|
|
Checkwrite Schedule
EPSDT Applicability to Medicaid Services and Providers
Proposed Clinical Coverage Policies
Effective March 1, 2008, Medicare began denying claims that did not contain a National Provider Identifier (NPI). As a result, if a provider requests a Medicare adjustment on a claim that when originally adjudicated did not contain an NPI, Medicare will adjudicate the adjustment claim but will not automatically cross the claim over to Medicaid due to the claim's lack of an acceptable NPI. Medicare contractors will inform the providers via the customary special provider notification letters that Medicare could not cross the claims over due to lack of a valid NPI.
Therefore, if a Medicare adjustment for claims submitted with no NPI affects Medicaid adjudication, N.C. Medicaid providers will need to submit a replacement claim or a manual adjustment request to EDS.
NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!
EDS, 1-800-688-6696 or 919-851-8888
Effective May 23, 2008, the National Provider Identifier (NPI) number will be required on pharmacy claims for the billing provider. Pharmacy providers are encouraged to submit the NPI number as the prescriber ID on pharmacy claims but may continue to submit the NPI number or the DEA number as the prescriber ID until further notice.
NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!
EDS, 1-800-688-6696 or 919-851-8888
Effective May 23, 2008, all claims must contain a National Provider Identifier (NPI). The N.C. Medicaid Program will no longer accept claims submitted without an NPI effective May 23, 2008. Unless the provider is atypical, failure to use the NPI by this date will result in a claim denial.
All claims should contain the following information:
Note: Pharmacy providers must submit claims with their NPI number and the prescriber’s NPI number or DEA number entered on the claim.
For placement of data on the 837 transaction, consult the X12 Implementation Guide. The NCECSWeb tool now contains fields to report this information. For CMS-1500, UB-04, and ADA claim forms, consult the June 2007 Special Bulletin, New Claim Form Instructions.
DMA encourages all providers (except pharmacies) to continue to submit their NPI, Medicaid Provider Number (MPN), and taxonomy. DMA will notify the billing provider by mail (Provider Ready letter) once it is determined that the NPI submitted on the claim is mapping correctly to the MPN submitted by the provider. Refer to future general Medicaid bulletins for additional information on the Provider Ready letters.
NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!
EDS, 1-800-688-6696 or 919-851-8888
Effective May 23, 2008, all claims must contain a National Provider Identifier (NPI) and a taxonomy code (except pharmacy claims, which only require an NPI). Claims will deny if they are
The following EOB codes indicate claim denials related to NPIs and taxonomy codes:
The following EOB codes indicate pharmacy claim denials related to NPI:
The following EOB codes have been modified to include NPI-related claim denials:
NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!
EDS, 1-800-688-6696 or 919-851-8888
Baby Love Program services include Maternity Care Coordination, Child Service Coordination, Maternal Outreach Worker Services, Childbirth Education, Home Visit for Newborn Care and Assessment, Home Visit for Postnatal Assessment and Follow-up Care, Skilled Nurse Home Visit, and Health and Behavior Intervention.
The Medicaid provider enrollment application for Baby Love Program services and the instructions for completion are now available on DMA’s Provider Enrollment web page. Choose Maternity Care Coordination/Child Service Coordination from the drop-down menu.
Baby Love Program provider qualifications can be found in the clinical policies listed on the Baby Love Program web page.
Provider Enrollment
DMA, 919-855-4050
Beginning May 1, 2008, as N.C. Health Choice (NCHC) recipients re-enroll in Health Choice, they will see two changes in their benefit cards.
The purpose of these two changes is to encourage providers to verify eligibility prior to rendering services rather than relying on the coverage end date currently on the front of the card. NCHC eligibility can be verified through the online mechanism currently in place through Blue Cross Blue Shield of North Carolina.
Cinnamon Narron
N.C. Health Choice, 919-284-0373
The Deficit Reduction Act of 2005 (DRA) includes provisions regarding state collection and submission of data for the purpose of collecting Medicaid drug rebates from manufacturers for all professional and institutional claims.
