March 2006 Medicaid Bulletin

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In This Issue...

All Providers:

Area Mental Health Providers:

AQUIP Users:

CAP/DA Lead Agencies:

Community Alternative Program Case Managers:

Children Developmental Service Agencies:

Community Alternative Program Case Managers:

Enhanced Mental Health Services Providers:

Home Infusion Therapy Providers:

Home Health Providers:

Local Management Entities:

Nursing Facility Providers:

Optical Service Providers:

Pharmacists:

Prescribers:

Private Duty Nursing:

 


Attention: All Providers

Carolina ACCESS Override Requests

The fax number for submitting Carolina ACCESS Override Requests has been changed to 919-816-4420. 

This fax line is dedicated to Carolina ACCESS Override Requests only.  Override requests for current or future dates of service can be made via telephone, 919-816-4321.

Override requests for past dates of service must be submitted in writing via fax or mail.  Referrals faxed to the old number do not need to be sent a second time.

EDS, 1-919-816-4321  

 


Attention: All Providers

Clinical Coverage Policies

The following new or amended clinical coverage policies are now available on the Division of Medical Assistance's website:

These policies supersede previously published policies and procedures.  Providers may contact EDS at 1-800-688-6696 or 919-851-8888 with billing questions.

 Clinical Policy and Programs
DMA, 919-855-4260



Attention: All Providers

Contacting EDS – Automated Attendant Telephone Line Instructions

The Automated Attendant Telephone Line (1-800-688-6696 or 919-851-8888) has been revised to include more options for providers when calling EDS.  Calls made from a touch-tone telephone can be routed to the appropriate units by an automated attendant as follows: 

For IPRS Provider Relations

Dial 5-3355

For NC PASARR

Dial 5-3505

Press 1 for Electronic Commerce Services

Press 1 to reach an ECS Analyst

Press 2 for Prior Approval

Press 802 - Optical or Hearing Aid

Press 803 - Long Term Care, Surgery or Out of State

Press 804 – Dental

Press 805 - Durable Medical Equipment

Press 809 – Enhanced Care, Therapeutic Leave or Hospice

Press 819 - Prior Approval Denial Notices

Press 3 for Provider Services

Press 806 – Physician’s Offices

 

Press 806 – County Health Department

Press 806 - Independent Practitioner

Press 806 - Local Education Agency

Press 807 – Hospitals

Press 807 – Long-Term Care Facility

Press 807 – Community Intervention Service Agencies

Press 807 – Residential Child Care Facility (Level II-IV)

Press 807 - Hearing Aid

Press 807 - Dialysis

Press 807 - Area Mental Health

Press 808 – Dental

Press 808 – Home Health Care Agency

Press 808 – Personal Care Services

Press 808 – Private Duty Nursing

Press 808 – Durable Medical Equipment

Press 808 – Ambulance

Press 808 – RHC/FQHC

Press 808 – Adult Care Homes

Press 808 – Community Alternative Programs

Press 808 – Home Infusion Therapy

Press 808 – Hospice

Press 808 – At-Risk Case Management

Press 817 - Pharmacy

Medicaid recipients are instructed to press 6 which will direct recipients to call the Care Line Information and Referral Service at 1-800-662-7030.  To speak with the receptionist providers are instructed to press 0.

 EDS, 1-800-688-6696 or 919-851-8888



Attention: All Providers

Corrected 1099 Requests – Action Required by March 1, 2006

Providers receiving Medicaid payments of more than $600 annually have been sent a 1099 MISC tax form from EDS. The 1099 MISC tax form is generated as required by IRS guidelines. They were mailed to individual providers and groups on January 24, 2006.  The 1099 MISC tax form reflects the tax information on file with Medicaid as of the last Medicaid checkwrite cycle date, December 22, 2005.

If the tax name or tax identification number on the annual 1099 MISC you receive is incorrect (for example, misspelled or transposed), a correction to the 1099 MISC must be requested. This ensures that accurate tax information is on file with Medicaid and sent to the IRS annually. When the IRS receives incorrect information on your 1099 MISC, it may require backup withholding in the amount of 28 percent of future Medicaid payments. The IRS could require EDS to initiate and continue this withholding to obtain correct tax data.

