In This Issue...
All Providers:
Adult Care Home Providers:
Child Service Coordination Providers:
Durable Medical Equipment Providers:
Hosptial Outpatient Departments:
Local Health Departments:
North Carolina Health Choice Providers:
Nursing Facility Providers:
Nurse Practitioners:
Outpatient Behavioral Health Service Providers School Based Health Centers:
Physicians:
Psychiatric Residential Treatment Facilities:
Seminars for Basic Medicaid billing guidelines are scheduled for October 2006. Registration information and a list of dates and site locations for the seminars will be published in the September 2006 general Medicaid bulletin.
EDS, 1-800-688-6696 or 919-851-8888
The following new or amended clinical coverage policies are now available on the Division of Medical Assistance's website:
These policies supersede previously published policies and procedures. Providers may contact EDS at 1-800-688-6696 or 919-851-8888 with billing questions.
Clinical Policy and Programs
DMA,
919-855-4260
First, Medicaid requirements to verify alien status have not changed. An undocumented alien will still be eligible for only emergency services while documented aliens must still provide verification of their alien status.
Effective September 1, most applicants for medical assistance who state they are United States citizens must provide citizenship/identity verification. Exceptions are: current and former SSI recipients and current and former Medicare recipients. Children in the NCHC program, ages 6 to 18, do not have to verify citizenship/identity. Medicaid applicants will not be approved until all eligibility requirements, including proof of citizenship/identity, are provided.
For those currently receiving Medicaid, citizenship and identity must be verified at next redetermination scheduled on or after September 1. This includes the newborn children automatically eligible for Medicaid. If verifications is not provided during redetermination process, the recipient will be recertified and given 3 months to provide proof of citizenship/identity. Children eligible in foster care will be considered recipients and given 3 months to verify citizenship/identity.
If applicant/recipient requests help in obtaining the documents, the county department of social services must help, especially if there is a fee involved.
Many counties have electronic data matches with the local register of deeds to verify births. CMS has said we can allow data matches. The State is currently working with State Vital Records to do an electronic match. However, that won’t be ready by September 1.
Copies of certified birth certificates are acceptable.
Another program’s evidence of citizenship/identity, such as Food Stamps, can be used to verify citizenship/identity for Medicaid.
There is a chart on the DMA website under county links, letters to county directors that gives the hierarchy on how CMS wants states to verify citizenship/identity. CMS will monitor states to ensure the lowest hierarchy is not always used to verify citizenship.
Hospitals or the companies they have hired to take applications must not hold these applications if they wish to pursue verification of citizenship/identity. Several companies now try to manipulate the date of application for the company’s benefit rather than the applicant’s benefit. This violates federal regulations in 42 CFR 435.906 that provides individuals must have the right to apply for medical assistance without delay. While county agencies and the applicants appreciate assistance in pursuing verifications, an applicant’s right to apply without delay must not be impeded. These verifications can be provided at a later date.
Eligibility Unit
DMA, 919-855-4000
Beginning September 1, 2006, the N.C. Medicaid Program will begin collecting the National Provider Identifier(s) (NPI) from currently enrolled Medicaid providers. The N.C. Medicaid NPI form will be published in the September general Medicaid bulletin and will also be available on DMA’s website. The form can be returned by fax or mail to the address listed on the form. Providers must also include with the NPI form a copy of the notification letter from the National Plan and Provider Enumeration System (NPPES).
DMA is pursuing options for e-mail, web-based and electronic batch submission. Details will be provided in future bulletins.
Providers are encouraged to apply for their NPI immediately. Please go to the NPPES website. Please indicate North Carolina as your state name and include your Medicaid provider number(s). Claims submitted after May 23, 2007, will deny without an NPI number.
Remember, applying for an NPI does not replace any enrollment or credentialing processes for N.C. Medicaid.
Provider Services
DMA, 919-855-4050
Effective with date of service November 1, 2006, the N.C. Medicaid program will no longer recognize CPT code 90718 (the old Td vaccine) as a VFC vaccine, nor reimburse for the administration fee (CPT codes 90471, 90472, 90465, or 90466) for this vaccine for VFC recipients through 18 years of age. Effective with date of service November 1, 2006, DMA will no longer recognize CPT 90718 for recipients over 18 years of age nor reimburse for the administration of this vaccine. Providers who report CPT 90718 for VFC recipients or bill for the administration of the vaccine after date of service October 31, 2006, and those who bill for the vaccine and administration fee for recipients over 18 years of age after date of service October 31, 2006, will have those claims denied.
Refer to the December 2005 general Medicaid bulletin for coverage information on DECAVAC (the new Td preservative-free vaccine), CPT code 90714.
