March 2001 NC Mediciad Bulletin title image

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In This Issue

All Providers:

Adult Care Home Providers:

Ambulance Providers:

Carolina ACCESS Primary Care Providers:

Community Alternatives Program Providers:

Dental Providers:

Durable Medical Equipment Providers:

Hospice Providers:

Hospitals:

Labs:

Nursing Facilities:

Personal Care Providers:

Providers Serving Gaston County Medicaid Recipients:

Psychiatric Providers:

Ventilator Long-term Care Providers:


 

Attention: Community Alternatives Program Providers
Community Alternatives Program Services Reimbursement Rate Increase

Effective with date of service January 1, 2001, the maximum allowable rate for the following Community Alternatives Program (CAP) services increased. Providers must bill their usual and customary charges.
 
Procedure 
Code
Description Maximum Reimbursement Rate
W8111 CAP-MR/DD Personal Care $3.36/15-minute unit
W8116 CAP/DA Respite Care In-Home $3.36/15-minute unit
W8119 CAP-MR/DD Respite Care Community Based $3.36/15-minute unit
W8141 CAP/DA In-Home Aide Level II $3.36/15-minute unit
W8142 CAP/DA In-Home Aide Level III-Personal Care $3.36/15-minute unit
W8143 CAP/C Personal Care $3.36/15-minute unit
W8144 CAP-MR/DD In-Home Aide Level I $3.36/15-minute unit
W8145 CAP/C Respite Care In-Home  $3.36/15-minute unit
W8167 CAP/AIDS Respite Care In-Home Aide Level $3.36/15-minute unit
W8172 CAP/AIDS In-Home Aide II $3.36/15-minute unit
W8173 CAP/AIDS In-Home Aide III-Personal Care $3.36/15-minute unit

Adjustments will not be made for claims already processed. Contact the EDS Provider Services Unit for detailed billing instructions.
 

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


Attention: Dental Providers
Dental Reimbursement Rate Increase

Effective with date of service January 1, 2001, dental reimbursement rates increased by 1.5 percent. Providers are expected to bill their usual and customary rate. The Division of Medical Assistance considers the billed amount in their rate setting efforts. New fee schedules are available upon request. Refer to Fee Schedules and Reimbursement Plans for information on requesting a new fee schedule.
 

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


Attention: Ventilator Long-term Care Providers
Authorized Persons to Sign Ventilator Addendum Form

Prior approval request forms for ventilator level of care require a ventilator addendum form. Effective January 1, 2001, all ventilator addendum forms must be signed and dated by the attending physician. All FL2s with ventilator addendum forms received by EDS without a physician’s signature and handwritten date will be returned to the county department of social services.
 

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


Attention: Ventilator Long-term Care Providers
Time Constraints for Provider Notification of Ventilator Prior Approval

When a ventilator level of care authorization is initially obtained for a recipient during a hospital stay, and the recipient later transfers to long-term care services, the receiving facility is required to notify EDS no later than 30 days from the day of admission. If notification to EDS is beyond 30 days, a new level of care review will be required.
 

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


Attention: Durable Medical Equipment Providers
Additions of Batteries and Calibration Solution/Chips for Blood Glucose Monitors to the Durable Medical Equipment Fee Schedule

Effective with date of service March 1, 2001, the following items will be added to the Durable Medical Equipment (DME) Related Supplies category of the DME Fee Schedule:
 
HCPCS Code Description Maximum Purchase Rate Limitations
A4254 replacement battery, for use with any medically necessary home blood glucose monitor owned by the patient, each $6.30 8 per year
A4256 normal, low, and high calibrator solution/chips $10.95 4 per year

Providers are reminded to bill their usual and customary rates. As with all DME, providers must maintain a physician’s prescription and a completed Certificate of Medical Necessity and Prior Approval form in their records.
 

Melody B. Yeargan, P.T., Medical Policy Section
DMA, 919-857-4020


Attention: Psychiatric Residential Treatment Facility and Residential Services Providers
Billing Reminders for Psychiatric Residential Treatment Facility and Residential Services

Psychiatric Residential Treatment Facility (PRTF) services are billed on a UB-92 claim form using bill type 891, revenue code 911, with one (1) unit per day.  The Area Program will complete the certificate of need (CON).  Prior authorizations and concurrent reviews will be performed by First Health of Tennessee (FH).  After the CON is completed and forwarded to FH, the provider is responsible for obtaining the authorizations.

Levels II - IV Residential services, submit your claims on a UB-92 using bill type 841, with the following procedure codes:

Level II - Enter revenue code 902 in form locator 42. Enter Y2346 in form locator 44. The Area Program will give prior authorization for the first 120 days; the provider must then obtain any additional authorization/extension from Value Options.

Level III - Enter revenue code 902 in form locator 42. Enter Y2345 in form locator 44. The Area Program will prior authorize the first 120 days; the provider must then obtain any additional authorization/extension of stay from Value Options.

Level IV - Enter revenue code 902 in form locator 42. Enter Y2344 in form locator 44. The Area Program will authorize services for the first 30 days; the provider must obtain approval from Value Options for any additional days.

Level II - IV services will enter only one (1) unit per day.

