February 2006 Medicaid Bulletin

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In This Issue...

All Providers:

Ambulatory Surgical Center Providers: 

CAP-MR/DD Service Providers:

Durable Medical Equipment Providers:

Home Health Providers:

Hospitals:

Independent Practioners:

Local Management Entities:

Nursing Facility Providers:

Optical Service Providers:

Pharmacists:

Physicians:

TCM/MR-DD Case Managers:



Attention: All Providers

Basic Medicaid Billing Seminar Schedule

Basic Medicaid Billing seminars are scheduled for March 2006.  Seminars are intended for providers who are new to the NC Medicaid program.  Topics to be discussed will include, but are not limited to, provider enrollment requirements, billing instructions, eligibility issues, and Managed Care.  Providers inexperienced in billing N.C.  Medicaid are encouraged to attend.  There will be a detailed question and answer session for Enhanced Mental Health Benefits providers at the end of these seminars.

The seminars are scheduled at the locations listed below.  Pre-registration is required.  Due to limited seating, registration is limited to two staff members per office.  Unregistered providers will be accommodated if space is available.

Providers may register for the Basic Medicaid Billing seminars by completing and submitting the registration form or by registering online.  Please indicate the session you plan to attend on the registration form.  Seminars begin at 10:00 a.m. and end at 2:00 p.m.  Providers are encouraged to arrive by 9:45 a.m. to complete registration.

Providers must print the PDF version of the Basic Medicaid Billing Guide and bring it to the seminar.

Tuesday, March 7, 2006
 Blue Ridge Community College
 Bo Thomas Auditorium
 College Drive
 Flat Rock, North Carolina

Tuesday, March 14, 2006
Coast Line Convention Center
501 Nutt Street
Wilmington, North Carolina

Wednesday, March 22, 2006
Hilton Greenville
207 SW Greenville Blvd.
Greenville, North Carolina

Monday, March 27, 2006
Jane S. McKimmon Center
1101 Gorman Street
Raleigh, North Carolina

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



Directions to the Basic Medicaid Seminars

Coast Line Convention Center – Wilmington, North Carolina (Tuesday, March 14, 2006)
Take I-40 east to Wilmington.  Take the US 17 exit.  Turn left onto Market Street.  Travel approximately 4 or 5 miles to Water Street.  Turn right onto Water Street.  The Coast Line Inn is located one block from the Hilton on Nutt Street behind the Railroad Museum.

Jane S. McKimmon Center – Raleigh, North Carolina (Monday, March 27, 2006)
Traveling East on I-40
Take exit 295 and turn left onto Gorman Street.  Travel approximately one mile.  The McKimmon Center is located on the right at the corner of Gorman Street and Western Boulevard.

Traveling West on I-40
Take exit 295 and turn right onto Gorman Street.  Travel approximately one mile.  The McKimmon Center is located on the right at the corner of Gorman Street and Western Boulevard.

Hilton Hotel – Greenville, North Carolina ( Wednesday, March 22, 2006)
Take Highway 264 east to Greenville. Turn right onto Allen Road in Greenville. Travel approximately 2 miles. Allen Road becomes Greenville Boulevard/Alternate 264. Follow Greenville Boulevard for 21/2 miles to the Hilton Greenville, which is located on the right.

Blue Ridge Community College, Bo Thomas Auditorium – Flat Rock, North Carolina (Tuesday, March 7, 2006)
Take I-40 to Asheville.  Travel east on I-26 to exit 53, Upward Rd..  Turn right and end of ramp.  At second light, turn right onto S. Allen Drive.  Turn left at sign onto College Drive.  First building on right is the Sink Building.  Bo Thomas Auditorium is on the left side of the Sink Building. 


Attention: All Providers

Clinical Coverage Policies

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


Attention:  All Providers

Correction to the 2006 CPT Code Update

The list of new covered CPT codes that was published in the January 2006 general Medicaid bulletin contained an error.  CPT codes 33598, 92230, and 92235 were inadvertently added to the table.  The correct codes are 36598 (new code), 92330 and 92335 (end-dated codes).

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



Attention:  All Providers

Informed Decisions Beneficiary Centered Enrollment Service

The implementation of the Informed Decisions Beneficiary Centered Enrollment (BCE) project that was announced in the December 2005 General Medicaid bulletin will be delayed.  More information will be published in future bulletin articles.

