The South Carolina Department of Disabilities and Special Needs (DDSN) serves persons with intellectual disabilities, autism, head and spinal cord injury and conditions related to each of these four disabilities. The mission of DDSN is to assist people with disabilities and their families through choice in meeting needs, pursuing possibilities, and achieving life goals; and minimize the occurrence and reduce the severity of disabilities through prevention.

Post Payment Claims Review - Purpose

Performance Measures in the DDSN-operated Home and Community Based Waivers require the State to assure that claims for waiver services are only paid when the service is appropriately authorized, documented and delivered in accordance with policy and the scope of the defined service. One way to determine whether claims are paid accurately is through a post payment claims review. 

The purpose and expectation of a post-payment review is, through review, to identify improper payment of services.  Examples of improper payment include, but are not limited to:>

• Billing for items or services that should not have been delivered (not authorized).
• Billing for items or services for which there is no documentation to support delivery. 
• Improper charges due to unit errors, duplicate charges, etc.
• Billing for services outside the scope of the authorized service. 

Post Payment Claims Review Process - Overview

The Post Payment Claims Review Process will include the following elements:

• A statistically valid random sample that is representative of all Medicaid Waiver Services that will ensure a 95% Confidence Interval +/- 5%.  The samples will be provider-based. Samples are selected by SC DHHS.

• A three-year cycle for the review of each provider agency.  Every three years, claims for each of the services delivered by the provider agency during the previous Waiver year will be reviewed to determine the following:
  • Was the service recipient eligible for the service at the time of the claim (e.g., Medicaid eligibility, waiver eligibility)?
  • Was the service authorized in the recipient’s Person-Centered Support Plan?
  • Is a properly executed authorization present?
  • Do the units of service delivered/claimed align with units of service authorized?
  • Is documentation to support the delivery of each service unit claimed available?
  • Was the service delivered in accordance with established policy, including Waiver service definition?

• Providers will receive written notification of the review and the specific claims being reviewed.  
  This notice will also include:
  • Dates of the review period and the sample selected, sent via secure email to the Executive Director.
  • The claims under review with acknowledgement that the sample may be expanded, at the discretion of DDSN and/or DHHS.
• • Examples of the types of documentation which may be submitted to justify the claims.
  • An acknowledgement that DDSN will use additional information as found in Therap or Phoenix Systems as part of the review.
  • The directions for submission via secure portal.
  • An acknowledgement that failure to submit by the deadline will result in findings.
  • Name and contact information for DDSN staff responsible for the review.

• No earlier than the 31^st calendar day following the notification to the provider, DDSN will begin the review.  DDSN will utilize a desk review approach.    In the event a provider has not submitted any documentation at the onset of the desk review, all claims will be considered unsupported and will result in findings.   DDSN will not provide reminders or re-send notifications.
• Once a desk review begins, DDSN reserves the right to request additional documentation from the provider.  If requested during the desk review, providers will be notified in writing and asked to submit the additionally requested documentation within 14 calendar days of the request. 
• A report of the preliminary findings will be issued to the provider within 30 days of the completion of the desk review.  The report will include information about any claims identified as unsupported. The provider will have thirty (30) calendar days to refute preliminary findings. Response by the provider is optional. No earlier than the 31^st calendar day following the issuance of the report of preliminary findings, the additionally submitted information, if any, will be reviewed.

• A final report of findings will be issued within 45 calendar days from the issuance of the preliminary report of findings. The final report will be issued to the provider and to SCDHHS. The report will include the claims determined inappropriate or not supported for which a claim adjustment is warranted. The report will include any notification that the provider is being referred to SCDHHS for further review/action.

Appendix A: CMS Improper Payment Fact Sheet 2022

Appendix B: Medicaid Claims Information for DDSN Operated Waivers