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In This Issue…… 

All Providers: Carolina ACCESS Override Request Form Carolina ACCESS Override Requests Carolina ACCESS Provider Application Available on the Internet Changes to the Initial Hemoglobin or Hematocrit Health Check Screening Component Copayment Amounts for Recipients CPT Code Bundling CPT Code Update 2002 CPT Codes End-Dated for 2002 Health Insurance Portability and Accountability Act Compliance Survey Checkwrite Schedule Electronic Cut-Off Schedule Area Mental Health Centers: Completion of the Residential Authorization Form Residential Authorization Form Durable Medical Equipment Providers: HCPCS Code Changes Health Departments: Diabetes Outpatient Self-Management Training: Supervision Clarification Provision of Psychological Services in Health Departments Home Health Agencies: Prior Approval Process Hospital Providers: Revenue Code Changes

Independent Practitioner Program Providers: Prior Approval Process Local Education Agencies: Prior Approval Process Nursing Facility Providers: Requests for Retroactive Prior Approval Tracking Forms for the Preadmission Screening and Annual Resident Review Process Nurse Practitioners: Apligraf HCPCS Code Change Outpatient Therapy Services: Prior Approval Process Physicians: Apligraf HCPCS Code Change Case Conference for Sexually Abused Children Prior Approval Process Psychiatric Residential Treatment Facility Providers: Denials Relative to Patient Monthly Liability Residential Treatment Facility Providers for Levels II through IV: Completion of the Residential Authorization Form

Attention: All Providers

Carolina ACCESS Provider Application Available on the Internet

It is extremely important that the information on file with DMA for all Carolina ACCESS (CA) practices remains current and accurate to avoid potential claim denials or contract sanctions. Providers are responsible for ensuring that information on file with the Medicaid program for their practice or facility remains up-to-date. The Carolina ACCESS Provider Information Change form is available on DMA’s website under the heading "Forms." (Refer to the article entitled Reporting Changes in Provider Status to Medicaid in the October 2001 general Medicaid bulletin for information on notifying Medicaid of changes within your practice.)

Questions about participating with the CA program or general questions about CA should be directed to the regional Managed Care Consultant (refer to the January 2002 general Medicaid bulletin) or DMA Managed Care at 919-857-4022.
 

Provider Services
DMA, 919-857-4017

Attention: Durable Medical Equipment Providers

HCPCS Code Changes

Only code E1390 requires prior approval. However, as with all durable medical equipment, a Certificate of Medical Necessity and Prior Approval form must be completed.
 

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

Attention: Independent Practitioner Program Providers, Local Education Agencies, All Providers of Outpatient Occupational, Physical, Speech, and Respiratory Therapy Services, Home Health Agencies, and Physicians

Prior Approval Process

Workshops regarding the prior approval process and billing are scheduled for the third week of May 2002. Please read your May general Medicaid bulletin promptly. The registration form and a list of the workshop locations will be included in the May general Medicaid bulletin.
 

Nora Poisella, Behavioral Health Services
Carol Robertson, Behavioral Health Services
DMA, 919-857-4020

Attention: Health Departments

Provision of Psychological Services in Health Departments

90801, 90802, 90804, 90806, 90808, 90810, 90812, 90814 and 90846, 90847 and 90853

Psychological services must be provided by a Licensed Clinical Social Worker (LCSW), an Advanced Practice Psychiatric Clinical Nurse Specialist (CNS), Advanced Practice Psychiatric Nurse Practitioner (NP) or Licensed Psychologist. All providers must function within the scope and practice of their state license and certification.

One of the following ICD-9-CM diagnosis codes must be present for the claim to process:

• 295.0 through 304.9
• 305.0
• 305.2 through 305.9
• 307.50
• 307.51
• 307.54
• 307.9
• 308 through 309.9
• 311 through 314.9
• V11.0 through V11.9
• V15.41 and V15.42
• V40 through V40.9
• V62.81, V62.82, and V62.83
• V70.1 and V70.2

Carol Robertson, Behavioral Health Services
DMA, 919-857-4020

Attention: Nursing Facility Providers

Tracking Forms for the Preadmission Screening and Annual Resident Review Process

To assure compliance with the federally mandated PASARR requirements, all Medicaid certified nursing facilities must complete the PASARR Tracking Form for every admission, regardless of pay source, and forward it to FH, the Division of Medical Assistance’s contractor for the PASARR program. The information documented on the Tracking Form communicates to FH the name of the admitting facility and assures that the facility will receive a copy of the Level I and, if appropriate, Level II screening results.