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


Attention: All Providers

Family Planning Waiver Services

Effective October 1, 2005, the Division of Medical Assistance (DMA) implemented a 5-year demonstration waiver project for Medicaid family planning services.  Eligible recipients are identified by a blue Medicaid identification card with the program class ‘MAFD’ and the following statement “FAMILY PLANNING WAIVER:  RECIPIENT ELIGIBLE FOR LIMITED FAMILY PLANNING SERVICES ONLY”.  Recipients eligible to receive waiver services are not eligible for Medicaid benefits under any other current program. 

The Automated Voice Response (AVR) system has been updated to identify recipients with the program class ‘MAFD’ as Medicaid Family Planning Waiver beneficiaries.  As a result, the AVR system will not provide dental history, an optical confirmation number, or durable medical equipment (DME) prior approval information for recipients covered by the waiver.  Instead, the AVR system will state:  “This recipient is eligible for limited Family Planning Services only.  Dental, DME, and optical services are not covered by the Family Planning Waiver Program.”

For more information, refer to the January 2006 Special Bulletin, Family Planning Waiver “Be Smart”.

Clinical Policy and Programs
DMA, 919-855-4260



Attention: All Providers

Medicare Part D Conference Calls for Providers

The Centers for Medicare and Medicaid Services (CMS) host a weekly conference call for providers.  The calls are scheduled for every Tuesday from 2:00 p.m. to 3:00 p.m. beginning January 3, 2006.  These 60-minute conference calls enable discussions of issues and resolutions involving the Medicare Part D program.  Providers are encouraged to use this time to ask questions and to describe problems so that CMS can continue to improve the Medicare Part D program.

To participate in this weekly conference call, dial the conference phone number 1-800-619-2457 and reference the password “Part D”.

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



Attention: All Providers

North Carolina Behavioral Management Project

The North Carolina Department of Health and Human Services has launched an innovative educational program that strives to improve the quality of care for Medicaid patients with mental illness.

The North Carolina Behavioral Pharmacy Management Project analyzes the prescribing of mental health medications for Medicaid members and identifies prescribing patterns inconsistent with evidence-based guidelines. When needed, physicians will be provided with educational materials and client survey information as well as peer-to-peer consultation.

The project is a collaborative effort that involves the Division of Medical Assistance and the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services and Comprehensive NeuroScience, Inc (CNS). Eli Lilly and Company is providing funding in support of the independent program. The North Carolina Physician’s Advisory Group serves as an advisor to the project.

The process begins with a review by CNS of Medicaid patient pharmacy claims data to identify prescribing and utilization trends for mental health and psychotropic medications. The researchers look at such categories as multiple medication prescribing in the same therapeutic class, prescribing above or below FDA-recommended dosing levels, failure of patients to fill their prescriptions in a timely fashion and patients with two or more physicians prescribing the same medications during the identical time period. Prescriptions that fall within these categories are then compared with best practices guidelines.

Information as to which pharmacy a prescriber’s patient is having their prescriptions filled will be noted on the prescriber’s Patient Detail Report. The pharmacy’s phone number will also be listed. A pharmacy may therefore be contacted by a physician in regards to this project.

The State expects the CNS review of prescribing practices to identify a small group of doctors who regularly fall outside of guidelines. These physicians will receive educational materials promoting adherence to the best practices guidelines. In addition, CNS will continue to monitor physicians for the duration of the program to determine whether prescribing problems improve.

The prescription monitoring program is working in several other states, including Missouri, where an analysis from the program’s first year shows a 98 percent reduction of patients who are prescribed the same mental health medications from multiple doctors; a 64 percent reduction of patients who are on two or more mental health medications of the same type; a 43 percent reduction of children on three or more psychotropic medications; and a 40 percent reduction of patients receiving an unusually high dosage of medication.

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



Attention: Ambulatory Surgical Centers

Covered Codes for Ambulatory Surgical Centers

Effective with date of service January 1, 2006, the following CPT procedure codes were added to the list of covered codes for an ambulatory surgical center.  These codes are covered in addition to the updated list of CPT codes published in the January 2006 general Medicaid bulletin.