Note: Until further notice, all claims must be submitted on paper. At this time, EDS is unable to accept claims submitted electronically from PRTF services.
 

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


Attention: All Labs
Lab Reimbursement Rates

Effective with date of service January 1, 2001, lab rates were modified. A 1.5-percent increase has been implemented not to exceed the national Medicare cap for most lab services. However, a rate decrease has been implemented for lab codes in which the current rate exceeded the 2001 national Medicare cap. Providers are expected to bill their usual and customary rate. New fee schedules are available upon request. Refer to Fee Schedules and Reimbursement Plans for information on requesting a new fee schedule.
 

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


Attention: Nursing Facilities, Adult Care Homes, Ambulance Providers, and Hospitals
Non-emergency Transportation by Nursing Facilities and Adult Care Homes

This article clarifies the responsibility that nursing facilities and adult care homes have when a Medicaid recipient requires medically necessary non-emergency transportation. This situation may arise, for example, when a Medicaid recipient needs to be transported to a physician’s office or from an emergency department back to the facility.

According to the North Carolina Medicaid State Plan, since October 1, 1994, nursing facilities have been responsible for medically necessary non-emergency transportation for residents, unless ambulance transport is required. The cost of this service is reimbursed under the facility’s direct rate, as written in the State Plan, Section 4.19 (d), Attachment 4.19-D .0102 (I):

"Effective October 1, 1994, nursing facilities are responsible for providing medically necessary transportation for residents, unless ambulance transportation is needed. The cost of this service shall be included with the facility’s direct cost and therefore reimbursed under the facility’s direct rate. Effective October 1, 1994, each facility’s direct rate shall be increased for the estimated cost of this service. These costs shall be cost settled like all other direct care costs."

This directive was most recently published for the nursing facility provider community in the N.C. Medicaid Nursing Facility Manual issued June 1, 2000.

Adult care homes are responsible for assuring that residents are transported to necessary resources and activities, including transportation to the nearest appropriate health facilities, according to the licensure rules by which the home is licensed. These facilities are also reimbursed for this service under the adult care home transportation rate by the N.C. Medicaid program.
 

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


Attention: Nursing Facility Providers
Physician Signature Dates on the Long-term Care Prior Approval Forms

Prior approval request forms require the physician’s signature date to be handwritten by the physician. All prior approval request forms with typed physician’s signature dates received by EDS will be returned to the county department of social services.
 

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


Attention: Durable Medical Equipment Providers
Coverage of Sterile and Non-sterile Gloves

This article is being published in order to clarify North Carolina Medicaid’s policy on coverage of sterile and non-sterile gloves for payment to Durable Medical Equipment (DME) providers.

Both sterile and non-sterile gloves must be ordered by the patient’s physician, who must specify on the Certificate of Medical Necessity and Prior Approval form when and how the gloves are to be used. Gloves may only be billed by DME providers when the patient owns the equipment with which the gloves are to be used. For example, gloves may be medically necessary for a patient who owns a suction machine. However, if Medicaid is paying monthly rental fees for the suction machine, the provider may not bill Medicaid for the gloves for use with that machine. DME providers may not bill for gloves for use during dressing changes, patient grooming, and bathing activities, etc. The gloves must be required for the protection of the patient and may not be provided for the protection of caregivers. The gloves may not be billed by providers in order for an adult care home, home health agency or other service provider to meet OSHA guidelines.

Additional clarification is provided in Section 6 of the N.C. Medicaid Durable Medical Equipment Manual (March 1, 1999 reprint) which states that a DME item or supply is covered if it is medically necessary. That section states that "an item is medically necessary if it is needed to maintain or improve a patient’s medical, physical or functional level." Also, note Step 4 of Section 6.4, which emphasizes the provider’s responsibility to assess the appropriateness of a DME item or supply. The first bullet in that section specifies that medical necessity assessment is the responsibility of the DME provider. Therefore, a physician’s written prescription for gloves is not sufficient to document medical necessity.
 

Melody B. Yeargan, P.T., Medical Policy Section
DMA, 919-857-4020


Attention: Durable Medical Equipment Providers
Addition of Non-disposable Nonfiltered Pneumatic Nebulizer

Effective with date of service March 1, 2001, HCPCS code A7005, "administration set, with small volume nonfiltered pneumatic nebulizer, non-disposable," has been added to the Durable Medical Equipment (DME) Related Supplies category of the DME Fee Schedule. The maximum new purchase reimbursement rate is $25.09. The maximum quantity limitation is two per year. Prior approval is not required. As with all DME, providers must maintain a physician’s prescription and a completed Certificate of Medical Necessity and Prior Approval form in their records.
 

Melody B. Yeargan, P.T., Medical Policy Section
DMA, 919-857-4020


Attention: All Providers
Medicare Crossovers

In order for Medicare crossover claims to process, your Medicaid provider number must be on file with EDS.  EDS will no longer systematically insert the providers Medicaid number on crossover claims.  Please complete the Medicare Crossover Reference Request form  and return to EDS Provider Enrollment.
 

