What is HIPAA

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Main Menu
Main Menu

• Thanks for taking the time to learn about changes
  in Medicaid billing as a result of HIPAA. This
  module will orient you to the changes and the
  next steps you must take in order to be compliant
  with HIPAA transaction and code sets requirements
  and get paid for services!

• Overview
• Code Sets
• Filing Options
• Transactions
• Eligibility Request / Response (270/271)
• Referral / Authorization (278)
• Claim Submission (837)
• Claim Payment / Advice (835)
• Claim Status Request / Response (276/277)
• Tools and Processes
• Resources
• SC Medicaid Web-Based Claims Submission Tool Demo

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Overview
Overview
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The Legislation
Overview

• Why was HIPAA enacted?
• HIPAA (Health Insurance Portability and
  Accountability Act) is a federal law enacted in
  1996.
• As health care became increasingly complex in the
  last decade, legislators recognized a need to
  make it easier for people to get insurance, to
  protect personal health information, and to
  reduce administrative costs while limiting fraud
  and abuse of the system.

• Health Insurance Portability and Accountability
  Act (HIPAA)
• Federal law enacted in 1996
• Designed to
• Provide better access to health insurance
• Protect Personal Health Information (PHI)
• Reduce administrative costs and limit fraud and
  abuse

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How It Affects YOU
Overview

• What is the impact of HIPAA?
• The impact of of HIPAA is bigger than Y2K. It
  affects every aspect of health care operations.
• HIPAA-mandated privacy regulations were effective
  April 14, 2003. Regulations standardizing
  transactions and code sets will be implemented
  October 16, 2003.
• National standardization of transaction and codes
  sets is projected to result in significant time
  and cost savings.
• Lets examine how these changes affect your
  transactions with SC Medicaid.

• Dimensions
• Security
• Privacy
• Transactions
• Code Sets
• Cost
• Larger effort than Y2K
• Benefit
• Significant time and cost savings, long-term
• Protection of protected health information (PHI)

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Codes
Code Sets
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Code Sets
Codes

• How will codes change?
• HIPAA mandates the standardization of medical and
  non-medical codes used in transactions.
• Bottom line, with HIPAA, you will use only
  standard code sets (listed to the right).
• SC Medicaid has cross-referenced (crosswalked)
  all local codes to national codes. This
  crosswalk may be accessed by visiting the SC
  Medicaid HIPAA web site www.scdhhshipaa.org.

• Medical
• ICD-9-CM (diagnosis and procedures)
• CPT-4 (physician procedures)
• HCPCS (ancillary services/procedures)
• CDT-2 (dental terminology)
• NDC (national drug codes)
• Non-medical
• Gender, marital status, citizenship, etc.
• Remittance Advice Codes (RARC)
• Claim Adjustment Reason Codes (CARC)

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Medical Code Crosswalk
Codes

• How do I read the Medical Code crosswalk?
• The medical code crosswalks are formatted as
  illustrated in the example to the right.
• The local code currently used is located in the
  first column the corresponding national code is
  located in the third column.

SC Medicaid Local Procedure Code Prior to October 16, 2003 SC Medicaid Local Procedure Code Description Prior to October 16, 2003 National Procedure Code Effective October 16, 2003 National Procedure Code Description Effective October 16, 2003 Notes
These are the codes from your current program manual. These are the code descriptions from your current program manual. These are the national codes you will be using. This is the description of the national code. This area will give you code specific information you will need in order to bill Medicaid.
Current Code
New Code
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Filing Options
Filing Options
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Filing Process(before 10/16/03)
Filing Options

• Summary of the current process for claims
  submission to SC Medicaid.
• Currently, providers submit claims to the
  Medicaid Management Information System (MMIS) in
  one of several ways
• Through a Clearinghouse or Billing Agency
• Through the MCCS, via paper, or electronic media
• Providers and clearinghouses currently use
  various different data formats for claims
  submission (in fact, there are about 400
  different formats being used in the US!). All
  electronic transactions regulated by HIPAA must
  be standardized to meet ANSI X12 4010A formats,
  as specified in the Implementation Guide. These
  standards may be found at www.wpc-edi.com/hipaa/hi
  paa/_40.asp.