Effective with date of processing July 1, 2008, the N.C. Medicaid Program will require providers to list the 11-digit National Drug Codes (NDC) in addition to the HCPCS codes and units on professional claims that crossover from Medicare for all drugs administered by providers in offices, clinics or outpatient facilities. Claims will continue to be reimbursed in the same manner.
Refer to the revised version (3/03/08) of the October 2007 Special Bulletin, National Drug Code Implementation, for instructions.
EDS, 1-800-688-6696 or 919-851-8888
The Deficit Reduction Act of 2005 (DRA) includes provisions regarding state collection and submission of data for the purpose of collecting Medicaid drug rebates from manufacturers for all professional and institutional claims.
Effective with date of processing July 1, 2008, the N.C. Medicaid Program will require providers to list the 11-digit National Drug Code (NDC) in addition to the HCPCS codes and units on all outpatient institutional claims billed with Revenue Codes 25X, 634, 635, and 636 for all drugs administered by physicians.
Providers affected by this change must implement a process to record and maintain the NDC(s) of the drug(s) administered to the recipient as well as the quantity of the drug(s) given. An 11-digit NDC must be billed with the individual HCPCS code that corresponds to the appropriate Revenue Code.
Refer to the revised version (3/03/08) of the October 2007 Special Bulletin, National Drug Code Implementation, for instructions.
EDS, 1-800-688-6696 or 919-851-8888
Community Care of North Carolina/Carolina ACCESS (CCNC/CA) override numbers are emergency authorization numbers issued by EDS for CCNC/CA-enrolled recipients that allow providers to receive reimbursement for medical services without authorization from the primary care provider (PCP). Override requests are considered only if extenuating circumstances beyond the control of the responsible parties affect access to medical care. The override request must come from the provider who rendered the service. Overrides will not be given to a Medicaid recipient.
The following steps must be followed before requesting an override:
EDS, 1-800-688-6696 or 919-851-8888
Independent Practitioner Program seminars are scheduled to be held in several locations throughout the State during the month of July 2008. The seminars are intended to educate providers on the basics of Medicaid billing for Independent Practitioner Program services.
The seminar sites and dates will be announced in the June 2008 general Medicaid Bulletin. Preregistration will be required and will be limited to two staff members per office. Unregistered providers are welcome to attend if space is available.
EDS, 1-800-688-6696 or 919-851-8888
Clinical Coverage Policy #1K-1, Breast Imaging Procedures, was published on June 1, 2007. At that time, new claims payment system audits were introduced. Issues with the system audits that were incorrectly causing claims to deny have been identified and corrected. Providers who received claim denials for the following codes with the following EOBs may resubmit new claims (not adjustments) for processing effective with date of service June 1, 2007.
|
EOB |
Description |
Codes Involved |
|---|---|---|
|
714 |
Routine, annual or screening mammography non-covered. |
77055 and 77056 billed with ICD-9-CM diagnosis codes 793.80 and 793.82 through 793.89. |
|
773 |
Exceeds limit per 365 days. |
RC403 billed with 2 units. |
|
5223 |
No payment for add-on code allowed if primary code in series is not paid for the same date of service, same provider. |
G0204 and G0206 billed with 77051, and G0202 billed with 77052. |
Clinical Coverage Policy #1K-1, Breast Imaging Procedures
EDS, 1-800-688-6696 or 919-851-8888
The following new or amended clinical coverage policies are now available on the DMA 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
In compliance with the Improper Payments Information Act of 2002, CMS implemented a Payment Error Rate Measurement (PERM) program to measure improper payments in the Medicaid program and the State Children’s Health Insurance Program (SCHIP). North Carolina has been selected as one of 17 states required to participate in PERM reviews of claims paid in federal fiscal year 2007 (October 1, 2006 through September 30, 2007).
CMS is using three national contractors to measure improper payments. One of the contractors, Livanta LLC (Livanta), will be communicating directly with providers and requesting medical record documentation associated with the sampled claims (approximately 800 to 1200 claims for North Carolina). Providers are required to furnish the records requested by Livanta within a timeframe indicated by Livanta.
Livanta began requesting medical records for the sampled claims in North Carolina on November 20, 2007. Providers are urged to respond to these requests promptly. Records must be submitted by providers no later than 60 days after issuance of the contractor’s letter requesting such records (PERM Final Rule, Federal Register/Vol. 72, No. 169/Friday, August 31, 2007/Rules & Regulations, pg. 50496).
