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In This Issue

All Providers:

• Basic Medicaid Seminar Schedule
• Directions to the Basic Medicaid Seminars
• Community Alternatives Program for Disabled Adults Referrals and Service Coordination
• Credentialing Requirements – Correction to Terminology, Provider Enrollment Guidelines
• Fee Schedules and Reimbursement Plans
• Medicare Crossovers
• Notice of Case Status
• Physician Reimbursement Rate Change
• Resubmission of a Previously Denied Claim
• Checkwrite Schedule
• Electronic Cut-Off Schedule

Adult Care Home Providers:

• Cancellation of the Adult Care Home Seminars and Individual Visits
• Non-emergency Transportation by Nursing Facilities and Adult Care Homes

Ambulance Providers:

• Non-emergency Transportation by Nursing Facilities and Adult Care Homes

Carolina ACCESS Primary Care Providers:

• Requirements for Disenrollment of Carolina ACCESS Enrollees

Community Alternatives Program Providers:

• Community Alternatives Program Services Reimbursement Rate Increase

Dental Providers:

• Dental Reimbursement Rate Increase

Durable Medical Equipment Providers:

• Additions of Batteries and Calibration Solution/Chips for Blood Glucose Monitors to the DME Fee Schedule
• Addition of Non-disposable Nonfiltered Pneumatic Nebulizer
• Coverage of Sterile and Non-sterile Gloves

Hospice Providers:

• Hospice Services Reimbursement Rate Increase

Hospitals:

• Non-emergency Transportation by Nursing Facilities and Adult Care Homes

Labs:

• Lab Reimbursement Rates

Nursing Facilities:

• Non-emergency Transportation by Nursing Facilities and Adult Care Homes
• Physician Signature Dates on the Long-term Care Prior Approval Forms

Personal Care Providers:

• Personal Care Services Reimbursement Rate Increase

Providers Serving Gaston County Medicaid Recipients:

• HMO Update

Psychiatric Providers:

• Billing Reminders for Psychiatric Residential Treatment Facility and Residential Services

Ventilator Long-term Care Providers:

• Authorized Persons to Sign Ventilator Addendum Form
• Time Constraints for Provider Notification of Ventilator Prior Approval

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:

• the enrollee repeatedly fails to comply with prescribed medical treatments;
• the enrollee shows repeated rude or inappropriate behavior;
• the enrollee repeatedly fails to keep scheduled appointments without notification;
• the enrollee is linked with the PCP in error;
• the enrollee’s health care needs can be better served by another PCP with medical training or experience which would be beneficial to the enrollee’s health, and the PCP change is mutually agreed upon by all parties;
• the enrollee has multiple serious conditions and the PCP wants to continue to provide care for the enrollee but requests the enrollee be disenrolled from CA and placed in exempt status because of ongoing and routine visits to specialty clinics;
• the PCP disenrolls from the CA program.

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

• Licensed as Registered Nurse
• Certified by the American Nurses Credentialing Center as an Advanced Practice Psychiatric Clinical Nurse Specialist if providing mental health services

• Licensed as Registered Nurse
• Certified by Board of Medical Examiners
• Certified by Board of Nursing
• Certified by American Nurses Credentialing Center as an Advanced Practice Psychiatric Nurse Practitioner if providing mental health services

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

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 Basic Medicaid Seminars

ASHEVILLE, NORTH CAROLINA

A-B TECHNICAL COLLEGE

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

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

Checkwrite Schedule

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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