| Providers are responsible for informing their billing agency for information in this bulletin | ||
| In This Issue |
||
|
All Providers:
Cap Providers: Carolina Access Providers: CRNA and Anesthesiologist Providers: DME Providers: |
Physicians: Dental Providers: Hospitals Providers: Health Check Providers: Prescribers: Psychiatric Hospital Providers: |
Home Health Providers:
Hospice Providers: Labs: Personal Care Providers: Dialysis Providers:
|
The Division of Medical Assistance (DMA) and EDS will be closed on Monday, January 17, 2000, in observance of Martin Luther King Jr.’s Birthday.
EDS, 1-800-688-6696 or 919-851-8888
Please refer to the Special Provider Bulletin for Year 2000 issued December 1999. The Special Bulletin consolidates information about Year 2000 activities and plans as well as instructions and suggestions for providers to move smoothly into the new century.
EDS, 1-800-688-6696 or 919-851-8888
As mentioned in several recent bulletins, Medicaid has replaced the old NECS software with newer NCECS software. The new software creates files for transmission over modem as well as on a mail-in diskette. The NECS software was DOS based; the NCECS runs in Windows 95, Windows 98 or Windows NT 4.0, which are classified as 32 bit operating systems. NCECS will not operate in a Windows 3.1 environment since it is not a year 2000 compliant system.
Based upon problems discovered internally, EDS has improved and corrected the NCECS product in several areas. This includes the following improvements:
Minimal PC requirements for the use of NCECS include:
Providers must supply the browser. These are on a release diskette as part of the Windows 95, 98 and NT Software, or may be downloaded and installed from one of the following addresses:
The Microsoft version is found at http://www.microsoft.com/catalog.
The Netscape version is available at http://home.netscape.com/computing/download/
ECS Unit, EDS, 1-800-688-6696 or 919-851-8888
Dialysis Providers treating recipients who receive ongoing dialysis treatments are paid a monthly Composite Rate. The Composite Rate includes services normally rendered to dialysis recipients such as physician visits, lab tests and medical supplies. In order to accurately process dialysis claims the provider must submit a dialysis start date, which is entered into the recipient’s dialysis file. Claims that include services covered in the Composite Rate will deny when the date of service is after the dialysis start date.
Recipients who have had acute illness involving the renal system, or receive successful kidney transplants which result in the return of normal renal function, may no longer require continued dialysis treatments.
It is imperative that providers notify EDS with the STOP date when dialysis treatments are terminated so the date of the last dialysis treatment can be entered in our records and future claims can be properly processed.
To notify EDS, providers should send a resolution inquiry form stating "Dialysis has terminated" including the Dialysis STOP date MM/DD/YYYY and the reason for discontinuation of the treatments to the address in the example given below:
EXAMPLE:
MEDICAID RESOLUTION INQUIRY
MAIL TO:
EDS PROVIDER SERVICES
P O BOX 300009
RALEIGH, NC 27622
Please Check: o Claim Inquiry o Time Limit Override
NOTE: PLEASE USE THIS FORM FOR TIME LIMIT OVERRIDES AND INQUIRIES ONLY. CLAIM, RAs, AND ALL RELATED INFORMATION MUST BE ATTACHED.
ADJUSTMENTS WILL NOT BE PROCESSED FROM THIS FORM.
Dialysis terminated 12/17/99 due to renal transplant 12/17/99Provider Number: 1234567
Provider Name and Address: Dr. B. Well, 99 Main Street, Yourtown NC 123345
Patient’s Name: Joan Doe Recipient ID: 987654321Z
Date of Service: From: 11/01/99 to 11/01/99 Claim Number: 1019993439231123
Billed Amount: 00.00 Paid Amount: 00.00RA Date: 1/1/00
Please Specify Reason for Inquiry Request:
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service January 1, 2000, Medicaid providers may bill the 2000 Current Procedural Terminology (CPT) codes. Claims filed with deleted 1999 CPT codes for dates of service January 1, 2000 through March 31, 2000 will be accepted for processing. However, the 2000 CPT codes must be used for dates of service on or after April 1, 2000.
The following new CPT codes require further review by the Division of Medical Assistance and are currently not covered:
New lab rates are effective with date of service January 1, 2000. A 1.4 % increase has been implemented not to exceed the national Medicare cap. A rate decrease has been implemented for lab codes in which the current rate exceeded the 2000 national Medicare cap. The actual billed amount on your claims must always contain your regular billed amount and not the price on the fee schedule unless the listed price represents what you normally bill another payor or patient. DMA considers the billed amount in their rate setting efforts. New fee schedules will be available at the end of January or early February. Please refer to instructions in the November 1999 bulletin on ordering fee schedules.