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


Attention: All Providers
Resubmission of a Previously Denied Claim

If one of the following EOBs is received and the validity is questionable, do not appeal by submitting an adjustment request. Please contact EDS Provider Services at 1-800-688-6696 or 919-851-8888. Adjustments submitted for these EOB denials will be denied with EOB 998 which states "Claim does not require adjustment processing, resubmit claim with corrections as a new day claim" or EOB 9600, which states "Adjustment denied; if claim was with adjustment it has been resubmitted. The EOB this claim previously denied for does not require adjusting. In the future, resubmit a new or corrected claim in lieu of sending an adjustment request." (Last revision 01/18/01)

EOBS THAT DO NOT REQUIRE ADJUSTMENT  
0002 0069 0128 0181 0236 0326 0574 0669 0825
0003 0074 0129 0182 0237 0327 0575 0670 0860
0004 0075 0131 0183 0240 0356 0576 0671 0863
0005 0076 0132 0185 0241 0363 0577 0672 0864
0007 0077 0133 0186 0242 0364 0579 0673 0865
0009 0078 0134 0187 0244 0394 0578 0674 0866
0011 0079 0135 0188 0245 0398 0580 0675 0867
0013 0080 0138 0189 0246 0424 0581 0676 0868
0014 0082 0139 0191 0247 0425 0584 0677 0869
0017 0084 0141 0194 0249 0426 0585 0679 0875
0019 0085 0143 0195 0250 0427 0586 0680 0888
0023 0089 0144 0196 0251 0428 0587 0681 0889
0024 0090 0145 0197 0253 0430 0588 0682 0898
0025 0093 0149 0198 0255 0435 0589 0683 0900
0026 0094 0151 0199 0256 0438 0590 0685 0905
0027 0095 0153 0200 0257 0439 0593 0688 0908
0029 0100 0154 0201 0258 0452 0604 0689 0909
0033 0101 0155 0202 0270 0462 0607 0690 0910
0034 0102 0156 0203 0279 0465 0609 0691 0911
0035 0103 0157 0204 0282 0505 0610 0698 0912
0036 0104 0158 0205 0283 0511 0611 0732 0913
0038 0105 0159 0206 0284 0513 0612 0734 0916
0039 0106 0160 0207 0286 0516 0616 0735 0917
0040 0108 0162 0208 0289 0523 0620 0749 0918
0042 0110 0163 0210 0290 0525 0621 0755 0919
0041 0111 0164 0211 0291 0529 0622 0760 0920
0046 0112 0165 0213 0292 0536 0626 0777 0922
0047 0113 0166 0215 0293 0537 0635 0797 0925
0049 0114 0167 0217 0294 0548 0636 0804 0926
0050 0115 0170 0219 0295 0553 0641 0805 0927
0051 0118 0171 0220 0296 0556 0642 0814 0929
0058 0120 0172 0221 0297 0557 0661 0817 0931
0062 0121 0174 0222 0298 0558 0662 0819 0932
0063 0122 0175 0223 0299 0559 0663 0820 0933
0065 0123 0176 0226 0316 0560 0665 0822 0934
0067 0126 0177 0227 0319 0569 0666 0823
0068 0127 0179 0235 0325 0572 0668 0824

 
0936 1048 1400 3002 7904 7948 7992 9211 9256
0940 1049 1404 3003 7905 7949 7993 9212 9257
0941 1050 1442 5001 7906 7950 7994 9213 9258
0942 1057 1443 5002 7907 7951 7996 9214 9259
0943 1058 1502 5201 7908 7952 7997 9215 9260
0944 1059 1506 5206 7909 7953 7998 9216 9261
0945 1060 1513 5216 7910 7954 7999 9217 9263
0946 1061 1866 5221 7911 7955 8174 9218 9264
0947 1062 1868 5222 7912 7956 8175 9219 9265
0948 1063 1873 5223 7913 7957 8326 9220 9266
0949 1064 1944 5224 7914 7958 8327 9221 9267
0950 1078 1949 5225 7915 7959 8400 9222 9268
0952 1079 1956 5226 7916 7960 8401 9223 9269
0953 1084 1999 5227 7917 7961 8901 9224 9272
0960 1086 2024 5228 7918 7962 8902 9225 9273
0967 1087 2027 5229 7919 7963 8903 9226 9274
0968 1091 2235 5230 7920 7964 8904 9227 9275
0969 1092 2236 6703 7921 7965 8905 9228 9291
0970 1152 2237 6704 7922 7966 8906 9229 9295
0972 1154 2238 6705 7923 7967 8907 9230 9600
0974 1156 2335 6707 7924 7968 8908 9231 9611
0986 1170 2911 6708 7925 7969 8909 9232 9614
0987 1175 2912 7700 7926 7970 9036 9233 9615
0988 1177 2913 7702 7927 7971 9054 9234 9625
0989 1178 2914 7703 7928 7972 9101 9235 9630
0990 1181 2915 7705 7929 7973 9102 9236 9631
0991 1183 2916 7706 7930 7974 9103 9237 9633
0992 1184 2917 7707 7931 7975 9104 9238 9642
0995 1186 2918 7708 7932 7976 9105 9239 9684
0997 1197 2919 7709 7933 7977 9106 9240 9801
0998 1204 2920 7712 7934 7978 9174 9241 9804
1001 1232 2921 7717 7935 7979 9175 9242 9806
1003 1233 2922 7733 7936 7980 9180 9243 9807
1008 1275 2923 7734 7937 7981 9200 9244 9919
1022 1278 2924 7735 7938 7982 9201 9245 9947
1023 1307 2925 7736 7939 7983 9202 9246 9993
1035 1324 2926 7737 7940 7984 9203 9247
1036 1350 2927 7738 7941 7985 9204 9248
1037 1351 2928 7740 7942 7986 9205 9249
1038 1355 2929 7741 7943 7987 9206 9250
1043 1380 2930 7788 7944 7988 9207 9251
1045 1381 2931 7794 7945 7989 9208 9252
1046 1382 2944 7900 7946 7990 9209 9253
1047 1399 3001 7901 7947 7991 9210 9254

