MedicaidCoverageMedium impact
Physician Services Provider Manual Updates
SC Medicaid - SCDHHS·SC · Gastroenterology, Internal Medicine, Endocrinology +2 more·Medical Policy
Effective date
Oct 1, 2026
We identified it
Sep 15, 2026
Summary
South Carolina Medicaid (SCDHHS) is adding coverage for ELF testing (CPT 81517) for liver disease risk assessment in patients with MASH and related conditions, requiring prior authorization and limiting to one test per six months for members 12+. Additionally, prostate cancer screening coverage is being expanded for Healthy Connections Medicaid members age 50+, with reimbursement rates to be published by October 1, 2026.
Action Required
By September 30, 2026: (1) Billing team must update billing system to recognize CPT 81517 as a covered service under South Carolina Medicaid and configure it to require prior authorization before claims submission. (2) Configure frequency limitation in system to allow only one test per six months per member. (3) Create or update clinical criteria checklist in EMR/billing system to verify patient meets at least one qualifying diagnosis (Type II diabetes, chronic HBV/HCV, MASLD/advanced MASH, alcoholic hepatitis, or elevated liver stiffness measurement). (4) Update provider encounter forms and billing templates to prompt for prior authorization request and diagnosis documentation. (5) For prostate cancer screening: ensure billing system reflects new coverage for members age 50+ once reimbursement rates are published on SCDHHS website by Oct 1, 2026. (6) Train billing and front desk staff on new requirements. Claims submitted without prior authorization for CPT 81517 will be denied. For MCO-enrolled members, direct authorization questions to their MCO. Contact SCDHHS Provider Service Center at (888) 289-0709 with implementation questions.