EDS, 1-800-688-6696 or 919-851-8888
The list of standard national codes used on the Electronic Remittance Advice (ERA) has been cross-walked to EOB codes as an informational aid to adjudicated claims listed on the Remittance and Status Report (RA). An updated version of the list is available on the Division of Medical Assistance’s HIPAA web page.
With the implementation of standards for electronic transactions mandated by the Health Insurance Portability and Accountability Act (HIPAA), providers now have the option to receive an ERA in addition to the paper version of the RA.
The EOB codes that providers currently receive on a paper RA are not used on the ERA. Because the EOB codes on the paper RA provide a greater level of detail on claim denials, all providers will continue to receive the paper version of the RA, even if they choose to receive the ERA transaction. The list is current as of the date of publication. Providers will be notified of changes to the list through the general Medicaid bulletin.
EDS, 1-800-688-6696 or 919-851-8888
Beginning September 1, 2006, Medicare crossover claims will be reported differently on the HIPAA 835 transaction set, the Unsolicited 277 transaction set and the HIPAA 277 Claim Status Response transaction set for North Carolina Medicaid. It may be necessary for providers to work with their software vendors regarding this change.
Medicare Part B crossover claims are processed in the Medicaid system using a billed amount that is built during claims adjudication. This billed amount consists of the Medicare coinsurance and deductible. Currently, this is the billed amount being reported on the 835 transaction. Providers have had difficulty reconciling their records because this is not the amount they actually billed Medicaid. Claims received and processed for the first checkwrite cycle in September will begin to report the actual billed amount on the claim.
In addition, the Claim Status Indicator (CLP02) will also be modified to reflect if Medicaid processed the claim as primary, secondary, or tertiary on paid claims. These codes are represented in the 835 as follows:
o 1 – Processed as Primary
o 2 – Processed as Secondary
o 3 – Processed as Tertiary
Other Claim Status Indicator codes used will remain unchanged.
Older Medicare crossover claims that adjudicated prior to September 1, 2006, that are being reported as reversed on HIPAA 835 transactions due to an adjustment, or that are being reported on the 277 Claim Status Response transactions, will continue to have their Billed Amount data element set to the NC Medicaid billed amount.
Medicare crossover claims that adjudicate on or after September 1, 2006 can be found using the Original Billed Amount specified in the 276 transaction only if it matches the claims’ Original Billed Amount. Medicare crossover claims that adjudicated prior to September 1, as well as all non-crossover claims, will continue to be found using the Original Billed Amount specified in the 276 transaction only if it matches the NC Medicaid Original Billed Amount.
Please reference the chart below:
Medicare Crossover Claims
|
Prior to September 1, 2006 |
September 1, 2006 and after |
|
|---|---|---|
|
835 Transaction will report |
Medicaid Bill amount |
Medicare Billed Amount |
|
Unsolicited 277 Transaction |
Medicaid Bill Amount |
Medicare Billed Amount |
|
Regular 276/277 using “Amount Billed” as search criteria use |
Medicaid Bill Amount |
Medicare Billed Amount |
|
Paid claims with no TPL, Claim Status Code on 835 will report |
1 = Primary |
2 = Secondary |
|
Paid claims with other TPL, Claim Status Code on 835 will report |
1 = Primary |
3 = Tertiary |
Non – Crossover Claims
|
Prior to September 1, 2006 |
September 1, 2006 and after |
|
|---|---|---|
|
835 Transaction will report |
Medicaid Billed Amount |
Medicaid Billed Amount |
|
Unsolicited 277 Transaction |
Medicaid Billed Amount |
Medicaid Billed Amount |
|
Regular 276/277 using “Amount Billed” as search criteria use |
Medicaid Billed Amount |
Medicaid Billed Amount |
|
Claims with no TPL, Claim Status Code on 835 will report |
1 = Primary |
1 = Primary |
|
Claims with Medicare TPL and/or other TPL, the Claims Status Code on 835 will report |
1 = Primary |
2 = Secondary Or 3 = Tertiary |
EDS, 1-800-688-6696 or 919-851-8888
Session Law 2005- 276 provided for additional Medicaid funding for the care of residents residing in Special Care Units for Persons with Alzheimer’s and Related Disorders (SCU-A) located in Adult Care Homes. Effective with the date of service October 1, 2006, the N.C. Medicaid Program will implement a special care rate for ACH providers Operating Special Care Units for Persons with Alzheimer’s and Related Disorders.
Medicaid will reimburse providers according to the following procedure:
5. Providers send the requested information via US Mail to:
DMA ACH Unit
NC DHHS
Division of
Medical Assistance
Facility and
Community Care Section
1985 Umstead Drive
2501 Mail Service Center
Raleigh, NC 27699-2501
Other important information for ACH Providers to know related to the Prior Approval for SCU-A Payment:
2. Recipients must receive Basic PCS at the same time as SCU-A services.
3. DMA will mail a decision notice to the ACH provider within 15 working days of receipt of prior approval request.
4. DMA will contact fiscal agent and authorize Medicaid reimbursement for days approved.
5. In order to avoid payment processing delays, beginning August 1, 2006, providers may begin to submit the required prior approval information to DMA for residents who currently reside in a SCU-A and are expected to remain until October1, 2006. Upon approval, the new rate will begin effective with date of service October 1, 2006.
