SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Organization Nursing Home No Specialty No Subspecialty Limited
Organization Nursing Home Complex Care Services No Subspecialty Limited Organization Nursing Home ICF/IID No Subspecialty Limited Organization Nursing Home Swing Bed No Subspecialty Limited Organization Nursing Home Swing Bed/Ventilator No Subspecialty Limited Organization Nursing Home Ventilator No Subspecialty Limited Organization Community Residential Care No Specialty No Subspecialty Limited Facilities (CRCF) Organization In-Patient Hospital Psychiatric No Subspecialty Limited Organization In-Patient Hospital Psychiatric Residential Treatment No Subspecialty Limited Facility (PRTF) Organization In-Patient Hospital General No Subspecialty Limited
Organization In-Patient Hospital Rehabilitative No Subspecialty Limited
Organization Psychiatric Residential No Specialty No Subspecialty Limited Treatment Facilities (PRTF) Organization Out-Patient Hospital No Specialty No Subspecialty Limited Organization Behavioral Health Services Developmental Evaluation Center No Subspecialty Moderate (DEC) Organization Behavioral Health Services Medical University of South Rehabilitative Behavioral Limited Carolina (MUSC) Health Services (RBHS) Organization Behavioral Health Services Medical University of South Targeted Case Management Limited Carolina (MUSC) (TCM) Organization Behavioral Health Services Medical University of South Community Mental Health Limited Page 1 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Carolina (MUSC) Organization Behavioral Health Services South Carolina Department of Rehabilitative Behavioral Limited Juvenile Justice (SC DJJ) Health Services (RBHS) Organization Behavioral Health Services South Carolina Department of Psychological Testing Limited Juvenile Justice (SC DJJ) Organization Behavioral Health Services South Carolina Department of Targeted Case Management Limited Juvenile Justice (SC DJJ) (TCM) Organization Behavioral Health Services South Carolina Division of Mental Rehabilitative Behavioral Limited Health (SC DMH) Health Services (RBHS) Organization Behavioral Health Services South Carolina Division of Mental Targeted Case Management Limited Health (SC DMH) (TCM) Organization Behavioral Health Services South Carolina Department of Rehabilitative Behavioral Limited Social Services (SC DSS) Health Services (RBHS) Organization Behavioral Health Services South Carolina Department of Targeted Case Management Limited Social Services (SC DSS) (TCM) Organization Behavioral Health Services Department of Alcohol and Other Rehabilitative Behavioral Limited Drug Abuse Services (DAODAS) Health Services (RBHS) Organization Behavioral Health Services Department of Alcohol and Other Targeted Case Management Limited Drug Abuse Services (DAODAS) (TCM) Organization Behavioral Health Services Department of Disabilities and Rehabilitative Behavioral Limited Special Needs (DDSN) Health Services (RBHS) Organization Behavioral Health Services Department of Disabilities and Targeted Case Management Limited Special Needs (DDSN) (TCM) Atypical Organization Behavioral Health Services Department of Disabilities and Home and Community Based Limited Special Needs (DDSN) Waiver Page 2 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Organization Behavioral Health Services Continuum of Care for Emotionally Rehabilitative Behavioral Limited Disturbed Children Health Services (RBHS) Organization Behavioral Health Services Continuum of Care for Emotionally Targeted Case Management Limited Disturbed Children (TCM) Atypical Organization Behavioral Health Services South Carolina Department of Managed Treatment Services Limited Social Services (SC DSS) for Children (MTS) Atypical Organization Health Maintenance HMO No Subspecialty Limited Organization (HMO) Atypical Organization Health Maintenance Medical Home Networks (MHN) No Subspecialty Limited Organization (HMO) Atypical Organization SCDHHS Special Enrollment Dental Broker No Subspecialty Limited Atypical Organization SCDHHS Special Enrollment Eligibility Verification No Subspecialty Limited Atypical Organization SCDHHS Special Enrollment Miscellaneous Providers No Subspecialty Limited Atypical Organization SCDHHS Special Enrollment Buy-In No Subspecialty Limited Atypical Organization SCDHHS Special Enrollment Clawback-Part B No Subspecialty Limited Atypical Organization SCDHHS Special Enrollment Transportation Broker No Subspecialty Limited Individual Other Medical Professionals Audiologist No Subspecialty Limited Individual Other Medical Professionals Anesthesiologist Assistant (AA) No Subspecialty Limited Atypical Individual Other Medical Professionals Behavioral Support Community Support Waiver Limited Individual Other Medical Professionals Certified Registered Nurse No Subspecialty Limited Anesthetist (CRNA) Individual Other Medical Professionals Licensed Dietician No Subspecialty Limited Individual Other Medical Professionals Licensed Independent Social No Subspecialty Limited Worker -Clinical Professional