Providers are reminded of the requirement in Section 1902(a)(27) of the Social Security Act and 42 CFR Part 431.107 to retain any records necessary to disclose the extent of services provided to individuals and, upon request, furnish information regarding any payments claimed by the provider for rendering services.
Provider cooperation to furnish requested records is critical in this CMS project. No response to requests and/or insufficient documentation will be considered a payment error. This can result in a payback by the provider and a monetary penalty for the N.C. Medicaid program.
Program Integrity
DMA, 919-647-8000
The Community Alternatives Program for Disabled Adults (CAP/DA) is a federal Medicaid waiver program that provides home and community-based services as an alternative to nursing home placement for Medicaid clients 18 years of age and older. CAP/DA waiver services, which are offered in all 100 counties in the State, include case management, adult day health, in-home aides, home-delivered meals, waiver supplies, in-home and institutional respite care, and home mobility aids.
This month, DMA is hosting five town hall meetings across the State to
Anyone is welcome to attend. We particularly encourage participation by CAP/DA lead agencies, CAP/DA consumers and caregivers, Medicaid providers, public officials, consumer advocates, and long-term care providers.
Preregistration for the meetings is not required. Sign-in for the meetings will begin at 9:00 a.m., and the meetings will run from 9:30 a.m. until 12:30 p.m. Because meeting room temperatures vary, please dress in layers to ensure your personal comfort. For more information, contact Michelle C. Wilder, DMA CAP/DA Consultant (919-855-4371).
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Statesville |
Asheville |
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Wilmington |
Winterville |
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Raleigh |
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Directions to the Town Hall Meetings
ASHEVILLE
Mountain Area Health and Education Center
Traveling East on I-40
Take I-40 East to exit 50. Turn onto Hendersonville
Road. Stay in the right-hand lane through five traffic lights. At the
6th traffic light, turn left into the Mission Hospitals emergency
entrance. Take the first right and then another immediate right into the
parking deck.
Traveling West on I-40
Take I-40 West to exit 50B onto Hendersonville
Road. Stay
in the right-hand lane through five traffic lights. At the 6th traffic
light, turn left into the Mission Hospitals emergency entrance. Take the
first right and then another immediate right into the parking deck.
Traveling East on I-26
Take I-26 to 240 East to exit 5B for Charlotte
Street. Exit
right onto Charlotte Street. At the 4th traffic light, turn
left onto Biltmore Avenue. Proceed through three traffic lights. At the
4th light, turn right into the Mission Hospitals emergency entrance. Take
the first right and then another immediate right into the parking deck.
RALEIGH
Wake County
Commons Building
Traveling on I-40
Take I-40 to the I-440 Outer Beltline. Take exit 15
onto Poole Road. Turn right and travel approximately 0.5 miles. Turn
left into the Wake County Office Park. Follow the winding road to the
bottom of the hill – there are small directional signs along the way. The
Commons Building is next to the last building in the park with a tall flagpole
in front. Parking is available across the street or on the left of the
facility.
Traveling West on Hwy 64
Take Hwy 64 West to the I-440 Inner Beltline. Take exit 15 onto Poole Road. Turn left and travel
approximately 0.5 miles. Turn left into the Wake County Office Park. Follow
the winding road to the bottom of the hill – there are small directional
signs along the way. The Commons Building is next to the last building
in the park with a tall flagpole in front. Parking is available across
the street or on the left of the facility.
STATESVILLE
Iredell County Department of Social Services
Traveling South on I-77
Take 1-77 South to exit 50. Turn left onto E. Broad
Street. Travel approximately 0.3 miles. Turn right onto Eastside Drive. Travel
approximately 0.6 miles. The Iredell County Department of Social Services
in located on the left.
Traveling North on I-77
Take I-77 North to exit 50. Turn right onto E. Broad
Street. Travel approximately 0.3 miles. Turn right onto Eastside Drive. Travel
approximately 0.6 miles. The Iredell County Department of Social Services
in located on the left.
