In This Issue...................................

All Providers:

Basic Medicaid Billing Seminar Schedule

Checkwrite Schedule

Clinical Coverage Policies

Correction to the 2006 CPT Code Update

Directions to the Basic Medicaid Seminar

Informed Decisions Beneficiary Centered Enrollment Service

Family Planning Waiver Services

Medicare Part D Conference Calls for Providers

North Carolina Behavioral Pharmacy Management Project

 

Ambulatory Surgical Center Providers: 

Covered Codes for Ambulatory Surgical Centers

 

CAP-MR/DD Service Providers:

Billing Update and Clarification for CAP-MR/DD Services

 

Durable Medical Equipment Providers:

Fee Schedule Changes for Interim Rates and Other Rate Changes

Procedural Change for Durable Medical Equipment Denials

 

Home Health Providers:

Systematic Reprocessing of Specialized Therapy Adjustments

 

Hospitals:

Acute Admission versus Behavioral Health Admission

Systematic Recoupments for DRG 521-523

 

Independent Practioners:

Systematic Reprocessing of Specialized Therapy Adjustments

 

Local Management Entities:

Billing Update and Clarification for CAP-MR/DD Services

 

Nursing Facility Providers:

Medicare Part D - Long Term Care Fax  System

 

Optical Service Providers:

CPT Code Changes for Dispensing Low Vision Aids

 

Pharmacists:

Administrative Update for Synagis Claims Processing

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

Denial on Medicaid Covered Excluded Drugs

Medicare Part D Long Term Care Fax System

Medicare Part D Prescription Drug Plans and Temporary First Fill Policies

 

Physicians:

HCPCS Code Changes for the Physician’s Drug Program

Systematic Reprocessing of Specialized Therapy Adjustments

 

TCM/MR-DD Case Managers:

Billing Update and Clarification for CAP-MR/DD Services

 

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 from DMA’s website at http://www.dhhs.state.nc.us/dma/medbillcaguide.htm and bring it to the seminar.

 

 

 

 

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

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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. 

 

 

 

 

Basic Medicaid Seminar Registration Form

 

 

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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 at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm:

 

5A – Durable Medical Equipment

9 – Outpatient Pharmacy Program

11B-1 – Lung Transplantation

 

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

 

 

 

 

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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

 

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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

 

 

 

 

 

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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

 

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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

 

 

 

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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

 

 

 

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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.

 

  

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.

 

 

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

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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:

 

 

 

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: