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

Attention: Health Check Providers

Health Check Seminars

Health Check seminars for all providers except for health departments are scheduled for May 2005. The April 2005 general Medicaid bulletin will have the registration form and a list of site locations for the seminars. The Seminars will focus on health check billing requirements, as well as vision and hearing assessments and developmental screenings.

A separate teleconference sponsored by the Division of Public Health is scheduled for health department providers. The April general Medicaid bulletin will include registration information for the teleconference.

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

Attention: Hospital Providers

Inpatient Services with Medicare Part B Coverage Only (No Part A or Part A Benefits Are Exhausted)

When a Medicaid patient, who received inpatient hospital services has Medicare Part B coverage only, or has Medicare Part B and Medicare Part A benefits are exhausted, a claim for the Part B charges must be filed with the Medicare carrier first. Do not indicate on the claim filed to Medicare that these charges should be crossed over to Medicaid. If the Medicare Part B claim is crossed over from the Medicare carrier, the provider must file an adjustment request in order to recoup all paid monies or a refund must be completed. Once payment has been received from Medicare Part B, file the UB-92 claim form to Medicaid completing the appropriate required fields. In addition, complete the following fields:

a. Form locator 4 - Indicate the proper bill type.

b. Form locator 32-35 a-b, code A3-C3 - Indicate that the Medicare Part A benefits are exhausted. Lifetime Reserve days must also be exhausted.

c. Form locator 50 - Indicate Medicare as a payer.

d. Form locator 54 - Indicate the Medicare Part B payment.

Note: Do not include the contractual adjustment for the Medicare Part B payment.

e. Form locator 84 – Indicate that the patient has no Medicare Part A benefits.

Do not attach a copy of the Medicare EMOB with the claim form.

If the Medicare EMOB is attached to the claim form, the claim will process incorrectly for payment. The payment from Medicare for the Part B charges will be treated like any other third party payment since the original charges are included in the Medicaid per diem/DRG rate.

If the Medicaid-allowed amount is more than the third-party payment, Medicaid will pay the difference up to the Medicaid-allowed amount. The payment (or nonpayment) must be accepted as payment in full.

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

Attention: Hospital Providers

Inpatient Crossovers and DRG payment

Inpatient crossovers (excluding Skilled Nursing Facility crossovers) are paid using the DRG assigned by Medicare. The Medicaid DRG allowable is calculated and the Medicare total payment is deducted from it. The amount is compared to the Medicare coinsurance and deductible amount. Payment is made for the lesser of the two amounts.

If a facility’s Medicare DRG payment is higher than its Medicaid payment, the crossover payment will be zero. The facility cannot bill the patient for the coinsurance/deductible. The payment (or nonpayment) must be accepted as payment in full. The deductible and coinsurance amount can be included on the Medicare cost report as bad debts.

Effective with date of service January 1, 1995, Medicaid no longer paid for non-covered days when Medicare benefits began or exhausted during an acute hospital stay. The hospital’s reimbursement is paid using the DRG assigned by Medicare. Since the hospital’s reimbursement is based on a DRG payment from Medicare and not the number of covered days, Medicaid liability is limited to the coinsurance/deductible as calculated above. Medicaid will not reimburse for non-covered DRG days. The non-covered days of eligibility cannot be billed to the patient because DRG payment is calculated as if the recipient were covered for the entire stay.

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

Attention: Hospitals

Clarification of Preadmission Review for Psychiatric and Substance Abuse Treatment

In addition to the review ValueOptions already performs for acute psychiatric inpatient hospital admissions for children under 21 years of age in a free standing psychiatric hospital and adults/children in a psychiatric unit of a general hospital, ValueOptions will review all recipients that have a primary mental health or substance abuse diagnosis, regardless of bed location. ValueOptions will not review ER visits or recipients in ICU beds. If the recipient is admitted to ICU and later transferred to the psychiatric unit please contact ValueOptions at the time of the transfer for prior approval.

If a claim denies for EOB 213 and the recipient was in a medical bed, please submit a copy of the history and physical along with the discharge summary to the Division of Medical Assistance, Clinical Policy and Programs, Behavioral Health Section, 2501 Mail Service Center Raleigh, NC 27699-2501 or providers may elect to send this information electronically via ProviderLink.

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

If the admission was determined to be a medical admission, an override of the denial will be sent to EDS for claims payment. Beginning the middle of March, this information will be submitted to EDS through ProviderLink.

For questions regarding ProviderLink, please contact 919-465-1855 or visit their website at www.providerlink.com.