Traveling on I-40
Take 1-40 to exit 152A for I-77 South. Take 1-77 South
to exit 50. Turn left onto E. Broad Street. Travel approximately 0.3
miles. Turn right onto Eastside Drive. Travel approximately 0.6 miles. The
Iredell County Department of Social Services in located on the left.
WILMINGTON
Department of Aging
Take I-40 East
to Wilmington. I-40 becomes US 117 South (N. College Road). Travel approximately
5.3 miles. The Department of Aging is located on the right.
WINTERVILLE
Fulford Building, Room
153
Pitt Community
College
Traveling West on Hwy 264
Take Hwy 264 West to Greenville. When you
reach Greenville, exit to Hwy 11 South. Follow Hwy 11 South for approximately
5.0 miles. Pitt Community College is located on the right.
Traveling East on Hwy 264
Take Hwy 264 East (Stantonsburg
Rd.) straight toward downtown Greenville. (DO NOT take exit 73B to Washington.) When
you arrive in Greenville, turn right onto Arlington Boulevard. Follow
Arlington Boulevard until you reach the stoplight at the intersection of
Arlington Boulevard and Memorial Drive. Turn right onto Memorial Drive/Hwy
11 South. Travel approximately 3.0 miles. Pitt Community College is located
on the right.
Michelle Wilder, CAP/DA Program
DMA, 919-855-4371
The list of standard national codes used on the Electronic Remittance Advice (ERA) has been cross-walked to EOB codes as an informational aid to adjudicated claims listed on the Remittance and Status Report (RA).
With the implementation of standards for electronic transactions mandated by the HIPAA, providers now have the option to receive an ERA in addition to the paper version of the RA.
The EOB codes that providers currently receive on a paper RA are not used on the ERA. Because the EOB codes on the paper RA provide a greater level of detail on claim denials, all providers will continue to receive the paper version of the RA, even if they choose to receive the ERA transaction. The crosswalk is current as of the date of publication. Providers will be notified of changes to the crosswalk through future general Medicaid Bulletins.
EDS, 1-800-688-6696 or 919-851-8888
In an effort to consolidate and decrease the number of cost reports required of a single provider, DMA now includes the cost reporting requirements for Residential Treatment Facility providers and CAP/MR-DD service providers within the 2007 Mental Health Cost Report administered by the Department of Health and Human Services (DHHS) Office of the Controller. A separate cost report in addition to the 2007 Mental Health Cost Report is no longer required.
Any CAP/MR-DD provider who rendered only CAP/MR-DD waiver services since filing the 2007 CAP/MR-DD Cost Report (due September 2007) and has a fiscal year end between July 1, 2007 and January 1, 2008 must file either the 2007 CAP/MR-DD Closeout Cost Report, administered by DMA, or the 2007 Mental Health Cost Report, administered by the DHHS Office of the Controller. Both the 2007 CAP/MR-DD Closeout Cost Report and the 2007 Mental Health Cost Report should be submitted to the DHHS Office of the Controller.
Example: A CAP/MR-DD provider renders only CAP/MR-DD services and has a December 31, 2007 fiscal year end. The provider must file an annual cost report but has the choice of filing either the 2007 CAP/MR-DD Closeout Cost Report or the 2007 Mental Health Cost Report using their cost data for the period January 1, 2007 through December 31, 2007.
Beginning with cost reporting periods ending on or after January 1, 2008 all Residential Treatment Facility providers and CAP/MR-DD service providers are required to file the 2008 Mental Health Cost Report. Effective January 1, 2008, the CAP/MR-DD Cost Report and the Residential Treatment Cost Report were discontinued.
Providers will no longer be granted exemptions based on the amount of Medicaid revenue received and number of months in business. If a provider has received an exemption for a current cost report period, the exemption will be allowed for that cost report period only. The Residential Treatment Cost Reports scheduled to be received at DMA by May 31, 2008 are still required as previously published.
Training sessions have been scheduled to familiarize providers with the instructions and data requirements needed to complete the Mental Health Cost Report. Refer to the CAP/MR-DD and Residential Providers Mental Health Cost Report Training Memo for information on the training sessions, including dates, times, locations, and registration information.