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


Attention: Personal Care Providers (excluding Adult Care Homes)
Personal Care Services Reimbursement Rate Increase

Effective with date of service January 1, 2001, the Medicaid maximum reimbursement rate for personal care service is $3.36 per 15-minute unit ($13.44 hour). No adjustments will be made to previously filed claims.

The provider's customary charges must be shown in form locator 47 on each UB-92 claim form filed. Public providers with nominal charges that are less than 50 percent of cost should report the cost of the service in form locator 47. The payment of each claim will be based on the lower of the billed charges or the maximum allowable rate.

Providers are expected to bill their usual and customary rates.
 

Debbie Barnes, Financial Operations
DMA, 919-857-4015


Attention: All Providers
Community Alternatives Program for Disabled Adults Referrals and Service Coordination

The Community Alternatives Program for Disabled Adults (CAP/DA) provides a variety of home and community services as an alternative to nursing facility care. The program serves disabled adults and the elderly. Each county has designated a lead administrative agency to oversee the day-to-day operation of the program at the local level. In most counties, the lead agency is the entry point for the program and provides case management for the program participants. There are a few counties in which the lead agency has arranged for another agency to handle these functions. Each year the Division of Medical Assistance publishes a list of the local primary contacts for CAP/DA in the Medicaid Bulletin. This year’s CAP/DA Lead Agency List shows the name, location, and phone number of the primary CAP/DA case management agency for each county. If the case management agency is not the lead agency, the name of the lead agency is shown in parentheses.

Providers of Medicaid home care services should use the list to coordinate with the client’s CAP/DA case manager any services that they provide to a CAP/DA client. CAP/DA case managers need to be aware when home health services, personal care services, durable medical equipment, home infusion therapy, private duty nursing or hospice are being considered or provided to a CAP/DA client. A "CI" or "CS" in the CAP block of the Medicaid ID card identifies CAP/DA clients.
 