Please Note:  If claims were billed under an individual provider number rather then a group number, the individual is considered to have received the income and the 1099 will reflect the individual's tax ID associated with the individual provider number rather than a Federal ID number, which is associated with a group number.  This is not the type of change that corrected 1099’s address.  If that is your situation, please bill under your group number as soon as you identify the issue. 

A correction to the original 1099 MISC must be submitted to EDS by March 1, 2006 and must be accompanied by the following documentation:

  • A copy of the original 1099 MISC
  • A signed and completed IRS W-9 form clearly indicating the correct tax identification number and tax name. (Additional instructions for completing the W-9 form can be obtained at www.irs.gov under the link "Forms and Pubs.")
  • Fax both documents to 919-816-3186-Attention: Corrected 1099 Request - Financial

    Or

    Mail both documents to:

    EDS
    Attention: Corrected 1099 Request - Financial
    4905 Waters Edge Drive
    Raleigh, NC 27606

    A copy of the corrected 1099 MISC will be mailed to you for your records. All corrected 1099 MISC requests will be reported to the IRS. In some cases, additional information may be required to ensure that the tax information on file with Medicaid is accurate. Providers will be notified by mail of any additional action that may be required to complete the correction to their tax information.

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



    Attention: All Providers

    Resubmitting Claims for Ophthalmology Procedure Codes with Modifiers 26 and TC

    Medicaid’s claims processing system has been updated to cover ophthalmology procedure codes billed with modifiers 26 (professional component) and TC (technical component) for dates of service January 1, 2004 and after when billed with the following ophthalmology procedure codes:  92060, 92081, 92082, 92083, 92235, 92265, 92270, 92275, 92283, and 92284.  This change is being made to comply with the Centers for Medicare and Medicaid Services (CMS). 

     Claims submitted for these procedure codes with modifiers 26 or TC that were denied may be resubmitted as a new claim.  If the claim was initially received and processed within the 365-day time limit, providers have 18 months from the date of the Remittance Advice to refile the claim.  The claim may be resubmitted electronically or on paper as a new claim.  Claims that have exceeded the 365-day time limit must be submitted on paper with a Medicaid Resolution Inquiry form and documentations supporting a time limit override.  For addition information on time limit overrides, refer to the Basic Medicaid Billing Guide on DMA’s website.

    When applicable, the following modifiers are also covered, effective with date of service December 1, 2005

    For additional information on billing with modifiers, refer to the April 1999 Special Bulletin, Modifiers.  The rates for 2004 and 2005 are as follows:

     

     

     

     

    2004 Rates

     

     

     

     

     

    2005 Rates

    CPT CODE

    TOS

    MOD

    EFF DATE

    Non-facility FEE

    Facility FEE

     

    CPT CODE

    TOS

    MOD

    EFF DATE

    Non-facility FEE

    Facility FEE

    92060

    5

    26

    1/1/2004

                   31.56

                 31.56

     

    92060

    5

    26

    1/1/2005

                 34.96

                 34.96

    92060

    T

    TC

    1/1/2004

                   13.88

                 13.88

     

    92060

    T

    TC

    1/1/2005

                  14.88

                  14.88

    92081

    5

    26

    1/1/2004

                   16.83

                 16.83

     

    92081

    5

    26

    1/1/2005

                   18.19

                   18.19

    92081

    T

    TC

    1/1/2004

                  22.27

                22.27

     

    92081

    T

    TC

    1/1/2005

                 26.54

                 26.54

    92082

    5

    26

    1/1/2004

                  20.36

                20.36

     

    92082

    5

    26

    1/1/2005

                 22.40

                 22.40

    92082

    T

    TC

    1/1/2004

                  30.04

                30.04

     

    92082

    T

    TC

    1/1/2005

                 34.86

                 34.86

    92083

    5

    26

    1/1/2004

                  23.23

                23.23

     

