February 2001 NC Medicaid Bulletin

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In This Issue...

All Providers:

Adult Care Home Providers:

Area Mental Health Centers:

Carolina ACCESS PCPs:

Dental Providers and Dental Health Dept. Clinics:

DME Providers:

Health Check Providers:

Nursing Facilities:

Physicians:

Prescribers:

 

Attention: All Dental Providers and Dental Health Department Clinics
Mandatory Use of the 1999 ADA Claim Form Effective March 1, 2001

Effective March 1, 2001, all requests for prior approval and all claims for payment for dental services must be submitted on the 1999 American Dental Association (ADA) claim form. Any claims or prior approval requests not received on the 1999 claim form beginning March 1, 2001 will be returned to the provider.

A sample of the 1999 ADA claim form is printed in the Dental Forms and Instructions Section of the May 2000 North Carolina Medicaid Dental Services manual. Refer to a copy of this manual for complete prior approval and billing instructions. Additional manuals may be purchased by contacting EDS Provider Enrollment or EDS Provider Services (919-851-8888 or 1-800-688-6696).

EDS, 1-800-688-6696 or 919-851-8888


Attention: Nursing Facility Providers

Preadmission Screening and Annual Resident Review

In the January 2001 Bulletin, providers were informed that residents "grandfathered" into the Preadmission Screening and Annual Resident Review (PASARR) program with forms used prior to February 1994 must have a First Health (formerly First Mental Health) PASARR screen and receive a PASARR number from First Health (FH) by January 1, 2001.

Due to the multitude of requests forwarded to FH, the deadline for these "grandfathered" residents has been extended to April 1, 2001.

Margaret O. Langston, RN, Institutional Services, Medical Policy Section
DMA, 919-857-4020


Attention: Carolina ACCESS PCPs and Area Mental Health Centers
Outpatient Mental Health Services for Children Birth through 20 Years of Age

Effective February 1, 2001, the Division of Medical Assistance will increase access to mental health services to children birth through 20 years of age by directly enrolling Licensed Psychologists, Licensed Clinical Social Workers, and Certified Child and Adolescent Psychiatric Nurse Practitioners and Clinical Nurse Specialists as Medicaid providers.

The benefit package includes 26 outpatient visits per calendar year when referred by the Carolina ACCESS PCP or Area Mental Health Center. Visits beyond the 26-visit limit will require the mental health provider to request prior authorization from Value-Options, the utilization review organization.

As the referring provider, the PCP or Area Mental Health Center will give the mental health provider a referral number for payment of the claim. The mental health provider cannot be paid unless the referring provider's number appears on the claim. To facilitate the referral process, referrals may be made by telephone, fax, or in writing. Mental health providers are expected to communicate the plan of care and anticipated length of treatment to the referring provider following the guidelines for patient confidentiality as a means to assure continuity of care.

Carol Robertson, Medical Policy Section
DMA, 919-857-4020


Attention: All Providers
Where to Obtain Forms

All forms - except claim forms - used by providers enrolled in the Medicaid program are available from EDS Provider Services. Many of the forms are included in the provider manuals, Medicaid Bulletins, and workshop handouts, and can be copied for use by the provider. Some forms are also available on the Division of Medical Assistance's Internet webpage. The following table lists where to obtain forms.
 
Name of Form
DMA Internet Home Page
Medicaid Publications (Bulletins, Provider Manuals, Workshop Handouts)
EDS Provider Services