Billing service/ Clearinghouse
MMIS
Tape, diskette, CD, etc.
MCCS
Paper
MCCS
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Filing Process (starting 10/16/03)
Filing Options

• How will the filing process change?
• Effective 10/16/03, all electronic claims must be
  submitted in HIPAA-compliant format.
• Claims will go to an assigned EDI mailbox, then
  will travel through a Translator to the MMIS.
  The Translator serves to convert HIPAA-compliant
  formats into formats that can be accepted by the
  MMIS.
• Providers will have two new options for
  submitting claims . . .

Billing service/ Clearinghouse
EDI Mailbox
MMIS
EDI Mailbox
TRANSLATOR
EDI
Tapes, ZIP files, diskettes, CDs
EDI Mailbox
MCCS
Paper
MCCS
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Web Filing
Filing Options

• Web Filing!
• Effective 10/16/03, providers may submit
  HIPAA-compliant claims via modem.
• Additionally, SC Medicaid is pleased to provide a
  web-based claims submission tool for providers to
  use at no charge. If you have an ISP (internet
  service provider), you can submit claims this
  way.

Billing service/ Clearinghouse
EDI Mailbox


Providers EDI software
EDI Mailbox
TRANSLATOR
MMIS
Tapes, ZIP files, diskettes, CDs
EDI Mailbox
MCCS
EDI Mailbox
Web Filing
Paper
MCCS
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Transactions
Transactions
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Transactions
Transactions

• What are transactions?
• Transactions in this context refers to EDI
  communications between the trading partner and
  the Translator.
• HIPAA-regulated electronic transactions that
  affect you are listed to the right.
• HIPAA-mandated formats may include changes on how
  units are reported, the number of digits in a
  date or medical record, etc.
• Lets review each of these transactions.

• Eligibility Request/ Response (270/271)
• Referral / Authorization (278)
• Claim/Encounter (837)
• Claim Payment / Advice (835)
• Claim Status Inquiry / Response (276/277)

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Eligibility Request / Response
Eligibility Request / Response
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Eligibility Request / Response (270/271)
Eligibility Request / Response

• What are the eligibility transactions?
• There are two transactions related to recipient
  eligibility, each with a unique transaction
  number.
• The Eligibility Request (270) is sent by the
  provider
• The Eligibility Response (271) is the answer sent
  by the MMIS
• Because they are so tightly related, these are
  often referred to as the 270/271.

Does s/he have insurance?
270 Eligibility Inquiry
271 Eligibility Response
MMIS Medicaid Management Information System
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Eligibility Request / Response (270/271)
Eligibility Request / Response

• How will I verify eligibility?
• Currently, providers may check eligibility via
  the telephone, using the Interactive Voice
  Response System (IVRS), or through an eligibility
  vendor. These methods will remain.
• The 270 transaction will allow providers to
  perform one or more eligibility inquiries using
  EDI software. The SC Medicaid Web-Based Claims
  Submission Tool will also provide for single
  eligibility checks via the Web.

• Interactive inquiry
• EDI through current vendor
• IVRS
• New option SC Medicaid Web-Based Claims
  Submission Tool
• Batch Inquiry - new functionality
• Transmit to EDI mailbox in HIPAA-compliant format

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Referral / Authorization
Referral / Authorization
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Referral / Authorization (278)
Referral / Authorization

• What is a referral/authorization transaction?
• The 278 transaction, Referral/Authorization,
  answers the question, Is this a covered
  service?

Is this a covered service?
278 Referral/Authorization
MMIS Medicaid Management Information System
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Referral / Authorization (278)
Referral / Authorization

• How will I obtain prior authorizations?
• Effective 10/16/03, you will continue using the
  phone/fax method if attachments are involved.
  If, however, there are no attachments, you now
  will have the added option of sending the 278
  electronically.
• The response from the MMIS will be an
  acknowledgement of receipt of your request. The
  authorization number will be mailed or called in
  as it is today.

• Referral / Authorization is sent electronically
  as a 278
• Process for sending required attachments will not
  change

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Claim Submission
Claim Submission
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Claim Submission (837)
Claim Submission

• Tell me about the claim submission transaction.
• This transaction, known as the 837, contains all
  the data required for the professional,
  institutional and dental claim forms sent to SC
  Medicaid.
• Claims may be submitted electronically via the
  837, or by paper.

