№ lp_1_21876
File format: docx
Character count: 7833
File size: 72 KB
Administrative source form governing inpatient prior authorization submissions to Medicaid in South Carolina via KePRO, defining required provider, member, clinical, and procedural information for review and determination.
Year:
Not specified
Region / jurisdiction:
South Carolina
Program:
Medicaid
Document type:
Administrative form
Purpose:
Prior authorization review for inpatient services
Submitting method:
Fax
Fax number:
1-855-300-0082
Responsible organizations:
KePRO; South Carolina Department of Health and Human Services
Provider identification:
National Provider Identifier (NPI); Medicaid ID
Mandatory provider location data:
9-digit ZIP code
Review types:
Initial; Recertification; Change; Cancel; Retrospective review
Service setting:
Inpatient; freestanding inpatient psychiatric
Population focus:
Medicaid members; psychiatric services for children under 21 and adults 65 and older
Eligibility window:
Up to 30 days prior to scheduled services
Clinical information required:
Diagnosis; severity of illness; intensity of services
Approval process:
Subject to medical necessity and eligibility verification
Price: 8 / 10 USD
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The product description is provided for reference. Actual content and formatting may differ slightly.
Note:
Year
Theme:
Prior Authorization
Document Type:
Fax Form
Organization / Institution:
Acentra Health, SCDHHS
Target Audience:
Medicaid Providers
Year:
N/A
Region / City:
N/A
Topic:
Medicaid, Prior Authorization, Targeted Case Management
Document Type:
Fax Request Form
Agency / Institution:
Acentra Health
Author:
N/A
Target Audience:
Healthcare providers, Medicaid service providers
Effective Period:
N/A
Approval Date:
N/A
Amendment Date:
N/A
Organization:
Acentra Health
Program:
South Carolina Department of Health and Human Services (SCDHHS)
Document type:
Administrative form
Purpose:
Prior authorization, recertification, change, or cancellation of outpatient Medicaid services
Submission method:
Fax
Fax number:
1-855-300-0082
Applicable services:
Mental Health Counseling, Therapies (PT, OT, SP), DME, Home Health, Hospice, Autism Spectrum Disorder
Provider identification:
National Provider Identifier (NPI) with 9-digit ZIP Code
Member identification:
Medicaid ID Number
Geographic scope:
South Carolina
Review types:
Initial, Recertification, Change, Cancel, Retrospective Prepayment Review
Governing criteria:
SCDHHS and InterQual guidelines
Associated system:
Atrezzo Connect
Submission timing:
Up to 30 days prior to scheduled services, excluding weekends and holidays
Year:
2026
Region / City:
South Carolina
Theme:
Medicaid, Prior Authorization
Document Type:
Form
Organization / Institution:
KEPRO-SCDHHS
Author:
KePRO
Target Audience:
Medicaid providers
Period of Validity:
Ongoing
Approval Date:
Not specified
Date of Changes:
Not specified
Year:
2019
Region / City:
North Carolina
Subject:
Data Privacy and Security
Document Type:
Best Practices Guide
Institution:
North Carolina Department of Public Instruction
Author:
Division of School Data, Research and Federal Policy
Target Audience:
NC Department of Public Instruction (DPI) staff, school and LEA staff
Period of Validity:
Ongoing
Approval Date:
August 30, 2019
Date of Modifications:
Not specified
Note:
Year
Year:
Not specified
Region / City:
Western Australia
Theme:
Healthcare, Continence Management
Document Type:
Referral Form
Organization / Institution:
Silver Chain
Author:
Not specified
Target Audience:
Medical practitioners, healthcare facilities, and clients
Period of validity:
Not specified
Approval Date:
Not specified
Date of amendments:
Not specified
Year:
2007
Region / City:
USA, Malaysia, Australia
Theme:
Telephony, Fax Solutions, Integration
Document Type:
Product Information
Organization / Institution:
FaxCore Software
Author:
FaxCore Software
Target Audience:
Small and Medium Enterprises (SMEs)
Period of Validity:
N/A
Approval Date:
N/A
Date of Changes:
N/A
Year:
2014
Region / City:
California
Document Type:
Compliance Notice
Organization:
Signature Networks PLUS
Author:
Signature Networks PLUS
Target Audience:
Medical Providers, Physician Offices
Period of Action:
Starting January 1, 2014
Approval Date:
Not specified
Amendment Date:
Not specified
Year:
Not provided
Region / City:
Greenville, NC
Topic:
Not specified
Document Type:
Contact Information
Organization / Institution:
East Carolina University
Author:
Not provided
Target Audience:
Not specified
Effective Period:
Not specified
Approval Date:
Not provided
Amendment Date:
Not provided
Year:
1997
Region / City:
United States
Topic:
Inpatient medication management
Document Type:
Manual
Organization / Institution:
Department of Veterans Affairs
Author:
Not specified
Target Audience:
Healthcare professionals in the Veterans Affairs system
Effective Period:
Ongoing updates
Approval Date:
December 1997
Revision Date:
August 2025
Year:
2026
Region / City:
United States
Subject:
Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) & Quality Reporting Program (QRP)
Document Type:
Supporting Statement
Agency:
Centers for Medicare & Medicaid Services (CMS)
Author:
U.S. Department of Health and Human Services
Target Audience:
Healthcare professionals, policymakers, and administrators in rehabilitation facilities
Effective Date:
October 1, 2026
Date of Approval:
Not specified
Date of Revision:
March 29, 2024
Expiration Date:
Not specified
Year:
2023
Region / City:
UK, Cyprus, Overseas
Subject:
Military Mental Health, Psychotherapy, Inpatient and Outpatient Services
Document Type:
Statement of Requirement
Organ / Institution:
Defence Medical Services
Author:
Defence Primary Healthcare
Target Audience:
Military Personnel, Healthcare Providers, Service Authorities
Period of Validity:
Not specified
Approval Date:
Not specified
Date of Amendments:
Not specified
Year:
2005
Region / City:
United States
Topic:
Health Systems Design and Development
Document Type:
Release Notes
Organization / Institution:
Department of Veterans Affairs
Author:
Department of Veterans Affairs
Target Audience:
Health care professionals using CPRS
Period of Validity:
April 2006
Approval Date:
1/31/2005
Modification Date:
5/18/2005
Year:
2027
Region / City:
United States
Topic:
Healthcare Technology, Medical Devices
Document Type:
Tracking Form
Agency / Organization:
Centers for Medicare & Medicaid Services
Author:
Unknown
Target Audience:
Healthcare Providers, Medical Device Manufacturers
Effective Period:
Fiscal Year 2027
Approval Date:
Unknown
Date of Changes:
Unknown
Acute Inpatient Psychiatric Admission Form for Patients Aged 10–17 with Neurodevelopmental Disorders
Patient Name:
____________________________________________
Date of Birth:
____________________
Home Address:
_________________________________________________________________________
Parent/Guardian Name/Phone/Email:
______________________________________________________
Expected Admission Type:
Voluntary / Involuntary
Referral for:
Acute Inpatient Psychiatric Treatment, approximately 30 days
Target Population:
Patients aged 10–17 with autism spectrum disorder, intellectual disability, or related neurodevelopmental disability
Current Psychiatric Provider:
UNC Psychiatry Outpatient (if applicable)
Diagnoses:
_____________________________________________________________________________
Current Medications:
____________________________________________________________________
Medical Problems:
______________________________________________________________________
Isolation Precautions:
No / Yes
Past Medical Hospitalizations or Surgeries:
__________________________________________________
Previous Psychiatric Treatment:
___________________________________________________________
Substance Use:
_________________________________________________________________________
Post-Treatment Residence Confirmed:
No / Yes
Department of Social Services / Child Protective Services Involvement:
_________________________
Consent for Medical Treatment:
___________________________________________________________
Last COVID Test:
___________________
Laboratory Results:
Within normal limits / Not done / Any abnormalities: ______________________
Pregnancy Status:
No / Yes
Seizure History:
No / Yes, well-controlled / Yes, uncontrolled
Last Vital Signs:
T______ P______ BP______ RR______ O2 Sat _____ Weight______ Height_______ BMI_________
Pending/Past Legal Problems:
_____________________________________________________________
ADL Support:
Independent / Needs Assistance with Eating, Hygiene, Walking (specify assist device)
Communication Method:
Verbally (sentences/words/phrases), Sign language, Pictures, Device, Gestures
Sensory Needs:
Hearing impaired / Visually impaired / Over/undersensitive to ____________________
Year:
2020
Region / City:
United States
Subject:
Alcohol withdrawal syndrome, Benzodiazepine-sparing regimens, Inpatient outcomes
Document type:
Research Article
Organization / Institution:
Not specified
Author:
Joshua T. Smith, Mary Sage, Herb Szeto, Yun Lu, Adriana Martinez, Patricia Kipnis, Vincent X. Liu
Target audience:
Healthcare professionals, medical researchers
Period of validity:
2018-2019
Approval date:
Not specified
Date of changes:
Not specified
Note:
Context
Year:
2023
Region / City:
Ohio
Topic:
Inpatient Reimbursement Methodology
Document Type:
Reimbursement Policy
Organization:
Ohio Bureau of Workers’ Compensation
Author:
Ohio Bureau of Workers’ Compensation
Target Audience:
Hospitals, healthcare providers, injured workers, medical professionals
Effective Period:
February 1, 2023 – January 31, 2024
Approval Date:
N/A
Amendment Date:
N/A