CPT Code

Payment Group

 

CPT Code

Payment Group

15001

1

 

43238

2

15836

3

 

44397

1

15839

3

 

45327

1

19296

9

 

45341

1

19298

1

 

45342

1

21120

7

 

45345

1

21125

7

 

45387

1

28108

2

 

45391

2

29873

3

 

45392

2

30220

3

 

46230

1

31545

4

 

46706

1

31546

4

 

46947

3

31603

1

 

52301

3

31636

2

 

57155

2

31637

1

 

57288

5

31638

2

 

58346

2

33212

3

 

58565

4

33213

3

 

62264

1

33233

2

 

64517

2

36475

3

 

64561

3

36476

3

 

64581

3

36478

3

 

64681

2

36479

3

 

65820

1

36834

3

 

66711

2

37500

3

 

67445

5

42415

7

 

67570

4

43237

2

 

67912

3

Effective December 31, 2005, the following codes were deleted from the list of covered codes for an ambulatory surgery center.  Claims submitted with these deleted codes for dates of service January 1, 2006 and after will deny.

21440

23600

23620

69725

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



Attention: CAP-MR/DD Providers, Local Management Entities, Targeted Case Managers for MR/DD

Billing Update and Clarification for CAP-MR/DD Services

With the implementation of the new CAP-MR/DD 1915 (c) waiver on September 1, 2005, questions have arisen about billing, service orders, and Medicaid payments.

This article addresses those questions.

1.  CAP-MR/DD consumers residing in a licensed community residential setting, foster home, alternative family living home or unlicensed alternative family living home that serves one adult may receive the Community Component of Home and Community Supports

The community component of Home and Community Supports does not replace the Residential Support provider’s responsibility to provide support to individuals in their home and community, but is intended to support those who choose to engage in community activities that are not provided through a licensed day program.

Providers billing for H2015 and H2015HQ in conjunction with Residential Supports will not be reimbursed on the same day of service that a consumer receives Day Supports, code T2021.

Case Managers and local approvers are responsible for incorporating the correct use of these services into the Plan of Care for their consumers receiving Residential Supports.

2.  Providers of Residential Supports:  H2016, T2014, T2020, and H2016HI, (which are daily rates), can bill and be reimbursed for the Community Component of Home and Community Supports, H2015 and H2015HQ.  All claim restrictions have been modified for the new waiver retroactively to September 1, 2005.  Payment is allowed for either the same provider or two different providers of these services billing on the same day of service.

Note:  For consumers residing in a Residential setting, the use of the Community

Supports service is limited to a maximum of 6 hours (24 units) a day.

All providers who have unpaid claims due to the system not paying Residential Supports on the same day of service as Home and Community Supports may resubmit claims for payment.  These codes are as follows:

Residential Supports Level I

H2016

$102.33/day

Residential Supports Level 2

T2014

$125.45/day

Residential Supports Level 3

T2020

$145.17/day

Residential Supports Level 4

H2016HI

$175.35/day

Home and Community Supports – Individual

H2015

$5.65/15 minute

Home and Community Supports – Group

H2015HQ

$3.15/15 minute


3.  Providers of Day Support in an unlicensed facility are authorized to bill for their services using codes  H2015 and H2015HQ until August 31, 2006 when they are required to be fully  licensed.  Settings that have not received their license as of August 31, 2006 will no longer be reimbursed for these services.

4.  The 24 units (6 hours) of Community Services under the codes H2015 and H2015HQ will decrease to 16 units (4 hours) effective DOS  (Day of Service) September 1, 2006. 

Questions may be addressed to the Behavioral Health Section of Clinical Policy Division, Division of Medical Assistance.