Contact Information
For all questions
related to the Mental Health Cost Report, contact Susan Kesler at Susan.Kesler@dhhs.nc.gov or
919-855-3680.
For all questions related to the 2007 CAP/MR-DD Closeout Cost Report, contact Mishawn Davis at Mishawn.Davis@dhhs.nc.gov or 919-855-4200.
Rate Setting
DMA, 919-855-4200
In order to assist providers enrolled in Community Care of North Carolina/Carolina ACCESS (CCNC/CA) with managing and coordinating care for their Carolina ACCESS patients, DMA provides four management reports. Primary care providers are strongly encouraged to review these reports each month.
|
Report Name |
Purpose |
|---|---|
|
Monthly Carolina ACCESS Enrollment Report |
Provides names and information about the recipients who are newly enrolled, currently enrolled, and no longer enrolled, effective the month the report is received. |
|
Monthly Emergency Room Management Report |
Provides names, diagnoses, and the cost of care for recipients who went to the emergency room for services. The reason for the visit is divided into emergency diagnoses and non-emergency diagnoses as defined by DMA. The data is based on claims processed during the previous month. |
|
Monthly Referral Report |
Provides the names of recipients who have seen another medical provider during the previous month. Providers can use this report to see where their patients obtained care and if they authorized the care. This also lets the provider know when an override is approved for services by another provider. |
|
Quarterly Utilization Report |
Shows providers the utilization and cost of recipients linked to their practice. Information is categorized by PCP office visits, ER/urgent care, pharmacy, hospital inpatient, inpatient and outpatient mental health, specialist referrals, labs, x-rays, and outpatient ambulatory. Information is based on date of payment. Provides comparison with PCP peer group. |
These reports are mailed to each CCNC/CA practice. Providers can also view and download the reports from a confidential website; however, the Provider Confidential and Security Agreement with an original signature must be on file with DMA in order for providers to access the website. Providers may complete and submit the security agreement to DMA. When the security agreement is received, EDS will assign a log-on and password to the practice.
Betty West, Managed Care
DMA, 919-647-8000
Effective with date of service January 1, 2008, the following dental procedure code has been added for the N.C. Medicaid Dental Program. This addition is a result of a recent policy change.
|
CDT 2007/2008 Code |
Description |
Reimbursement Rate |
|---|---|---|
|
D0145 |
Oral evaluation for a patient under three years of age and counseling with primary caregiver
|
$38.07 |
In an effort to promote the establishment of a “dental home” for Medicaid recipients under the age of 3, DMA has adopted CDT procedure code D0145 at an enhanced reimbursement in comparison to the rate paid for D0120 (periodic oral evaluation). Providers will now have the flexibility to choose from three different non-emergent care diagnostic procedure codes for recipients under the age of 3: D0150, D0120, and D0145. Procedure code D0150 (comprehensive oral evaluation) continues to be the most appropriate service to render at the initial visit for all patients under the age of 3. For subsequent periodic visits, providers may choose from either D0120 or D0145.
It is important to remember that D0145 must be provided on the same date of service and billed in conjunction with D1206 (topical fluoride varnish; therapeutic application for moderate to high caries risk patients) to receive payment for any claim including D0145. In addition, other dental services (except D0120, D0140, D0150, D0160, D0170, and D1203) may be provided on the same date of service as the D0145 and D1206 diagnostic/preventive oral health service package. Evidence-based research has demonstrated that topical fluoride varnish is the safest and most effective means of preventing caries in preschool children at risk for early childhood caries. If providers do not wish to apply topical fluoride varnish (D1206) to a patient under 3 years of age at a periodic visit, they may still use procedure code D0120 to report and receive reimbursement for the periodic oral evaluation rendered on that date of service.
Sample
Periodicity Schedule for Diagnostic and Preventive Services for Preschool Recipients
|
Age (months) |
Procedures Performed |
|---|---|
|
6 |
D0150, D1206 |
|
12 |
D0145, D1206 |
|
18 |
D0145, D1206 |
|
24 |
D0145, D1206 |
|
30 |
D0145, D1206 |
|
Before 36 |
D0145, D1206 |
|
42 or older |
D0120, D1206 |
Providers are reminded to bill their usual and customary charges rather than the Medicaid rate. For complete coverage criteria and additional billing guidelines, please refer to Clinical Coverage Policy 4A, Dental Services.