Page 3 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
(LISW-CP) Individual Other Medical Professionals Licensed Marriage and Family No Subspecialty Limited Therapist (LMFT) Individual Other Medical Professionals Licensed Master Social Worker No Subspecialty Limited Ordering/Referring (LMSW) Individual Other Medical Professionals Licensed Psycho-Educational No Subspecialty Limited Ordering/Referring Specialist (LPES) Individual Other Medical Professionals Licensed Professional Counselor No Subspecialty Limited (LPC) Individual Other Medical Professionals Licensed Nurse Midwife (LPN No Subspecialty Limited Ordering/Referring Licensed by DHEC) Individual Other Medical Professionals Licensed Nurse Midwife (RN No Subspecialty Limited Ordering/Referring Licensed by DHEC) Individual Other Medical Professionals Advanced Practice Registered Certified Nurse Midwife Limited Ordering/Referring Nurse (APRN) Individual Other Medical Professionals Advanced Practice Registered Certified Nurse Practitioner Limited Ordering/Referring Nurse (APRN) Individual Other Medical Professionals Advanced Practice Registered Clinical Nurse Specialist (CNS) Limited Ordering/Referring Nurse (APRN) Individual Other Medical Professionals Occupational Therapist No Subspecialty Limited Individual Other Medical Professionals Physical Therapist No Subspecialty Moderate Individual Other Medical Professionals Physician Assistant No Subspecialty Limited Individual Other Medical Professionals Psychologist No Subspecialty Limited Atypical Individual Other Medical Professionals Psychologist-Behavioral Support HASCI Waiver Limited
Page 4 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Atypical Individual Other Medical Professionals Psychologist- Behavioral Support ID/RD Waiver Limited Individual Other Medical Professionals Speech Pathologist No Subspecialty Limited Individual Physician, Osteopath Allergy and Immunology No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Anesthesiology No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Cardiovascular Disease No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Dermatology No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Dispensing Physician No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Emergency Medicine No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Endocrinology & Metabolism No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Family Practice No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Gastroenterology No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath General Practice No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Geriatrics No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Gynecology No Subspecialty Limited Ordering/Referring Individual
Page 5 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Individual Physician, Osteopath Hematology No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Infectious Diseases No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Internal Medicine No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Neonatology No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Nephrology/ESRD No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Neurology No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Neuropathology No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Nuclear Medicine No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Obstetrics No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Obstetrics & Gynecology No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Occupational Medicine No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Oncology No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Ophthalmology No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Osteopathy No Subspecialty Limited
Page 6 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Ordering/Referring Individual Individual Physician, Osteopath Otorhinolaryngology No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Pathology No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Pathology, Clinical No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Pathology, Hospital No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Pediatric Subspecialist No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Pediatrics No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Pediatrics, Allergy No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Pediatrics, Cardiology No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Physical Medicine & Rehabilitation No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Psychiatry No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Psychiatry, Child No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Pulmonary Medicine No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Radiology No Subspecialty Limited Ordering/Referring Individual
