April 2006 Medicaid Bulletin

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In This Issue...

All Providers:

Ambulance Providers:

CAP-MR/DD Providers:

Dental Providers:

Direct Enrolled Mental Health Providers:

Health Check Providers:

Local Management Entities:

All Mental Health Providers:

Nurse Practitioners:

Optical:

Pharmacy:

Physicians:

Prescribers and Pharmacists:


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

Epogen HCPCS Code Changes for the Physician’s Drug Program

Effective with date of service December 31, 2005, the following HCPCS codes for epoetin alfa (Epogen) were end-dated and replaced with new codes. Claims submitted for dates of service on or after January 1, 2006 using the end-dated codes will deny.

End-Dated HCPCS Code

New HCPCS Code

Description

Unit

Maximum Reimbursement Rate

Q4055

J0886

Epoetin alfa (for ESRD on dialysis)

1000 units

$10.00

Q0136

J0885

Epoetin alfa (for non-ESRD use)

1000 units

$9.49

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



Attention: All Providers

Family Planning Waiver Provider Seminar

In order to further clarify the Medicaid “BE SMART” Family Planning Waiver program, a provider seminar has been scheduled for May 2006.  This seminar is designed to assist providers in reducing the number of denied claims when billing for Family Planning Waiver services and to specifically address provider questions as they relate to the “BE SMART” program.  This seminar will also include a session on recipient eligibility, covered services, and billing.

Preregistration for this seminar is required.  Providers may register for this seminar by completing and submitting the registration form or by registering online.  A confirmation notice will be mailed to each registered participants.  The deadline for registration is April 30, 2006.

The seminars begin at 9:00 a.m. and end at 12:00 p.m.  Providers should arrive at least 30 minutes early.  Lunch will not be provided at the seminar.

Providers must print a copy of the May 2006 Special Bulletin, Medicaid Family Planning Waiver Program and bring it to the seminar.

Dates and Locations:

Monday, May 8, 2006
Jane S. McKimmon Center
1101 Gorman Street
Raleigh, NC

Thursday, May 18, 2006
Greenville City Hotel and Bistro
203 West Greenville Blvd.
Greenville, NC

Monday, May 22, 2006
Asheville Crown Plaza
One Holiday Inn Drive
Asheville, NC

Tuesday, May 23, 2006
Harris Conference Center
3216 CPCC West Campus Drive
Charlotte, NC

 

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



Directions to the Medicaid Family Planning Waiver Provider Seminars

Harris Conference Center - Charlotte, North Carolina – Tuesday, May 23, 2006

Traveling on Interstate 85
Take exit 33, Billy Graham Parkway.  Travel approximately 1.6 miles.  Turn left on Morris Field Drive.  Turn right on CPCC West Campus Drive.

Traveling on Interstate 77
Take exit 6B, Woodlawn Road.  Woodlawn Road becomes Billy Graham Parkway.  Travel 3.5 miles.  Turn right on Morris Field Drive.  Turn right on CPCC West Campus Drive.

Traveling from Uptown Charlotte
Take US-74 West (Wilkinson Blvd).  Travel 2.6 miles.  Turn left on Morris Field Drive.  Turn right on CPCC West Campus Drive. 

Asheville Crown Plaza – Asheville, North Carolina – Monday, May 22, 2006

From Interstate 240 West, take exit 3B.  Turn right and follow the signs directing you to the Crown Plaza Resort Hotel, which is located directly behind Westgate Shopping Center.

Jane S. McKimmon Center – Raleigh, North Carolina – Monday, May 8, 2006

Traveling East on I-40
Take exit 295 and turn left onto Gorman Street. Travel approximately one mile.  The Jane S. McKimmon Center is located on the right at the corner of Gorman Street and Western Boulevard.

Traveling West on I-40
Take exit 295 and turn right onto Gorman Street.  Travel approximately one mile.  The Jane S. McKimmon Center is located on the right before your reach Western Boulevard.

Greenville City Hotel and Bistro – Greenville, North Carolina – May 18, 2006

From Raleigh
Take 264 East to Wilson, N.C. and then to Greenville. Coming into Greenville city limits, turn right at the 2nd stoplight onto 264 Alternate (also called Allen Road). The hotel is 5 miles from the turn on the right.