EDS, 1-800-688-6696 or 919-851-8888
Effective with dates of service January 1, 2000, Physicians’ fees are based on the Medicare fee schedule resource based relative value system currently in effect. This change results in paying physician services equal to Medicare for the same procedure for the same date of service and uses updated (RBRVS) values.
Medicare has adopted a new relative value method to calculate physician fees for facility-based services furnished in hospital (inpatient, outpatient and emergency room), ambulatory surgical center and skilled nursing facility settings. This method is the facility based fee concept. It identifies two levels of practice expense RVUs, facility and non-facility, for each procedure code. The non-facility practice expense RVUs are used for services performed in a physician’s office and for services to a patient in the patient’s home, facility or institution other than hospital, skilled nursing facility (SNF) or ambulatory surgical center (ASC). The facility practice expense RVUs are used for services furnished to hospital, SNF and ASC patients.
The allowable for a specific code is determined by the place of service, as indicated on the claim, where the procedure is performed. There are numerous codes that are only performed by definition in a certain setting and will have only one level of practice expense. The fees for these types of codes are the same for non-facility and facility regardless of the place of service indicated on the claim. Modifier pricing is not affected by this change.
The voice inquiry system has been updated and will allow providers to enter the place of service in order to provide the appropriate allowable for the code in question.
New fee schedules will be available at the end of January or early February. Please refer to instructions in the November 1999 bulletin on ordering fee schedules.
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service January 1, 2000, reimbursement rates increase by 1.4%. The actual billed amount on your claims must always contain your regular billed amount and not the price on the fee schedule unless the listed price represents what you normally bill another payor or patient. DMA considers the billed amount in their rate setting efforts. New fee schedules will be available at the end of January or early February. Please refer to instructions in the November 1999 bulletin on ordering fee schedules.
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service January 1, 2000, hospice rates are as follows:
|
|
|
Routine Home Care
|
Continuous Home Care
|
Inpatient Respite Care
|
General Inpatient Care
|
Hospice Intermediate R & B
|
Hospice Skilled
R & B |
|---|---|---|---|---|---|---|---|
|
Metropolitan Statistical Area
|
SC
|
RC 651
Daily |
RC 652
Hourly (1) |
RC 655
Daily (2) (3) (4) |
RC 656
Daily (3) (4) |
RC 658
Daily (5) |
RC 659
Daily (5) |
|
Asheville
|
39
|
95.76
|
23.29
|
99.77
|
426.98
|
88.92
|
118.54
|
|
Charlotte
|
41
|
101.17
|
24.60
|
104.17
|
449.38
|
88.92
|
118.54
|
|
Fayetteville
|
42
|
91.77
|
22.32
|
96.51
|
410.44
|
88.92
|
118.54
|
|
Greensboro/WS/HP
|
43
|
100.16
|
24.36
|
103.35
|
445.21
|
88.92
|
118.54
|
|
Hickory
|
44
|
95.51
|
23.23
|
99.56
|
425.91
|
88.92
|
118.54
|
|
Jacksonville
|
45
|
85.73
|
20.85
|
91.59
|
385.41
|
88.92
|
118.54
|
|
Raleigh/Durham
|
46
|
102.08
|
24.83
|
104.91
|
453.15
|
88.92
|
118.54
|
|
Wilmington
|
47
|
98.68
|
24.00
|
102.14
|
439.06
|
88.92
|
118.54
|
|
Rural
|
53
|
89.76
|
21.83
|
94.87
|
402.10
|
88.92
|
118.54
|
|
Goldsboro
|
105
|
92.79
|
22.57
|
97.34
|
414.66
|
88.92
|
118.54
|
|
Greenville
|
106
|
99.34
|
24.16
|
102.68
|
441.80
|
88.92
|
118.54
|
|
Norfolk, Currituck Co
|
107
|
90.94
|
22.12
|
95.84
|
407.00
|
88.92
|
118.54
|
|
Rocky Mt.
|
108
|
96.29
|
23.42
|
100.19
|
429.15
|
88.92
|
118.54
|
Note: Because providers are expected to bill their usual and customary charges, no adjustments will be accepted.
