Behavioral Health Services

Behavioral Health

Addressing behavioral health issues is just as important as addressing physical health issues. Both require coordinated medical attention and care. It makes sense for these services to be integrated, and for a health plan to manage both a member’s physical and behavioral health benefits.

Therefore, SCDHHS-contracted managed care organizations (MCOs) will cover Rehabilitative Behavioral Health and associated outpatient mental health services beginning July 1, 2016.

Public Notice: Proposed RBHS Inclusion in the Coordinated Care Benefit

Medicaid Psychiatric Residential Treatment Facility (PRTF) Directory»

Member FAQs

Effective July 1, 2016, the South Carolina Department of Health and Human Services (SCDHHS) will include outpatient mental health services and Rehabilitative Behavioral Health Services (RBHS) as part of the Managed Care benefit.

I heard and read about changes to behavioral health services. How does this impact me?

While there is no change in benefits, there will be changes for providers to file claims as well as changes in the referral process. Providers will need to verify eligibility and, for some services, receive prior authorization from the member’s health plan. Providers will file claims with your health plan.

How do I know if a service requires prior authorization?

Your provider will handle the prior authorization process for you. Your provider will contact your health plan if the service requires prior authorization.

I have an appointment scheduled before July 1, 2016. How will this affect me?

The change does not take place until July 1, 2016, and will not have any effect on this appointment.

I have an appointment scheduled on or after July 1, 2016. How will this affect me?

If you have an appointment scheduled on or after July 1, 2016, and are currently enrolled in a health plan, your outpatient mental health services will be covered by the MCO.

There may be a grace period where your provider does not need to request prior authorization. The grace period will depend on the type of service and date of the appointment. Your provider will be aware of these requirements and can call your health plan with questions.

Who do I call if I have questions regarding my health plan benefits?

If you have questions please contact your health plan at the Member Service phone number below:

Absolute Total Care: (866) 433-6041
Healthy Blue by BlueChoice of SC: (800) 574-8864
Molina Healthcare of SC: (855) 882-3901
First Choice by Select Health of SC: (888) 276-2020
Humana Healthy Horizons of SC: (866) 432-0001

How do I know if I am in a health plan?

Contact the Healthy Connections Member Service Center at (888) 549-0820.

Can I change the health plan I am enrolled in?

All enrollees have an annual 90-day choice period during which a change may be made to their health plan. Healthy Connections members required to participate in a health plan may choose to transfer to another health plan during the 90-day period.

What phone number should I call to change health plans?

You should contact South Carolina Healthy Connections Choices at (877) 552-4642 or online at SCChoices.com.

Will all of my children be enrolled within the same health plan?

Each Healthy Connections member is able to enroll with the health plan of their or their responsible party’s choice.

Provider FAQs

Providers will be required to file claims for outpatient mental health services to the Managed Care Organizations (MCOs) for enrolled members. Providers must verify eligibility and contact the applicable MCO for prior authorization, when required, before rendering services.

I am hearing and reading about changes to behavioral health services. How does this impact me?

While there is no change in the member benefit, there will be administrative changes for providers. Some changes include prior authorization processes and processes for filing claims.

For dates of service on or after July 1, 2016, providers will need to verify eligibility and for some services receive prior authorization from the member’s MCO. For dates of service on or after July 1, 2016, providers will file claims with the member’s MCO.

Why do SCDHHS approved providers have to enroll and credential with each MCO?

All MCOs are required to enroll and credential providers as outlined in the current SCDHHS/MCO contract and 42 CFR 438.214.

Will providers still have to be enrolled with SCDHHS if their clients are enrolled with an MCO?

Providers will have to enroll and remain enrolled in good standing with SCDHHS prior to contracting with any of the MCOs.

How do I know if a service requires prior authorization?

Once you have contracted and enrolled with an MCO, the MCO will provide detail regarding the appropriate authorization and claim billing procedures.

Will all beneficiaries be enrolled in an MCO?

Some beneficiaries will remain enrolled in fee-for-service (FFS)/traditional Medicaid. This document provides a listing of those members that are mandatorily enrolled in managed care, those that have a choice between FFS or managed care and those that cannot be enrolled in managed care.

I have Medicaid beneficiaries scheduled before July 1, 2016. How will this affect their appointment/treatment?

The change does not take place until July 1, 2016, and will not have any effect on this appointment.

