South Carolina medical billing and payer rules

Timely filing in South Carolina

South Carolina law and the federal No Surprises Act

The Department of Insurance says South Carolina has no surprise billing law, and CMS recorded in 2021 that the state identified no law governing the out-of-network rate. Federal IDR therefore decides those disputes for insured plans.

Major payers

How does South Carolina Healthy Connections Medicaid work for billing?

South Carolina's Medicaid program is called Healthy Connections Medicaid, and the South Carolina Department of Health and Human Services (SCDHHS) is the single state agency that administers it. The Provider Administrative and Billing Manual (July 1, 2026) says SCDHHS runs both a fee-for-service program and a fully capitated managed care program through managed care organizations (MCOs).

Fee-for-service claims go to SCDHHS. Managed care claims go to the member's plan, which owns payment and reconsideration. A primary care case management and Medical Home Network model is only available to members who qualify for the Medically Complex Children's Waiver.

Which managed care plans does SCDHHS list?

The SCDHHS member page for managed care organizations says the agency partners with five MCOs: Absolute Total Care, BlueChoice (Healthy Blue), Humana Healthy Horizons, Molina and Select Health (First Choice). Read the plan from the eligibility response on the date of service.

What changed on January 1, 2026?

The SCDHHS Health and Managed Care Plans page says that effective January 1, 2026, SCDHHS added some Healthy Connections Medicaid members to the managed care service delivery model for medical services. All waiver services remain in fee-for-service.

What is the SCDHHS Web Tool?

The free browser-based Web Tool accepts UB-04 and CMS-1500 claims, attachments, eligibility queries, claim status checks and electronic remittance advice. A provider must first sign a Trading Partner Agreement (TPA) with SCDHHS. If a billing agent will see your remittance advice, both of you need a TPA on file, and yours must name the agent.

SCDHHS generates remittance advice every Friday, and the manual says it stays on the Web Tool for three years after the payment date. The manual does not name the fee-for-service fiscal agent, so we do not name one here.

How do you enroll, and how often do you revalidate?

A provider must be licensed or certified for its type, hold an NPI where eligible, and complete the online enrollment application, which includes the participation agreement, Electronic Funds Transfer Agreement, W-9 and Trading Partner Agreement. The manual says this enrollment also applies to providers who contract with Healthy Connections Medicaid MCOs.

Providers must be inside the South Carolina Medicaid Service Area, meaning the state plus areas of North Carolina and Georgia within 25 miles of the border, unless SCDHHS approves otherwise. All providers except durable medical equipment suppliers must revalidate every five years, and DME suppliers every three. A provider that fails to resubmit is terminated. Changes in address, specialty, group affiliation or ownership must reach the Provider Service Center within 30 days.

What is the South Carolina Medicaid timely filing limit?

SCDHHS considers only clean claims received and entered into its claims processing system within one year from the date of service, or the date of discharge for hospital claims. The manual's Time Limit for Submitting Claims section says this limit is not extended because of third-party liability requirements. A clean claim is edit and error free and can be processed without more information from the provider or another party.

Claims with edit code 509 or 510 on a remittance, or CARC 29 on an electronic remittance advice, have not met the clean claim standard. Providers cannot bill the member for claims denied for untimely filing, so a lost window is a write-off, not a patient balance.

What about Medicare cost sharing and retroactive eligibility?

The one-year limit does not apply to Medicare cost-sharing claims or retroactive eligibility. For dual members, bill Medicare first. Medicaid secondary claims get two years from service or discharge, or six months after Medicare pays, whichever is later. Retroactive eligibility claims must arrive within six months of eligibility being added and within three years of service, with DHHS Form 945 or the eligibility approval letter attached.

What is the managed care filing window?

This page cites no statewide number for the five MCOs from any SCDHHS page. We load each plan's window into the account at onboarding instead of assuming the one-year rule applies.

How do you ask for reconsideration or appeal a denied Medicaid claim?

Fee-for-service reconsideration is informal and comes first. Submit the SCDHHS-CR form with documents within 30 days of the remittance advice showing the denial. SCDHHS answers in writing within 60 days; if it upholds the denial, you have 30 days from receipt of that decision to appeal.

A formal appeal goes in writing to the SCDHHS Division of Appeals and Hearings, within 30 days of the notice of adverse action or of the remittance advice reflecting the denial, whichever is later.

Three denials do not qualify for SCDHHS reconsideration: documentation failures (submit a new claim with documents), prior authorization denials from SCDHHS contracted agents, and any MCO denial, which goes through the plan first.

Who is the Medicare contractor in South Carolina?

Palmetto GBA, LLC is the Medicare Administrative Contractor (MAC) for Part A and Part B claims in South Carolina, under Jurisdiction M (JM). CMS's MACs-by-state document lists North Carolina, South Carolina, Virginia and West Virginia together under jurisdiction M and Palmetto GBA, with a carve-out for Part B in Arlington and Fairfax counties and the city of Alexandria in Virginia, which does not touch South Carolina.

Do not confuse JM with Jurisdiction J, which the same CMS document assigns to Alabama, Georgia and Tennessee. It also lists Palmetto GBA as the home health and hospice MAC for South Carolina and CGS Administrators as the durable medical equipment MAC.

Medicare timely filing is 1 calendar year after the date of service under 42 CFR 424.44(a)(1). Palmetto GBA's claim status tools are not described here, so use its site. See Medicare billing rules for the federal rules.

What is South Carolina's prompt payment law?