    92083

    5

    26

    1/1/2005

                 25.56

                 25.56

    92083

    T

    TC

    1/1/2004

                   35.01

                 35.01

     

    92083

    T

    TC

    1/1/2005

                 40.53

                 40.53

    92265

    5

    26

    1/1/2004

                  35.65

                35.65

     

    92235

    5

    26

    1/1/2005

                  41.94

                  41.94

    92265

    T

    TC

    1/1/2004

                  50.44

                50.44

     

    92235

    T

    TC

    1/1/2005

                 75.98

                 75.98

    92270

    5

    26

    1/1/2004

                   37.61

                 37.61

     

    92265

    5

    26

    1/1/2005

                  39.41

                  39.41

    92270

    T

    TC

    1/1/2004

                  38.63

                38.63

     

    92265

    T

    TC

    1/1/2005

                 40.76

                 40.76

    92275

    5

    26

    1/1/2004

                  46.46

                46.46

     

    92270

    5

    26

    1/1/2005

                 40.84

                 40.84

    92275

    T

    TC

    1/1/2004

                  47.96

                47.96

     

    92270

    T

    TC

    1/1/2005

                 40.42

                 40.42

    92283

    5

    26

    1/1/2004

                    7.89

                  7.89

     

    92275

    5

    26

    1/1/2005

                  51.37

                  51.37

    92283

    T

    TC

    1/1/2004

                   24.13

                 24.13

     

    92275

    T

    TC

    1/1/2005

                 50.75

                 50.75

    92284

    5

    26

    1/1/2004

                   10.77

                 10.77

     

    92283

    5

    26

    1/1/2005

                    8.68

                   8.68

    92284

    T

    TC

    1/1/2004

                   69.81

                 69.81

     

    92283

    T

    TC

    1/1/2005

                 25.87

                 25.87

     

     

     

     

     

     

     

    92284

    5

    26

    1/1/2005

                   11.54

                   11.54

    Source:

    DMA

    Rate

    Setting

     

     

     

    92284

    T

    TC

    1/1/2005

                  60.17

                  60.17

    Clinical Policy and Programs
    DMA, 919-855-4260

     


    Attention: All Providers

    Extension of the Medicare Part D Transitional Coverage Period

    The U.S. Department of Health and Human Services has notified Medicare Part D prescription drug plans (PDP’s) that the 30-day transitional coverage period will be extended for an additional 60 days.  This will provide more time for beneficiaries to find out if they can save money by using other drugs that work in similar ways and may cost significantly less.  This action reinforces steps already taken by many PDP’s to help assure a smooth transition for beneficiaries.

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

     



    Attention: All Providers

    Medicare Part D Exceptions and Appeals Information from CMS

    If a provider is seeking prior authorization or a formulary exception from a Medicare Part D prescription drug plan (PDP) and the plan’s routine protocol fails or the contacts are being made after normal business hours, the exceptions numbers that are provided on the Centers for Medicare and Medicaid Services (CMS) website may be used.  The Medicare Part D appeals telephone numbers provided on the CMS website may be used to contact the plan to appeal a determination. Exceptions and appeals information and downloads for Medicare Part D prescription drug plans may be found at http://www.cms.hhs.gov/prescriptiondrugcovgenin/.

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


    Attention: All Providers

    Five-Year State Plan for Developmental Disability Services

    The North Carolina Council on Developmental Disabilities is a state agency that carries out a variety of activities with, and in support of, persons of any age with developmental disabilities, their family members, and other agencies and organizations involved with them.  Examples of such activities include policy development and legislative advocacy at the state and federal level.  The Council also funds demonstration projects to promote innovative, person-centered approaches to providing services and supports.  In addition to developmental needs and community support, many of these projects address health and medical needs.  They are carried out in partnership with the Division for Medical Assistance and local health related agencies and providers.