Page 7 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Individual Physician, Osteopath Radiology, Diagnostic No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Radiology, Therapeutic No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Rheumatology No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Surgery, Cardiovascular No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Surgery, Colon & Rectal No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Surgery, General No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Surgery, Neurological No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Surgery, Orthopedic No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Surgery, Pediatric No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Surgery, Plastic No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Surgery, Thoracic No Subspecialty Limited Ordering/Referring Individual Individual Physician, Osteopath Surgery, Urological No Subspecialty Limited Ordering/Referring Individual Organization Groups Allergy and Immunology No Subspecialty Limited Organization Groups Anesthesiologist Assistant (AA) No Subspecialty Limited Organization Groups Anesthesiology No Subspecialty Limited Page 8 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Organization Groups Audiologist No Subspecialty Limited Organization Groups Cardiovascular Disease No Subspecialty Limited Organization Groups Certified Nurse Practitioner No Subspecialty Limited Organization Groups Certified Registered Nurse No Subspecialty Limited Anesthetist (CRNA) Organization Groups Dermatology No Subspecialty Limited Organization Groups Emergency Medicine No Subspecialty Limited Organization Groups Endocrinology & Metabolism No Subspecialty Limited Organization Groups Family Practice No Subspecialty Limited Organization Groups Gastroenterology No Subspecialty Limited Organization Groups General Practice No Subspecialty Limited Organization Groups Geriatrics No Subspecialty Limited Organization Groups Gynecology No Subspecialty Limited Organization Groups Hematology No Subspecialty Limited Organization Groups Hybrid Clinic No Subspecialty Limited Organization Groups Infectious Disease No Subspecialty Limited Organization Groups Internal Medicine No Subspecialty Limited Organization Groups Licensed Dietician No Subspecialty Limited Organization Groups Licensed Independent Social No Subspecialty Limited Worker -Clinical Professional (LISW-CP) Organization Groups Licensed Marriage and Family No Subspecialty Limited Therapist (LMFT) Organization Groups Licensed Professional Counselor No Subspecialty Limited Page 9 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
(LPC) Organization Groups Licensed Psycho-Educational No Subspecialty Limited Specialist (LPES) Organization Groups Multiple Specialty Group No Subspecialty Limited Organization Groups Neonatology No Subspecialty Limited Organization Groups Nephrology/ESRD No Subspecialty Limited Organization Groups Neurology No Subspecialty Limited Organization Groups Neuropathology No Subspecialty Limited Organization Groups Nuclear Medicine No Subspecialty Limited Organization Groups Clinical Nurse Specialist No Subspecialty Limited Organization Groups Physician Assistant No Subspecialty Limited Organization Groups Nurse Midwife No Subspecialty Limited Organization Groups Obstetrics No Subspecialty Limited Organization Groups Obstetrics & Gynecology No Subspecialty Limited Organization Groups Occupational Medicine No Subspecialty Limited Organization Groups Occupational Therapist No Subspecialty Limited Organization Groups Oncology No Subspecialty Limited Organization Groups Ophthalmology No Subspecialty Limited Organization Groups Osteopathy No Subspecialty Limited Organization Groups Otorhinolaryngology No Subspecialty Limited Organization Groups Pathology No Subspecialty Limited Organization Groups Pathology, Clinical No Subspecialty Limited Organization Groups Pathology, Hospital No Subspecialty Limited