The requirements also mandate that when a screening has not been completed prior to admission or an annual review is not performed within the fourth quarter after the previous preadmission screen or annual resident review, Medicaid reimbursement must be denied. Once the Level I and, if appropriate, Level II screen is completed, Medicaid reimbursement will resume.

The Level I or Level II screening results must be kept in the resident’s medical record to allow availability to the facility’s care planning team and to federal and state auditors.

Tracking Forms must be completed for the following:

1. All first time admissions in the Level I process:

• Unless there is a significant change in status, no further contact with FH is required for Level I residents.
  
    

2.  All first time admissions in the Level II process and if:

• the Level II resident transfers to another Medicaid certified nursing facility;
• the Level II resident expires; or
• the Level II resident is discharged from the nursing facility. (Discharge means that the resident no longer resides in a Medicaid-certified nursing facility.)

Margaret O. Langston, RN, Institutional Services, Medical Policy Section
DMA, 919-857-4020

Attention: Nursing Facility Providers

Requests for Retroactive Prior Approval

Effective January 1, 2001, nursing facilities may request consideration of retroactive prior approval for nursing facility (NF) level of care with the initial FL2 submission to EDS. If the retroactive request is within thirty (30) days from the telephone prior approval or FL2 criteria review, medical records may not be needed by EDS to make a level of care decision. If the retroactive request is for a time period exceeding thirty (30) days, medical record documentation will be required by EDS to support the retroactive request and level of care decision.

EDS will also consider retroactive prior approval requests in the following instances:

• The Medicaid applicant’s eligibility was unknown when the nursing facility services were provided. When this situation occurs, a request for retroactive prior approval must be made in writing to EDS accompanied by documentation of Medicaid eligibility from the county department of social services, including the Medicaid eligibility approval date(s), the Medicaid application date, and medical record documentation for the requested time period. EDS must have this information before retroactive prior approval and level of care can be authorized.



Note: Retroactive prior approval will not be granted for time periods exceeding ninety (90) days from the date Medicaid eligibility was determined.

• The Medicaid recipient’s prior approval for service had not been obtained, but nursing facilities services were provided. In these situations, EDS will consider requests for retroactive prior approval and level of care. These requests must be made in writing to EDS with supporting medical record documentation for the requested retroactive time period and a current signed and dated FL2.



Note: Retroactive prior approval request approved in this category will not be granted for time periods exceeding ninety (90) days from the current request date.

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

Attention: All Providers

Changes to the Initial Hemoglobin or Hematocrit Health Check Screening Component

This change allows providers to perform hemoglobin or hematocrit screenings at the same time as the initial lead screenings performed at 12 months of age. As a reminder, federal regulations require lead screenings be performed at 12 and 24 months of age.
 

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

Attention: All Providers

CPT Code Bundling

Since procedures should be billed using the most comprehensive code to describe the service performed, the CCI bundles the component procedures of the service into the comprehensive code. Only the comprehensive code is paid.

Providers will receive an Explanation of Benefits (EOB) denial code if a component code is billed with the comprehensive code. The EOB indicates that the component code cannot be billed in addition to the comprehensive code.

Modifiers that define a separately identifiable service, such as modifier 59, will allow some coding pairs to unbundle. Medical records documenting the appropriate use of the modifier must be kept on file for at least five years to allow for post-payment reviews.
 

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

Attention: Physicians

Case Conference for Sexually Abused Children

Effective with date of service, April 1, 2002, Current Procedural Terminology (CPT) procedure code 99361 or 99362 should be billed to report a face-to-face case conference by a physician with health professionals or community agency representatives to coordinate patient care for sexually abused children.
 

99361	Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care (patient not present); approximately 30 minutes
99362	approximately 60 minutes

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

Attention: Hospital Providers

Revenue Code Changes

The following obsolete revenue codes were discontinued effective October 2001:
 

Revenue Code	Definition
RC 175	Nursery Neonatal – ICU
RC 701	Cast Room – Other
RC 890	Other – Donor Bank – General
RC 891	Other – Donor Bank – Bone
RC 892	Other – Donor Bank - Organ (Other Than Kidney)
RC 893	Other – Donor Bank – Skin
RC 899	Other – Donor Bank – Other

Ann H. Kimbrell, R.N., Institutional Services
DMA, 919-857-4020

Attention: All Providers

CPT Codes End-Dated for 2002

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

Attention: All Providers

CPT Code Update 2002

Claims submitted for dates of service January 1, 2002 through March 31, 2002 with deleted codes will be accepted for processing. Claims for dates of service on or after April 1, 2002 must be filed using the 2002 CPT codes listed in the table above.

