LOCAL EDUCATION AGENCIES (LEA) SERVICES …

LOCAL EDUCATION AGENCIES

(LEA) SERVICES PROVIDER

MANUAL

JANUARY 1, 2023

South Carolina Department of Health and Human Services

LOCAL EDUCATION AGENCIES (LEA)

SERVICES PROVIDER MANUAL

SOUTH CAROLINA DEPARTMENT OF

HEALTH AND HUMAN SERVICES

CONTENTS

1. Part I- School-Based Rehabilitative Therapy Services¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­...1

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Program Overview ..................................................................................................... 1

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Individuals with Disabilities Education Act and Medicaid¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­.¡­.1

2. Covered Populations .............................................................................................................3

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Eligibility/Special Populations ................................................................................... 3

3. Eligible Providers...................................................................................................................4

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Provider Qualifications.............................................................................................. 4

4. Covered Services and Definitions........................................................................................ 10

5. Utilization Management ....................................................................................................... 25

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Prior Authorization .................................................................................................. 25

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Other Service Limitations ....................................................................................... 25

6. Reporting/Documentation .................................................................................................... 26

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School Based Rehabilitative Therapy Services ........................................................ 26

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Special Needs Transportation Program ................................................................... 30

7. Billing Guidance ..................................................................................................................32

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School Based Administrative Claiming ..................................................................... 32

8. Part II- School-Based Rehabilitative Behavioral Health Services¡­¡­¡­¡­¡­¡­¡­¡­¡­...¡­¡­33

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Program Overview¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­.¡­¡­¡­¡­¡­¡­....33

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LOCAL EDUCATION AGENCIES (LEA)

SERVICES PROVIDER MANUAL

SOUTH CAROLINA DEPARTMENT OF

HEALTH AND HUMAN SERVICES

9. Covered Populations¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­.¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­.¡­¡­¡­¡­¡­.¡­¡­¡­¡­.36

10. Eligible Providers¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­.¡­¡­.¡­¡­¡­¡­¡­.¡­.......37

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Provider Qualifications¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­.¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­. ¡­.37

11. Covered Services and Definitions¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­...¡­¡­¡­¡­¡­¡­¡­...46

12. Utilization Management¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­...¡­...66

13. Reporting/ Documentation¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­...¡­¡­¡­¡­¡­¡­¡­¡­...67

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Documentation Requirements¡­.¡­¡­¡­¡­¡­¡­¡­¡­.¡­¡­¡­¡­¡­¡­¡­¡­¡­.¡­¡­¡­¡­.67

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Individualized Plan of Care (IPOC)¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­70

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90 Day Progress Summary¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­.¡­¡­¡­¡­¡­¡­¡­.¡­¡­...74

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Clinical Service Notes (CSN)¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­.¡­¡­¡­¡­¡­¡­.75

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Service Specific Documentation Requirements¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­...78

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Discharge/Transition criteria¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­86

14. Billing Guidance¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­...¡­¡­¡­.¡­¡­¡­¡­....87

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Service Unit Contact Time¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­...¡­.¡­87

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Service Specific Billing Guidance¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­. .¡­.88

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LOCAL EDUCATION AGENCIES (LEA)

SERVICES PROVIDER MANUAL

SOUTH CAROLINA DEPARTMENT OF

HEALTH AND HUMAN SERVICES

1

PART I-SCHOOL BASED REHABILITATIVE

THERAPY SERVICES

PROGRAM OVERVIEW

The South Carolina Department of Health and Human Services (SCDHHS) provides Medicaid

reimbursement for medically necessary services provided to Medicaid-eligible individuals in the

Local Education Agency (LEA). Medical Necessity means the need for treatment services is

necessary to diagnose, treat, cure, or prevent an illness, or participation in services is reasonably

expected to relieve pain, improve and preserve health, or be essential to life. This includes, but is

not limited to, children under the age of 21 years who have or are at risk of developing sensory,

emotional, behavioral or social impairments, physical disabilities, medical conditions, intellectual

disabilities or related disabilities, or developmental disabilities or delays.

Each LEA recognized as such by the South Carolina Department of Education (SCDE) has

contracted with SCDHHS to provide Medicaid-reimbursable school-based services to Medicaideligible children with special needs. Individual service providers employed or contracted by a LEA

must meet the specified Medicaid provider qualifications.

INDIVIDUALS WITH DISABILITIES EDUCATION ACT AND MEDICAID

The development of an Individualized Education Program (IEP), Individualized Family Service Plan

(IFSP) is a requirement of the Individuals with Disabilities Education Act (IDEA). The development

of an Individualized Health Plan (IHP) is a requirement of Section 59-63-80 of the South Carolina

Code of law. Medicaid requires school-based services to be indicated on the IEP, IFSP, IHP or the

Individualized Treatment Plan (ITP). However, Medicaid will not reimburse for any administrative or

direct services performed for pre-IEP/IFSP/IHP activities. Medicaid will not reimburse for the IEP

team member meetings or the cost related to attendance at those meetings by medical

professionals.

The following policies apply when an LEA relies upon Social Security Act ¡ì1903(c) (42 U.S.C.

1396b(c)) as its basis for billing Medicaid:

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Medicaid-reimbursed school-based rehabilitative therapy services must be included in the IEP or

IFSP.

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Medicaid-reimbursed school-based rehabilitative behavioral health services are required to be

included in the IEP, IFSP, ITP or Individual Plan of Care (IPOC).

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LOCAL EDUCATION AGENCIES (LEA)

SERVICES PROVIDER MANUAL

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SOUTH CAROLINA DEPARTMENT OF

HEALTH AND HUMAN SERVICES

Medicaid-reimbursed Medicaid Adolescent Pregnancy Prevention Services (MAPPS) are not

required to be included in the IEP, IFSP, IHP or ITP.

LEAs must adhere to the applicable IDEA requirements when Medicaid-reimbursed school-based

services are included in the IEP or IFSP. However, Rehabilitative Behavioral Health Services

(RBHS) must be indicated on an IPOC. The IEP or IFSP may be used as the IPOC if all of the

minimum components are indicated. If IDEA permits the Medicaid-reimbursed school-based service

to be documented in attachments to the IEP file, then such documentation meets these

requirements.

NOTE: References to supporting documents and information are included throughout the manual.

This information is found at the following locations:

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Provider Administrative and Billing Manual

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Forms

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Section 4 - Procedure Codes

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