and enrollment information will be distributed through Medicaid bulletins, SCDHHS website messages and alerts, training and orientation activities for certain programs and updates to Program Manuals.
Who initiated these new screening and enrollment guidelines?
The Centers for Medicare and Medicaid Services (CMS), under standards established by the Affordable Care Act (ACA), with a focus on strengthening requirements for Medicaid provider screening and other enrollment requirements.
Will a provider be notified if they are terminated “for cause” and do they have appeal rights?
Yes, a provider will be notified via certified mail when terminated for cause. The provider does have appeal rights.
Will the entities in each screening category stay the same?
CMS will continuously evaluate whether they need to change the assignment of categories of providers and suppliers to various risk categories. If they assign certain groups of providers and/or suppliers to a different category, this change will be proposed in the Federal Register.