The Bulletin Came May 15. The Manual Is Live This Morning.
Today, July 1, the South Carolina Department of Health and Human Services replaces its September 2025 ASD Services Provider Manual with a rewritten version that applies to every date of service from today forward.
The timeline was short. SCDHHS published the bulletin on May 15, 2026. Provider comments were due June 1 – a 17-day window. Six and a half weeks after the announcement, the new manual governs your claims.
This is a full manual replacement, not a policy patch. The bulletin identified six areas of change: telehealth guidance, medical necessity criteria, the non-covered services list, provider qualifications and enrollment, plan of care and documentation requirements, and procedure code standards. An updated Adaptive Behavior Services fee schedule takes effect the same day.
If you bill South Carolina Medicaid for ABA services, several things about how you scheduled, authorized, and documented care yesterday are no longer correct today. Here’s what changed and what to do about each one.
97151 Assessments Can No Longer Happen Over Telehealth
The clearest scheduling change: Behavior Identification Assessment (97151) is no longer allowable via telehealth for dates of service on or after today.
If your intake pipeline includes telehealth assessment blocks – common for rural families, waitlisted clients, or practices covering wide catchment areas – those appointments need to convert to in-person before the service is rendered. A 97151 delivered over video today is a non-covered service, and the claim behind it is a denial waiting to happen.
Two codes went the other direction:
- 97156 (Family Adaptive Behavior Treatment Guidance) is now permanently telehealth-eligible. Parent training over video, which had been running on temporary policy, is settled law in South Carolina Medicaid.
- 97155 (Adaptive Behavior Treatment with Protocol Modification) is now permanently telehealth-eligible – with prior authorization.
That 97155 condition is where practices will get caught. A BCBA directing a session remotely was one thing under temporary telehealth flexibility. Under the new manual, it’s a covered configuration only when the authorization on file supports it. If your BCBAs deliver protocol modification via telehealth and the client’s current authorization doesn’t reflect that, you have a gap between how you deliver care and what the payer has approved.
South Carolina didn’t ban telehealth. It sorted ABA codes into three buckets – never (97151), always (97156), and only-with-authorization (97155) – and the sorting took effect overnight.
Medical Necessity Now Runs Through InterQual, Administered by Acentra
The new manual tightens medical necessity review to the InterQual Applied Behavior Analysis Treatment Criteria, administered by Acentra, the state’s Quality Improvement Organization.
This changes how your treatment plans get read.
InterQual is a criteria-based review system. A reviewer working through it checks whether specific elements are present and support the requested intensity: baseline data, measurable goals with mastery criteria, documented progress against prior authorization periods, dosage justification tied to assessment results, discharge criteria. The persuasiveness of your clinical narrative doesn’t enter into it.
Plans written for a human reviewer who reads generously can fail a criteria-based review that reads literally. The treatment plan that sailed through in March may stall in August, and the difference won’t be the client’s clinical picture. It will be whether the plan maps cleanly onto the criteria set.
The practical shift: treat InterQual’s elements as a template, not a suggestion. Every plan of care and every reauthorization request should let a reviewer locate baseline, goal, progress, dosage rationale, and discharge criteria without hunting. If your current plan template buries dosage justification in a narrative paragraph, restructure it before your next reauthorization, not after your first denial.
One scope note: South Carolina runs most of its Medicaid population through five managed care organizations – Absolute Total Care, Healthy Blue, First Choice by Select Health, Humana Healthy Horizons, and Molina. MCO members follow their plan’s authorization process. Confirm with each plan how it’s applying the new manual rather than assuming the fee-for-service rules transfer one-to-one.
Every Prior Authorization Is Now Valid for Six Months
Under the new manual, all prior authorizations are valid for six months, with reauthorization requests due 10 to 30 days before expiration.
Standardization cuts both ways. A uniform six-month period is easier to track than a mix of durations. It also means two full reauthorization cycles per client per year, each one now reviewed against InterQual criteria, each with a 20-day submission window that, if missed, can produce a coverage gap where sessions are delivered but not payable.
Run the math on a 40-client caseload: 80 reauthorization packets a year, each requiring current progress data and a criteria-aligned plan update. That’s a workload with a deadline attached, and the deadline now has teeth on both ends: submit too late and you risk a lapse; the manual’s window also tells you not to submit more than 30 days early.
Every active authorization in your system needs an expiration date and a tickler set 30 days ahead of it. If you’re tracking authorizations in a spreadsheet, today is the day that stops being adequate.
The Non-Covered List Grew, and Provider Screening Got Stricter
Two quieter changes in the rewrite carry compliance weight.