Behavioral Health Section
DMA, 919-855-4290


Attention:  Durable Medical Equipment Providers

Fee Schedule Changes for Interim Rates and Other Rate Changes

Effective February 1, 2006, rates have been changed for some Durable Medical Equipment (DME) codes previously added with interim rates.  Medicare pricing has now become available for the HCPCS codes below:

A4233

Replacement battery, alkaline (other than j cell), for use with medically necessary home glucose monitor woned by patient, each

A4234

Replacement battery, alkaline, j cell, for use with medially necessary home glucose monitor owned by patient, each

A4235

Replacement battery, lithium, for use with medically necessary home glucose monitor owned by patient, each

A4236

Replacement battery, silver oxide, for use with medically necessary home glucose monitor woned by patient

E0911

Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar

E0912

Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, free standing, complete with grab bar

E2222

Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, each

E2223

Manual wheelchair accessory, valve, any type, replacement only, each

E2225

Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each

E2226

Manual wheelchair accessory, caster fork, any size, replacement only, each

E2371

Power wheelchair accessory, group 27 sealed lead acid battery, (e.g.gel cell, absorbed glassmat), each

K0601

Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt

K0602

Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt

K0603

Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt

K0604

Replacement battery for external infusion pump ownen by patient, lithium, 3.6 volt

K0605

Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt

In addition, fees for the following HCPCS codes were changed to the Medicare reimbursement rate:

A4614

Peak expiratory flow rate meter , hand-held  

A7006

Administration set, with small volume filtered pneumatic nebulizer

E0277

Powered pressure-reducing air mattress

E0424

Stationary compressed gaseous oxygen system, rental; includes contents (per unit), regulator, flowmeter, humidifier, nebulizer, cannula or mask and tubing. 1 unit = 50 cu. ft.

E0431

Portable gaseous oxygen system, rental; includes regulator, flowmeter,  humidifier, cannula or mask and tubing

E0434

Portable liquid oxygen system, rental; includes portable container, supply  reservoir, humidifier, flowmeter, refill adapter, contents gauge, cannula  or mask and tubing

E0439

Stationary liquid oxygen system, rental; includes use of reservoir, contents (per unit), regulator, flowmeter, humidifier, nebulizer, cannula or mask and tubing. 1 unit = 10lbs

E0561

Humidifier, non-heated, used with postive airway pressure device

E0562

Humidifier, heated, used with positive airway pressure device

E0570

Nebulizer, with compressor

E0691

Ultraviolet light  therapy system panel, includes bulbs/lamps, timer and eye protection, treatment area two square feet or less

E0951

Heel loop/holder,  any type, with or without ankle strap, each

E0961

Manual wheelchair accessory, wheel lock brake extension (handle), each

E0967

Manual wheelchair accessory, hand rim with projections, any type, replacement only, each

E0974

Manual wheelchair accessory, anti-rollback device, each

E0981

Wheelchair accessory, seat upholstery, replacement only

E0982

Wheelchair accessory, back upholstery, replacement only

E1390

Oxygen concentrator, capable of delivering 85 percent or greater oxygen concentration at the the prescribed rate

K0552

supplies for external infusion pump, syringe type cartridge, steril

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.

Rate Setting
DMA, 919-855-4200



Attention: Durable Medical Equipment Providers

Procedural Change for Durable Medical Equipment Denials

Effective January 1, 2006, denied prior approval requests for durable medical equipment may not be resubmitted to EDS for reconsideration.  When prior approval requests are denied, documentation regarding the denial and appropriate appeal procedures will be sent to the provider and the recipient.  Please see the January 2006 Special Bulletin Prior Approval Process and Request for Non-Covered Services for details.  Clinical coverage policy 5A “Durable Medical Equipment” has been updated to reflect this change in procedure.  This policy can be found on DMA’s website.

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


Attention:  Head Start/Local Education Agencies, Home Health Providers, Independent Practitioner Providers, Local Health Departments, Local Management Entities, and Physicians

Systematic Reprocessing of Specialized Therapy Adjustments

Specialized therapy claims that have been paid or denied incorrectly will be systematically identified and adjusted. System generated adjustments are currently scheduled for the month of February or March, but please continue to check your bulletins and remittance and status report (RA) for detailed information. Providers will initially see the system generated adjustment in a pending status located in the section of the RA titled “Claims in Process”. Once the system generated adjustments are completed they will appear in the Adjusted Claims” as well as the “Financial Items” sections of the RA.

Please advised that if you do not have enough revenue to cover any outstanding monies owed to North Carolina Medicaid, the transfer of adjustment balances will apply. Transfer of adjustments or other Medicaid recovery balances will be initiated from an inactive provider (no claims payment) to an active provider (claims payment) when it has been determined that both providers are operating under the same tax entity; thus, the same tax identification number. This will ensure North Carolina Medicaid’s timely recovery of monies due to the program. For additional information about transfer of adjustment balances, please refer to Medicaid Program Implements Penalties and Interest Assessments, Special Bulletin V, October 1999.