Page 10 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Organization Groups Pediatrics No Subspecialty Limited Organization Groups Pediatrics, Allergy No Subspecialty Limited Organization Groups Pediatrics, Cardiology No Subspecialty Limited Organization Groups Physical Medicine & Rehabilitation No Subspecialty Limited Organization Groups Physical Therapist No Subspecialty Moderate Organization Groups Psychiatry No Subspecialty Limited Organization Groups Psychiatry, Child No Subspecialty Limited Organization Groups Psychologist No Subspecialty Limited Organization Groups Pulmonary Medicine No Subspecialty Limited Organization Groups Radiology No Subspecialty Limited Organization Groups Radiology, Diagnostic No Subspecialty Limited Organization Groups Radiology, Therapeutic No Subspecialty Limited Organization Groups Retail Clinic No Subspecialty Limited Organization Groups Rheumatology No Subspecialty Limited Organization Groups Speech Pathologist No Subspecialty Limited Organization Groups Surgery, Cardiovascular No Subspecialty Limited Organization Groups Surgery, Colon & Rectal No Subspecialty Limited Organization Groups Surgery, General No Subspecialty Limited Organization Groups Surgery, Neurological No Subspecialty Limited Organization Groups Surgery, Orthopedic No Subspecialty Limited Organization Groups Surgery, Pediatric No Subspecialty Limited Organization Groups Surgery, Plastic No Subspecialty Limited Organization Groups Surgery, Thoracic No Subspecialty Limited
Page 11 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Organization Groups Surgery, Urological No Subspecialty Limited Organization Groups Therapist/Multiple Specialty Group No Subspecialty Limited Organization Medical Clinic Social Services Targeted Case Management Limited (TCM) Organization Medical Clinics Ambulatory Diabetes Patient No Subspecialty Limited Education Organization Medical Clinics Ambulatory Surgery Centers No Subspecialty Limited Organization Medical Clinics CORF, CARF No Subspecialty Moderate Organization Medical Clinics Developmental Rehabilitation Commission for the Blind Limited Centers (DRC) Organization Medical Clinics Developmental Rehabilitation Infusion Center Limited Centers (DRC) Organization Medical Clinics Developmental Rehabilitation Local Education Agencies Limited Centers (DRC) Organization Medical Clinics Developmental Rehabilitation No Subspecialty Limited Centers (DRC) Organization Medical Clinics Developmental Rehabilitation Outpatient Pediatric AIDS Limited Centers (DRC) Clinic (OPAC) Organization Medical Clinics Developmental Rehabilitation School Districts Limited Centers (DRC) Organization Medical Clinics Developmental Rehabilitation School for the Deaf and Blind Limited Centers (DRC) Organization Medical Clinics Developmental Rehabilitation Wil Lou Gray Limited Centers (DRC)
Page 12 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Organization Medical Clinics DHEC/Children’s Rehabilitative No Subspecialty Limited Services (CRS) Organization Medical Clinics End Stage Renal Disease (ESRD) No Subspecialty Limited Organization Medical Clinics Federally Funded Health Clinics No Subspecialty Limited (FFHC) Organization Medical Clinics Federally Qualified Clinics (FQHC) No Subspecialty Limited Organization Medical Clinics Genetic No Subspecialty Limited Organization Medical Clinics Hematology No Subspecialty Limited Organization Medical Clinics Maternal and Child Health Centers Postpartum Infant Home Visits Limited Organization Medical Clinics Maternal and Child Health Centers Preventive Rehabilitative Limited Services for Primary Care Enhancement (PRSPCE) Organization Medical Clinics Rural Health Centers (RHC) No Subspecialty Limited Organization Medical Clinics Sickle Cell No Subspecialty Limited Organization Medical Clinics Speech and Hearing Clinics No Subspecialty Limited Atypical Organization Contractors/Vendors DHEC Orthodontics No Subspecialty Limited Atypical Organization Contractors/ Vendors Eyewear Contract No Subspecialty Limited Atypical Organization Contractors/Vendors Maxillofacial Prosthodontics No Subspecialty Limited Individual Dentist, Individual Dentistry No Subspecialty Limited Individual Dentist, Individual Endodontist No Subspecialty Limited Individual Dentist, Individual Oral Surgery No Subspecialty Limited Individual Dentist, Individual Orthodontics No Subspecialty Limited Individual Dentist, Individual Pedodontics No Subspecialty Limited Individual Dentist, Individual Periodontist No Subspecialty Limited
Page 13 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Organization Dentist, Group Dentistry No Subspecialty Limited Organization Dentist, Group Endodontist No Subspecialty Limited Organization Dentist, Group Oral Surgery No Subspecialty Limited Organization Dentist, Group Orthodontics No Subspecialty Limited Organization Dentist, Group Pedodontics No Subspecialty Limited Organization Dentist, Group Periodontist No Subspecialty Limited Individual Optician, Individual Optician No Subspecialty Limited Organization Optician, Group Optician No Subspecialty Limited Individual Optometrist, Individual Optometry No Subspecialty Limited Organization Optometrist, Group Optometry No Subspecialty Limited Individual Podiatrist, Individual Podiatry No Subspecialty Limited Organization Podiatrist, Group Podiatry No Subspecialty Limited Individual Chiropractor, Individual Chiropractic No Subspecialty Limited Organization Chiropractor, Group Chiropractic No Subspecialty Limited Organization Home Health No Specialty No Subspecialty High Risk- New Moderate – Currently Enrolled Organization Hospice No Specialty No Subspecialty High Risk- New Moderate – Currently enrolled