Please pay this claim
837 Claim Submission
MMIS Medicaid Management Information System
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Claim Submission (837)
Claim Submission

• What changes can I expect in the claims
  submission process?
• The data you will be required to transmit will
  not change much. The 837 does expand the number
  of detail lines per claim. Also, the other
  insurance information has expanded from 2 to 10
  carriers.
• The 837 will be used also for void and
  replacement claims. A void is an action to
  eliminate a claim filed incorrectly. Once the
  void occurs, a replacement claim may then be
  submitted with the correct information.
• Be aware that whether you void one or multiple
  claims, you will receive only one gross
  adjustment.

• Three formats
• Professional (CMS 1500)
• Institutional (UB 92)
• Dental (ADA Dental Claim Form 1999, Version 2000)
• Report up to 10 insurance carriers
• Also used for void and replacement claims

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Split Claims
Claim Submission

• How will the MMIS process these claims with
  increased detail lines?
• Claims (with the exception of Institutional) that
  exceed the original limit of detail lines will be
  split.
• That is, when a claim comes in with more detail
  lines than currently exist on the MMIS, it will
  be split into multiple claims, all identified by
  the same claim control number (CCN). For
  example, a Professional claim holds a maximum of
  8 detail lines today. If a claim with 20 detail
  lines comes in, it will be split into three
  claims with 8, 8 and 4 detail lines,
  respectively.
• Please note that split claims will not suspend.

PROFESSIONAL CLAIM 20 detail lines
8 detail lines
8 detail lines
MMIS
4 detail lines
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Split Claims on the Remittance Advice
Claim Submission

• How will I know that a claim has been split?
• You will notice claim splitting when you receive
  the remittance advice (RA).
• You will know that claims are related by looking
  at the CCN. The split claims will share the same
  CCN however, they will differ on the 15th and
  16th digits.
• For Professional claims, the first claim in the
  split will be denoted by a 10 this number will
  be incremented by 10 for the remaining claims in
  the split.
• For Dental claims, the 15th and 16th digits will
  increase by increments of 20.
• The graphic to the right illustrates this
  numbering system.

Paper and Electronic RA (Professional) xxxxxxxx
xxxxxx10x xxxxxxxxxxxxxx20x xxxxxxxxxxxxxx30x
Paper and Electronic RA (Dental) xxxxxxxxxxxxxx
10x xxxxxxxxxxxxxx30x xxxxxxxxxxxxxx50x
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Claim Payment / Advice
Claim Payment / Advice
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Claim Payment / Advice (835)
Claim Payment / Advice

• What is the claim payment / advice transaction?
• The 835 provides information on how Medicaid is
  paying for services billed on the 837 or by paper
  claim. It reflects both paid and denied
  services.
• Payments are made via check or EFT, depending on
  the agreement with the provider, and are
  accompanied by an remittance advice explaining
  payment or non-payment reasons.

Here is your payment
835 Claim Payment
MMIS Medicaid Management Information System
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Claim Payment / Advice (835)
Claim Payment / Advice

• How will payment change?
• Starting October 16th, automated posting to
  accounts receivable will be possible if your
  practice management system allows that function.
  The claim payment will communicate claim
  adjudication, and contain denials and partial
  payments.
• You may continue to receive payment via check or
  EFT. You will continue to receive the paper RA
  and may also elect to receive an electronic RA
  (835). The electronic RA will contain the
  national EOB codes, and the paper RA will retain
  the current codes.

• Allows for automated posting to accounts
  receivable since payment is matched to claims
• EFT option remains
• Codes
• National Explanation of Benefits (EOB) codes on
  835
• Claim Adjustment Reason Code
• Remittance Advice Remark Code
• Current edit codes remain on paper RA

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Claim Status Request / Response
Claim Status Request / Response
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Claim Status Request / Response (276/277)
Claim Status Request / Response

• What are the claims status transactions?
• There are two transactions related to claim
  status, each with a unique transaction number.
• The Claim Status Request (276) is sent by the
  provider
• The Claim Status Response (277) is the answer
  sent by the MMIS
• Because they are so tightly related, these are
  often referred to as the 276/277.