Instructions for completing the Adult Care Home SCU-A form:
1. This form is only to be used by Adult Care Homes with Special Care Unit Designations.
2. Print clearly.
3. All copies of items submitted must be legible.
4. The complete facility information is only due once per year- as per schedule or upon facility status change or as otherwise needed.
5. This is a HIPAA requirement: The completed form and information must be sent in a sealed envelope with “confidential” written in red and then placed in another envelope and addressed as in #6 below. DMA will not accept faxed records.
6. Completed form must be sent via US Mail to the following address:
NC DHHS – DMA
ACH Unit
Facility and
Community Care
1985 Umstead Drive
2501 Mail Service Center, Raleigh, NC 27699-2501
7. For questions contact: Nancy Roberts @ 919-855-4116 or Julie Budzinski @ 919-855-4368 or Julie.Budzinski@dhhs.nc.gov.
Clinical Policy and Programs
DMA, 919-855-4116 and /or 919-855-4368
Effective July 1, 2006, the new eligibility definition for the North Carolina infant-toddler program at should be used when determining the appropriateness of a referral to the program. Clinical Coverage Policy #1M-1, Child Service Coordination, has been updated to direct providers to the North Carolina early intervention services webpage for eligibility requirements.
Clinical Policy and Programs
DMA, 919-855-4260
Effective with date of service August 1, 2006, the following codes are added to the capped rental section of the Durable Medical Equipment (DME) Fee Schedule:
|
K0734 |
Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth |
|
K0735 |
Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth |
|
K0736 |
Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any depth |
|
K0737 |
Skin protection and positioning wheelchair seat cushion, adjustable, with 22 inches or greater, any depth |
The codes may be covered if the recipient has a diagnosis or a condition that may cause breakdown of the skin due to immobility and sitting in a wheelchair for long periods of time. The recipient must be wheelchair bound. The codes do not require prior approval, however, medical necessity must be documented on the Certificate of Medical Necessity/Prior Approval (CMN/PA) form The lifetime expectancy for all these codes is 3 years.
For current pricing on these and all DME codes, refer to DMA’s Fee Schedule web page.
For all billings, providers are reminded to bill their usual and customary rates. Do not automatically bill the established maximum reimbursement rate. Payment will be the lesser of the billed usual and customary rate or the maximum reimbursement rate.
EDS, 1-800-688-6696 or 919-851-8888
Effective with dates of service on or after August 1, 2006, rates have been changed for the Durable Medical Equipment (DME) HCPCS code below previously added with an interim rate. Medicare pricing has now become available for this code:
|
E0705 |
TRANSFER BOARD OR DEVICE, ANY TYPE, EACH |
Effective with the same date, other DME rates have changed based on the normal annual review of DME rates.
For current pricing on all DME codes, refer to DMA's Fee Schedule web page.
For all billings, providers are reminded to bill their usual and customary rates. Do not automatically bill the established maximum reimbursement rate. Payment will be the lesser of the billed usual and customary rate or the maximum reimbursement rate.
Rate Setting
DMA, 919-855-4200
Due to the recent notification of changes in the professional fees and code schedule for Medicaid, which became effective July 1, the State Health Plan of North Carolina will be delayed in processing payments for July 2006 dates of service. We apologize for any inconvenience this has caused.
Becky Murray
North Carolina State Health Plan, 919-881-2300
Nursing Facilities that choose to keep resident records electronically must meet the following requirements to facilitate the Minimum Data Set (MDS) Validation Review process:
1. The facility must have an electronic signature policy. The reviewer may
request to see the policy.
2. The facility must have an identified procedure for making corrections
to electronic entries.
3. Computer access to the residents’ information must be available to the
reviewer.
4. Hard copies of documentation are not routinely required; however, the
State reserves the right to request that certain records be printed or produced
at
the time of the review.
5. All Supportive Documentation Guidelines must be followed, including signatures,
initials, and dates.
6. The entire medical record is subject to review.
7. The facility must have written policies in place to ensure the privacy
and integrity of the record.
Clinical Policy and Programs
MDS Validation Review Consultant
DMA, 919-855-4356
Prior to the initial outpatient behavioral health visit, recipients under the age of 21 require a referral by a Carolina Access (CA) Primary Care Provider (PCP), the LME or a Medicaid enrolled psychiatrist. Practitioners who are employed and working for a CA Primary Care Physician or Medicaid enrolled psychiatrist billing under the “incident to” guidelines will not need a referral. Services provided by a physician do not require a referral.