Key to Hospice Rate Table:
SC = Specialty Code
RC = Revenue Code
Effective with date of service January 1, 2000, the maximum allowable rate
for the following CAP services increased. Providers must bill their usual and
customary charges.
|
Procedure Code
|
Description
|
Reimbursement Rate
|
|---|---|---|
|
W8111
|
CAP-MR/DD Personal Care
|
$3.18/15" Unit
|
|
W8116
|
CAP/DA Respite Care-In Home
|
$3.18/15" Unit
|
|
W8119
|
CAP-MR/DD Respite Care Community Based
|
$3.18/15" Unit
|
|
W8141
|
CAP/DA In-Home Aide Level II
|
$3.18/15" Unit
|
|
W8142
|
CAP/DA In-Home Aide Level III-Personal Care
|
$3.18/15" Unit
|
|
W8143
|
CAP/C Personal Care
|
$3.18/15" Unit
|
|
W8144
|
CAP-MR/DD In-Home Aide Level I
|
$3.18/15" Unit
|
|
W8167
|
CAP/AIDS Respite Care-In-Home/Aide Level
|
$3.18/15" Unit
|
|
W8172
|
CAP/AIDS In-Home Aide II
|
$3.18/15" Unit
|
|
W8173
|
CAP/AIDS In-Home Aide III-Personal Care
|
$3.18/15" Unit
|
No adjustments will be made for claims already processed. Contact the EDS Provider Services Unit for detailed billing instructions.
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service January 1, 2000, the Medicaid maximum reimbursement rate for personal care service is $3.18 per 15-minute unit ($12.72/hour). No adjustments will be made to previously filed claims.
The providers’ customary charges to the general public must be shown in form locator 47 on each UB-92 claim form filed. Public providers with nominal charges that are less than 50 percent of cost should report the cost of the service in form locator 47. The payment of each claim will be based on the lower of the billed charges or the maximum allowable rate.
Debbie Barnes, Financial Operations
DMA, 919-857-4165
Based on recommendations of a committee representing the Association for Home
Health and Hospice Care of North Carolina and the Division of Medical Assistance,
the home health medical supply list is amended effective with date of service
January 1, 2000.
HCPCS Code W4645 - I.V. infusion start kit (venipuncture kit) is replaced with
HCPCS Codes W4740 and W4741 to allow providers to bill for the kits separately.
Effective with date of service January 1, 2000, claims for W4645 will not be
paid.
|
HCPCS Code
|
Description
|
Billing Unit
|
Maximum Rate
|
|---|---|---|---|
|
W4740
|
I.V. infusion start kit (sterile drape; tourniquet;
2x2; tape; alcohol/ iodine wipe; transparent dressing)
|
Each
|
2.63
|
|
W4741
|
Venipuncture kit (includes butterfly needle, all sizes;
tourniquet; 2x2’s (2); tape; alcohol swabs (2); iodine prep)
|
Each
|
2.63
|
The following items are added to the supply list and may be billed effective
with date of service January 1, 2000:
|
HCPCS
Code |
Description
|
Billing
Unit |
Maximum
Rate |
|---|---|---|---|
|
W4742
|
Cotton-tip applicators (sterile)
|
Each
|
.10
|
|
W4738
|
Catheter (Coude’-type)
|
Each
|
4.20
|
|
W4739
|
Drain sponge
|
Each
|
.85
|
DMA, 919-857-4021
Effective with date of service January 1, 2000, blood glucose monitors with
special features (e.g. voice synthesizers, automatic timers, etc.), are being
added to the Capped Rental category of the DME Fee Schedule. The code, maximum
reimbursement rates, and lifetime expectancy are as follows:
|
CODE
|
DESCRIPTION
|
RENTAL
|
NEW
|
USED
|
LIFETIME EXPECTANCY
|
|---|---|---|---|---|---|
|
E0609
|
blood glucose monitor with special features (e.g. voice
synthesizers, automatic timers, etc.)
|
$ 60.50
|
$605.02
|
$453.78
|
5 years
|
Providers are expected to bill their usual and customary rates.
Prior approval is required. Medical necessity must be documented on the Certificate of Medical Necessity and Prior Approval form. All of the following coverage criteria must be met:
Carolina ACCESS (CA) primary care providers (PCPs) must communicate all pertinent changes made within the practice to the local Managed Care Representative. Changes may involve hospital admitting privileges, the CA contact person for the office, new office hours, new providers added to the practice, etc. The Managed Care Representative will notify the DMA Managed Care Section and the change will be made to the CA Application and Agreement on file. If you need to know your Managed Care Representative’s name or phone number, please call the DMA Managed Care Section at 919-857-4022.