276 Claim Status Inquiry
277 Claim Status Response
MMIS Medicaid Management Information System
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Claim Status Request / Response (276/277)
Claim Status Request / Response

• How will I check the status of a claim?
• Checking claim status will be faster and easier.
  The 276 transaction allows providers to check the
  status of more than one claim at a time.
• The 277 will indicate where the claim is in the
  cycle (in receipt or not found, ready for
  payment, need more information, paid).
• The response will also enable Medicaid to request
  additional information from the provider
  regarding the claim. This more efficient process
  should reduce the incidence of duplicate claim
  filing.

• New electronic option
• Multiple claim status can be checked in one
  transmission
• Replies indicate claim status
• Claim in receipt, or not found
• Ready for payment cycle
• Needs more information
• Already paid/processed

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Tools and Processes
Tools and Processes
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Exchange of Data
Tools and Processes

• How data will flow effective October 16, 2003?
• As discussed earlier, electronic transactions
  exchanged between providers and the MMIS will
  pass through a Translator.
• An electronic mailbox will hold both inbound and
  outbound transactions. Each time a transaction is
  sent by a provider, the Translator will send to
  the mailbox a 997 (Acknowledgment) that will tell
  the provider if the transaction format (not
  content) was compliant and has been forwarded to
  the MMIS. If the transaction is not format
  compliant, the 997 message will explain why.
• Providers will be responsible for checking
  regularly for outbound transactions from
  Medicaid.

transaction

Billing service/ Clearinghouse
EDI Mailbox
997
MMIS
EDI Mailbox
EDI
Tapes, ZIP files, diskettes, CDs
EDI Mailbox
MCCS
Paper
MCCS
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Next Steps to 10/16/03
Tools and Processes

• What must providers do and by when?
• First, choose a method for your practice to
  submit HIPAA-compliant claims. You may choose
  more than one method.
• Second, sign a Trading Partner Agreement. You
  can get a copy by visiting our web site
  www.scdhhshipaa.org.
• Finally, test sending claims using your chosen
  method before 10/16/03. This test will need to
  be scheduled in advance by calling
  1-888-289-0709.

• Choose your method of submission
• South Carolina Medicaid Web-Based Claims
  Submission Tool
• EDI (HIPAA-compliant software)
• Paper
• Tapes, diskettes, CDs and Zip Files
• Clearinghouse/Billing Agency
• Sign a Trading Partner Agreement
• Test

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Resources
Resources
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Call or E-mail for HELP!
Resources

• I have more questions! Where can I go for
  answers?
• Listed to the right are a variety of links and
  phone numbers where you can get additional
  information.
• The most comprehensive web site about HIPAA and
  SC Medicaid is www.scdhhshipaa.org. It contains
  the most current information about instructor-led
  training events and national codes.
• Questions may be emailed to info_at_scdhhshipaa.org.
  If you wish to speak to a person, call SC
  Medicaid HIPAA Provider Outreach at
  1-888-289-0709 and one of our friendly
  representatives will assist you.

• SC Medicaid
• www.scdhhshipaa.org
• SC Medicaid HIPAA Provider Outreach
• 1-888-289-0709
• www.dhhs.state.sc.us
• Statewide Training Sessions
• Online Training
• Testing Resources
• www.hipaadesk.com
• www.claredi.com
• Implementation Guide
• www.wpc-edi.com/hipaa/HIPAA_40.asp
• CMS
• www.cms.gov

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Check your Understanding
Resources
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Resources
Self-Test

• What have you learned?
• Click the hippo to bring up a question.
• See if you know the answer. Then click again to
  see if you answered correctly.
• Good luck!

• HIPAA is designed to simplify healthcare
  administrative processes.
• True.
• TPA stands for third-party agreements.
• False (Trading Partner Agreement)
• Transactions and Code Sets are a part of the
  Administrative Simplification process.
• True
• Providers who bill on the CMS 1500 are exempt
  from HIPAA regulations.
• False. Everyone must be compliant!
• An EDI transaction is the filing of a claim using
  the CMS 1500.
• False. It is the electronic exchange of
  information.

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Self-Test (cont.)

• Keep going . . .
• Click the hippo again to bring up the next
  question. See if you know the answer. Then
  click again to see if you answered correctly.

• Trading Partner Agreements apply to providers
  filing claims electronically only.
• False. All entities wishing to conduct
  electronic transactions with SC Medicaid must
  sign an agreement.
• 837 is the transaction that requests eligibility.
  
• False. 837 is the Claim Submission transaction.
• SC Medicaid created the Health Insurance
  Portability and Accountability Act of 1996.
• False. HIPAA is a federal law.
• The South Carolina Medicaid Web-Based Claims
  Submission Tool requires the purchase of software
  for use.
• False. Providers access the free application
  online via the Internet!
• Clearinghouses are required to comply with all
  HIPAA deadlines.
• True.

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Where next?

• Where do I go next?
• To review sections of this module, click the home
  button to return to the Main Menu.
• To see samples of the web-based claims submission
  tool, click the DEMO icon.
• To visit the SCHIPAA web site and download codes
  or companion guides, click the last button.
• To exit this presentation, just close this
  window!
• Thanks for taking this course and best wishes
  on your journey to HIPAA compliance!

DEMO
WEB SITE
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South Carolina Medicaid
WEB-BASED CLAIMS SUBMISSION TOOL
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This screen will appear when you type in the web
address. The MAIN MENU lists all the familiar
tasks of claims submission. Lets explore the
different options available from the Main Menu.
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1. LIST MANAGEMENT
List Management Tired of typing the same codes
and names over and over each time you complete a
new claim form? List Management lets you build
your own frequently-used lists of codes and
patient information. So, instead of typing a
patient name or procedure code, you can just
select it from a list. One click -- and the
correct code is in the field! To build a list,
click List Management on the Main Menu.
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1. LIST MANAGEMENT
A submenu of lists appears. Select the list you
want to build. We will click Recipient in
order to add a patient to the list.
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The Recipient List Add/View screen appears. To
add patient information, type in the fields
provided (top half of screen) and click SUBMIT.
The name is added to your list. To edit patient
information, just click the EDIT button by the
patients name on the Recipient Information list
(lower half of the screen) and make the changes.
Its that simple!
1. LIST MANAGEMENT
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2. CLAIMS ENTRY
Claims Entry When you click the Claims Entry
option, you will be given the choice to enter a
Dental, CMS 1500, or UB 92 claim. For example, to
complete a professional claim, well select CMS
1500.
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2. CLAIMS ENTRY
The CMS 1500 Results screen will appear. All
claims you have keyed, but not yet submitted,
will be listed. You can view, edit, copy or
delete one of these claims by clicking the radio
button next to it and then clicking the desired
action button (Add, Edit, Copy, View, History,
Delete). Create a new claim by clicking the ADD
button.
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2. CLAIMS ENTRY
The CMS 1500 screen will appear -- an online
claim form. Complete the fields as you would
normally. Then save your work by clicking the
SAVE button. NOTE Wherever you see an ellipses
icon (see green box), there is a list from which
you can select information (and save
keystrokes!). In this case, the ellipses
indicate the existence of a Recipient List.
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3. CLAIMS SUBMISSION
Claims Submission Once you have completed your
claims, submitting them is an easy task. Simply
click Claims Submission
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3. CLAIMS SUBMISSION

• The Claims Submission screen appears.
• Type the Contact Information in the fields
  provided.
• Then select the type of claims you are submitting
  from the list at the bottom of the screen (only
  one claim type may be submitted at a time). In
  this example, we have two CMS 1500 claims to be
  submitted. We clicked the radio button next to
  CMS 1500 to select them.
• Click the SUBMIT button to send the claims.

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3. CLAIMS SUBMISSION
This message appears to let you know the claims
have been sent. You may click the batch ID to
view the details of your submission.
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If you are interested in this tool. . .

• You need
• Computer with ISP and Internet connection
• Speed depends on computer and connection.
  Pentium II equivalent is recommended.
• Login ID and Password
• Assigned when you register and sign TPA
• Complete a Web Interest Form to learn more!

For more information 1-888-289-0709 or
info_at_scdhhshipaa.org
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Where next?
Main Menu
See demo again!
DEMO
EXIT presentation and return to web site
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