South Carolina - Case Management Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The South Carolina Department of Health and Human Services (SCDHHS) enrolls Case Management providers to operate across the state's Home and Community-Based Services (HCBS) waivers using the Phoenix case management system. Providers are responsible for assessment, person-centered service planning, referral, and ongoing monitoring of participants' full service packages.

Applicants must comply with strict conflict-free case management mandates, meaning an agency cannot provide both case management and direct HCBS waiver services, such as home health or personal care, to participants. Additionally, provider agencies must operate from a commercially zoned office location, with residential or non-commercial locations requiring explicit prior approval from SCDHHS before an enrollment application is accepted.

1. Service Definition and Scope

Case Management in South Carolina assists waiver participants in gaining access to needed waiver, State plan, medical, social, and educational services. Case managers conduct ongoing monitoring, problem-solving, and coordination of the person-centered service plan.

All case management activities, including case transfers and documentation, must be managed within the state's Phoenix system.

• Objective: Assist participants in accessing waiver, State plan, medical, and social services regardless of funding source.
• Core Functions: Assessment, care planning, service counseling, and interagency case staffing.
• System Usage: Providers must utilize the SCDHHS Phoenix system for all case documentation and monitoring.
• Availability: Case managers must be accessible between 8:30 a.m. and 5:00 p.m., Monday through Friday.
• Conflict-Free Mandate: Providers cannot deliver both case management and direct HCBS services to the same population.

2. Regulatory and Oversight Agencies

The primary oversight authority for Medicaid HCBS waivers in South Carolina is SCDHHS, which manages provider enrollment, policy, and compliance. For specific populations, the South Carolina Department of Disabilities and Special Needs (DDSN) qualifies providers before Medicaid enrollment.

Professional licensing boards oversee the individual credentials required for staff acting as case managers.

• South Carolina Department of Health and Human Services (SCDHHS): Administers the Medicaid program, manages the Phoenix system, and enforces the HCBS Provider Manual (https://www.scdhhs.gov/).
• South Carolina Department of Disabilities and Special Needs (DDSN): Qualifies providers for intellectual disability and related disabilities waivers prior to SCDHHS enrollment (https://ddsn.sc.gov/).
• South Carolina Department of Public Health (DPH): Sets the PPD Tuberculin test requirements under Regulation 61-122 (https://dph.sc.gov/).
• South Carolina Board of Social Work Examiners: Licenses social workers acting as case managers (https://llr.sc.gov/sw/).

3. Gatekeeping Prerequisites: Who Can Even Apply

South Carolina enforces strict structural and operational prerequisites before a Case Management enrollment application is accepted. The state mandates conflict-free operations and specific commercial zoning requirements for agency offices.

Agencies must clear these structural hurdles before SCDHHS will process an enrollment application.

• Conflict-Free Case Management: Agencies providing direct HCBS waiver services (e.g., home health, hospice) are structurally barred from enrolling as case management providers.
• Commercial Zoning Requirement: Provider agencies must be housed in a commercially zoned or un-zoned area; non-commercial locations require explicit prior approval from SCDHHS.
• DDSN Qualification: For DDSN-operated waivers, applicants must first be qualified or verified by the DDSN Quality Management division before applying to SCDHHS.
• Employment Restrictions: Case managers hired after August 1, 2014, cannot hold outside employment exceeding four hours between 8:30 a.m. and 5:00 p.m., Monday through Friday.

4. Licensure and Certification Requirements

South Carolina does not issue a distinct "Case Management Agency" facility license through DPH. Instead, approval is achieved through professional licensure of the individual staff members and agency-level qualification by SCDHHS or DDSN.

Agencies must ensure all operating staff hold the specific degrees, certifications, or state licenses mandated by the HCBS Provider Manual.

• Business Licensure: The provider must be licensed to operate a business in South Carolina and be in good standing with the state and counties served.
• Professional Licensure (Social Workers): Must hold an active license from the South Carolina Board of Social Work Examiners.
• Professional Licensure (Nurses): Must hold an active Registered Nurse (RN) license from the S.C. State Board of Nursing.
• Certification (Care Managers): Non-licensed staff must hold credentials such as Certified Geriatric Care Manager or Certified Case Manager, coupled with two years of experience.

5. Medicaid Provider Enrollment

Enrollment is processed through the SCDHHS Provider Enrollment portal. Agencies must secure their National Provider Identifier (NPI) and taxonomy before submitting the online application.

The enrollment process includes screening, licensure verification, and potential site visits.

• Enrollment Portal: Applications are submitted online via the SCDHHS Provider Enrollment site (https://providerservices.scdhhs.gov).
• Processing Timeline: SCDHHS typically processes complete enrollment applications within 30 business days of receipt.
• Effective Date: The Medicaid enrollment date can be backdated up to 90 days from the approval date.
• Required Identifiers: Applicants must obtain and submit an NPI and the appropriate case management taxonomy code.