The annual review of new CPT codes is ongoing. Providers will be notified concerning coverage of other new codes in future general Medicaid bulletins.
 

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

Attention: Health Departments

Diabetes Outpatient Self-Management Training: Supervision Clarification

The health department provider number should be used when billing the service. Refer to the November 1999 general Medicaid bulletin for additional coverage information.
 

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

Attention: All Providers

Copayment Amounts for Recipients

Providers may not charge copayments for the following services:

• Hospital emergency department services including physician services delivered in the emergency department
• Family planning services
• Services in state-owned psychiatric hospitals
• Services covered by both Medicare and Medicaid
• Services to persons under the age of 21
• Services related to pregnancy
• Services provided to residents of nursing facilities (NF), intermediate care facilities for mental retardation (ICF-MR), and psychiatric hospitals
• Health Check (EPSDT) related services
• Services provided to participants in the Community Alternatives Program (CAP)
• Services to enrollees of prepaid plans (HMOs) except services not covered under the HMO’s plan such as prescriptions and dental services
• Rural Health Clinic (RHC) core services
• Federally Qualified Health Center (FQHC) core services
• Nonhospital dialysis facility services
• Hospital inpatient services (inpatient physician services are not exempt)
• Home health services
• Hearing aid services
• Ambulance services
• Mental health clinic services
• Hospice services
• Durable medical equipment (DME)
• Private duty nursing (PDN) services
• Home infusion therapy

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

Attention: All Providers

Health Insurance Portability and Accountability Act Compliance Survey

Additional information regarding HIPAA can be found on the Division of Medical Assistance’s website.
 

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

Attention: Physicians and Nurse Practitioners

Apligraf HCPCS Code Change

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

Attention: Area Mental Health Center and Residential Treatment Facility Providers for Levels II through IV

Completion of the Residential Authorization Form

It is the responsibility of the Area Mental Health Center to submit the completed RAF to ValueOptions and EDS. The Area Mental Health Center may submit the completed RAF to ValueOptions either by fax at 919-941-0433 or by e-mail at ncmedicaid@valueoptions.com. A copy must also be submitted to EDS by fax at 919-233-6834.

Residential Treatment Facility providers for Levels II through IV are encouraged to obtain a copy of the RAF for their records for each and every child admitted to their facilities through the Area Mental Health Center, and to verify that the dates of admission and other information are accurate. Medicaid reimbursement will not occur until the RAF has been received and processed. In order to ensure that the RAF is received, the Residential Treatment Facility providers for Levels II through IV may also submit a copy of the RAF to ValueOptions and EDS.
 

Reba Hamm, Behavioral Health Services
DMA, 919-857-4020

Attention: Psychiatric Residential Treatment Facility Providers

Denials Relative to Patient Monthly Liability

Effective April 1, 2002, when a child is admitted to a PRTF bed, the DSS in the child's county of eligibility must be notified of the admission so the PML can be determined. The DSS will issue a Notification of Eligibility for Medicaid/Amount and Effective Date of Patient’s Liability form (DMA-5016), which indicates the amount of PML to be entered on the claim. Continue to bill on the UB-92 claim form using Bill Type 891 in form locator 4 and Revenue Code 911 in form locator 42. The PML must be entered in form locator 39 with a Value Code of 23. Failure to enter the code and a PML amount (even if the amount is $0.00) will result in denial of the claim.
 

Carolyn Wiser, Behavioral Health Services
DMA, 919-857-4025

Attention: All Providers

Carolina ACCESS Override Requests

The procedure to request an override before a service is rendered has not changed. Please continue to call the EDS Managed Care Unit at 1-800-688-6696 or 919-816-4321. Providers rendering medical care to a CA enrollee must contact the PCP for authorization. Providers must verify the PCP by viewing the recipient’s current Medicaid identification card or calling the Automated Voice Response (AVR) system at 1-800-723-4337. Overrides (verbal or written) will not be considered unless the PCP has been contacted and refused to authorize treatment.

PCPs are contractually required to provide services or authorize another provider to provide services until the county department of social services changes the CA status of a recipient. EDS is authorized to issue CA overrides only when extenuating circumstances beyond the control of the responsible parties affect access to medical care and the PCP refused to authorize treatment.
 

Laurie Giles, Managed Care Section
DMA, 919-857-4022

Checkwrite Schedule

Electronic Cut-Off 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.
 
 

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