Dental Program
DMA, 919-855-4280
When providers submit orthodontic records for prior approval review by the EDS orthodontic consultants, all models must be of acceptable diagnostic quality and properly trimmed. In addition, all radiographs (panoramic and cephalometric films) must be of acceptable diagnostic quality.
Records found to be below clinically acceptable standards will be returned to the provider. Claims for records with non-diagnostic films and unacceptable models will not be paid until diagnostic radiographs and models are resubmitted to EDS.
Dental Program
DMA, 919-855-4280
Effective with date of service January 1, 2008, DMA reimburses local health departments for oral contraceptives (birth control pills) when billed through the Physician’s Drug Program. HCPCS procedure code S4993 (contraceptive pills for birth control) with the FP modifier appended to the code (S4993 FP) must be used when requesting reimbursement. One of the following ICD-9-CM diagnosis codes must also appear on the claim: V25.01 (prescription of oral contraceptives) or V25.41 (contraceptive pill). The reimbursement rate is $3.35 per pack.
The N.C. Medicaid Program covers one pack of oral contraceptives per 28 days for a maximum of 14 packs per 365 days for female recipients ages 11 through 55 for every program category except the Family Planning Waiver (MAF-D). Providers must follow the guidelines established in the May 2006 Special Bulletin, Family Planning Waiver, when dispensing birth control to Family Planning Waiver recipients.
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of processing July 1, 2008, providers submitting inpatient or outpatient institutional claims will be required to complete FL14, Priority of Visit, and FL15, Point of Origin for Admission or Visit, according to the instructions documented in the UB-04 Data Specifications Manual.
If code 4, Newborn, is used, providers must also enter one of the codes listed in the UB-04 Manual from the Code Structure for Newborn in FL15. This requirement applies to all claim formats (paper, 837I, and NCECSWeb claims).
Inpatient and outpatient claims will be denied with EOB 1808 or EOB 319 if these fields are not completed according to the instructions in the UB-04 Manual. Refer to the UB-04 Manual for guidelines on coding FL14 and FL15 and resubmit the claim for processing.
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service May 1, 2008, the Orthotic and Prosthetic Fee Schedule was updated to reflect the annual increase to the maximum allowable rates. In addition to the annual rate update, the rates for the codes listed in the following table were changed from manual pricing to an established Medicare rate. The requirement for prior approval was also end-dated effective with date of service April 30, 2008 for the HCPCS codes in the following table that are listed without an asterisk after the code.
|
Code |
Description |
|---|---|
|
L3806 |
WHFO, includes one or more non-torsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment |
|
L3808 |
WHFO, rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment |
|
L3915 |
WH orthosis, includes one or more non-torsion joint(s),elastic bands, turnbuckles, may include soft interface, straps, prefabricated, includes fitting and adjustment |
|
L3925 |
Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), non-torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, includes fitting and adjustment. |
|
L3929 |
Hand finger orthosis, includes one or more non-torsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment. |
|
L3931 |
Wrist hand finger orthosis, includes one or more non-torsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment. |
|
L6624* |
UE addition, flexion/extension and rotation wrist unit |
|
L6639* |
UE addition, heavy-duty feature, any elbow |
Note: An asterisk (*) after the code indicates that prior approval is required. Bold type indicates that the item is covered by Medicare.
Please refer to the online fee schedule. Providers are reminded to bill their usual and customary charges rather than the Medicaid rate.
A Certificate of Medical Necessity and Prior Approval (CMN/PA) must be completed for all items, regardless of the requirement for prior approval. The coverage criteria for these items have not changed. Refer to the Clinical Coverage Policy 5B, Orthotics and Prosthetics, for detailed coverage information.
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of request July 1, 2008, Children’s Special Health Services will no longer review requests on behalf of DMA for prior approval of oral nutrition products, including formulas and supplies for oral feedings, for recipients ages birth through 20 years of age. Requests for these products will be considered by DMA on a case-by-case basis. Providers must submit requests for these products using the Non-Covered Services Request Form.