Barbara Schwab, CAP/DA Administrative Officer
DMA, 919-857-4021
 

CAP/DA LEAD AGENCY LIST
County Lead Agency City Telephone #
Alamance Alamance County DSS Burlington (336) 229-3187
Alexander Alexander County DSS Taylorsville (828) 632-1080
Alleghany Alleghany Memorial Hospital Sparta (336) 372-4464
Anson Anson Community Hospital Wadesboro (704) 695-3409
Ashe Ashe Services for Aging, Inc. West Jefferson (336) 246-2461
Avery Sloop CAP Newland (828) 733-1062
Beaufort Beaufort County DSS Washington (252) 975-5500
Bertie  University Home Care - Cashie
(Lead Agency - East Carolina Health-Bertie)
Windsor (252) 794-2622
Bladen Bladen County Hospital Elizabethtown (910) 862-6221
Brunswick Brunswick County DSS Bolivia (910) 253-2118
Buncombe Buncombe County DSS Asheville (828) 250-5814
Burke Burke County DSS Morganton (828) 439-2000
Cabarrus Cabarrus County DSS Kannapolis (704) 920-1400
Caldwell Caldwell County DSS Lenoir (828) 757-1180
Camden Albemarle Regional Health Service Elizabeth City (252) 338-4066
Carteret Carteret County DSS Beaufort (252) 728-3181
Caswell Caswell County Health Dept. Yanceyville (336) 694-9592
Catawba Catawba County DSS Hickory (828) 695-5619
Chatham Chatham County Health Dept. Pittsboro (919) 542-8220
Cherokee District Memorial Hospital Andrews (828) 321-4113
Chowan Chowan Hospital Edenton (252) 482-6322
Clay Clay County Health Dept. Hayesville (828) 389-1444
Cleveland Cleveland Regional Medical Center
Care Solutions
Shelby (704) 487-0968
Columbus Columbus County Dept. of Aging Whiteville (910) 640-6602
Craven Craven Regional Medical Center New Bern (252) 633-8240
Cumberland Cumberland County DSS Fayetteville (910) 677-2388
Currituck Albemarle Regional Health Service Elizabeth City (252) 338-4066
Dare Dare County DSS Manteo (252) 473-1471
Davidson Davidson County Senior Services Thomasville (336) 474-2754
Davie Davie County Hospital Mocksville (336) 751-8340
Duplin Duplin Home Care & Hospice
(Lead Agency - Duplin General Hospital)
Kenansville (910) 296-0819
Durham Durham County DSS Durham (919) 596-5076
Edgecombe Edgecombe Home Care & Hospice Tarboro (252) 641-7518
Forsyth  Senior Services, Inc.
(Lead Agency - Forsyth County Health Dept.)
Winston Salem (336) 725-0907
Franklin Franklin County DSS Louisburg (919) 496-5721
Gaston Gaston County DSS Gastonia (704) 862-7540
Gates  Chowan Hospital Home Care
(Lead Agency - Gates County DSS)
Edenton (252) 482-6322
Graham Graham County Health Dept. Robbinsville (828) 479-4201
Granville Granville Medical Center Oxford (919) 690-3242
Greene Greene County DSS Snow Hill (252) 747-5932
Guilford Guilford County Health Dept. Greensboro (336) 373-3331
Halifax Halifax County DSS Halifax (252) 536-6537
Harnett Harnett County Dept. on Aging Lillington (910) 893-7596
Haywood Haywood County Council on Aging Waynesville (828) 452-2370
Henderson Margaret R. Pardee Hospital Hendersonville (828) 696-1000
Hertford Hertford County DSS Winton (252) 358-7830
Hoke Duke/St. Joseph Home Health Raeford (910) 875-8198
Hyde Hyde County DSS Swan Quarter (252) 926-3371
Iredell Iredell County DSS Statesville (704) 878-5090
Jackson Harris Regional Hospital Sylva (828) 586-7410
Johnston Johnston County DSS Smithfield (919) 989-5300
Jones Jones County DSS Trenton (252) 448-7581
Lee Lee County DSS Sanford (919) 718-4690
Lenoir Lenoir Memorial Hospital Kinston (252) 522-7947
Lincoln Lincoln County DSS Lincolnton (704) 732-1969
Macon Macon County DSS Franklin (828) 349-2124
Madison Madison County DSS Marshall (828) 649-2711
Martin Martin County DSS Williamston (252) 809-6403
McDowell McDowell County DSS Marion (828) 652-3355
Mecklenburg Mecklenburg County Health Dept. Charlotte (704) 336-4700
Mitchell Mitchell County DSS Bakersville (828) 688-2175
Montgomery Montgomery County DSS Troy (910) 576-6531
Moore  FirstHealth Home Care (Lead Agency - Moore County DSS) West End (910) 295-2211
Nash Nash County Health Dept. Rocky Mount (252) 446-1777
New Hanover New Hanover Health Network Wilmington (910) 343-7711
Northampton Northampton County DSS Jackson (252) 534-5811
Onslow Onslow Council on Aging Jacksonville (910) 455-2747
Orange Orange County DSS Hillsborough (919) 245-2882
Pamlico Pamlico County Senior Services Alliance (252) 745-7196
Pasquotank Albemarle Regional Health Service Elizabeth City (252) 338-4066
Pender Pender Adult Services Burgaw (910) 259-9119
Perquimans Albemarle Regional Health Service Elizabeth City (252) 338-4066
Person Person County DSS Roxboro (336) 599-8361
Pitt Pitt County DSS Greenville (252) 413-1101
Polk St. Luke’s Hospital Columbus (828) 894-3524
Randolph Randolph Hospital Asheboro (336) 625-5151
Richmond Richmond Memorial Hospital Rockingham (910) 997-5800
Robeson Southeastern Regional Medical Center Lumberton (910) 618-9405
Rockingham Rockingham County Council on Aging, Inc. Reidsville (336) 349-2343
Rowan CapCare Rowan Regional Medical Center Salisbury (704) 210-5509
Rutherford Rutherford Hospital, Inc. Forest City (828) 245-3575
Sampson Sampson County Dept. of Aging Clinton (910) 592-4653
Scotland  Scotland Home Health (Lead Agency - Scotland County Health Dept.) Laurinburg (910) 277-2484
Stanly Stanly County DSS Albemarle (704) 982-6100
Stokes Stokes County DSS Danbury (336) 593-2861
Surry Surry County Friends of Seniors Dobson (336) 401-8500
Swain Swain County Health Dept. Bryson City (828) 488-3792
Transylvania Transylvania Community Hospital Brevard (828) 883-5473
Tyrrell Tyrrell County DSS Columbia (252) 796-3421
Union Union County DSS Monroe (704) 296-6170
Vance Vance County DSS Henderson (252) 492-5001
Wake Resources for Seniors, Inc. Raleigh (919) 872-7933
Warren Warren County DSS Warrenton (252) 257-5974
Washington Washington County Center Plymouth (252) 793-4041
Watauga Watauga County Project on Aging Boone (828) 265-8090
Wayne Wayne Memorial Hospital, Inc. Goldsboro (919) 731-6314
Wilkes Home Care of Wilkes Regional Medical Center North Wilkesboro (336) 903-7745
Wilson Wilson Medical Center Wilson (252) 399-8228
Yadkin Yadkin County DSS Yadkinville (336) 679-3385
Yancey Yancey County Health Dept. Burnsville (828) 682-7967