Referrals may be made by telephone, fax or in writing to the mental health provider. The referring provider will give the mental health provider a referral number that must be placed in block 19 of the CMS 1500 claim form in order for the claim to be paid. Failure to put the referral number on the claim when filing will result in denial of payment.
Recipients age 21 and over do not require a referral.
Behavioral Health Services
DMA, 919-855-4290
The N.C. Medicaid program covers cetuximab (Erbitux) for use in the Physician’s Drug Program for the diagnosis of colorectal carcinoma. Recently, the Food and Drug Administration also approved Erbitux for the diagnosis of head and neck carcinoma.
In accordance with the new FDA approved diagnoses for Erbitux, the following ICD-9-CM diagnosis codes are required when billing for Erbitux:
and
1. 153.0 through 154.8
2. 140.0 through 149.9
3. 160.0 through 161.9
4. 195.0
5. 162.0
6. 171.0
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service July 1, 2006, the N.C. Medicaid program covers triptorelin pamoate (Trelstar Depot for injection and Trelstar LA for injection) for use in the Physician’s Drug Program, when billed with HCPCS code J3315. Triptorelin is a synthetic hormone that stops the production of testosterone. It is approved by the FDA for palliative treatment of advanced prostrate cancer. It is an alternative treatment for prostrate cancer when orchiectomy or estrogen replacement administration is either not indicated or not acceptable to the patient. It is available in two forms as described below.
|
Drug name |
HCPCS Code |
Dosage |
Frequency of Administration |
Billing Unit |
|---|---|---|---|---|
|
Trelstar Depot |
J3315 |
3.75 mg |
Monthly |
1 unit |
|
Trelstar LA |
J3315 |
11.25 mg |
Once every 12 weeks (3 months) |
3 units |
Both forms of Trelstar are to be reconstituted with sterile water only and administered as single intramuscular injections. Both forms are also available in the Clip’N’Ject single-dose delivery system use. ICD-9-CM diagnosis code 185, malignant neoplasm of prostate, must be billed with Trelstar Depot or Trelstar LA.
Billing Requirements:
Example
|
21 Diagnosis |
24A Date(s) of Service |
24B Place of Service |
24D Procedures, Services or Supplies |
24F Charges |
24G Units |
|---|---|---|---|---|---|
|
185 |
08212006 |
11 |
J3315 |
$ |
1 Unit |
For Medicaid billing, one unit of coverage is 3.75 mg. The maximum reimbursement rate per unit is $260.23.
EDS, 1-800-688-6696 or 919-851-8888
Effective September 1, 2006, local management entities (LMEs) will begin to endorse Level II (program type) and Levels III and IV psychiatric residential treatment facilities that have one, two, or three beds. As each facility obtains this endorsement, providers should submit an enrollment packet to DMA to obtain a Medicaid provider number. With the Medicaid provider number, providers may begin direct billing.
EDS will offer two workshops in September to train these providers on billing and the authorization process. Registration information will be published in the September general Medicaid bulletin.
Behavioral Health
DMA, 919-855-4290
Information related to the implementation of the new Medicaid Management Information System, NCLeads, can be found online. Please refer to the NCLeads website for information, updates, and contact information related to the NCLeads system.
Provider Relations
Office of MMIS Services
919-647-8315
In accordance with Session Law 2005-276, proposed new or amended Medicaid clinical coverage policies are available for review and comment on DMA's website. To submit a comment related to a policy, refer to the instructions on the website. Providers without Internet access can submit written comments to the address listed below.
Gina Rutherford
Division of Medical Assistance
Clinical Policy Section
2501 Mail Service Center
Raleigh, NC 27699-2501
The initial comment period for each proposed policy is 45 days. An additional 15-day comment period will follow if a proposed policy is revised as a result of the initial comment period.
Month |
Electronic Cut-Off Date |
Checkwrite Date |
|---|---|---|
|
July (d) |
06/30/06 |
07/06/06 |
|
07/07/06 |
07/11/06 |
|
|
07/14/06 |
07/18/06 |
|
|
07/21/06 |
07/27/06 |
|
|
August |
08/04/06 |
08/08/06 |
|
08/11/06 |
08/15/06 |
|
|
08/18/06 |
08/22/06 |
|
|
08/25/06 |
08/30/06 |
|
|
September (e) |
09/01/06 |
09/06/06 |
|
09/08/06 |
09/12/06 |
|
|
09/15/06 |
09/19/06 |
|
|
09/22/06 |
09/28/06 |
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.
| _____________________ | _____________________ | |
|
Mark T. Benton, Senior Deputy Director and Chief Operating Officer |
Cheryll Collier | |
| Division of Medical Assistance | Executive Director | |
| Department of Health and Human Services | EDS |