South Carolina Code of Regulations › Chapter 126 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › Article 4 - PROGRAM EVALUATION › Subarticle 2 - PROGRAM INTEGRITY › Section 126-425 - Beneficiary Utilization

Current through Register Vol. 48, No. 6, June 28, 2024
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.