 
  DMA and EDS Telephone Contact List
Topic/Reason For Call Call Telephone Number
Accident-Related Issues DMA Third Party Recovery 1-919-733-6294
Automatic Deposits EDS Finance Unit 1-800-688-6696 or 1-919-851-8888
Billing Issues EDS Provider Services 1-800-688-6696 or 1-919-851-8888
Carolina ACCESS DMA Managed Care 1-888-245-0179 or 1-919-857-4022
Checkwrite Information AVR System 1-800-723-4337
Claims Status AVR System 1-800-723-4337
Coverage Issues EDS Provider Services 1-800-688-6696 or 1-919-851-8888
Denials (eligibility) DMA Claims Analysis 1-919-857-4018
Denials (other than eligibility) EDS Provider Services 1-800-688-6696 or 1-919-851-8888
Drug Use Review DMA Program Integrity 1-919-733-3590
Eligibility Information (current day) AVR System 1-800-723-4337
Fee Schedules DMA Financial Operations 1-919-857-4015
Forms (information and orders) EDS Provider Services 1-800-688-6696 or 1-919-851-8888
Fraud and Program Abuse DMA Program Integrity 1-919-733-6681
Health Check DMA Managed Care 1-888-245-0179 or 1-919-857-4022
HMO Risk Contracting DMA Managed Care 1-888-245-0179 or 1-919-857-4022
Manuals/Bulletins EDS Provider Services 1-800-688-6696
Medicare Crossovers EDS Provider Services 1-800-688-6696 or 1-919-851-8888
Prior Approval EDS Prior Approval Unit 1-800-688-6696 or 1-919-851-8888
Private Insurance DMA Third Party Recovery 1-919-733-6294
Procedure Code Pricing AVR System 1-800-723-4337
Provider Enrollment – Managed Care DMA Managed Care 1-888-245-0179 or 1-919-857-4022
Provider Enrollment – MQB EDS Provider Services 1-800-688-6696 or 1-919-851-8888
Provider Enrollment – All Others DMA Provider Services 1-919-857-4117
Third Party Insurance Code Book DMA Third Party Recovery 1-919-733-6294 FAX: 1-919-715-4725


Attention: Hospice Providers
Hospice Services Reimbursement Rate Increase

Effective with date of service January 1, 2001, the maximum allowable rate for the following hospice services increased. The hospice rates are as follows:
 
   
Routine Home Care
Continuous Home Care
Inpatient Respite Care
General Inpatient Care
Hospice Intermediate R & B
Hospice Skilled 
R & B
Metropolitan Statistical Area
SC
RC 651
Daily
RC 652
Hourly
(1)
RC 655
Daily
(2) (3) (4)
RC 656
Daily
(3) (4)
RC 658
Daily
(5)
RC 659
Daily 
(5)
Asheville
39
97.28 23.65 103.77 432.94 93.64 124.44
Charlotte
41
101.38 24.64 107.29 449.91 93.64 124.44
Fayetteville
42
94.37 22.94 101.28 420.91 93.64 124.44
Greensboro/
Winston-Salem/
High Point
43
98.42 23.92 104.75 437.67 93.64 124.44
Hickory
44
98.98 24.06 105.23 439.99 93.64 124.44
Jacksonville
45
89.58 21.77 97.18 401.07 93.64 124.44
Raleigh/Durham
46
102.21 24.84 108.00 453.36 93.64 124.44
Wilmington
47
103.42 25.14 109.04 458.38 93.64 124.44
Rural
53
92.84 22.57 99.97 414.56 93.64 124.44
Goldsboro
105
93.17 22.65 100.25 415.92 93.64 124.44
Greenville
106
101.88 24.76 107.72 452.00 93.64 124.44
Norfolk
Currituck County
107
93.96 22.84 100.94 419.23 93.64 124.44
Rocky Mount
108
96.16 23.37 102.82 428.33 93.64 124.44

Note: Providers are expected to bill their usual and customary charges.  Adjustments will not be accepted.

Key to Hospice Rate Table:

SC = Specialty Code
RC = Revenue Code
 

  1. A minimum of eight hours of continuous home care must be provided.
  2. There is a maximum of five consecutive days including the date of admission but not the date of discharge for inpatient respite care. Bill for the sixth and any subsequent days at the routine home care rate.
  3. Payments to a hospice for inpatient care are limited in relation to all Medicaid payments to the agency for hospice care. During the 12-month period beginning November 1 of each year and ending October 31, the aggregate number of inpatient respite and general inpatient days may not exceed 20 percent of the aggregate total number of days of hospice care provided during the same time period for all the hospice’s Medicaid patients. Hospice care provided for patients with acquired immune deficiency syndrome (AIDS) is excluded in calculating the inpatient care limit. The hospice refunds any overpayments to Medicaid.
  4. Date of Discharge: For the day of discharge from an inpatient unit, the appropriate home care rate must be billed instead of the inpatient care rate unless the recipient expires while an inpatient. When the recipient is discharged as deceased, the inpatient rate (general or respite) is billed for the discharge date.
  5. When a Medicare/Medicaid recipient is in a nursing facility, Medicare is billed for routine or continuous home care, as appropriate, and Medicaid is billed for the appropriate long-term care rate. When a Medicaid only hospice recipient is in a nursing facility, the hospice may bill for the appropriate long-term care (SNF/ICF) rate in addition to the home care rate provided in revenue code 651 or 652. See section 8.15.1, page 8-12, of the N.C. Medicaid Community Care Manual for details.