From New Bern
Take 17 North to Vanceboro, N.C. In Vanceboro, take 43 East to Greenville. At the 3rd stoplight coming into Greenville (Plaza Mall is on your left), turn left onto Greenville Boulevard. The hotel is  approximately 2 miles on the left.

From North/South of North Carolina
Take Interstate 95 to Wilson, N.C. In Wilson, take 264 East to Greenville. Coming into Greenville city limits, turn right at the 2nd stoplight onto 264 Alternate (also Allen Road). The hotel is 5 miles from the turn on the right.



Attention: All Providers

2006 ICD-9-CM Diagnosis Codes

The following new 2006 ICD-9-CM procedure codes have been implemented effective with date of service October 1, 2005. 

00.40

00.41

00.42

00.43

00.45

00.46

00.47

00.48

00.66

00.70

00.71

00.72

00.73

00.74

00.75

00.76

00.80

00.81

00.82

00.83

00.84

01.26

01.27

37.41

37.49

81.18

84.56

84.57

84.58

84.71

84.72

84.73

86.97

86.98

92.20

 

The following new 2006 ICD-9-CM diagnosis codes have been implemented effective with date of service October 1, 2005. 

259.5

276.50

276.51

276.52

278.02

287.30

287.31

287.32

287.33

287.39

291.82

292.85

327.00

327.01

327.02

327.09

327.10

327.11

327.12

327.13

327.14

327.15

327.19

327.20

327.21

327.22

327.23

327.24

327.25

327.26

327.27

327.29

327.30

327.31

327.32

327.33

327.34

327.35

327.36

327.37

327.39

327.40

327.41

327.42

327.43

327.44

327.49

327.51

327.52

327.53

327.59

327.8

362.03

362.04

362.05

362.06

362.07

426.82

443.82

525.40

525.41

525.42

525.43

525.44

525.50

525.51

525.52

525.53

525.54

567.21

567.22

567.23

567.29

567.31

567.38

567.39

567.81

567.82

567.89

585.1

585.2

585.3

585.4

585.5

585.6

585.9

599.60

599.69

651.70

651.71

651.73

760.77

760.78

763.84

770.10

770.11

770.12

770.13

770.14

770.15

770.16

770.17

770.18

770.85

770.86

779.84

780.95

799.01

799.02

996.40

996.41

996.42

996.43

996.44

996.45

996.46

996.47

996.49

V12.42

V12.60

V12.61

V12.69

V13.02

V13.03

V15.88

V17.81

V17.89

V18.9

V46.13

V46.14

V49.84

V58.11

V58.12

V62.84

V64.00

V64.01

V64.02

V64.03

V64.04

V64.05

V64.06

V64.07

V64.08

V64.09

V69.5

V72.42

V72.86

V85.0

V85.1

V85.21

V85.22

V85.23

V85.24

V85.25

V85.30

V85.31

V85.32

V85.33

V85.34

V85.35

V85.36

V85.37

V85.38

V85.39

V85.4

 

The following 2006 ICD-9-CM procedure codes are non-covered effective with date of service October 1, 2005: 

39.73

The following 2006 ICD-9-CM diagnosis codes are non-covered effective with date of service October 1, 2005. 

V26.31

V26.32

V26.33

V59.70

V59.71

V59.72

V59.73

V59.74

Providers must use current national codes from the 2006 ICD-9-CM manual when submitting claims to N.C. Medicaid.

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



Attention: CAP-MR/DD Providers

2006 CAP – MR/DD Cost Report

A new CAP – MR/DD waiver program with new waiver service definitions and rates for CAP-MR/DD became effective September 1, 2005 instead of July 1, 2005 as had been anticipated originally.  As a result, cost data for the period July 1, 2005 through June 30, 2006 would be based on two different waiver programs with different services and funding sources.  This would complicate the reporting process, and the value of such data is questionable.  Therefore, the Division of Medical Assistance (DMA) is not requiring a CAP-MR/DD cost report to be submitted by providers for the period of July 1, 2005, through June 30, 2006.