First, the manual expands the list of non-covered services. Before your billing team submits this week’s claims, someone should read that list end to end and reconcile it against your current service mix. Services that were payable under the September 2025 manual may not be payable for dates of service starting today, and the first denial is an expensive way to find out.
Second, the manual aligns provider screening with the federal “high risk” screening categories CMS strengthened in September 2025, and clarifies documentation requirements for high-risk provider enrollment. This lands in a specific national context: CMS directed all 50 states in April to submit provider revalidation plans within 30 days, and the HHS OIG has recommended more than $123 million in recoupments across its first four state ABA audits. South Carolina is building the screening infrastructure federal reviewers expect to see. Expect enrollment and revalidation paperwork to get more demanding, and keep your credentialing files current before you’re asked for them.
A New Fee Schedule Lands Today Too
The updated Adaptive Behavior Services fee schedule takes effect today alongside the manual. SCDHHS did not preview the new rates in the May bulletin, so the first authoritative version is the schedule itself – pull it from the SCDHHS fee schedule page this morning and load it into your billing system before claims go out.
For context on where South Carolina starts: under the schedule in force through yesterday, 97153 paid $14.88 per 15-minute unit (capped at 160 units per week) and 97155 paid $21.25 per unit (capped at 64 units per month). That 97155 rate ranked second-lowest in the Southeast – roughly 34% below North Carolina’s $32.22 and 46% below Virginia’s $39.40.
Whatever direction the new schedule moves, verify it line by line against what your system expects. A silent rate change is how practices spend 90 days underbilling or overbilling before anyone notices, and Georgia’s providers learned this spring how fast reimbursement assumptions can go stale.
H.3974 Opens the School Door – Slowly
One more South Carolina change runs on a longer clock. Gov. Henry McMaster signed H.3974 on May 18, 2026. The law requires school districts to consider parent and guardian requests for medically necessary ABA services – delivered by licensed BCBAs, BCaBAs, BCBA-Ds, and RBTs – during the school day, evaluated case-by-case under an ADA framework rather than solely through IDEA. Districts can deny access only where it creates an undue burden or fundamentally alters operations.
The State Board of Education’s model policy is due January 6, 2027, and districts must adopt it (or an equivalent) by July 1, 2027. Providers who want to bill Medicaid for in-school services will need background checks, liability insurance, and written agreements with districts in place first.
Nothing about H.3974 changes your billing today. But if school-based delivery fits your service model, the groundwork – district relationships, credentialing files, insurance documentation – starts now, because the districts writing their policies over the next year will work first with the providers already at the table.
What to Do Today
This morning, before sessions start:
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Convert any telehealth 97151 appointments to in-person. Every behavior identification assessment scheduled as telehealth for today or later is now a non-covered configuration. Reschedule before the service is rendered.
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Audit every client receiving 97155 via telehealth. Confirm the authorization on file covers telehealth delivery. Where it doesn’t, either move those sessions in-person or get the authorization corrected before billing.
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Pull the new fee schedule and load it. Compare every ABA code line by line against your billing system’s current rates. Flag discrepancies before today’s sessions become tomorrow’s claims.
This week:
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Map your treatment plan template against the InterQual ABA criteria. Baseline data, measurable goals, progress documentation, dosage justification, discharge criteria – each should be findable at a glance. Restructure the template once; every future reauthorization inherits the fix.
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Calendar every active authorization on the six-month cycle. Expiration date plus a reminder 30 days out, for every client. Two reauthorization windows per client per year is the new baseline workload. Build it into someone’s job.
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Read the expanded non-covered services list in full. Reconcile it against your service mix and brief your billing team on anything that moved.
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Contact each MCO you’re contracted with. Absolute Total Care, Healthy Blue, First Choice, Humana, Molina – confirm how each is implementing the new manual’s authorization and telehealth rules for its members.
This is the kind of change that punishes practices running authorizations on spreadsheets and treatment plans on memory. The failure mode is quiet: a 97151 rendered over video on July 3, an expired authorization nobody flagged in September, a reauthorization packet that reads well but doesn’t map to InterQual. Systems that track authorization validity, alert before exhaustion, and enforce payer-specific billing rules exist precisely so a manual rewrite becomes a configuration change instead of a fire drill.
South Carolina gave providers six and a half weeks. Vermont gave six, and clinics there lost 16-17% of revenue before most had modeled the impact. The states are moving faster than the industry’s operational habits. The practices that absorb these rewrites without losing revenue are the ones that treat the provider manual as a living document, because as of this morning, in South Carolina, it is one.
StreamABA tracks authorization validity windows, flags authorizations before they exhaust, and applies payer-specific billing rules at claim time. Questions about getting your South Carolina authorizations and telehealth scheduling squared away under the new manual? Reach out at [email protected] – we’ll walk through it with you.
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