DMA Managed Care Section 919- 857-4022
Providers receiving Medicaid payments of more than $600 annually will receive a 1099 MISC tax form from Electronic Data Systems Corporation (EDS). This 1099 MISC tax form is generated as required by IRS guidelines. It will be mailed to each provider no later than January 31, 2000. The 1099 MISC tax form will reflect the tax information on file with Medicaid as of the last Medicaid Checkwrite cycle date, December 23, 1999. If the tax name or tax identification number on the annual 1099 MISC you receive is incorrect, a correction to the 1099 MISC can be requested. Requesting a correction is in your best interest. Correction ensures accurate tax information is on file with Medicaid and sent to the IRS annually. When the IRS receives incorrect information on your 1099 MISC it may require backup withholding in the amount of 31 percent of future Medicaid payments. The IRS could require EDS to initiate and continue this withholding to obtain correct tax data.
A correction to the original 1099 MISC must be submitted by March 15, 2000 and must be accompanied by the following documentation:
or
mail both documents to:
EDS
4905 Waters Edge Drive
Raleigh, NC 27606
Attention: Corrected 1099 Request – Financial
Upon receipt of the fax or mailed correction request, tax information on file
with Medicaid will be updated according to the Special W-9 or IRS W-9. Tax information
updates can be verified by checking the last page of each Medicaid Remittance
and Status Report (RA) which reflects both provider tax name and tax identification
number on file. Additionally, a copy of the corrected 1099 will be generated
and mailed for your record retention. All corrected 1099 requests will be summarized
and reported to the IRS as required.
EDS, 1-800-688-6696 or 919-851-8888
Complete all four parts of the Special
W-9 Form and return to EDS. Incomplete forms will be returned to
you for proper completion.
First Mental Health (FMH) performs utilization review of inpatient services in all psychiatric hospitals and in specified general hospitals for individuals under the age of 21, and through 64 years of age in psychiatric units of specified general hospitals. This includes pre-admission and concurrent review. As a result of this review, either additional days are certified because the information is complete and the client meets criteria for continued stay, or the case has to be referred for a physician consultation due to insufficient information to justify the stay. At this time, FMH arranges a "peer to peer" telephone conference between the consulting physician and the attending physician to discuss the case and obtain more information. Failure of the client’s physician to keep the appointment for the "peer to peer" consultation will result in denial of continued stay for the client. This denial is an administrative or technical denial. There is no appeal process for the client.
The Division of Medical Assistance recommends all participants follow through in the "peer to peer" consultation. If a conference is scheduled and it is subsequently decided that the conference is not needed, please call and cancel.
In January 2000, FMH will send a letter to hospital administrators in facilities that have administrative denials. This letter will serve as a reminder to comply with procedures involving the "peer to peer" consultation. In subsequent months a letter will be sent to facilities whose physicians continue to cause administrative or technical denials.
If there are questions, contact Carolyn Wiser, RN or Callie Silver, RN, at
919-857-4025.
In order to identify prescribers better in our claims processing system, we are going to move from using the UPIN on pharmacy claims to using the DEA number. The target date for the implementation of this change is April 1, 2000.
This change in information submitted on the pharmacy claims will facilitate the work of the Third Party Recovery Section, the Drug Utilization Review Program, and the Pharmacy Review Section.
If you receive inquiries from EDS or DMA to verify your provider numbers and DEA numbers, please respond immediately. It is critical that these numbers match in our system and that our provider files are correct.
EDS, 1-800-688-6696 or 919-851-8888
The Third Party Recovery Section within the Division of Medical Assistance frequently receives telephone calls from Medicaid recipients concerning providers who bill them for services, which have already been filed with Medicaid and other health insurance plans.
When a provider bills the Medicaid program and indicates an insurance payment on the claim form and/or attaches an insurance EOB, the third party payment is applied toward the Medicaid allowable for the claim. If the third party payment is equal to or greater than the Medicaid allowed amount, Medicaid will pay $0.00 on that claim. If the third party payment is less than the Medicaid allowed amount, Medicaid will pay the difference between the third party payment and the Medicaid allowed amount. The provider must not bill the Medicaid recipient (or any financially responsible relative or representative of that recipient) for any difference above the Medicaid payment or other third party payment.
If the provider is notified of the availability of other insurance coverage after Medicaid has made payment, the provider must file the charges with the third party payer. Upon receipt of the insurance payment, the provider must refund Medicaid the lesser of the two payments.
When the recipient’s private health insurance company pays the recipient directly, the provider may bill the recipient for the amount of the insurance payment. If the amount is unknown, the provider may bill the total charges until the payment amount is known. When the provider has determined the amount of the insurance payment, the provider may then file the claim with Medicaid, indicating the insurance payment amount in the appropriate block on the claim form. Medicaid will process the claim for payment, less the insurance payment. The provider may continue to bill the recipient up to the amount of the insurance payment until full insurance payment is received.