6. Staffing, Training and Background Checks

SCDHHS sets strict educational and experience minimums for case managers. Agencies must ensure staff meet these standards, complete annual training, and undergo health screenings.

Unlicensed staff face specific degree and experience prerequisites before they can bill for services.

• Degree Requirements: Unlicensed staff must hold a bachelor's or master's degree in a health or human services field from an accredited institution.
• Experience Minimum: Degree-holding staff and certified case managers must have at least two years of assessment and care planning experience (internships cannot count for more than six months).
• Annual Training: Non-licensed case managers and supervisors must complete a minimum of 10 hours of relevant in-service training per calendar year.
• Health Screening: All staff must complete a PPD Tuberculin test in accordance with DPH Regulation R.61-122.
• Identification: Case managers must display a photo identification badge identifying the provider and the employee during all participant interactions.

7. Documentation, Policies and Records

Providers must maintain comprehensive operational policies, particularly regarding service continuity and communication. All case management activities must be documented in the state's Phoenix system.

Agencies must also supply the necessary technology for staff to access state systems securely.

• Back-Up Plan Policy: Must document procedures for covering cases during absences, including transferring cases in Phoenix and notifying the Area Administrator.
• Independent Case Manager Agreements: Independent providers must maintain a signed agreement with a back-up Case Manager.
• Communication Standards: Case managers must record a professional voicemail greeting clearly identifying their name and the provider agency.
• Mandated Reporting Policy: Agencies must maintain policies acknowledging staff as mandated reporters of Abuse, Neglect, and Exploitation (ANE), with immediate termination consequences for failure to report.
• Technology Requirements: Providers must supply all necessary computer hardware and software for staff to access the Phoenix system, as detailed in the Phoenix Help section.

8. Billing, Rates and Claims

Case management services are billed to SCDHHS based on authorized units in the person-centered service plan. Providers must ensure all activities are documented in Phoenix to support claims.

Reimbursement is contingent upon strict adherence to authorized service limits and proper system documentation.

• Authorization Requirement: Services must be prior-authorized and documented in the Phoenix system before billing.
• Billing System: Claims are submitted through the SCDHHS Medicaid Management Information System (MMIS) portal.
• Non-Billable Activities: Providers cannot bill for time spent on administrative agency tasks or services provided by a back-up manager if not properly transferred in Phoenix.
• Rate Setting: Reimbursement rates are established by SCDHHS and published in the HCBS Waiver fee schedules on the agency's website.

9. Approval Sequence and Timeline

The pathway to becoming a billable case management provider involves sequential approvals, starting with business setup and ending with Medicaid enrollment and system access.

Providers must clear zoning and qualification steps before submitting the final Medicaid application.

• Step 1: Establish a commercially zoned office location and secure local business licenses.
• Step 2: (If applicable) Complete the DDSN Qualified Provider Application phase for intellectual disability waivers.
• Step 3: Submit the Medicaid provider enrollment application via providerservices.scdhhs.gov.
• Step 4: Undergo SCDHHS screening, licensure verification, and potential site visits (30 business day processing time).
• Step 5: Receive Medicaid ID and complete required training for Phoenix system access.

10. Common Denials and Survey Findings

SCDHHS conducts random and targeted Quality Assurance reviews. Failures to comply with the HCBS Provider Manual result in a structured sanction process, including strikes, suspensions, and termination.

Suspensions require an acceptable Plan of Correction before a provider can resume operations.

• Zoning Violations: Applications denied because the agency office is in a residential zone without prior SCDHHS approval.
• Conflict of Interest: Findings issued when an agency is discovered providing both case management and direct care services to the same participant.
• Availability Failures: Sanctions applied when case managers are unreachable during the required 8:30 a.m. to 5:00 p.m. window or hold excessive outside employment.
• Training Deficiencies: Citations for failing to document the required 10 hours of annual in-service training for non-licensed staff.
• Sanction Escalation: Providers face a minimum one-month suspension and removal from the choice list for uncorrected compliance failures.

11. Key Contacts and Resources

Providers should utilize the official SCDHHS and DDSN portals for manuals, enrollment applications, and policy updates.

The SCDHHS Provider Call Center is the primary point of contact for enrollment status inquiries.

• SCDHHS Provider Enrollment: Portal for applications and status checks (https://providerservices.scdhhs.gov).
• SCDHHS HCBS Provider Manuals: Source for the Case Management Scope of Services (https://www.scdhhs.gov/).
• SC DDSN Provider Network: For agencies seeking to serve DDSN waiver populations (https://ddsn.sc.gov/providers/qualified-provider-application).
• SCDHHS Provider Call Center: Support for enrollment and billing inquiries at (888) 289-0709.

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