    The Council has started developing its new State Plan to cover the 2006 through 2011 time period.  The State Plan is an important document because it determines the types of projects the Council can fund, and the policy and legislative issues upon which they focus.  As part of the process to develop the State Plan, the Council seeks input from a wide variety of sources:  consumers, advocacy and professional organizations, and providers. 

    The Council’s Five-Year State Plan can be reviewed online at the Council’s website (http://www.nc-ddc.org).  Comments can be submitted to the Council through the website or to Council staff person Duncan Munn (919-420-7901 or Fax 919-420-7917).  Feedback is requested prior to April 28.

    Input can also be provided through a series of local public hearings to be held across the state this spring.  For information on the public hearing schedule, refer to the Council’s website at http://www.nc-ddc.org.

    Clinical Policy and Programs
    DMA, 919-855-4260



    Attention: Area Mental Health Providers

    Addition of Facility-Based Crisis Intervention Services for Children

    Effective with date of service October 1, 2005, through March 19, 2006, LME Providers can bill for Facility-Based Crisis Intervention Services for Children ages 00-20.  The HCPC code/modifier combination to be used to bill for this service is S9485 with modifier HA.  This service is to be billed on a per diem basis at a rate of $372.23 per day. 

    This service will no longer be a covered service once the new Enhanced Services are implemented on March 20, 2006.

    Effective with date of service March 20, 2006, this service will be available for adults only and will be billed per hour at the rate of $18.78 per hour.  The HCPC code used to bill the service will be S9484.

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


    Attention: All Enhanced Mental Health Services Providers and Local Management Entities

    Billing Codes

     Effective with dates of service March 20, 2006, in accordance with mental health reform, providers will no longer be able to bill the following codes with their local management provider number:

    Providers may continue to bill H0036 HQ with their local management entity provider number until May 31, 2006.

    Note: Children’s Developmental Service Agencies and Community Based Rehabilitation Services who bill for services provided for ages 0 through 3 years with the HCPCS code H0036 codes are not affected by the change.

    HCPCS code H0035 billed with no modifier continues to be a covered service for all enhanced mental health services providers and local management entities.

     Behavioral Health Services
    DMA, 919-855-4291



    Attention: Home Health, Private Duty Nursing and Community Alternative Program Case Managers

    Deletion of Home Health Medical Supply Procedure Code

    HCPCS procedure code J1642, Injection, Heparin Sodium (heparin lock flush), will be removed from the home health fee schedule, effective February 1, 2006.  Providers can bill heparin sodium IV flush kits (Hep-Loc kits) using the home health supply miscellaneous code, T1999, on any claim submitted after this date, regardless of the date of service on the claim.  This action is being taken to comply with HIPAA policy.  The code did not adequately describe the supply and the corresponding Medicare allowed rate did not cover the cost.  The maximum allowable for most procedure codes must be set at Medicare rates.  The billed amount for this service should be the agencies usual and customary charge for the item.

    Adelle Kingsberry, Clinical Policy
    DMA, 919-855-4380  


     Attention: CAP/DA Lead Agencies and AQUIP Users

    Quarterly AQUIP System Training Seminar

     The first quarterly AQUIP training seminar for CAP/DA Lead Agencies and other AQUIP users is scheduled for March 28, 2006 at the Days Inn Conference Center in Southern Pines.  Attendance at these sessions is of the utmost importance.  The seminar will focus on the items covered in the seminars that were held in December including the new AQUIP system, RUGs, Quality Measures and changes to the AQUIP User/System Manual.

    Lead agencies were provided with a list of AQUIP users in their county who are required to attend the training seminar.  Please contact your lead agency to determine if your attendance is required.

    Pre-registration is required.  CAP/DA Lead Agency staff and other AQUIP users may register online by going to the AQUIP web site at https://www2.mrnc.org/aquip and clicking on registration.  A computer-generated confirmation number will confirm your registration.

    This AQUIP training session is scheduled to begin at 9:30 a.m. and end at 3:30 p.m. Lunch will not be provided.  Registration will be from 8:30 a.m. to 9:30 a.m.

