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SC Medicaid - SCDHHSMedicaid · Reimbursement · Claims & Billing · SCHigh impact

Outpatient Hospital Drugs and Biologicals Payment Update

Act
by Sep 30, 2026
Effective date
Oct 1, 2026
Identified
Sep 3, 2026

Summary

Effective October 1, 2026, South Carolina Medicaid will change how it reimburses outpatient hospital drugs and biologicals. These drugs will now be reimbursed using the same methodology as physician-administered drugs, and certain outpatient hospital drugs will be reimbursed as add-ons without the outpatient hospital multiplier applied. This affects billing methodology and reimbursement calculations for all outpatient drugs and biologicals at hospital facilities.

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What to do

by Sep 30, 2026 · 3 steps
01Billing team must prepare for the payment methodology change by (1) reviewing the updated Hospital Services Provider Manual once published by SC DHHS on or after October 1, 2026; (2) identifying which outpatient hospital drugs and biologicals will be classified as add-ons and exempt from the outpatient hospital multiplier; (3) updating billing system logic to apply the physician-administered drug reimbursement methodology to applicable outpatient hospital drugs; (4) modifying claim submission and reimbursement calculation processes to remove the outpatient hospital multiplier from designated add-on drugs; (5) training billing staff on the new payment structure.
02For MCO-enrolled members, coordinate with managed care organizations regarding coverage and authorization requirements.
03Contact SC DHHS Provider Service Center at (888) 289-0709 (Mon-Thu 7:30am-5pm, Fri 8:30am-5pm) or via https://www.scdhhs.gov/providers/contact-provider-representative with questions.
If missed: Failure to implement these changes by the effective date will result in claim denials and revenue loss.

Original notice

Outpatient Hospital Drugs and Biologicals Payment Update
scdhhs.gov · Always check the source before changing claims.
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SC Medicaid - SCDHHS policiesSC policy changes

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