South Carolina SC

South Carolina Medicaid (SCDHHS / Healthy Connections) expresses FFS prior-authorization criteria INLINE inside per-provider-type Provider Manuals (one Manual.pdf per provider type: Physicians, Hospital, DME, Pharmacy, etc.), not as a single PA code list or a per-MCO grid. Each manual page on scdhhs.gov links to provider.scdhhs.gov/internet/pdf/manuals/<Type>/{Manual,Forms,CCR,Section 4 (Procedure Codes)}.pdf. PA criteria are written drug-by-drug / service-by-service within the manual text (e.g. Physicians manual 'Prior Authorization' section ~p.197 plus per-drug criteria like Xolair, CGM, 17-P). AUTHORITY/UM VENDOR: FFS medical PA is administered by Acentra Health (formerly Kepro), the QIO, via the Atrezzo provider portal ('Web Tool'). Pharmacy is state-administered: PDL and pharmacy PA criteria are published by Magellan/First Health Services (FHSC) at southcarolina.fhsc.com - current PDL effective 2026-05-01 marks PA/step-therapy per drug. Managed care PA goes to one of 6 Healthy Connections MCOs which follow the state PDL with limited variation. DEAD PINS: state_meta pa_index (scdhhs.gov/forms/2/Prior%20Authorization)=404; provider_manual (provider.scdhhs.gov/internet/portal/manuals)=404; pharmacy (scdhhs.gov/pharmacy)=404. Live replacements in data.repin_candidates. No login/bot-wall on manual PDFs (direct curl w/ browser UA + Referer = 200).

Single state-directed PDL; MCOs retain claims & PA processing for their own members; FFS rail run by Prime; Hep C and TB drugs carved out to FFS / SCDPH

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

Last award: 2024-07-01. Next due: None. Contracts extended through: None.

## 1. How SC requires PA South Carolina (SC) Medicaid requires prior authorization (PA) through a structured yet varied approach, depending on the type of service and provider. For durable medical equipment (DME), specific criteria are outlined in the Durable Medical Equipment Services Manual, which mandates clinical necessity documentation and the use of CPT/HCPCS codes. The Pharmacy Manual does not detail specific PA processes or criteria but references a separate pharmacy prior-authorization drug list (PDL) managed by Magellan/FHSC for certain drugs like Duloxetine capsules. Physicians' services require PA for certain office/outpatient exams, with medical necessity justification as the primary documentation requirement. Inpatient hospital services necessitate pre-authorization for out-of-state hospitals within 25 miles of SC borders, requiring detailed clinical and patient history documentation. Behavioral health (BH) services are carved into managed care organizations (MCOs), meaning MCOs handle PA processes for their members. ## 2. How SC publishes and reports PA SC Medicaid publishes its PA requirements through provider manuals specific to each type of service or provider, available on the South Carolina Department of Health and Human Services (SCDHHS) website. These manuals include inline criteria for services requiring prior authorization and specify documentation requirements. For example, the Durable Medical Equipment Services Manual requires clinical necessity and diagnosis codes using CPT/HCPCS codes. The pharmacy PDL is managed by Magellan/FHSC and can be accessed via their portal or specific documents like the current 2026 PDL. The Acentra/Atrezzo Unified Management (UM) portal is used for submitting PA requests, though specifics on its usage are not detailed in the provided documents. ## 3. SC's CMS-0057-F and PA-reform compliance posture The findings do not explicitly mention South Carolina's compliance with CMS-0057-F or specific PA reform initiatives. The state has an active Medicaid 1115 waiver program, including Healthy Connections Works and Palmetto Pathways to Independence, which may incorporate PA reforms. However, the exact alignment with CMS-0057-F standards is not specified in the provided information. **WISeR is not applicable to SC** — the CMS "Wasteful and Inappropriate Service Reduction" Medicare PA model applies only to AZ, NJ, OH, OK, TX, and WA. ## 4. How SC runs its own program SC Medicaid operates a hybrid system involving both fee-for-service (FFS) and managed care organizations (MCOs). The pharmacy carve-out involves a single state-directed PDL, with MCOs handling claims and PA processing for their members. The FFS rail is run by Prime, the current fiscal agent. Behavioral health services are carved into MCOs, while long-term support services (LTSS) are carved out to FFS. The state has an ongoing procurement cycle for MCO contracts, with the last award made on July 1, 2024. The transition between fiscal agents, such as from ACS-Inc to Conduent/Gainwell, is tracked to ensure continuity in service delivery and data management. ## 5. Patterns, what's notable, and what's missing/uncertain **Patterns:** - SC Medicaid uses provider-specific manuals for PA criteria. - The pharmacy PDL is managed separately by Magellan/FHSC. - Behavioral health services are carved into MCOs, while LTSS remains in FFS. **Notable:** - Specific documentation requirements vary widely across service types (e.g., clinical necessity vs. trial of preferred products). - The transition between fiscal agents is carefully tracked to maintain service continuity. - Multiple 1115 waivers indicate a proactive approach to Medicaid reform and innovation. **Missing/Uncertain:** - Details on the Gold Card law and its impact on PA processes. - Comprehensive information on step-therapy protocols for various services. - Effective dates and revisions for pharmacy PDL criteria beyond the Duloxetine example. - Detailed usage guidelines for the Acentra/Atrezzo UM portal.