I have beneficiaries scheduled on or after July 1, 2016. How will this affect me?

Please contact the Medicaid beneficiary’s MCO for additional information regarding service authorization for any dates on or after July 1, 2016.

Who do I call if I have questions regarding a beneficiary’s managed care benefits?

If you have questions regarding prior authorization, the beneficiary’s managed care benefits, etc., please contact the beneficiary’s MCO at the phone number below:

Absolute Total Care: (866) 433-6041
Healthy Blue by BlueChoice of SC: (866) 757-8286
First Choice by Select Health: (888) 559-1010
Molina Healthcare of SC: (855) 882-3901
Humana Healthy Horizons of SC: (800) 523-0023

Am I notified by SCDHHS if the client is no longer enrolled with the MCO?

All eligibility and enrollment can be verified using the SCDHHS Web Tool, which is free of charge, or one of the available card swipe systems. For more information call (888) 289-0709. Upon checking eligibility, providers will be able to determine managed care participation. The Web Tool will list the name and phone number of the MCO.

You must check eligibility before each visit as Medicaid eligibility status may change on a daily basis.

Managed Care Organization (MCO) FAQs

Should letters be sent to all members notifying them of the mental health carve-in?

Letters only need to be sent to those members that you see from the FFS Medicaid data receiving Outpatient Mental Health Services from a Private Rehabilitative Behavioral Health Provider, DMH, DAODAS or a school district. Your mailing needs to at least encompass those members.

Should we send letters to all providers or just to those providers of RBHS services notifying them of the outpatient mental health carve-in? Do we even need a provider letter?

SCDHHS alerts, provider trainings and bulletins will suffice for the provider notification. You are not required to send out a separate provider notification.

What should the MCO contract with providers of Outpatient mental health services contract look like? Will SCDHHS do a review of the contract?

As long as you have the required appendix in your contract with these providers it will not be necessary for you to share your contract or boilerplate with SCDHHS. You may structure the contract with providers how you best feel fits the needs for your business.

How will enrollment and credentialing be handled?

Currently all of the providers that provide any of these mental health services will be enrolled at the clinic level. The MCOs are welcome to explore delegated credentialing agreements with DMH. Both private and public providers of Rehabilitative Behavioral Health services are enrolled at the clinic level. Encounters will reflect the clinic provider IDs at both the billing and rendering location on the encounter. If MCOs would like to credential to the individual rendering level for the private providers they are welcome to credential below the clinic level but the MCOs’ encounter submission to SCDHHS must be at the clinic level at this time.

Will the MCOs enroll all the current Medicaid RBHS providers?

MCOs are not required to enroll all current Medicaid RBHS providers. They may choose to enroll based on their credentialing requirements and network needs.

Will we get continuity of care files from all of the provider types, LEA/DOE providers, private RBHS providers, DMH and DAODAS?

Initially, SCDHHS was not planning on providing files for each of the entities listed. The intention was for providers of these services to reach out directly to each MCO. SCDHHS is currently researching to see if the agency can provide some additional information through KEPRO or another method.

The MCO contract draft requires an in-state BH QI position. Can plans consider RN or MPH as well as other listed professionals? This would create parity with currently required quality positions.

SCDHHS is planning to make some modifications to the draft contract that will address the issue.

Does DJJ and/or DOE have accreditation for these services?

Neither of these entities are accredited by Commission on Accreditation of Rehabilitation Facilities (CARF).

Has SCDHHS done site visits for either DJJ and/or DOE?

SCDHHS is not aware of any state agency performing site visits for either of these provider types.

Does anyone refer to DJJ or DOE or are there services limited in scope to those at risk for either incarceration or children in school?

These two state agencies would only see the members in those settings specific to either DJJ or DOE. They would not actively accept referrals from outside their setting.

If MCOs are contracting and credentialing at the group level, will claims come in at the group level (without individual practitioners listed)?

Yes. Claims and encounters will be processed at the group level without the individual practitioner listed on the claim. The rendering and bill to provider ID will be the same on the claim.

Are adolescents placed in DJJ automatically enrolled in Medicaid? Any designation of DJJ and not being eligible to be on MCOs?

There is no automatic Medicaid enrollment of youth in DJJ's custodial care. If these youth were covered by Medicaid MCOs before they entered DJJ they would still be covered as they are for physical health by the MCOs.

Are school-based providers currently providing these services required to be licensed?