    Driving Directions to the Days Inn Conference Center 650 US Hwy 1 at Morganton Rd. Southern Pines. 910-692-8585

    From North

    Highway 1 South to Southern Pines, take the Morganton Rd. Exit.  Make a right onto Morganton Rd.  Hotel is on the right.

    From South

    Highway 1 North to Southern Pines, take the Morganton Rd. Exit.  Make a left on Morganton Rd.  Hotel is on the right.

    From East

    I-40 West to Exit 293 I-440/US 1/US 64 to Exit 293A Highway 1 South to Southern Pines.  Take Morganton Rd. Exit.  Hotel is on right.

    From West

    I-40 East to Hwy 220 South to Hwy 211 East to 15/501 South.  Make a left onto Morganton Rd.  Hotel is approximately 1.5 miles on the left.

    From 15/501 South

    15/501 South left onto Morganton Rd.  Hotel is approximately 1.5 miles on the left.

    From 15/501 North

    Right at Morganton Rd.



    Attention: Children Developmental Service Agencies

    Case Management Code

    Effective with date of service March 1, 2006, Children’s Developmental Service Agencies (CDSA’s) will no longer be able to bill case management with the code T1016.  CDSA's should continue to use T1017 HI to bill for case management.

     Carol Robertson, Behavioral Health Services

    DMA, 919-855-4290


    Attention: Home Infusion Therapy Providers

    Billing for Services with Medicare Part D

    Home Infusion Therapy (HIT) providers may bill the Medicaid program for the professional therapy component when the drug is covered under the Medicare Part D program.  The HIT provider should bill Medicaid using the procedure code(s), S9325, S9329 or S9494, as applicable to the therapy provided and the procedure code for the nursing component, T1030.  The appropriate modifier(s) should be used when billing multiple concurrent therapies.  The drug should be billed to Medicare according to Medicare Part D following their guidelines.

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

     


     Attention: Nursing Facility Providers

    Successful MDS Validation Review Seminar

     In April 2006, Myers and Stauffer is scheduled to present seminars on “Going From Better to BEST” Strategies For a Successful MDS Validation Review for nursing facility providers.

    The seminar is designed and produced under contract with the Division of Medical Assistance.  The latest statistics of the Medicaid MDS validation reviews will be presented, including a discussion of the most frequently unsupported MDS RUG-III items.

    Special emphasis will be placed on a thorough discussion of the updated supportive documentation guidelines, restorative nursing program elements and documentation on mood, behavior and cognition MDS items.  Case studies will be presented that include a RUG-III calculation and will demonstrate the financial impact of an unsupported assessment.

    Training Locations and Dates:

    Fayetteville – April 11th
    Holiday Inn I-95
    1944 Cedar Creek Road
    Fayetteville, NC 28312
    (919) 323-1600

    Greenville – April 13th
    Hilton Greenville
    207 Greenville Blvd. SW
    Greenville, NC  27834
    (252) 355-5000

    Asheville – April 18th
    Crowne Plaza Resort
    One Holiday Drive
    Asheville, NC  28806
    (828) 254-3211

    Charlotte – April 19th
    Marriott Executive Park
    5700 Westpark Drive
    Charlotte, NC  28217

    Raleigh – April 20th
    Hilton North Raleigh
    3415 Wake Forest Road
    Raleigh, NC  27609
    (919) 872-2323

    Seminar Hours

    Registration begins at 8:30 a.m.  The seminar begins promptly at 9:00 a.m. and concludes by 3:30 p.m.  Providers may register online at http://www.mslc.com.  If you have questions, please call Myers & Stauffer at 1-800-877-6927.

     Facility Services Unit
    DMA, 919–855-4350



    Attention: All Optical Service Providers

    CPT Code Changes for Dispensing Low Vision Aids

     The Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) deleted CPT code 92392, effective with date of service December 31, 2005.  The replacement HCPCS code, V2797, is covered by the N. C. Medicaid program effective with date of service January 1, 2006.  Claims submitted with end-dated codes will deny.