Rate Setting
DMA, 919-855-4200



Attention: Dental, Ambulance, Optical, Direct Enrolled Mental Health Providers and Local Management Entities

Family Planning Waiver Provider Conference Call

In order to further clarify the Medicaid “BE SMART” Family Planning Waiver program, a provider conference call has been scheduled for May 2006 for following provider groups:  Dental, Ambulance, Optical, Direct Enrolled Mental Health Providers and Local Management Entities (LMEs).  These conference calls are designed to address provider questions about the “BE SMART” program and to provide a brief overview on recipient eligibility, covered services, and billing.  Each provider group and will have a specific date and time in which to call.  Each conference call will be 30 minutes in duration.  Staff from both EDS and DMA will be available to assist in answering provider questions. 

Preregistration for this conference call is required.  Only one person from each agency will need to register.  Providers may register by completing and submitting the registration form or by registering online. A confirmation notice will be mailed to each provider agency.  The notification will include the conference call-in telephone number and password.  Providers will need this information in order to participate in the conference call.  The deadline for registration is April 30, 2006.

Providers should print a copy of the May 2006 Special Bulletin, Medicaid Family Planning Waiver Program to use as a reference during the conference call.

Dates and Starting Times:

Provider Group

Date

Starting Time(s)

Dental

Wednesday, May 10, 2006

9:00 a.m.

10:00 a.m.

 

Ambulance

Wednesday, May 10, 2006

2:00 p.m.

   

Optical

Wednesday, May 10, 2006

3:00 p.m.

   

Direct-Enrolled Mental Health Providers and LMEs

Thursday, May 11, 2006

9:00 a.m.

11:00 a.m.

2:00 p.m.


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



Attention: Direct Enrolled Mental Health Providers and Local Management Entities

Carolina ACCESS Override Requests

Mental health services provided to recipients under the age of 21 require a referral from the recipient’s Carolina ACCESS primary care provider (PCP), the LME or a Medicaid enrolled psychiatrist. Obtaining a Carolina ACCESS override does not override the referral requirements referenced in the January 2005 and May 2005 Medicaid special bulletins

Please contact EDS Provider Services for billing questions.

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



Attention: Health Check Providers

Health Check Seminars

Health Check seminars for all providers, except health departments, are scheduled for May 2006.  Attendance at these seminars is very important. The seminars will focus on Health Check billing requirements, as well as vision and hearing assessments and developmental screenings.

A separate teleconference for local health departments sponsored by the Division of Public Health is scheduled for Wednesday, May 31, 2006.  Health departments should refer to the next page for information on registering for the teleconference.  Both the seminars and the teleconference will use the April 2006 Special Bulletin, Health Check Billing Guide 2006, as the primary handout for the session.  Providers must access and print the PDF version of the special bulletin and bring it to the session.

Preregistration is required.  Providers not registered are welcome to attend the seminars if space is available.  Providers may register by completing the registration form or by registering online. Please indicate the session you plan to attend on the registration form.  Seminars begin at 10:00 a.m. and end at 1:00 pm.  Providers are encouraged to arrive by 9:45 a.m. to complete registration.  Lunch will not be provided at the seminar.

Tuesday, May 2, 2006
Asheville Crown Plaza
One Holiday Inn Drive
Asheville, NC 28806

Tuesday, May 9, 2006
Greenville City Hotel & Bistro
203 Greenville Blvd SW
Greenville, NC 27834

Thursday, May 11, 2006
Jane S. McKimmon Center
1101 Gorman Street
Raleigh, NC 27601

Monday, May 15, 2006
Harris Conference Center
3216 CPCC West Campus Dr.
Charlotte NC 28208



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



Directions to the Health Check Billing Seminars

Crown Plaza Hotel & Resort – Asheville, North Carolina – Tuesday, May 2, 2006

From Interstate 240 West, take exit 3B.  Turn right and follow the signs directing you to the Crown Plaza Resort Hotel, which is located directly behind Westgate Shopping Center.

Greenville Hilton – Greenville, North Carolina – Tuesday, May 9, 2006

Take US 64 east to US 264 east.  Follow 264 east to Greenville.  Once you enter Greenville, turn right on Allen Road.  After traveling approximately 2 miles, Allen Road becomes Greenville Boulevard/Alternate 264.  Follow Greenville Boulevard for approximately 2½ miles.  The City Hotel & Bistro is located on the right.

Jane S. McKimmon Center – Raleigh, North Carolina – Thursday, May 11, 2006

Traveling East on I-40
Take exit 295 and turn left onto Gorman Street.  Travel approximately one mile.  The McKimmon Center is located on the right at the corner of Gorman Street and Western Boulevard.