South Carolina's prompt pay rules are in Article 3 of Chapter 59, Title 38 of the South Carolina Code of Laws, the Health Care Financial Recovery and Protection Act. Under S.C. Code 38-59-230, an insurer must direct payment of a clean claim within 20 business days for an electronic claim or 40 business days for a paper claim.

The clock runs from the later of two dates: the insurer's receipt of the claim, or the date it has everything needed for the claim to count as clean, including documents it reasonably requests. The statute's definition of a clean claim in 38-59-210(8) includes that the claim is received by the insurer within 120 business days of the date of service. File inside that window.

What interest applies when an insurer pays late?

Under S.C. Code 38-59-240, a late insurer pays interest at the rate in Section 34-31-20(A), counted from the 21st business day for electronic claims or the 41st business day for paper claims, up to the date it directs payment. Section 34-31-20(A) sets the legal rate at eight and three-fourths percent per annum.

No interest is owed on a duplicate claim sent while the first is in process, to a provider who balance bills in breach of its agreement, during force majeure, or when payment goes to the plan member.

What else does the statute require of insurers?

• Defect notice: if a defect keeps a claim out of the adjudication system, the insurer must give notice within 20 business days for electronic claims or 40 for paper (38-59-230(C)).
• No paper conversion: a clearinghouse or billing service may not convert electronic claims to paper (38-59-230(D)).
• Recoupment notice: written notice at least 30 business days before overpayment recovery, and no recovery begun more than 18 months after payment, with exceptions for fraud, self-insured plan requirements and government programs (38-59-250).

Who is outside the law, and who enforces it?

Section 38-59-260 excludes claims under a national account delivery program where the insurer is not solely responsible for processing and payment, and claims under programs sponsored by a state or federal governmental entity other than as an employer. The Department of Insurance enforces the article under 38-59-270, and it creates no private right of action.

The SCDOI FAQ says that when an employer self-insures, state patient protections do not apply, so a self-funded ERISA plan sits outside the Department's reach. Our prompt pay comparison shows how clocks differ by state. We did not read the Medicaid MCO contracts, so whether these clocks bind the five MCOs is left unstated.

Does South Carolina have its own surprise billing law?

No. The South Carolina Department of Insurance states in its No Surprises Act FAQ that South Carolina does not have a no surprise billing law. CMS reached the same practical result in its December 28, 2021 letter: South Carolina has no All-Payer Model Agreement and identified no state laws governing the out-of-network rate, so federal IDR applies.

CMS's letter adds that the Department of Insurance will enforce the outcome of federal IDR for insured group and individual coverage in South Carolina.

Who enforces what?

The CMS letter splits enforcement. The Department of Insurance said it will enforce most issuer provisions but lacks authority over section 2799A-4. SCDHHS and the Department of Labor, Licensing, and Regulation said they lack authority over the provider and facility sections, so CMS enforces those directly. The letter is from 2021. See all state surprise billing laws.

Can an out-of-network ER group balance bill a patient?

For emergency services, the federal rule governs. The Department of Insurance FAQ says the No Surprises Act prohibits balance billing by out-of-network providers, with certain exceptions, and lists out-of-network emergency services as covered. Balance billing after a covered emergency visit is not a state-law question here. This page cites no South Carolina statute on ground ambulance billing, so it states no rule.

How do you dispute an out-of-network underpayment in South Carolina?

Start federal open negotiation within 30 business days of the initial payment or denial, then start IDR within 4 business days after negotiation ends. Under 45 CFR 149.510, either party may initiate a 30-business-day open negotiation period during the 30-business-day period beginning on the day the provider receives the initial payment or notice of denial, and IDR initiation must come in the 4-business-day period beginning on the first business day after the last day of open negotiation.

How do you file a complaint with the South Carolina Department of Insurance?

The SCDOI FAQ says that for a specific problem with an insurance company, broker, agent or adjuster, you file a complaint with its Office of Consumer Services using the online complaint form at doi.sc.gov/complaint. The Department lists 803-737-6160 as its main phone.

Which payers matter most in South Carolina?

Blue Cross and Blue Shield of South Carolina is the largest health insurer in the state on the Department of Insurance's 2024 accident and health premiums table, which ranks it first by premiums written. UnitedHealthcare Insurance Company, Cigna Health and Life Insurance Company and Aetna Life Insurance Company follow in second through fourth place. The table covers all accident and health lines, so it ranks premium written, not hospital claims.

On the government side, the payers are Palmetto GBA for Medicare Part A and Part B, SCDHHS for fee-for-service Medicaid, and the five Healthy Connections MCOs. Humana Healthy Horizons, Molina and Select Health sit on that MCO list with Absolute Total Care and BlueChoice (Healthy Blue). See our Blue Cross Blue Shield and Medicaid guides.

This page cites no Department of Insurance document that ranks Medicare Advantage plans in South Carolina, so none are named.

How we handle billing in South Carolina

We sort every South Carolina payer into its own clock: one year for fee-for-service Medicaid, the plan's own window for each of the five MCOs, one calendar year for Medicare under Palmetto GBA JM, and 20 or 40 business days for state-regulated insurers. Claims go out within 24 hours of charge entry, and we work denials within 48 hours.

For underpaid out-of-network claims, we first confirm the plan is insured or self-funded, then manage the open negotiation and IDR deadlines through our out-of-network billing and IDR work. Our hospital and facility billing covers the UB-04 side, and emergency medicine billing covers ER groups. Book a call and we will check your South Carolina payer mix first. Nearby: North Carolina and Georgia.