Third Party Recovery Section, DMA, 919-733-6294
The Carolina ACCESS Emergency Room Reimbursement Policy includes payment of the following ancillary services without prior authorization from the primary care provider:
Individual Visits
EDS is offering individual provider visits for Certified Registered Nurse Anesthetists (CRNA) and Anesthesiologist providers. Please complete and return the CRNA & Anesthesiologist Provider Visit Request Form. An EDS Provider Representative will contact you to schedule a visit and discuss the type of issues to be addressed.
EDS, 1-800-688-6696 or 919-851-8888
Health Check seminars will be held in March 2000. The February Medicaid Bulletin will have the registration form and a list of site locations for the seminars. Please fill out the form Issues you would like adressed at the Health Check Seminar and return to the following address:
Provider Services
EDS
P.O. Box 300009
Raleigh, NC 27622
EDS, 1-800-688-6696 or 919-851-8888
Seminars for Home Health providers will be held in February 2000. Each provider is encouraged to send new and/or appropriate administrative, clinical, and clerical personnel. The primary topic is the October 1999 Special Bulletin regarding new Home Health billing instructions effective with February 1, 2000 date of service. The agenda also includes Program Integrity issues, commonly identified Home Health program errors, and a review of procedures for filing home health claims, common billing errors, and follow-up procedures.
Due to limited seating, pre-registration is required. Providers not registered
are welcome to attend when reserved space is adequate to accommodate. Please
select the most convenient site and return the completed Home
Health Provider Seminar Registration Form to EDS as soon as possible. Seminars
begin at 10:00 a.m. and end at 1:00 p.m. Providers are encouraged to arrive
by 9:45 a.m. to complete registration.
Note: Providers are requested to bring their most updated Community Care
Manual. Additional manuals will be available for purchase at $20.00.
Directions
|
Monday,
February 21, 2000
WakeMed MEI Conference Center 3000 New Bern Avenue Raleigh, NC Park at East Square Medical Park |
|
FOUR POINTS SHERATON
Tuesday, February 8, 2000
I-40 East into Wilmington to Highway 17 - just off of I-40. Turn left onto Market Street and the Four Points Sheraton is located on the left.
MARTIN COMMUNITY COLLEGE
Thursday, February 10, 2000
Highway 64 into Williamston. The college is approximately 1-2 miles west of Williamston. The Auditorium is located in Building 2.
CATAWBA VALLEY TECHNICAL COLLEGE
Wednesday, February 16, 2000
Take I-40 to exit 125 and go approximately ½ mile to Highway 70. Head East on Highway 70 and the college is approximately 1.5 miles on the right. Ample parking is available. Entrance to Auditorium is between the Student Services and the Maintenance Center. Follow sidewalk (towards Satellite Dish) and turn right to Auditorium Entrance.
HOLIDAY INN CONFERENCE CENTER
Monday, February 21, 2000
Take I-85 to exit 75 and go approximately ½ mile. The Holiday Inn is located on the right.
WAKEMED MEI CONFERENCE CENTER
Monday, February 21, 2000
Directions to the Parking Lot:
Take the I-440 Raleigh Beltline to New Bern Avenue, Exit 13A (New Bern Avenue, Downtown). Go toward WakeMed. Turn left at Sunnybrook road and park at the East Square Medical Plaza which is a short walk to the conference facility. Parking is not allowed in the parking lot in front of the Conference Center. Vehicles will be towed if not parked in the East Square Medical Plaza parking lot located at 23 Sunnybrook Road.
Directions to the Conference Center from Parking Lot:
Cross the street and ascend steps from sidewalk up to Wake County Health
Department. Cross Health Department parking lot and ascend steps (with a blue
handrail) to MEI Conference Center. Entrance doors are on the left.
|
January 12, 2000
|
February 8, 2000
|
March 7, 2000
|
|
January 19, 2000
|
February 15, 2000
|
March 14, 2000
|
|
January 27, 2000
|
February 24, 2000
|
March 21, 2000
|
|
March 30, 2000
|
|
January 7, 2000
|
February 4, 2000
|
March 3, 2000
|
|
January 14, 2000
|
February 11, 2000
|
March 10, 2000
|
|
January 21, 2000
|
February 18, 2000
|
March 17, 2000
|
|
March 24, 2000
|
Electronic claims must be transmitted and completed by 5:00 p.m. on the
cut-off date to be included in the next checkwrite. Any claims transmitted after
5:00 p.m. will be processed on the second checkwrite following the transmission
date.
|
|
|
| Paul R. Perruzzi, Director | John W. Tsikerdanos |
| Division of Medical Assistance | Executive Director |
| Department of Health and Human Services | EDS |
| Home | Top | |