Page 14 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Atypical Individual Community Long Term Care Attendant Care No Subspecialty Limited (CLTC), Individual Atypical Individual Community Long Term Care Case Manager No Subspecialty Limited (CLTC), Individual Atypical Individual Community Long Term Care Companion Individual No Subspecialty Limited (CLTC), Individual Atypical Organization Community Long Term Care Adult Care Homes No Subspecialty Moderate (CLTC), (Organization- Administrative Agencies w/one location) Atypical Organization Community Long Term Care Adult Day Care Services No Subspecialty Moderate (CLTC), (Organization- Administrative Agencies w/one location) Atypical Organization Community Long Term Care Attendant Care No Subspecialty Moderate (CLTC), (Organization- Administrative Agencies w/one location) Atypical Organization Community Long Term Care Case Management No Subspecialty Moderate (CLTC), (Organization- Administrative Agencies w/one location) Atypical Organization Community Long Term Care Companion Agency No Subspecialty Moderate (CLTC), (Organization- Administrative Agencies w/one location)
Page 15 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Atypical Organization Community Long Term Care Early Intensive Behavioral No Subspecialty Moderate (CLTC), (Organization- Intervention (EIBI) Administrative Agencies w/one location)
Atypical Organization Community Long Term Care Environmental Modifications No Subspecialty Limited (CLTC), (Organization- Administrative Agencies w/one location) Atypical Organization Community Long Term Care Home Delivered Meals No Subspecialty Moderate (CLTC), (Organization- Administrative Agencies w/one location) Organization Community Long Term Care Incontinent Supplies Moderate (CLTC), (Organization- No Subspecialty Administrative Agencies w/one location) Atypical Organization Community Long Term Care In-Home Respite No Subspecialty Moderate (CLTC), (Organization- Administrative Agencies w/one location) Atypical Organization Community Long Term Care Institutional Respite No Subspecialty Limited (CLTC), (Organization- Administrative Agencies w/one location)
Page 16 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Organization Community Long Term Care Medicaid Nursing No Subspecialty Moderate (CLTC), (Organization- Administrative Agencies w/one location) Atypical Organization Community Long Term Care Nursing Home Transition Services Limited (CLTC), (Organization- No Subspecialty Administrative Agencies w/one location) Organization Community Long Term Care Nutritional Supplements No Subspecialty Moderate (CLTC), (Organization- Administrative Agencies w/one location) Atypical Organization Community Long Term Care PACE No Subspecialty Moderate (CLTC), (Organization- Administrative Agencies w/one location) Atypical Organization Community Long Term Care Personal Care I No Subspecialty Moderate (CLTC), (Organization- Administrative Agencies w/one location) Atypical Organization Community Long Term Care Personal Care II No Subspecialty Moderate (CLTC), (Organization- Administrative Agencies w/one location)
Page 17 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Atypical Organization Community Long Term Care Personal Emergency Response No Subspecialty Limited (CLTC), (Organization- System (PERS) Administrative Agencies w/one location) Atypical Organization Community Long Term Care Pest Control No Subspecialty Limited (CLTC), (Organization- Administrative Agencies w/one location) Organization Community Long Term Care Specialized Medical Supplies and No Subspecialty Moderate (CLTC), (Organization- Equipment Administrative Agencies w/one location) Organization Community Long Term Care Tele-monitoring No Subspecialty Limited (CLTC), (Organization- Administrative Agencies w/one location) Atypical Organization Community Long Term Care Attendant Care No Subspecialty Limited (CLTC), Fiscal Agent only for Individuals providing Attendant Care and Companion Services) Atypical Organization Community Long Term Care Companion Individual No Subspecialty Limited (CLTC), Fiscal Agent only for Individuals providing Attendant Care and Companion Services)