1-800-688-6696
or
919-851-8888

Other
Attorney Medicaid Lien Request (DMA-2071)
X
X
ADA Dental Claim (version 1999)
American Dental Association
1-800-947-4746
Adult Care Home Personal Care Physician Authorization and Care Plan (DMA-3050)
X
Certificate of Need (DMA 3009)
X
Certificate of Need (DMA 3009-A)
X
Certification of Signature on File
X
X
X
CLIA Certification 
X
X
X
DEA Number Request
X
X
X
Disability Determination Transmittal DMA-4037)
X
X
Electronic Funds Transfer Authorization Agreement
X
X
X
Emergency Certification for Medicaid (DMA-5050)
X
X
Fee Schedule Request 
X
X
X
HCFA-1500 Claim
Available from most office supply stores
Health Insurance Information Referral (DMA-2057)
X
X
X
Health Insurance Premium Payment Application (DMA-2069)
X
X
Individual Authorization (DMA-3019)
X
X
Instructions for Medicaid Lien Request (DMA-2071-I)
X
X
Insurance Medicaid Lien Request (DMA-2072)
X
X
Long Term Care Services (FL2)
X
Long Term Care Services Utilization Review Report (FL12)
X
Medicaid Claim Adjustment Request
X
X
X
Medicaid Credit Balance Report
X
X
X
Medicaid Resolution Inquiry
X
X
X
Medical Provider Verification (DMA-5037)
X
X
Medicare Crossover Reference Request
X
X
X
Notification of Change in Provider Status 
X
X
X
Personal Care Services (PCS) Physician Authorization and Plan of Care (DMA-3000)
X
X
Pharmacy Adjustment Request (372-200)
X
X
X
Pharmacy Claim
X
Prior Approval
  • Certificate of Medical Necessity and Prior Approval for DME (372-131)
  • General Request for Prior Approval (372-118)
  • Supplement to Dental Prior Approval
  • Request for Visual Aids (372-017)
  • Psychiatric Prior Approval
  • Private Duty Nursing Referral
X
Provider Visit Request
X
X
X
Referral for Diagnosis and Treatment
X
Referral to Local Social Security Office(DMA-5049)
X
X
Report of Medical Examination(DMA-5006)
X
X
Six Prescription Limit Override(DMA-3098)
X
X
X
State-to-State Ambulance Transport Addendum (372-118A)
X
Sterilization Consent Statement
X
X
TPR Accident Information Report(DMA 2043)
X
X
X
TPR Health and Accident Resources Information (DMA-2041)
X
X
UB-92 Claim
Available from most office supply stores

EDS, 1-800-688-6696 or 919-851-8888


Attention: Physicians and Durable Medical Equipment Providers
Upper and Lower Extremity Compression Sleeves

This article is intended to provide clarification of the billing guidelines for compression sleeves.

Durable Medical Equipment (DME) providers can bill for a medically necessary segmental or nonsegmental pneumatic appliance for use with pneumatic compressor, full arm. These appliances are used with a compressor (E0650, E0651 or E0652), which must be rented on a monthly basis. A pneumatic compression device is covered only for the treatment of refractory lymphedema. When it is necessary for a recipient to be treated with a segmental or nonsegmental pneumatic compressor on an upper extremity, one of the following appliance procedure codes should be used:

Note: DME providers may also bill half-arm appliances as well as lower extremity appliances. The procedure codes listed above require prior approval. Providers are expected to bill their usual and customary rates.

Jobst compression sleeves for upper and lower extremities are covered under physician services when they are medically necessary. Jobst compression sleeves are not attached to a compressor. A qualified staff member must measure the recipient's extremity. The sleeve must be ordered specifically for the recipient and dispensed from the physician's office to the recipient. Billing guidelines require the invoice to be submitted with the claim. The invoice must identify the item ordered (Jobst compression sleeve) and indicate it was ordered for the recipient. W5120 must be billed for compression sleeves for either the upper and lower extremities.

EDS, 1-800-688-6696 or 919-851-8888


Attention: All Prescribers
Recommendations from Drug Utilization Review Study

Last quarter the Drug Utilization Review (DUR) Board, consisting of practicing physicians and clinical pharmacists, conducted a review of prescription claims for diabetic patients who have been diagnosed with hypertension and who were not on an ACE-inhibitor, beta blocker, or angiotension II receptor antagonist.

Surprising results revealed that calcium channel blockers were prescribed as the preferred drug by many practitioners in North Carolina. For example, Norvasc was the 11th most frequently prescribed Medicaid prescription dispensed between August 1999 through August 2000.

Based on recent information in the New England Journal of Medicine (1999; 340:677-84), calcium channel blockers have proven inferior to other anti-hypertensives, especially in selected subgroups such as elderly patients with both diabetes and systolic hypertension. These agents, which are more expensive, do not decrease morbidity and mortality in this patient population.

It is apparent from this DUR Board review that prescribing practices are not consistent with evidence-based guidelines. We encourage prescribers to consider evidence-driven prescribing practices (as described below) for the treatment of hypertension in the diabetic population.