Debbie Barnes, Financial Operations
DMA, 919-857-4015


Attention: All Providers
Notice of Case Status

The Notice of Case Status form (DMA-5020) serves as a referral to Medicaid from providers of inpatient medical care and as a notice of case status from the county department of social services (DSS). Due to confidentiality requirements, DSS is prohibited from responding to a DMA-5020 referral regarding a Medicaid applicant unless it contains the patient’s or his representative’s signature and date. A Medicaid applicant is an individual whose request for assistance is pending or has been denied.

Exception: The signature requirements are waived if the referral is for automatic newborn coverage or eligibility dates for an authorized Medicaid recipient. The eligibility dates for an authorized recipient is the only information that can be released without the patient’s or his representative’s signature.

Prior to sending the DMA-5020 to DSS, please ensure that the form is dated and contains the patient’s or his representative’s signature, except as noted above. A referral form designed by the provider will be accepted as long as it is dated, signed as required by the Medicaid applicant or his representative, and specifically states that the patient or his representative has given consent for a referral to Medicaid.

Upon receipt of a properly completed referral form, DSS will complete the notice of case status and return the form to the provider within 15 workdays from the date of receipt.
 

Vanessa Broadhurst, Medicaid Eligibility Unit
DMA, 919-857-4019


Attention: All Carolina ACCESS Primary Care Providers
Requirements for Disenrollment of Carolina ACCESS Enrollees

The majority of Managed Care mp/patient relationships are positive for both parties. However, on occasion, it may become necessary to disenroll a Carolina ACCESS (CA) enrollee from a practice. A CA primary care provider (PCP) may disenroll a CA enrollee from their practice as long as it is with good cause and prior written notice has been provided to the enrollee. According to the guidelines listed in the 1915 (b) (1) waiver of the Social Security Act that allows operation of the CA program, good cause is defined as:

Additionally, a CA enrollee may be disenrolled for nonpayment of copayments or an outstanding balance if this is a standard operating procedure for the practice, is applicable to all patients regardless of payor source, and prior written notice has been provided to the enrollee.

As stated in section 6.1(B)(b) of the Agreement for Participation as a Primary Care Provider in Carolina ACCESS, in addition to notifying the enrollee in writing of the decision to disenroll, the local Managed Care Representative (MCR) in the enrollee’s county of residence must also be notified. This will allow the MCR to address any concerns with the enrollee and to initiate the disenrollment process, which includes the selection of a new PCP by the enrollee. Because 30 to 60 days are required to complete the changes and to have the correct information printed on the Medicaid ID card, prompt MCR notification is required.

Additional information on the disenrollment process is included in the Managed Care Provider Manual. Questions about the disenrollment process may be directed to the local MCR or Regional Managed Care Consultant.
 

Vickie Dean, RN, Managed Care Section
DMA, 919-857-4022


Attention: Providers Serving Gaston County Medicaid Recipients
HMO Update

Effective December 31, 2000, The Wellness Plan of North Carolina, Inc. is no longer serving as an HMO to Medicaid recipients in Gaston County.
 

Julia McCollum, Managed Care Section
DMA, 919-857-4022


Attention: All Providers
Credentialing Requirements – Correction to Terminology in January 2001 Medicaid Special Bulletin I, Provider Enrollment Guidelines

The name of the certification that clinical nurse specialists and nurse practitioners receive from the American Nurses Credentialing Center to provide mental health services has been changed to Advanced Practice Psychiatric Clinical Nurse Specialist and Advanced Practice Psychiatric Nurse Practitioner. The credentialing requirements listed in the January 2001 Special Bulletin for clinical nurse specialists and nurse practitioners should be corrected to:

Clinical Nurse Specialist

Nurse Practitioner – In-State


Darlene Pilkington, Provider Services Unit
DMA, 919-857-4017


Attention: All Physicians
Physician Reimbursement Rate Change

Effective with date of service January 1, 2001, physician fees are based on the Medicare fee schedule Resource Based Relative Value System (RBRVS) currently in effect. This change results in paying physician services the Medicare rate and uses updated RBRVS values.

Effective with date of service January 1, 2001, all non-Medicare rates for physician services increased by 1.5 percent. Providers are expected to bill their usual and customary rate. New fee schedules are available upon request. Refer to Fee Schedules and Reimbursement Plans for information on requesting a new fee schedule.
 

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


Attention: All Providers
Fee Schedules and Reimbursement Plans

Fee Schedule Request Form
There is no charge for fee schedules or reimbursement plans requested from the Division of Medical Assistance (DMA). However, all requests for publications must be made on the Fee Schedule Request form and mailed to:

Division of Medical Assistance
Financial Operations - Fee Schedules
2509 Mail Service Center
Raleigh, N. C. 27699-2509

Or fax your request to DMA’s Financial Operations section at 919-715-0896.