If you are currently an inactive provider or do not have recent claim activity, action should be taken to pay off all balances due within 30 days. Providers should refund the monies due to North Carolina Medicaid after receiving the remittance and status report with the outstanding balance.

If effort to eliminate the adjusting of claims already identified for systematic processing, all specialized therapy adjustments and replacement claims submitted by providers will be denied until the system adjustments have been completed. If you have submitted an adjustment request or replacement claim for a specialized therapy service that has been identified for systematic adjustment it will be denied with EOB 2046 that states: “Adj request denied. Adj/replacement claims for specialized therapy services will be adjusted systematically.”

When you receive your RA, please review it for the adjusted specialized therapy claims to determine if your intial adjustment request has been addressed. If so, no further action is required. Once the systematic adjustments have been completed, the denials of manual adjustments will no longer be in effect.

Any questions about the system generated adjustments should be directed to 1-800-688-6696 ext 53120.

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



Attention:  Hospitals

Acute Admission versus Behavioral Health Admission

If a hospital submits an acute hospital admission with a behavioral health diagnosis, the claim will deny with EOB 213 (No Prior Approval on File.  Contact Value Options at 1-888-510-1150 for Confirmation).  If the recipient was in a medical bed and it was truly NOT a behavioral health admission, hospital providers must submit the claim directly to the Division of Medical Assistance.  Providers should submit a copy of the claim with the history and physical along with the discharge summary.  Claims and attachments should be mailed to the:

Division of Medical Assistance

Clinical Policy and Programs, Behavioral Health Section

2501 Mail Service Center

Raleigh, NC 27699-2501

In addition, providers may elect to send this information electronically via ProviderLink. For questions or information regarding ProviderLink, please contact 919-465-1855 or visit their website at http://www.providerlink.com/.

A review of the medical records attached will be conducted, if the admission was determined to be a behavioral admission and prior approval should have been obtained from ValueOptions; a non-certification letter with a provider appeal form describing the appeals process will be enclosed and mailed to the facility.

If the admission was determined to be a medical admission, an override of the denial will be sent to EDS for claims payment.

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



Attention:  Hospitals

Systematic Recoupments for DRG 521-523

DMA has been coordinating with the N.C. Hospital Association (NCHA) to resolve overpayments involving reimbursement of DRG 521-523 for dates of service and RA dates from October 1, 2001 to April 30, 2002.  Overpayments occurred because claims were priced utilizing a DRG rather than correctly pricing with a per diem.  Claims processed during this timeframe for DRG 521-523 which were incorrectly priced or denied will be identified and correcting adjustments will be made.  Claims will be reprocessed beginning with the March 14, 2006 checkwrite.

Providers will receive a written report identifying claims that were overpaid by Medicaid. The report will note the individual accounts involved and quantify amounts owed to Medicaid.  Providers must respond to EDS by March 1, 2006, and need to include either an electronic or paper copy of the enclosed report as well as a check for amounts owed Medicaid.  If a provider disagrees, the provider must submit a letter asserting that no money is owed to Medicaid.  The contents of this letter are specified below.  If providers do not notify Medicaid by the due date, EDS will recoup amounts owed to Medicaid occur on the accounts to reduce the original payment by the overpayment.

Please note that refund amounts should be quantified by each ICN.  When sending a refund, providers do not need to file adjustments.  Letters indicating that no money is owed to Medicaid must include the facility name, provider number, contact name, telephone number, and a signed statement indicating that your facility was not overpaid.  Providers should also submit documentation or substantiate their facility was not overpaid.

Any questions about the report or reporting requirements should be directed to Brenda Bradfield at 1-800-688-6696 or 919-851-8888.

Reports and letters should be mailed to:

EDS
Attn: James Greene/DRG 521-523 Refunds
PO Box 300011
Raleigh, NC 27622

Requests for exceptions must be sent in writing to:

Division of Medical Assistance
Finance Management
Attn:  Tom Galligan
2501 Mail Service Center
Raleigh, NC 27699-2501

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



Attention: Nursing Facilities and Pharmacists

Medicare Part D - Long-Term Care Fax System

In addition to using the web-based Prescription Plan Finder tool at http://www.medicare.gov/ for individual resident inquiries, nursing facilities without Internet access or those who need Medicare prescription drug plan enrollment information for multiple residents can now do so via a special fax-based procedure from the Centers for Medicare and Medicaid Services (CMS). 