The Sixth Report of Joint National Committee on Prevention, Detection, Evaluation, Treatment of High Blood Pressure (JNCVI) reported an increasing prevalence of patients who have a diagnosis of both hypertension and diabetes. An estimated 35 percent to 75 percent of diabetic complications (stroke, coronary artery disease, peripheral vascular disease, blindness, ESRD, and amputation) can be attributed to hypertension. Consensus statements from JNCVI and the American Diabetes Association (ADA) recommend ACE-inhibitors as first-line therapy for patients with hypertension and concomitant Diabetes Mellitus (DM) with nephropathy. The ADA recommends the use of ACE-inhibitors for both normotensive and hypertensive patients with Type I DM and microalbuminuria. Guidelines also advocate the use of ACE-inhibitors in hypertensive Type 2 DM patients with microalbuminuria. Appropriate prescribing in this patient population should decrease progression to overt nephropathy and ESRD, and decrease health care costs.

The findings from published randomized clinical trials (FACET, ABCD, MIDAS, SHEP) of hypertensive patients with diabetes or prediabetes show it is prudent to use ACE-inhibitors and low-dose diuretics as the preferred first-line agents. ACE-inhibitors are superior to calcium channel blockers in preventing cardiovascular events.

In conclusion, strong evidence exists that ACE-inhibitors and beta blockers are effective and that ACE-inhibitors are better than calcium channel blockers as first-line agents for diabetics. ACE-inhibitors can significantly reduce the risk of death, heart attacks, and heart failure complications for those patients at risk.

Please use this educational message and share it with your peers and patients. This information is intended to enhance patient health care outcomes.
 

Sharman Leinwand, DUR Coordinator, Program Integrity Section
DMA, 919-733-3590 ext. 229


Attention: All Providers
Corrected 1099 Requests - Action Required by March 1, 2001

The 1099 MISC form is generated as required by IRS guidelines and is mailed to each provider by January 31 every year. The 1099 MISC tax form mailed to providers for 2000 reflects the tax information on file with Medicaid as of the last Medicaid Checkwrite cycle date, December 15, 2000.

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. Correction ensures that 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 1, 2001 and must be accompanied by the following documentation:

Fax both documents to 919-859-9703, Attention: Corrected 1099 Request

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 Advice (RA), which reflects both the provider tax name and tax identification number on file. Additionally, a copy of the corrected 1099 MISC will be generated and mailed for your record retention. All corrected 1099 MISC requests will be summarized and reported to the IRS as required.

EDS, 1-800-688-6696 or 919-851-8888
 


Attention: All Providers
Stereotactic Pallidotomy

The Division of Medical Assistance began covering Stereotactic Pallidotomy, CPT code 61720, beginning with date of service November 1, 2000. Coverage is only for ICD9-CM diagnosis code 332.0, Idiopathic Parkinson's Disorder, and prior approval is required.

Documentation must support all of the following:

  1. Recipient must exhibit at least rigidity and bradykinesia.
  2. Recipient must have typical paralysis agitans.
  3. Recipient must have shown optimal response to levodopa in the past.
  4. There must be a neurological evaluation that indicates the recipient has become refractory to medical therapy or has developed intolerance to medication.
  5. The absence of advanced cerebral atrophy, focal lesion or lacuna of the basal ganglia must be documented through MRI or CT.
  6. Recipient must be alert, cooperative, and in general good health.
  7. Recipient must have had active disease for more than five years.
Prior approval may be denied if any of the following are present: Prior approval will not be considered for: EDS, 1-800-688-6696 or 919-851-8888


Attention: All Providers
Renovation of the MMIS System - Identification Tracking Measurement Enhancement (ITME) Project

The Division of Medical Assistance (DMA) is upgrading and enhancing the Medicaid Management Information System (MMIS). The goals of the renovation, as noted in the April, 2000 Bulletin, are:

The enhancements will include minimal changes to the Remittance and Status Advice (RA), submission of adjustment requests, prior approval, and voice response and eligibility verification systems.

Changes to the following parts are detailed in the Provider Impact section of this article.