Traveling West on I-40
Take exit 295 and turn right onto Gorman Street.  Travel approximately one mile.  The McKimmon Center is located on the right at the corner of Gorman Street and Western Boulevard.

Piedmont College Harris Conference Center- Charlotte, North Carolina – Monday, May 15, 2006

Traveling on Interstate 85
Take exit 33, Billy Graham Parkway.  Travel approximately 1.6 miles.  Turn left onto Morris Field Drive.  Turn right onto CPCC West Campus Drive.

Traveling on Interstate 77
Take exit 6B, Woodlawn Road.  Woodlawn Road becomes Billy Graham Parkway.  Travel 3.5 miles.  Turn right on Morris Field Drive.  Turn right on CPCC West Campus Drive.



Attention: All Providers

Family Planning Waiver Services

Effective with date of service October 1, 2005, the Division of Medical Assistance (DMA) implemented a 5-year demonstration waiver project for Medicaid family planning services.  Recipients eligible to receive waiver services are not eligible for benefits under any other current Medicaid program. 

Eligible recipients are issued a blue Medicaid identification card with the following statement printed on the card:

FAMILY PLANNING WAIVER:  RECIPIENT ELIGIBLE FOR LIMITED FAMILY PLANNING SERVICES ONLY.

The Medicaid Family Planning Waiver benefit program code and class MAFD, is also indicated on the card.  Providers should pay close attention to the program code “MAF” and the program class “D” to be able to properly identify family planning waiver recipients.  Family Planning Waiver recipients are only eligible for limited family planning services. Inpatient hospital services are not covered.  Outpatient hospital services that are not related to family planning are also not covered by the Family Planning Waiver.

The Automated Voice Response System (AVRS), on-line and batch eligibility requests have been modified to provide the fourth character program class “D,” which will help to identify family planning waiver recipients.  Medicaid Family Planning Waiver is the only program that reports the fourth character of “D.”  All others Medicaid program codes will continue to report the normal three characters.

For more information, refer to the January 2006 Special Bulletin, Family Planning Waiver “Be Smart”.

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



Attention: Mental Health Services Providers

Utilization Review

In the future ValueOptions will be performing utilization review for all Medicaid mental health, substance abuse, and developmental disabilities services. 

Information will be available after April 10, 2006 on the ValueOptions web site http://www.valueoptions.com regarding transition and training, registration information, and workshop times and locations.  Once on that web page click link for providers, and on contract specific information, Medicaid or Health Choice.  Please also monitor the web sites for the Division of Medical Assistance and the Division of Mental Health, Developmental Disabilities, Substance Abuse Services after April 10, 2006 for information.

If you have questions, please contact Carol Robertson at 919-855-4290

Behavioral Health Services
DMA, 919-855-4290



Attention: Pharmacy

Family Planning Waiver Provider Conference Call

In order to further clarify the Medicaid “BE SMART” Family Planning Waiver program, a provider conference call has been scheduled for May 2006 for Pharmacy providers.  This conference call is designed to address provider questions about the “BE SMART” program and to provide a brief overview on recipient eligibility, covered services, and billing.  Your provider group and will have a specific date and time in which to call.  Each conference call will be 30 minutes in duration.  Staff from both EDS and DMA will be available to assist in answering provider questions. 

Preregistration for this conference call is required.   Only one person from each agency will need to register.  Providers may register by completing and submitting the registration form or by registering online.   A confirmation notice will be mailed to each provider agency.  The notification will include the conference call-in telephone number and password.  Providers will need this information in order to participate in the conference call.  The deadline for registration is April 30, 2006.

Providers should print a copy of the May 2006 Special Bulletin, Medicaid Family Planning Waiver Program to use as a reference during the conference call.

Dates and Starting Times:

Provider Group

Date

Starting Time(s)

Pharmacy

Tuesday, May 9, 2006

9:00 a.m.

10:00 a.m.

11:00 a.m.

2:00 p.m.

3:00 p.m.

4:00 p.m.