EDS, 1-800-688-6696 or 919-851-8888
Personal Care Services Cost Report training for the 2007 cost reports are scheduled for June 2008. The sessions are intended to provide instructions on the completion of the cost report, which is due by July 25, 2008. The registration form, the 2007 PCS Cost Report schedule, an instruction manual, and other related materials for the training will be available on DMA’s website by May 14, 2008.
Because the training site can accommodate only 60 to 70 participants per session, preregistration is required. Registration forms will be processed on a first-come, first-served basis. Registration forms must be received and confirmed at least five business days prior to the date of the training class you select. The registration form may be submitted by e-mail or by mail to the address listed on the form. A confirmation of your registration will be sent to you via e-mail.
All of the training sessions will be held at the following location:
N.C. Department of Transportation Training Center
313 Chapanoke
Road
Garner,
NC 27603
The dates and times are listed below. Participants may register for either the morning session or the afternoon session. Please choose the training date and time that is most convenient for you.
|
Training Dates |
Session Time |
Session Time |
|---|---|---|
|
Tuesday, June 10, 2008 |
9:00 a.m. to 12:00 noon |
1:30 p.m. to 4:30 p.m. |
|
Thursday, June 19, 2008 |
9:00 a.m. to 12:00 noon |
1:30 p.m. to 4:30 p.m. |
|
Friday, June 20, 2008 |
9:00 a.m. to 12:00 noon |
1:30 p.m. to 4:30 p.m. |
Rate Setting
DMA, 919-855-4200
Effective with date of request July 1, 2008, Children’s Special Health Services will no longer review requests on behalf of DMA for prior approval of augmentative and alternative communication devices for recipients ages birth through 20 years of age. Requests for these devices will be considered by DMA on a case-by-case basis. Providers must submit requests for these devices using the Non-Covered Services Request Form.
EDS, 1-800-688-6696 or 919-851-8888
The Carolinas Center for Medical Excellence (CCME) announces continuing provider training for Personal Care Services (PCS) as approved by DMA.
The 2nd calendar quarter training sessions (PCS Provider Training Session VIII) of 2008 are scheduled for June 2008. The training is recommended for registered nurses, agency administrators, and agency owners who have a working knowledge of the PCS program and applicable DMA policies. This training allows CCME to offer 4.25 Continuing Nursing Education (CNE) contact hours to all nurses at no cost to the participants.
Preregistration is required and space is limited to 150 participants at each session. Registration will be provided online or by fax. To register online, visit CCME’s website and click on the appropriate link in Upcoming Events. When you have completed the online registration, you will receive a computer-generated number to confirm your registration. Bring the number with you to the session.
To register by fax, complete the form on page 22 and fax it to the attention of Alisha Brister at 919-380-9457. A member of the PCS team will contact you with a registration number, which you should bring with you to the session.
If you need to cancel at any time, please contact Alisha Brister 919-380-9860 (x2018) to allow others to register. Please e-mail Alisha Brister at CCME (abrister@thecarolinascenter.org) for further information on registering.
Sign-in will start at 8:00 a.m. at each location. The presentations will begin at 9:00 a.m. and run through 1:30 p.m., with one or two 15-minute breaks. Please plan ahead for the late lunch hour, as coffee, hot tea, and water will be the only refreshments provided. Considering the variability in meeting room temperature, please dress in layers to ensure your personal comfort.
|
Greenville |
Fayetteville |
|
Cary |
Winston-Salem |
|
Hickory |
|
Directions to the Personal Care Services Provider Training Sessions
CARY
Embassy Suites
Traveling East
on I-40
Take I-40 East
into Raleigh to exit 287 for Harrison Avenue. At the end of the exit ramp,
turn right onto Harrison Avenue. Stay in the right-hand lane. Turn right
after the traffic light onto Harrison Oaks Boulevard. The hotel is located
on the right approximately 3/10 of a mile from the turn.
Traveling West
on I-40
Take I-40 West
(toward Raleigh-Durham International Airport) to exit 287 for Harrison
Avenue. At the end of the exit ramp, turn left onto Harrison Avenue. Stay
in the right-hand lane. Turn right after the traffic light onto Harrison
Oaks Boulevard. The hotel is located on the right approximately 3/10 of
a mile from the turn.