Nursing facilities can provide the required authentication information for each of their Medicare residents by fax to Medicare at 1-785-830-2593.  The information should be indicated on a fax cver sheet (see sample) along with the name and phone number of a voice contact at the nursing facility. 

Nursing Facility Actions and Instructions:  

  1. Information should be for multiple beneficiaries and all the names may be included on a single request form.
  2. Nursing facility representatives will supply the required authentication information for each patient they are requesting information on to 1-800-MEDICARE via fax.  The required authentication information includes:
  1. Use a fax cover sheet to transmit the required information.  CMS will fax back your fax cover sheet with the patient Medicare prescription drug plan enrollment information.  A sample fax cover sheet is provided.
  2. The fax cover sheet must contain the following attestation statement signed by a nursing facility representative:

I attest that the Medicare prescription drug plan enrollment information to be provided by CMS about patients on the attached list will be used by the nursing home only for Medicare prescription drug coverage purposes.

  1. The fax cover sheet must also contain the following: 

   6.  Use the following safeguards when faxing to CMS’ secure site:

Do NOT put individually identifiable or sensitive information on the fax cover sheet. 

Medicare Customer Service Representative Actions:

1.      Medicare Customer Service Representatives (CSRs) will process the requests and fax them back to the nursing facility within three business days.

2.      Due to privacy concerns, information faxed back to nursing facilities will include only the first initial, last name, and prescription drug plan enrollment information for each beneficiary.

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

CMS Medicare Prescription Drug Plan Enrollment Information Request Fax Cover Sheet



Attention: Optical Providers

CPT Code Changes for Dispensing Low Vision Aids

In order to comply with the Centers for Medicare and Medicaid Services (CMS) CPT code changes, CPT code 92392 was end-dated on December 31, 2005 and replaced with V2797 effective with date of service January 1, 2006.  Claims submitted with end-dated codes will deny.

Discontinued  Procedure Code

Description

New Procedure Code

Description

92392

Supply of low vision aids

V2797

Vision supply, accessory and/or service component of another HCPCS vision code.

The new code, V2797 must be billed with procedure codes V2600, V2610, or V2615 on the same date of service with the same billing provider.  Claims that are submitted without the secondary code will deny.  Denied claims may be corrected and resubmitted as a new claim.

The rate for the new code remains the same as the rate of the discontinued code.

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


Attention: Pharmacists

Administrative Update for Synagis Claims Processing

The following information clarifies the current administrative process for Synagis claims processing: 

The N.C. Medicaid program should not be billed for Synagis claims unless there is an accurate and complete 2005-2006 Synagis criteria form on file in the pharmacy or a Synagis Medical Review Outside of Criteria form for season 2005-2006 that has been reviewed and approved by DMA on file in the pharmacy.  Payment of Synagis claims for dates of service prior to October 10, 2005 and after March 15, 2006 will not be allowed and will be subject to recoupment by Program Integrity. 

Claims for Synagis doses that include multiple vial strengths must be submitted as a single compound drug claim. Synagis doses that require multiple vial strengths that are submitted as individual claims will be subject to recoupment by Program Integrity.

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



Attention: Pharmacists

CMS Process to Ensure Effective Transition to Medicare Part D Prescription Drug Coverage

In spite of efforts to identify and auto-enroll dually eligible individuals prior to the effective date of their Medicare Part D eligibility, it is possible that some individuals may show up at pharmacies before they have been auto-enrolled.  For this reason, the Centers for Medicare and Medicaid Services (CMS) have developed a process for a point-of-sale (POS) solution to ensure full dual eligible individuals experience no coverage gap.  When beneficiaries present at a pharmacy with evidence of both Medicaid and Medicare eligibility, but without current enrollment in a Part D plan, they can have the claim for their medication submitted to a single account for payment.  The beneficiary can leave the pharmacy with a prescription, and a CMS contractor will immediately follow up to validate eligibility and facilitate enrollment into a Part D plan.