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



Attention: Physicians and Nurse Practioners

Abatacept, 250 mg (Orencia, J3590) Billing Guidelines

Effective with date of service January 1, 2006, the N.C. Medicaid program covers abatacept (Orencia) for use in the Physician’s Drug Program when billed with HCPCS code J3590 (unclassified biologics).  Orencia is the first selective modulator of a co-stimulatory signal required for full t-cell activation, for the treatment of rheumatoid arthritis (RA) approved by the Food and Drug Administration (FDA).  Orencia is indicated for reducing the signs and symptoms of RA, inducing major clinical response, slowing the progression of structural damage, and improving physical function in adult patients with moderately to severely active RA who have had an inadequate response to one or more disease-modifying anti-rheumatic drugs (DMARDS), such as methotrexate (MTX) or tumor necrosis factor (TNF) antagonists.  Orencia may be used as monotherapy or concomitantly with DMARDs other than TNF antagonists.  Orencia should not be administered concomitantly with TNF antagonists and is not recommended for use with anakinra.

Orencia is administered as a 30-minute intravenous infusion at a fixed dose based on weight range approximating 10 mg/kg at day 0, 2 weeks, 4 weeks, and every four weeks thereafter.

For Medicaid Billing:

  • The ICD-9-CM diagnosis code 714.0 (rheumatoid arthritis) is required when billing for Orencia.
  • Providers must bill Orencia with HCPCS code J3590, with the original invoice or copy of the original invoice, attached to the CMS-1500 claim form.  An invoice must be submitted with each claim.  The paper invoice must include the recipient’s name and Medicaid identification number, the name of the medication, the dosage given, the National Drug Code (NDC) number from the vial(s) used, the number of vials used, and the cost per dose.
  • Providers must indicate the number of units given in block 24G on the CMS-1500 claim form.
  • Providers must bill their usual and customary charge. 
  • One unit of coverage is 250 mg. The maximum reimbursement rate per unit is $506.25.  The fee schedule for the Physician’s Drug Program is available on DMA’s Fee Schedule web page.

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



    Attention: Physicians and Nurse Practioners

    Lymphocyte Immune Globulin, Antithymocyte Globulin, Equine, Parenteral, 250 mg (Atgam, J7504) - Billing Guidelines

    Effective with date of service January 1, 2006, the N.C. Medicaid program covers lymphocyte immune globulin, anti-thymocyte globulin equine sterile solution (Atgam) for use in the Physician’s Drug Program when billed with HCPCS code J7504.  Atgam is a lymphocyte-selective immunosuppressant.  The FDA approved indications for Atgam include the management of allograft rejection in renal transplant patients and the treatment of moderate to severe aplastic anemia in patients who are unsuitable for bone marrow transplantation.  The current FDA recommended dosing schedules for Atgam are provided below.

    Renal Allograft Recipients:

  • Delaying the onset of allograft rejection:  Give a fixed dose of 15 mg/kg daily for 14 days, then every other day for 14 days for a total of 21 doses in 28 days.  Administer the first dose within 24 hours before or after the transplant.
  • Treatment of rejection:  The first dose of Atgam can be delayed until the diagnosis of the first rejection episode.  The recommended dose is 10 to 15 mg/kg daily for 14 days.  Additional alternate-day therapy up to a total of 21 doses can be given.
  • Aplastic Anemia:  Administer 10 to 20 mg/kg daily for 8 to 14 days.  Additional alternate-day therapy up to a total of 21 doses can be administered.

    For Medicaid Billing:

  • Providers must bill J7504 for Atgam.
  • Providers must indicate the number of units given in block 24G on the CMS-1500 claim form. 
  • Providers must bill their usual and customary charge.
  • One unit of coverage is 250 mg.  The maximum reimbursement rate per unit is $299.24.  The fee schedule for the Physician’s Drug Program is available on DMA’s Fee Schedule web page.

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



    Attention: Prescribers and Pharmacists

    Clarification on Coverage of Birth Control Pills for Diagnoses Other than Contraception

    The N.C. Medicaid program does not cover birth control pills for indications that are not considered medically accepted indications for their use.  A medically accepted indication is defined as the use of a drug that is supported by the Food and Drug Administration or which is cited in drug use review compendia including:

  • American Hospital Formulary Service Drug Information,
  • United States Pharmacopeia-Drug Information, or
  • DRUGDEX Information System.
  • Clinical Coverage Policy No. 9, Outpatient Pharmacy Program, was revised on February 1, 2006, to reflect current Medicaid pharmacy policy and supercedes any past references in bulletin articles and pharmacy newsletters.  