Part I - Remittance and Status Advice
Part II - Adjustment Requests - NEW FORM
Part III - Prior Approval (PA)
Part IV - Automated Voice Response (AVR) System and Eligibility Verification System (EVS)    

Implementation Schedule

Updated Implementation Date: The implementation of system changes for the ITME project has been extended to February 9, 2001. The revised date of February 9, 2001 supercedes the original implementation date reflected in the September and October, 2000 ITME bulletin articles. Please note that all references to effective dates in the remainder of this article have been revised to reflect the extended date of February 9, 2001.

The RA will reflect the changes noted in Part I beginning February 9, 2001. Part II reflects the new N.C. Medicaid adjustment form. Use of this form is required as of February 9, 2001. Part III provides new instructions for submitting services that have been prior approved. Part IV addresses changes to the AVR System and EVS resulting from this enhancement.

Provider Impact

Part I: Remittance and Status Advice (RA) - See Example 1

RA modifications/format changes will be kept to only those that are necessary in conjunction with the ITME project. Overall, the RA will look very similar to the current format. Please note the format changes on the RA sample following this article (Example 1).

Addition of Financial Payer Code

A financial payer code follows the claim internal control number (ICN) in the first line of the claim data reflected on the RA. This financial payer code denotes the entity responsible for payment of the claims listed on the RA. Upon implementation, N.C. Medicaid will be the only financially responsible payer; therefore, the N.C. Medicaid payer code of NCXIX (five characters) will be reflected. 

Addition of Population Group Payer Code

The RA reflects the population payer code for each claim detail. The population payer code is printed at the beginning of each claim detail line on the RA. The population payer code denotes the special program/population group from which a recipient is receiving Medicaid benefits. Examples of population payer codes are as follows:
Code Name Description
CA-I Carolina ACCESS All recipients enrolled in Medicaid's Carolina ACCESS program
CA-II ACCESS II All recipients enrolled in Medicaid's ACCESS II program
CAB ACCESS III - Cabarrus County All recipients enrolled in Medicaid's ACCESS III program for Cabarrus County
PITT ACCESS III - Pitt County All recipients enrolled in Medicaid's ACCESS III program for Pitt County
HMOM Health Maintenance Organization (HMO) All recipients enrolled in Medicaid's HMO program
NCXIX Medicaid All recipients not enrolled in any of the above noted population payer programs. Any recipient not identified with Carolina ACCESS, ACCESS II, ACCESS III, or HMO will be assigned the NCXIX population payer code to identify them with the Medicaid fee-for-service program.

Other population payers may be designated by DMA in the future.

Addition of new totals following the current claim total line

An additional line is added following each claim total line of the paid and denied claim sections of the RA for the following claim types: Medical (J), Dental (K), Home Health, Hospice and Personal Care (Q), Medical Vendor (P), Outpatient (M), and Professional Crossover (O). This additional line reflects original claim billed amount, original claim detail count, and total number of financial payers. Upon implementation in February, 2001, N.C. Medicaid will be the only financial payer; these new totals will reflect the submitted claim totals.

These additional totals do not appear for claim types Drug (D), Inpatient (S), Nursing Home (T), and Medicare Crossover (W) since they are not processed at the claim detail level and will not have multiple financial payers assigned, based on current N.C. Medicaid billing policy.

Addition of a new summary page at end of RA

For each Medicaid population payer identified on the paper RA, a new summary page showing total payments by population payer is provided at the end of the RA. This provides population payer detail information for tracking and informational purposes.

New specifications for Tape RA

Updated specifications have been mailed to all Tape RA Providers. If you are currently receiving a Tape RA and have not received the updated specifications, or have questions regarding the changes, please contact Glenda Raynor, Manager of EDS Electronic Commerce Services, at 919-851-8888 extension 5-3099.  

Part II: Adjustment Requests - NEW FORM (Example 2)

The N.C. Medicaid program will begin using a new RA format in February, 2001. This new format affects the way adjustment request forms are completed by the provider and processed by EDS. The appropriate "financial payer" information found on the new RA will be required on all adjustment request forms after February 9, 2001. DMA and EDS have implemented a new adjustment request form to help with these changes. One of the predominant changes is in the "claim number" field. This area is now identified with twenty boxes, each box for one number of the referenced claim number. Until February 9, 2001, there will be five empty boxes at the end of the claim number. After the February 9, 2001 implementation of the MMIS enhancements, these spaces will be used for the financial payer code information. Providers may begin using this new adjustment request form now if it facilitates implementing these changes. (Refer to example of claim field below.) Please contact EDS Provider Services with questions about the new format and processing of an adjustment request.