Page 18 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Atypical Organization Community Long Term Care Attendant Care No Subspecialty Moderate (CLTC), (Organization – Administrative Affiliates only w/multiple locations) Organization Community Long Term Care Case Management No Subspecialty Moderate (CLTC), (Organization – Administrative Affiliates only w/multiple locations) Atypical Organization Community Long Term Care Companion Agency No Subspecialty Moderate (CLTC), (Organization – Administrative Affiliates only w/multiple locations) Organization Community Long Term Care Medicaid Nursing No Subspecialty Moderate (CLTC), (Organization – Administrative Affiliates only w/multiple locations) Atypical Organization Community Long Term Care PACE No Subspecialty Moderate (CLTC), (Organization – Administrative Affiliates only w/multiple locations) Atypical Organization Community Long Term Care Personal Care I No Subspecialty Moderate (CLTC), (Organization – Administrative Affiliates only w/multiple locations) Atypical Organization Community Long Term Care Personal Care II No Subspecialty Moderate (CLTC), (Organization –
Page 19 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Administrative Affiliates only w/multiple locations) Atypical Individual Home Again Transition Coordinator Care Managers Certified Limited Atypical Individual Home Again Transition Coordinator Licensed Independent Social Limited Worker (LISW) Atypical Individual Home Again Transition Coordinator Licensed Master Social Worker Limited (LMSW) Atypical Individual Home Again Transition Coordinator Registered Nurse (RN) Limited Atypical Individual Home Again Transition Coordinator Licensed Baccalaureate Social Limited Worker (LBSW) Atypical Organization Home Again- Administrative Transition Coordinator No Subspecialty Limited Agency Atypical Organization Home Again – Administrative Transition Coordinator No Subspecialty Limited Affiliate Organization Pharmacy Chain No Subspecialty Limited Organization Pharmacy Compounding No Subspecialty Limited Organization Pharmacy Dispensing Physician No Subspecialty Limited Organization Pharmacy Government-Based No Subspecialty Limited Organization Pharmacy Home Infusion No Subspecialty Limited Organization Pharmacy Hospital In-Patient No Subspecialty Limited Organization Pharmacy Independent No Subspecialty Limited Organization Pharmacy Institutional No Subspecialty Limited Organization Pharmacy Long Term Care No Subspecialty Limited Organization Pharmacy Mail-Order No Subspecialty Limited
Page 20 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Organization Durable Medical Equipment Diabetic Shoes No Subspecialty High-Risk – New Moderate – Already enrolled Organization Durable Medical Equipment Diabetic Supplies No Subspecialty High-Risk – New Moderate – Already enrolled Organization Durable Medical Equipment Durable Medical Equipment No Subspecialty High-Risk – New Moderate – Currently enrolled Organization Durable Medical Equipment Enteral/Parenteral Therapy No Subspecialty High-Risk – New Moderate – Currently enrolled Organization Durable Medical Equipment Home Infusion Therapy No Subspecialty High-Risk – New Moderate – Currently enrolled Organization Durable Medical Equipment Medical/Surgical Supplies No Subspecialty High-Risk – New Moderate –
Page 21 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Currently enrolled Organization Durable Medical Equipment Orthotics and Prosthetics No Subspecialty High-Risk – New Moderate – Currently enrolled Organization Laboratory No Specialty No Subspecialty Moderate Organization Independent X-Ray CAT Scan No Subspecialty X-Ray (Not (Portable/Free Standing) & Port) – Limited Physiology Lab X-Ray (Port) – Moderate Organization Independent X-Ray Mobile Ultrasound No Subspecialty X-Ray (Not (Portable/Free Standing) & Port) – Limited Physiology Lab X-Ray (Port) – Moderate Organization Independent X-Ray MRI No Subspecialty X-Ray (Not (Portable/Free Standing) & Port) – Limited Physiology Lab X-Ray (Port) – Moderate Organization Independent X-Ray Physiology Lab No Subspecialty X-Ray (Not (Portable/Free Standing) & Port) – Limited Physiology Lab X-Ray (Port) – Moderate Organization Independent X-Ray Portable X-Ray No Subspecialty X-Ray (Not (Portable/Free Standing) & Port) – Limited Physiology Lab X-Ray (Port) – Moderate
Page 22 of 23 02/09/2015
SOUTH CAROLINA MEDICAID PROVIDER ENROLLMENT PROVIDER TYPE/SPECIALTY LISTING
Enrollment Type Provider Type Specialty Description Subspecialty Description Risk Description Category
Organization Independent X-Ray Stationary X-Ray No Subspecialty X-Ray (Not (Portable/Free Standing) & Port) – Limited Physiology Lab X-Ray (Port) – Moderate Organization Ambulance Services Air No Subspecialty Moderate Organization Ambulance Services Ground No Subspecialty Moderate Atypical Organization Contractual Transportation No Specialty No Subspecialty Limited (Community Alternative Program (CAP) Agencies) Individual Medicare Catastrophic Social Workers No Subspecialty Limited Coverage Act (MCCA) Qualified Medicare Beneficiary (QMB)
Page 23 of 23 02/09/2015