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



    Attention: Prescribers and Pharmacists

    Nicotine Products on the Over-The-Counter Coverage List

    The following nicotine products are available over-the-counter for reimbursement by N.C. Medicaid in conjunction with a prescription order by the physician.

    OTC Medication Name and Strength

    NDC

    MFG

    Effective Date of Coverage

    Nicoderm CQ  7mg/24hours (14)

    00766-1470-12

    GSK

    7/20/2005

    Nicoderm CQ  7mg/24hours (14)

    00766-1440-20

    GSK

    2/03/2006

    Nicoderm CQ  14mg/24hours (14)

    00766-1430-20

    GSK

    7/20/2005

    Nicoderm CQ 21mg/24hours (7)

    00766-1450-10

    GSK

    7/20/2005

    Nicoderm CQ 21mg/24hours (14)

    00766-1450-20

    GSK

    7/20/2005

    Nicotrol 15mg/16hrs (7)

    00045-0602-08

    GSK

    7/20/2005

    Nicotrol 15mg/16hrs (7)

    00009-5197-02

    GSK

    7/20/2005

    Commit 2mg

    00135-0208-01

    GSK

    7/20/2005

    Commit 2mg

    00135-0208-03

    GSK

    7/20/2005

    Commit 4 mg

    00135-0209-01

    GSK

    7/20/2005

    Commit 4 mg

    00135-0209-03

    GSK

    7/20/2005

    Nicorette Gum 2mg (48)

    00766-0045-45

    GSK

    7/20/2005

    Nicorette Gum 2mg (48)

    00766-0043-60

    GSK

    7/20/2005

    Nicorette Gum 2mg (108)

    00766-0045-08

    GSK

    7/20/2005

    Nicorette Gum 2mg (168)

    00766-0045-60

    GSK

    8/17/2005

    Nicorette Gum 4mg (48)

    00766-0047-48

    GSK

    7/20/2005

    Nicorette Gum 4mg (108)

    00766-0047-08

    GSK

    7/20/2005

    Nicorette Gum 4mg (168)

    00766-0047-60

    GSK

    7/20/2005

    Refer to General Clinical Policy No. A-2 on DMA’s website for additional information.

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



    Attention: Prescribers and Pharmacists

    Pharmacy Episodic Drug Policy - Quantity Limitations on Sedative Hypnotics

    The N.C. Medicaid program will implement the pharmacy episodic drug policy on May 1, 2006.  This new policy allows DMA to impose quantity limitations for drugs used episodically and in quantities that support less than daily use.  Quantity limitations will be based on FDA labeling and evidence-based guidelines that are in line with best practice standards.

    The first drug classes that quantity limitations will be placed on are the sedative hypnotic drug classes H2E and H8B.  Recipients will be able to obtain 15 units of these drugs each month with additional quantities requiring prior authorization.  Prior authorization for quantities in excess of 15 units each month must be requested through the N.C.  Medicaid prior authorization program.  Prior authorization criteria and forms for the sedative hypnotics are available on the DMA ACS Prior Authorization website.

    The following limitations will be in effect on May 1, 2006:

    Episodic Drugs Quantity Dispensing Limits

    Drug

    GCN

    Quantity Limit per Month

    Maximum Days Supply

    Prior Authorization Allowed for Excess Quantities

    Ambien, Ambien CR

    00870, 00871, 25456, 25457

    15

    34

    Yes

    Sonata

    92723, 92713

    15

    34

    Yes

    Prosom, Estazolam

    19181, 19182

    15

    34

    Yes

    Dalmane, Flurazepam

    14250, 14251

    15

    34

    Yes

    Restoril, Temazepam

    13840, 13841, 13845, 24036

    15

    34

    Yes

    Halcion, Triazolam

    14280, 14281, 14282

    15

    34

    Yes

    Doral

    40870, 40871

    15

    34

    Yes

    Lunesta

    23925, 23926, 23927

    15

    34

    Yes

    Rozerem

    25202

    15

    34

    Yes

     

     

     

     

     

     

     

     

     

     

     

    Refer to Clinical Coverage Policy No. 9, Outpatient Pharmacy Program, on DMA’s website at for additional information on the pharmacy episodic drug policy.

    ACS
    1-866-246-8505
    Fax: 1-866-246-8507



    Attention: Prescribers and Pharmacists

    Pharmacy Seminars

    Seminars for the outpatient pharmacy program are scheduled for May 2006.  This seminar is designed to educate prescribers and pharmacists on the policy changes that will be effective no earlier than June 1, 2006.  

    Preregistration for this seminar is required.  Providers may register for this seminar by completing and submitting the registration form or by registering online.  A confirmation notice will be mailed to each registered participants.  The deadline for registration is April 30, 2006.

    The seminars begin at 7:00 p.m. and end at 9:00 p.m.  Providers should arrive at least 30 minutes early. 

    Providers must print a copy of the May 2006 Special Bulletin, Outpatient Pharmacy Program and bring it to the seminar.

    Dates and Locations:

    Thursday, May 4, 2006
    Greenville City Hotel and Bistro
    203 West Greenville Blvd.
    Greenville, NC

    Thursday, May 11, 2006
    Coast Line Convention Center
    503 Nutt St.
    Wilmington, NC

    Tuesday, May 16, 2006
    Wake Technical Community College
    9101 Fayetteville Rd.
    Raleigh, NC

    Wednesday, May 24, 2006
    Asheville Crown Plaza
    One Holiday Inn Drive
    Asheville, NC

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



    Directions to the Medicaid Pharmacy Seminars

    Greenville City Hotel and Bistro – Greenville, North Carolina – Thursday, May 4, 2006

    From Raleigh
    Take 264 East to Wilson, N.C. and then to Greenville. Coming into Greenville city limits, turn right at the 2nd stoplight onto 264 Alternate (also called Allen Road). The hotel is 5 miles from the turn on the right.

    From New Bern
    Take 17 North to Vanceboro, N.C. In Vanceboro, take 43 East to Greenville. At the 3rd stoplight coming into Greenville (Plaza Mall is on your left), turn left onto Greenville Boulevard. The hotel is approximately 2 miles on the left.

    From North/South of North Carolina
    Take Interstate 95 to Wilson, N.C. In Wilson, take 264 East to Greenville. Coming into Greenville city limits, turn right at the 2nd stoplight onto 264 Alternate (also Allen Road). The hotel is 5 miles from the turn on the right.

    Coast Line Convention Center - Wilmington, North Carolina – Thursday, May 11, 2006

    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.

    Wake Technical Community College- Raleigh, North Carolina – May 16, 2006

    From I-40, take the South Saunders Street/U.S. 70 East/U.S. 401 South exit. Follow U.S. 401 South approximately nine miles. The college will be on the left.

    Asheville Crown Plaza – Asheville, North Carolina – Wednesday, May 24, 2006

    From Interstate 240 West, take exit 3B.  Turn right and follow the signs directing you to the Crown Plaza Resort Hotel, which is located directly behind Westgate Shopping Center.



    Attention: Prescribers and Pharmacists

    Prescription Limitations

    Effective no earlier than June 1, 2006, the monthly prescription limitation will change from 6 prescriptions per recipient per month to 8 prescriptions per recipient per month.  Pharmacists will be able to override the monthly prescription limit with three additional prescriptions per recipient per month.  Overrides will be available at the discretion of the pharmacist and in consultation with the recipient’s physician based on the assessment of the recipient’s need for additional medications during the month of service.

    Some recipients have clinical indications that warrant more prescriptions than are allowed under the monthly prescription limitations and will be exempt from the monthly limitations.  DMA will require that recipients receiving more than 11 prescriptions per month be evaluated as part of a medication therapy management program.  Recipients identified for the medication therapy management program who require more than 11 prescriptions each month will be restricted to a single pharmacy.  Pharmacies participating in this program will be eligible for a monthly medication therapy management fee for each Medicaid recipient being managed. The recipient’s physician and pharmacist will be reviewing the recipient’s medication profile to ensure clinically appropriate and cost effective use of drug therapy. 

    For more detail information, please refer to the May 2006 Special Bulletin, Outpatient Pharmacy Program.

    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

    April

    04/07/06

    04/11/06

     

    04/13/06

    04/18/06

     

    04/21/06

    04/27/06

    May

    04/28/06

    05/0206

     

    05/05/06

    05/09/06

     

    05/12/06

    05/16/06

     

    05/19/06

    05/25/06

    June

    06/02/06

    06/06/06

            (c)

    06/09/06

    06/13/06

     

    06/16/06

    06/22/06

    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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