Claim # field on Adjustment form from RA prior to February 9, 2001:
 
Claim #:
# # # # # # # # # # # # # # #

Claim # field on Adjustment form from RA after February 9, 2001:
 
Claim #:
# # # # # # # # # # # # # # # N C X I X

Part III: Prior Approval (PA)

Effective February 9, 2001, entering the prior approval number on the claim form by the provider to receive payment for services rendered will no longer be required. This holds true for all prior approved Medicaid services, regardless of the entity giving the prior approval.

Prior approval requirements and the criteria for approval of services have not changed. Those services that previously required prior approval before the implementation of the enhanced MMIS will continue to require prior approval. If a service was approved prior to February 9, 2001 but was not provided or billed until after February 9, 2001, the original prior approval is still valid. The MMIS will verify that prior approval was obtained before claims payment can occur. If the services being submitted on the claim form require prior approval, and approval has not been obtained, that claim will be denied. The only change is that the input of the prior approval number is no longer required on the claim form by the provider as of February 9, 2001.

Part IV: Automated Voice Response (AVR) System and Eligibility Verification System (EVS)

These systems will be enhanced with new messages that will explain under which special Medicaid program or programs a recipient is enrolled as a participant. Additional information regarding these system enhancements will be provided in subsequent bulletin articles.

EDS, 1-800-688-6696 or 919-851-8888
 
 


Attention: Health Check Providers (Physicians, Nurse Practitioners, Nurse Midwives, Federally Qualified Health Centers, Rural Health Clinics)
Coverage of Health Check Screenings Performed by Child Health Nurse Screeners - Correction to Initial Rostering Requirements

This article corrects the initial rostering requirements listed in the article titled Coverage of Health Check Screenings Performed by Child Health Nurse Screeners published in the September 2000 Medicaid Bulletin. The requirements are as follows:

ROSTERING REQUIREMENTS

Initial Requirements

To become a Rostered Child Health Nurse Screener, a nurse must:

  1. The North Carolina Child Health Training Program (CHTP) with documented 60 hours minimum of clinical preceptorship.

  2.   OR
  3. Comparable pediatric history and physical examination courses with documented 60 hours of clinical preceptorship, and successful completion of the CHTP Challenge Procedure, which includes written and clinical examinations.
A letter acknowledging the RN's rostered status will be mailed from the Office of Public Health Nursing and Professional Development (OPHNPD) upon successful completion and documentation of the initial requirements. A roster of RNs who qualify as Health Check screeners for purposes of Medicaid reimbursement will be maintained by the OPHNPD. The local employing agencies or providers must maintain documentation of the RN's rostered status and documentation must be made available to the Division of Medical Assistance or its agents upon request.

EDS, 1-800-688-6696 or 919-851-8888


Attention: All Providers
Basic Medicaid Seminars

Basic Medicaid seminars are scheduled for April 2001. The March General Medicaid Bulletin will have the registration form and a list of site locations for the seminars. Please list any issues you would like addressed at the seminars. Return form to:

Provider Services
EDS
P.O. Box 300009
Raleigh, NC 27622


EDS, 1-800-688-6696 or 919-851-8888


Attention: Adult Care Home Providers
Adult Care Home Seminars

Adult Care Home seminars are scheduled for April and May 2001. The March General Medicaid Bulletin will have the registration form and a list of site locations for the seminars. Please list any issues you would like addressed at the seminars. Return form to:

Provider Services
EDS
P.O. Box 300009
Raleigh, NC 27622
EDS, 1-800-688-6696 or 919-851-8888


Checkwrite Schedule
February 6, 2001
March 6, 2001
April 10, 2001
February 13, 2001
March 13, 2001
April 17, 2001
February 22, 2001
March 20, 2001
April 26, 2001
March 29, 2001

 

Electronic Cut-Off Schedule
February 2, 2001
March 2, 2001
April 6, 2001
February 9, 2001
March 9, 2001
April 12, 2001
February 16, 2001
March 16, 2001
April 29, 2001
March 23, 2001


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 Assitance Executive Director
Department of Health and Human Services EDS
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