NOTE: PHONE REQUESTS ARE NOT ACCEPTED
 

Request for Diskette of Physician Fee Schedule and Anesthesia Base Units Schedule
The Physician Fee Schedule and the Anesthesia Base Units Schedule are also available on diskette or by e-mail from DMA at no charge.  DMA stipulates that the information provided be used only for your internal analysis.  Providers are expected to bill their usual and customary rate.

Please complete the Request for Diskette of Physician Fee Schedule and Anesthesia Base Units Schedule form with each request:

Mail the request to:

Division of Medical Assistance
Financial Operations – Fee
2509 Mail Service Center
Raleigh, North Carolina 27699-2509
Or fax your request to DMA’s Financial Operations section at 919-715-0896.
 

Pam Munson, Financial Operations
DMA, 919-857-4164


Attention: Adult Care Home Providers
Cancellation of the Adult Care Home Seminars and Individual Visits

The Adult Care Home seminars that were scheduled for April and May 2001, have been cancelled. EDS is now offering individual provider visits for Adult Care Home providers. These visits are offered for new as well as existing providers with billing issues. Please complete and return the Adult Care Home Provider Visit Request form to the address listed below. An EDS Provider Representative will contact you to schedule a visit and discuss the type of issues to be addressed.

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


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


Attention: All Providers
Basic Medicaid Seminar Schedule

Seminars for Basic Medicaid are scheduled for April 2001. The seminars are intended for providers who are new to N.C. Medicaid program. Topics to be discussed will include, but are not limited to, provider enrollment requirements, billing instructions, eligibility issues, and Managed Care, including Carolina ACCESS and HMOs. Persons inexperienced in billing N.C. Medicaid are encouraged to attend.

Due to limited seating, preregistration is required and limited to two staff members per office. Unregistered providers are welcome to attend when reserved space is adequate to accommodate. Please select the most convenient site and return the completed registration form to EDS as soon as possible. Seminars begin at 10:00 a.m. and end at 1:00 p.m. Providers are encouraged to arrive by 9:45 a.m. to complete registration.

Return the Basic Medicaid Seminar Registration form to:

Provider Services
EDS
P.O. Box 300009
Raleigh, N.C. 27622
Directions to the sites
 
Tuesday, April 3, 2001
A-B Technical College
340 Victoria Road
Asheville, NC
Laurel Auditorium 
Tuesday, April 10, 2001
Coastline Convention Center
501 Nutt Street 
Wilmington, NC
Wednesday, April 11, 2001
Ramada Inn Plaza
3050 University Parkway
Winston-Salem, NC
Monday, April 23, 2001
WakeMed 
MEI Conference Center
3000 New Bern Avenue
Raleigh, NC
   



Directions to the Basic Medicaid Seminars

ASHEVILLE, NORTH CAROLINA

A-B TECHNICAL COLLEGE

Directions to the College
Take I-40 to exit 50. Travel north on Hendersonville Road, which turns into Biltmore Avenue. Continue on Biltmore Avenue toward Memorial Mission Hospital. Turn left onto Victoria Road.

Campus
Stay on Victoria Road. Turn right between the Holly Building and the Simpson Building. The Laurel Building/Auditorium is located on the right, behind the Holly Building.
 

WILMINGTON, NORTH CAROLINA

COASTLINE CONVENTION CENTER

Take I-40 east to Wilmington. Take the Highway 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.

WINSTON-SALEM, NORTH CAROLINA RAMADA INN PLAZA Take I-40 Business to Cherry Street exit. Continue on Cherry Street for approximately 2 to 3 miles. Turn left at the IHOP Restaurant. The Ramada Inn Plaza is located on the right.

RALEIGH, NORTH CAROLINA WAKEMED MEI CONFERENCE CENTER

Driving and Parking Directions
Take the I-440 Raleigh Beltline to New Bern Avenue, exit 13A (New Bern Avenue, Downtown). Travel toward WakeMed. Turn left onto Sunnybrook Road.

Parking is available at the former CCB Bank parking lot, a short walk to the conference facility. The entrance to the Conference Center is at the top of the stairs to WakeMed’s Medical Education Institute.

Parking is also available on the top two levels of Parking Deck P3. To reach this deck, exit the I-440 Beltline at exit 13A. Proceed to the Emergency entrance of the hospital (on the left). Follow the access road up the hill to the gate for Parking Deck P3. After parking in P3, walk down the hill past the Medical Office Building and past the side of the Medical Education Institute. Turn right at the front entrance of the building and follow the sidewalk to the Conference Center entrance.

Illegally parked vehicles will be towed. Parking is not permitted at East Square Medical Plaza, Wake County Human Services, the P4 parking lot or in front of the Conference Center.
 
 



Checkwrite Schedule

March 6, 2001 April 10, 2001 May 8, 2001
March 13, 2001 April 17, 2001 May 15, 2001
March 20, 2001 April 26, 2001 May 22, 2001
March 29, 2001   May 31, 2001


Electronic Cut-Off Schedule  

March 2, 2001 April 6, 2001 May 4, 2001
March 9, 2001 April 12, 2001 May 11, 2001
March 16, 2001 April 20, 2001 May 18, 2001
March 23, 2001   May 25, 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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