• 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.

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

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 www.scdhhs.gov/Provider and select “FAQ Guide” for instructions on how to update information in your profile.

Revalidation FAQs PDF

The trading partner agreement form needs to be completed.

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.

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)

The nursing facility must submit a request for an adjustment. The adjustment process must be completed before the hospice can be paid for room and board dates of service.

If a beneficiary no longer has the insurance policy that is seen on the Web Tool, the provider can refer the beneficiary to their eligibility counselor/worker, or complete the Health Insurance Information Referral Form (HIIRF) to update the beneficiary’s third party payer information. Making a change to a policy that already exists in the Medicaid Management Information System (MMIS) takes five days. The HIIRF Form can be faxed to 803-252-0870.

If you do not fully complete the provider revalidation process within 30 days from the date on the notification letter, it is considered voluntary termination from South Carolina Healthy Connections Medicaid. You will need to enroll as a new provider. Revalidation FAQs PDF

If any information that you used for your provider enrollment has changed and you have not informed SCDHHS of the change, you will need to follow the standard procedure to update your information. Please go to www.scdhhs.gov/Provider and select “FAQ Guide” for instructions on how to update information in your profile. Revalidation FAQs PDF

If the revalidation notification letter is returned to South Carolina Healthy Connections Medicaid as undeliverable mail, we will call you using the phone number on file in order to update your address. You will need to follow the standard procedure to update your address. 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. Once the address information is updated and the revalidation notification letter is re-sent, the provider will still have 30 days from the date on the original revalidation notification letter to fully complete the provider revalidation process.

If you are unable to be reached using the phone number on file, your inability to complete the provider revalidation process means that you have voluntarily terminated as a South Carolina Healthy Connections Medicaid provider and will need to enroll as a new provider.

Revalidation FAQs PDF

If your revalidation reference number does not work on the website, ensure that the computer you are using meets the web application system requirements for the provider revalidation application. Please visit https://www.scdhhs.gov/ProviderRequirements and scroll to the section labeled “Web Application System Requirements” for more information.

If you are still unable to use your revalidation reference number, please contact the Provider Service Center at (888) 289-0709, option 4.

Revalidation FAQs PDF

If there are NPIs associated with your Medicaid ID that you do not want to revalidate, do not complete an enrollment application for them. No action is needed on your part. Revalidation FAQs PDF

A checklist of the documentation that you will need for the provider revalidation process can be found by copying and pasting this link you’re your browser https://www.scdhhs.gov/sites/default/files/Online%20Enrollment%20Application%20Visual%20Guide.pdf or by visiting https://www.scdhhs.gov/Provider and selecting “Online Application Visual Guide” from the “Provider Enrollment Information” section. This is currently a link to the Provider Online Enrollment Application Visual Guide. The information needed for enrollment is very similar to the information needed for revalidation. Revalidation FAQs PDF

A credit balance is a positive amount that remains in a patient’s account which may have resulted from multiple reimbursements from several payers, adjustments to previously paid claims of a provider, duplicate payment, or subrogation events due to accidents and other injury cases. When another third party payer reimburses a provider for claims that Medicaid paid, either in part or in full, a refund is due to the Medicaid Program.

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.

If your service requires a referral, the MHN gives you an authorization number.

All enrolled South Carolina Healthy Connections Medicaid providers who are not Durable Medical Equipment (DME) suppliers must revalidate their enrollment criteria every five years in accordance with the Affordable Care Act. DME suppliers must revalidate every three years. Revalidation FAQs PDF

The payment cycle is: Wed-Mon, payments are processed on Tuesday, and payment is received as early as Friday.

The PO boxes and physical address are included in the Provider manual as well as on the mailing envelope.

NOTE: Late change forms should be sent overnight or faxed, with all attachments, to (803) 870-9020. Forms should not be faxed unless they are sent past the deadline. Faxed corrections should be received no later than the third working day of each month for Nursing Home providers and the 17th day of the month for OSS providers.

The Non-Contractual box is to be selected/entered when the provider is not contracted with the beneficiary’s third party payer.

You must wait for the rejection, and then do a correction. An adjustment can only be made to a paid claim.

TADs are not yet available on the Web Tool. Medicaid will continue to send copies of the TADs to providers until the TADs are available on the Web Tool.

Nursing Home change forms are due to MCCS on the first working day of each month. OSS change forms are due no later than the 17th of each month. These dates are subject to change based on holidays, etc.

South Carolina Healthy Connections Medicaid mailed revalidation notification letters for phase 1 of provider revalidation on June 4^th, 2015. Providers should not take any steps to revalidate until they receive their revalidation notification letters. It is important that providers keep their address information up to date to ensure that they receive the revalidation notification letter.

South Carolina Healthy Connections Medicaid provider revalidation will occur in phases beginning in June 2015 and ending in March 2016. Providers should not take any steps to revalidate until they receive their revalidation notification letters. It is important that providers keep their address information up to date to ensure that they receive the revalidation notification letter.

Revalidation FAQs PDF

The system recognizes when your password does not meet the password requirements.  However, if you have reviewed your selected password and it does meet the password requirements, contact the EDI Support Center at 1-888-289-0709, and choose Option “1”. 

Reports are due by the 30th day of the following month after the respective quarter end. If the report has not been submitted by the due date, a late notification letter will be sent to the provider.

You should check before providing services.

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

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.

You would use a void if you bill for something by mistake; accidental claim submission, for example.

Appendix 2 of your SCDHHS Provider Manual.

On the Claim Entry screen, go to the Document tab to attach your documentation. (Effective August 17, 2015) Claims Attachments – Web Tool Reference Guide.

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

The Medicaid Credit Balance Report Certification Page and Claim Detail forms can be found under the For Providers menu option at SCDHHS.gov – see Credit Balance Forms.

That form can be found on SCDHHS.gov.

During the online enrollment process, organizations cannot affiliate individuals to their group. It is the responsibility of the individual provider to affiliate with a group. The request must be on the business letterhead to include the Group’s Medicaid Legacy ID number and the provider’s NPI number with the provider’s or an authorized signature via Fax: (803) 870-9022 or Mail: Medicaid Provider Enrollment, PO Box 8809 Columbia, SC 29202-8809. Updates will be processed within ten (10) days of receipt.

The reports and checks may be mailed regular or certified mail to MIVS, Attn: Benefit Recovery – Credit Balance Reporting, P.O. Box 8355, Columbia, SC 29202-8355 or may be sent by facsimile to MIVS, Attn: Benefit Recovery – Credit Balance Reporting, 803-462-2582.

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. 

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

The hospice agency is responsible for pharmaceutical costs related to pain management and symptom control of the terminal illness.

Prior to requesting the removal of an Individual provider from your group practice ensure that the pending claims are adjudicated. However, if the provider has already been removed from the group prior to the claim(s) being adjudicated and needs to be added back to the group,  submit the request on the business letterhead with the provider’s or an authorized signature via Fax: (803) 870-9022 or Mail: Medicaid Provider Enrollment, PO Box 8809, Columbia, SC 29202-8809. Updates will be processed within ten (10) days of receipt. 

Contact the PSC, option “2” for claims issues. 

SCDHHS requires updates to a provider’s file to be submitted in writing on business letterhead with the provider’s or an authorized signature. Submit any updated changes via Fax: (803) 870-9022 or Mail: Medicaid Provider Enrollment, PO Box 8809, Columbia, SC 29202-8809. Updates will be processed within ten (10) days of receipt.

A provider is notified about rejections via the Enrollment Rejection Letter. The rejection letter indicates the reason(s) for the rejection. For further assistance, contact the Provider Service Center at 1 (888) 289-0709, option 4.

When an Individual provider is affiliated with a group, the original group enrollment date remains the same regardless of when the individual provider was affiliated. The individual provider does not receive a new enrollment date when affiliated with the group.

Providers that submit inaccurate or incomplete information will be notified of the rejected credit balance report. The provider will be instructed to re-submit another report for the applicable quarter.

A 951 Edit Code means the beneficiary was not eligible for Medicaid on the date of service. The beneficiary and/or responsible party for the beneficiary might not have completed the annual Medicaid eligibility review. Inform the nursing facility caller to contact the beneficiary’s eligibility caseworker.                                                                                                                                                                                

Yes, a provider will be notified via certified mail when terminated for cause. The provider does have appeal rights.

No.

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

A provider can verify Managed Care Organization enrollment on the eligibility section of the Web Tool under the “Beneficiary Special Program Data” section.

Upon approval of enrollment (the provider has met all necessary requirements); the enrollment date of the provider’s effective date will retroactively begin 90 days prior to the date of receipt of the application. However, depending on the provider’s type/ specialty, if the provider is required to sign a contractual agreement in addition to the provider enrollment agreement, the enrollment date is the effective date of the contract. Note: Medicaid will not pay for claims prior to an enrollment effective date or before the provider’s licensure/certification date.

No, because it did not process. 

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.

Yes, they will receive a copy of the 181 to verify the income change. It is recommended that the NF or ICF/MR attach a copy of the most current 181 when invoicing the hospice. Recurring income is noted in Section III of DHHS Form 181. Medicaid Eligibility is responsible for determining recurring income.

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

Yes

No, it is not tied to another system. Updates are your responsibility.

No, there is no limit on password attempts.