In accordance with state statute, LEAs are considered governmental agencies under the DOE and are exempt from the licensing requirements for private providers.

Would LEA be a responsibility of MCOs?

Yes, if the member is enrolled with the MCO, then the mental health services provided by an LEA would be included in the MCO's coverage array.

Will COB apply to DMH? Will MCOs coordinate for all RBHS services?

Yes, TPL requirements do apply for these services and, where applicable, MCOs would want to coordinate benefits.

If school-based providers do not have an NPI, taxonomy or Medicaid ID, should we deny claims and direct the provider to SCDHHS?

SCDHHS is unaware of any school district providers without a Medicaid ID, NPI or taxonomy. However, if there is a school-based provider that does not have these, then yes, MCOs should have them reach out to SCDHHS to enroll as a provider.

Would Magellan be able to provide list of drugs that they have authorized for MCO members?

If the member was with a MCO then any drugs would have been paid for through plan's pharmacy benefit while they were in the MCO. The only claims Medicaid FFS would have paid for would have been DMH administered J codes.

In the SCDHHS bulletin outlining requirements that RBHS providers have to be licensed, one of the bullets indicates if a provider is pursuing a license they can continue to provide services. Would the group bill with the non-licensed individual as the servicing provider or the supervising individual?

From a claim/encounter perspective the provider will use the clinic provider ID to indicate both the bill to and rendering ID number on claim/encounter. At this time the claim will reflect neither individual just the clinic.

Why may MCOs need a MOU to share information with state agencies they do not directly contract with?

If this is in reference to the Continuum of Care (COC), it is because the COC only serves as case managers; they do not provide RBHS services. Because both the MCO and the COC will be involved with the same members it may be necessary to create a memorandum of understanding (MOU) to share information in the care of a particular member.

Will private providers need to be credentialed individually?

No, private providers of RBHS will be credentialed at the group level. Continuum of Care is not a provider; they are a referring agency only.

Will LIPs providers currently enrolled with MCOs continue to be credentialed individually instead of by group/clinic?

Correct. The LIPs provider enrollment does not change; they continue to be credentialed individually. At some future point the MCOs and SCDHHS will undertake individual credentialing with the RBHS providers.

If the MCO has a current contract with Medicare Prime (dual demonstration) will they be allowed to amend the contract with Medicaid coverage and include Article 1?

Yes.

It has been reported that schools are reimbursed at 100% FFS, but also receive a settlement at the end of each year. Is this accurate and will you please provide methodology for this type of reimbursement?

Cost settlements are currently done with school districts. SCDHHS will have more information regarding future approach to cost settlement at a later date.

Many private RBHS providers have noted that they have unlicensed staff in their groups (with bachelor's and master's degrees). Given the new direction from SCDHHS that only government providers can use unlicensed personnel, how will these providers be treated?

MCOs will be required to enforce and abide by the RBHS policies. If upon review and investigation you find that the private contracted RBHS providers are not abiding by these policies the provider will need to be terminated. The Community Support Services do not require a master's level nor a license, so staff who are unlicensed at the independent level and have a bachelor's degree can provide those services.

Subfiles vs. Monthly Fee Schedules: How will the monthly fee schedules that are sent to the MCOs on a routine basis compare to the RBHS subfiles that were distributed to MCOs for configuration? Will there be a comparison of the updated monthly fee schedules to the RBHS files sent to the MCOs for implementation purposes?

The monthly fee schedule and the excel spreadsheets should match one another in the fee schedule updates MCOs receive the first week of July. SCDHHS will use the excel spreadsheets MCOs have been sent to update its system. SCDHHS has started this process and updated coding; the agency will update pricing next week.

Subfiles vs. Monthly Fee Schedules: If there are provider questions or issues with rates, who do MCOs refer the provider(s) to?

MCO questions regarding rates should be directed in the same manner that is being done currently. Provider questions regarding rates can be directed to info@scdhhs.gov.

For subfile E, H2017, when is this to be billed with a specific modifier as opposed to the 000 modifier?

There is a description of when providers need to bill certain modifiers for H2017 located on page five in the Rehabilitative Behavioral Health Services provider manual.

Can a TCC or CIS provider, using their new CPT codes, provide TCC or CIS services, plus PRS, on the same date of service?

Group PRS cannot be provided on the same day as CIS. Individual PRS can be provided on the same day as CIS. Regarding TCC, neither group nor individual PRS may be provided on the same day.