In order for this process to operate effectively, there must be a uniform and straightforward set of instructions that all pharmacists can follow no matter which prescription drug plan (PDP) networks they are in or where they are located in the country. This requires a single account administered by one payer. In addition, a national plan that offers a basic plan for a premium at or below the regional low-income premium subsidy amount in every PDP region will be able to both process the initial prescription (generally at in-network rates) and enroll the beneficiary within a matter of days, thus eliminating any gap in coverage. Therefore, CMS has contracted with Wellpoint, an approved national PDP, to manage a single national account for payment of prescription drug claims for the very limited number of dually eligible beneficiaries who have not yet been auto-enrolled into a Part D plan at the time they present a prescription to a pharmacy.

Details on the four step POS facilitated enrollment process are provided below:

  1. Request the beneficiary’s Medicare Part D Plan Identification (ID) card.
    Beneficiaries may have a plan enrollment “acknowledgement letter” that should contain the BIN, PCN, GROUP, and Member ID information.  If the beneficiary has no proof of enrollment, their plan’s billing information may be available through the new E1 query.  If none of these sources of information are available and the beneficiary is dually eligible for Medicare and Medicaid, the POS facilitated enrollment process will allow the beneficiary’s prescription to be filled.
  1. Submit an E1 transaction to the Troop Facilitator.  This ensures that the beneficiary has not already been assigned to a PDP. If the E1 transaction returns a valid BIN/PCN indicating the beneficiary has been enrolled with a PDP or Medicare Advantage Prescription Drug Plan (MA-PD), the pharmacist may not submit the claim under the POS facilitated enrollment. (If the E1 returns a help desk phone number, this means that the beneficiary has been enrolled in a PDP but the billing data is still in process.)
  1. Identify a “Dually Eligible” beneficiary.  The first step is to request the beneficiary’s  Medicare and Medicaid identification cards.  If the beneficiary cannot provide clear evidence of enrollment in both programs, the claim should not be processed under the POS facilitated enrollment process.  Please see the options below that are available to verify a beneficiary’s dual eligibility.

            To verify Medicaid eligibility:  Any of the following can be used to verify Medicaid eligibility:

In addition to these options to verify Medicaid eligibility, the North Carolina Automated Voice Response System (AVRS) is readily accessible twenty-four hours each day at 1-800-723-4337 except for 1:00 a.m.-5:00 a.m. on the first, second, fourth and fifth Sunday and 1:00 a.m.-7:00 a.m. on the third Sunday. Additional information on the N.C. AVRS.

To verify Medicare eligibility:  Any of the following can be used to verify Medicare eligibility:

  1. Bill the POS Contractor.  There is no need to call WellPoint to confirm enrollment as no enrollment pre-exists the claim submission.  There are no edits for non-formulary, prior authorization or step therapy drugs.  However, drugs excluded from Medicare or Part D coverage will not be paid for.

Make sure an E1 query has first been submitted to rule out evidence of enrollment in a Part D plan before billing Wellpoint. Enter the claim into the pharmacy claims system in accordance with the Wellpoint payer sheet. This payer sheet is available at:  http://www.anthem.com/jsp/antiphona/apm/nav/ilink_pop_native.do?content_id=PW_A081085

It is important that the payer sheet is carefully reviewed so that claims are submitted in the required format. It is critical that both the Medicaid ID number and the Medicare ID number (HICN) are submitted to validate the beneficiary’s “dual eligible” status.  Submission of claims without both of these numbers will be considered invalid.

If there are problems with these submission requirements, another option is available until the pharmacy provider’s software vendor can support these requirements.  For systems that do not currently support two beneficiary numbers, the following alternative requirements may be used:

Beneficiary Coverage:

The days supply is limited to fourteen days.  This will allow for an appropriate opportunity for beneficiaries to be enrolled in a PDP.

For Further Assistance with the POS Facilitated Enrollment Process:

        Pharmacy Help Desk:  (800)-662-0210
        Hours of Operation:  Monday - Friday, 8:30 a.m.-12:00 a.m.
        Saturday and Sunday, 9:00 a.m.-7:00 p.m.

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


Attention: Pharmacists

Denial on Medicaid Covered Excluded Drugs

Pharmacy providers receiving a denial on a Medicaid covered excluded drug for a Medicaid eligible recipient after the Medicare Part D prescription drug program begins on January 1, 2006 may contact the EDS pharmacy unit to check for coverage status of the drug.

