S.C. Code Regs. § 126-425

Current through Register Vol. 48, No. 5, May 24, 2024

Section 126-425 - Beneficiary Utilization

A. Definitions.

(1) The Division of Program Integrity of the South Carolina Department of Health and Human Services (DHHS) is designed to safeguard against unnecessary, harmful, wasteful, and uncoordinated utilization of services by Medicaid eligible beneficiaries and health care providers.

(2) Medicaid Beneficiary - an individual who has been determined to be eligible for health services as described in the State Plan under Title XIX and Title XXI of the Social Security Act, as amended.

(3) Beneficiary Profile - a comprehensive statistical and utilization profile of a Medicaid beneficiary who has deviated from predefined thresholds, standards of medical care, and other criteria for the purposes of analysis and review.

(4) Misutilization ("misuse") - overuse, underuse, harmful, wasteful, and uncoordinated use of Medicaid services or improper or incorrect use of services provided under the Medicaid Program, whether intentional or unintentional.

(5) Restriction ("restricted") - The limitation of a Medicaid beneficiary to Medicaid services provided by a designated primary physician practitioner, pharmacy, hospital, or mental health provider for other than emergency health care. A restriction may be to more than one provider. A designated primary physician practitioner may make referrals to other health care providers, which will not be affected by the restriction designation.

(6) Provider - an individual, partnership, corporation, association, or institution that is eligible to provide medical assistance to a beneficiary pursuant to the State Medical Assistance Plan in accordance with Title XIX and Title XXI of the Social Security Act, as amended. A provider must be licensed, as applicable, under State law, is in good standing with applicable professional review boards, has not had a license revoked or suspended, and has not been convicted of fraud in any legal jurisdiction.

(7) Practitioner - a physician or other health care professional licensed under State law to practice his or her profession, is in good standing with applicable professional review boards, has not had a license revoked or suspended, and has not been convicted of fraud in any legal jurisdiction.

(8) Treatment Pathway - is the most appropriate medical condition specific treatment protocol. Treatment pathways have been researched and approved by professional associations, provide desired outcomes, include definitive evaluation and re-evaluation plateaus, offer a coordinated health team approach to care, eliminate duplication of costly services, and reduce errors.

(9) Medically Reasonable and Necessary ("medically necessary") - means procedures, treatments, medications or supplies ordered by a physician, dentist, chiropractor, mental health care provider, or other approved, licensed health care practitioner to identify or treat an illness or injury. Procedures, treatments, medications or supplies must be administered in accordance with recognized and acceptable medical and/or surgical discipline at the time the patient receives the service and in the least costly setting required by the patient's condition. All services administered must be in compliance with the patient's diagnosis, standards of care, and not for the patient's convenience. The fact that physician prescribed a service or supply does not deem it medically necessary.

B. Beneficiary Policies.

(1) The services that are governed by this program are as follows:

(a) All medical services rendered by a Medicaid provider for non-emergency services;

(b) Beneficiaries' use of Medicaid services;

(2) Services that are not governed by this program are as follows:

(a) Emergency services which are necessary to prevent death or serious impairment of the health of a beneficiary;

(b) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services;

(3) Beneficiary profiles shall be reviewed to identify potential utilization or compliance issues.

(4) Providers shall refer suspected misusers of Medicaid services to the DHHS.

(5) Beneficiaries identified as suspected misusers of Medicaid services will be notified in writing that he/she will be restricted subject to paragraph A (5). The period of restriction shall be in accordance with 42 CFR 431.54(e). DHHS shall monitor restricted beneficiaries' utilization patterns.

(6) The factors to be considered in making a determination whether to implement a restriction shall include all or some of the following:

(a) Medical factors;

(b) Patient utilization history;

(c) The degree of aberrancy;

(d) Any history of prior misutilization;

(e) Utilization patterns inconsistent with their peers;

(f) Utilization patterns inconsistent with treatment pathways;

(g) Evidence of abusive, duplicative, and wasteful utilization practices;

(h) Evidence of drug-seeking behaviors;

(i) Evidence of utilization patterns that could cause harm to the beneficiary;

(j) The degree of compliance with medical advice and treatment pathways;

(k) Evidence that a beneficiary's medical outcomes and health status may be improved by following treatment pathways and coordinated care.

(7) Rights and conditions of beneficiary during restriction period.

(a) Beneficiaries will be notified by mail of a pending restriction or action subject to 42 CFR 431.206 through 42 CFR 431.214.

(b) Beneficiaries are given freedom of choice of their primary providers. If a beneficiary does not select a primary provider, DHHS may select one for the beneficiary.

(c) A beneficiary will be released from restriction upon DHHS determination that the beneficiary's service utilization patterns are in compliance with treatment pathways and consistent with their medical needs.

(8) Fair Hearing - any Medicaid beneficiary who has been notified in writing by DHHS or its designee of a pending restriction due to misutilization of Medicaid services may exercise his/her right to a fair hearing. Notice will be given pursuant to 42 CFR 431, Subpart E and the Fair Hearing will be conducted pursuant to R. 126-150 etseq. and 42 CFR 431, Subpart E.

S.C. Code Regs. 126-425

Amended by State Register Volume 28, Issue No. 5, eff May 28, 2004; State Register Volume 42, Issue No. 05, eff. 5/25/2018.