     

    Discontinued  Procedure Code

    Description

    New Procedure Code

    Description

    92392

    Supply of low vision aids

    V2797

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

     

     

     

     

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

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

     


    Attention: Pharmacists

    Medicare Part B Override Code Update

     Pharmacists may continue to use the Medicare Part B override code to submit claims to Medicaid in situations where a recipient has been inaccurately identified as Medicare Part B eligible.  These situations include cases where there are errors in the Medicaid eligibility file indicating that the recipient has Medicare Part B coverage when they are not eligible or when their coverage has been terminated.  In these situations, enter a ‘1’ in the PA/MC field.  If the claim must be submitted on paper, enter an ‘O’ in the family planning field and indicate the reason the override is needed in the space at the bottom of the manual claim form.

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

     


    Attention: Pharmacists

    Recipients with Medicare Deductibles

     Pharmacy providers who bill pharmacy claims for recipients who have a Medicare deductible should bill Medicaid for the portion of the pharmacy claim that is applied to the Medicare deductible on the pharmacy manual claim form.  These claims will be manually reviewed for payment.  An ‘O’ should be entered in the family planning field on the form.  A copy of the Medicare explanation of benefits (EOB) must also accompany the claim.

    A copy of the pharmacy manual claim form is available on DMA’s website.

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

     


    Attention: Prescribers and Pharmacists

    N.C. Medicaid Upper Limits for Betaseron 0.3mg, Migranal Nasal Spray and Toradol/Ketolac 10mg Tablets

    The N.C. Medicaid program will implement limits on the number of dosage units that can be dispensed each month for prescriptions for Betaseron 0.3mg vial, Migranal Nasal Spray and Toradol/Ketolac 10mg tablets.  These limits are based on the Food and Drug Administration’s approved dosing recommendations.

    Effective with date of service March 1, 2006, the following upper limits will apply:

    Drug Description

    Upper Limit

    Betaseron 0.3mg vial

    30 mls per month

    Migranal Nasal Spray 4ml

    2 kits per month

    Migranal Nasal Spray 6ml

    1 kit per month

    Toradol 10mg tablets

    20 tablets per month

    Ketorolac 10mg tablets

    20 tablets per month

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

     


    NCLeads Update

    Information related to the implementation of the new Medicaid Management Information System, NCLeads, can be found online.  Please refer to the NCLeads website for information, updates, and contact information related to the NCLeads system.

    Provider Relations
    Office of MMIS Services
    919-647-8315

     


    Proposed Clinical Coverage Policies

    In accordance with Session Law 2003-284, proposed new or amended Medicaid clinical coverage policies are available for review and comment on DMA's website. To submit a comment related to a policy, refer to the instructions on the website. Providers without Internet access can submit written comments to the address listed below.

    Gina Rutherford
    Division of Medical Assistance
    Clinical Policy Section
    2501 Mail Service Center
    Raleigh, NC 27699-2501

    The initial comment period for each proposed policy is 45 days. An additional 15-day comment period will follow if a proposed policy is revised as a result of the initial comment period.


    2006 Checkwrite Schedule

    Month

    Electronic Cut-Off Date

    Checkwrite Date

    March

    03/03/06

    03/07/06

     

    03/10/06

    03/14/06

     

    03/17/06

    03/21/06

     

    03/24/06

    03/30/06

    April

    04/07/06

    04/11/06

            (c)

    04/13/06

    04/18/06

     

    04/21/06

    04/27/06

    May

    04/28/06

    05/02/06

     

    05/05/06

    05/09/06

     

    05/12/06

    05/16/06

     

    05/19/06

    05/25/06

     

    Electronic claims must be transmitted and completed by 5:00 p.m. on the cut-off date to be included in the next checkwrite.  Any claims transmitted after 5:00 p.m. will be processed on the second checkwrite following the transmission date.

    _____________________   _____________________
    Mark T. Benton, Senior Deputy Director and
    Chief Operating Officer
      Cheryll Collier
    Division of Medical Assistance   Executive Director
    Department of Health and Human Services   EDS

                                                                                                                                                               

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