South carolina department of health and human services medicaid policy and procedures manual
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101.13.04 Release of Eligibility Information (Eff. 10/01/13)Disclosure of eligibility/financial information without the permission of the applicant/ beneficiary should only occur for purposes directly connected with the administration of the program and then only to persons, agencies, and entities with comparable confidentiality standards. Listings of Medicaid applicants/beneficiaries may not be released to anyone without the consent of DHHS. As required by federal law, all application data will be automatically sent to the Federally Facilitated Marketplace (FFM) for those applications who contain an individual who is not eligible for Medicaid but is assessed to be potentially eligible for other affordable insurance programs. Application data will also be automatically received from the FFM for any individual or their family who is assessed potentially Medicaid eligible by the FFM. Eligibility information may be automatically sent to the FFM for any applicant who requests eligibility assessment or determination by either the FFM or SCDHHS. Medical providers who are enrolled in the South Carolina Medicaid program may verify a beneficiary’s eligibility for Medicaid benefits for the previous 12 months by utilizing the Medicaid Interactive Voice Response System (IVRS) or a Point of Sale (POS) device. DHHS has contracted with GovConnect to maintain the IVRS. To access IVRS, medical providers must use a touch-tone phone to call the toll-free telephone number: 1-888-809-3040, and enter their six (6)-character Medicaid Provider Identification. Medical providers will be prompted to enter the related Dates of Service and one of the following beneficiary identifiers:
The system then submits the data provided and plays the beneficiary eligibility information back to the medical provider over the phone to include beneficiary special program status; Medicare coverage, third-party insurance coverage, and service limitations/visit count information. This service is provided 24 hours per day, seven (7) days per week in a real time environment, and there is no charge to the medical provider for this service. In addition, on the back of the Healthy Connections (Medicaid) Insurance Card is a magnetic strip that may be utilized in POS devices to access information regarding Medicaid eligibility, third-party insurance coverage, beneficiary special programs, and service limitations 24 hours per day, seven (7) days per week in a real time environment. There is a fee to the medical provider for this service. Medical providers that have contracted with the Department of Health and Human Services to provide a Sponsored Medicaid Worker must have a DHHS Form 934 ME, Appointment of Agent for Medicaid Determination and Appeal Process, signed by the applicant/beneficiary to receive information concerning an application/review or appeal being processed by a worker for individuals in the facility. Organizations who have signed a Memorandum of Agreement with the Department of Health and Human Services to act as an intake site, must also use the DHHS Form 934 ME in order to receive information from the eligibility worker regarding the applicant/ beneficiary during the Medicaid application/review and/or appeal process. 101.13.05 Release of Medical Information (Eff. 07/01/08)Generally, release of medical information must be authorized by the patient/beneficiary. Beneficiary consent should be obtained before responding to a request for information from an outside source. Consent should include a description of the information to be released and identification of the receiving entity. The consent should be signed by the beneficiary or responsible party and witnessed. Only the information described may be released and only to the entity described.
101.13.06 South Carolina Health Information Exchange (SCHIEx) (Eff. 07/01/08)SCHIEx (SKY-eks), the South Carolina Health Information Exchange, gives healthcare providers, such as doctors and hospitals, the ability to view medical information on Medicaid beneficiaries. The information available includes medications, diagnosis, procedures, and common problems. Having this information will help the healthcare provider coordinate care for better continuity and quality, as well as assist with controlling cost. This clinical data is collected from 10-years of paid SC Medicaid claims, as well as information shared from participating providers' electronic medical record (EMR) systems. Medical Information for Medicaid beneficiaries will be included in SCHIEx, but participation is not mandatory. A beneficiary can opt-out, or choose not be included, by contacting the Resource Center at 1-888-549-0820. If a beneficiary decides not to participate, a healthcare provider will not be able to see any of that person’s medical information. Individuals who have opted-out can later opt-in by contacting the Resource Center. Table of Contents 101.13.07 Request for Information on Medicaid Beneficiaries from External Parties (Rev. 06/01/08)The Attorney General’s Medicaid Fraud Control Units (provider and beneficiary) are directly involved in the administration of the Medicaid program and handle cases under agreements with the Division of Program Integrity. Therefore, the Department of Health and Human Services is committed to cooperating with these units of the Attorney General’s office in providing information on beneficiaries who receive Medicaid. DHHS is not authorized to disseminate information directly to external parties other than those units of the Attorney General’s office. Any requests coming from other entities such as: The State Law Enforcement Division (SLED), The Federal Bureau of Investigations (FBI), Drug Enforcement Administration (DEA), The U.S. Attorney’s office, other units of the Attorney General’s Office or the U.S. Marshal’s office, must be referred by the local eligibility office to the Office of General Counsel (OGC) within the Department of Health and Human Services. Upon receipt of the request, the Office of General Counsel will review the request and advise the local office. For any requests that are deemed questionable, local offices may contact the Office of General Counsel. |