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



Attention: Pharmacists

Medicare Part D Prescription Drug Plans and Temporary First Fill Policies

Medicare Part D prescription drug plans are required to establish a transition process for Medicare/Medicaid full-benefit, dually eligible enrollees who are transitioning from other prescription drug coverage.  This transition process includes filling of a temporary one-time transition supply for a prescription drug that is not on the formulary of the Medicare Part D drug plan in which the beneficiary is enrolled.  This accommodates the immediate need of the beneficiary and allows the beneficiary and the drug plan to work out with the prescriber an appropriate alternative medication or completion of an exception request to maintain coverage. 

Temporary first fill policies can vary from plan to plan based on the drug in question, the unique needs of an individual or an individual’s setting (e.g., a long term care setting).

The following information includes temporary first fill policies for Medicare Part D prescription drug plans available in North Carolina:

Organization

Formulary

 ID #

New Enrollee General Transition Day Supply (First Fill)

New Enrollee Long Term Care Transition Day Supply (First Fill)

SilverScript

619

30 days

90 days

Blue Cross Blue Shield of North Carolina

786

30 days

90-180 days

Blue Cross Blue Shield of North Carolina

787

30 days

90-180 days

SilverScript

897

30 days

90 days

Cigna Healthcare

1241

Utilization management clinical edits lifted during the 30-day transition period

Utilization management clinical edits lifted during the 90-day transition period

Pennsylvania Life Insurance Company

1446

60 days

60 days

RxAmerica

1479

30 days

30 days initially. Based on exceptions process outcome, may extend up to 90-180 days

RxAmerica

1644

30 days

30 days initially. Based on exceptions process outcome, may extend up to 90-180 days

Humana, Inc.

1863

30 days

Up to 90 days

WellCare

2003

30 days

90 days

WellCare

2129

30 days

90 days

Unicare

2493

90 days

90 days

Unicare

2546

90 days

90 days

WellCare

2629

30 days

90 days

PacifiCare Life and Health Insurance Company

2654

30 days

30 days initially, but may be extended up to 90 days if stabilized on multiple non-formulary medications

PacifiCare Life and Health Insurance Company

2656

30 days

30 days initially, but may be extended up to 90 days if stabilized on multiple non-formulary medications

Aetna Medicare

2662

Up to 30 day supply for all Part D medications and for select drugs, 1 plan year

90-180 days for all Part D medications or 1 plan year coverage

Aetna Medicare

2681

Up to 30 day supply for all Part D medications and for select drugs, 1 plan year

90-180 days for all Part D medications or 1 plan year coverage

Coventry AdvantraRx

2759

30 days

Up to 90 days

Coventry AdvantraRx

2764

30 days

Up to 90 days

Coventry AdvantraRx

2766

30 days

Up to 90 days

Medco Health Solutions, Inc.

3164

30 days

Up to 90 days

Sterling Prescription Drug Plan

3245

30 days

90 days

United American Insurance Company

3296

30 days

90 days

MemberHealth

3422

30 days

90-180 days

United Healthcare

3440

30 days

Up to 90 days

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


Attention: Physicians

HCPCS Code Changes for the Physician’s Drug Program

Due to recent information from the Centers for Medicare and Medicaid Services (CMS), HCPCS codes J7317 and J7320 will not be end dated effective with date of service December 31, 2005. HCPCS code J7318 will not be covered effective with date of service January 1, 2006.

This information supercedes the information published in the January 2006 general Medicaid bulletin article titled HCPCS Changes for the Physician’s Drug Program.

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


NCLeads Update

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


Proposed Clinical Coverage Policies

In accordance with Session Law 2003-284, 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.


2006 Checkwrite Schedule

Month

Electronic Cut-Off Date

Checkwrite Date

February

02/03/06

02/07/06

 

02/10/06

02/14/06

 

02/17/06

02/23/06

March

03/03/06

03/07/06

 

03/10/06

03/14/06

 

03/17/06

03/21/06

 

03/24/06

03/30/06

April

040/7/06

0411/06

 

04/13/06

04/18/06

 

04/21/06

04/27/06

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

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