FAYETTEVILLE
Holiday
Inn
Take I-95 to exit 49. The hotel is visible from the exit ramp.
GREENVILLE
Hilton Greenville
Take US 64 East to US 264 East to Greenville. Turn
right at the 2nd traffic light as you come into the city onto
Allen Road/US Alternate 264. Travel approximately 2 miles. Allen Road
becomes Greenville Boulevard/Alternate 264. Follow Greenville Boulevard
for 2½ miles. The Hilton Greenville is located on the right.
HICKORY
Park Inn
Gateway Conference Center
Take I-40 to exit
123. Follow the signs to Highway 321 North. Take the first exit (Hickory
exit) and follow the ramp to the traffic light. Turn right at the light
onto US 70. The Gateway Conference Center is located on the right.
WINSTON-SALEM
Hawthorne Inn
Traveling East
on I-40
Take I-40 East to
I-40 Business into downtown Winston-Salem. Take exit 5C for Cherry Street
and turn onto High Street. The front entrance of the hotel is immediately
on your right.
Traveling West
on I-40
Take I-40 West
to the I-40 Business split (Exit 206) into downtown Winston-Salem. Take
exit 5C for Cherry Street. Turn left onto First Street at the first traffic
light. Turn left at the next traffic light onto Marshall Street. Cross
over I-40 Business and travel through the next traffic light. The hotel’s
rear parking entrance is located on the right as you head downhill. Turn
into the parking lot and drive around the building to the hotel’s front
entrance.
Traveling North/South
on I-85
Travel on I-85. Exit
onto Highway 52 North. Take the exit for I-40 Business West (exit 109B). Take
exit 5C for Cherry Street. Turn left onto First Street at the first traffic
light. Turn left at the next traffic light onto Marshall Street. Cross
over I-40 Business and travel through the next traffic light. The hotel’s
rear parking entrance is located on the right as you head downhill. Turn
into the parking lot and drive around the building to the hotel’s front
entrance.
CCME, 919-380-9860
The planned implementation date of the second generation antihistamines prior authorization program has been delayed to May 5, 2008.
On May 5, 2008, the N.C. Medicaid Outpatient Pharmacy Program will implement a new prior authorization program for second generation antihistamines. Medications that will require prior authorization include Clarinex, Allegra, fexofenadine, Xyzal and Zyrtec (prescription versions only). All over-the-counter (OTC) versions of loratadine, Claritin, cetirizine and Zyrtec will not require prior authorization. Pharmacists will receive a point-of-sale message that PA is required for these medications. An additional message will indicate that override at point-of-sale is allowed for these medications. If the prescriber has indicated that the PA criteria have been met by writing one of the following phrases on the face of the prescription in his or her own handwriting, the pharmacist will be able to override the PA edit:
For generic fexofenadine
1.“Failed loratadine and failed cetirizine for 30 days”
2.“Allergy to loratadine and cetirizine”
For liquid formulations other than loratadine syrup and cetirizine syrup
For all other second generation antihistamines
1. “Failed loratadine for 30 days, failed cetirizine for 30 days and failed fexofenadine for 30 days”
2. “Allergy to fexofenadine, loratadine, and cetirizine”
If the second generation antihistamine has a generic version available, “medically necessary” must also be written on the face of the prescription in the prescriber’s own handwriting in order to dispense the brand name drug. A “1” in the PA field (461-EU) or a “2” in the submission clarification field (420-DK) will override the PA edit. These overrides will be monitored by Program Integrity.
Providers may also contact ACS at 866-246-8505 (telephone) or 866-246-8507 (fax) to request PA for these medications. The PA criteria and request form for the second generation antihistamines are available on the N.C. Medicaid Enhanced Pharmacy Program website. If the PA is approved by ACS, the POS override codes will not be needed.
EDS, 1-800-688-6696 or 919-851-8888
In the event that a pharmacist is presented with a prescription that does not meet the tamper-resistant prescription pad requirements and elects to call the prescriber to verify the prescription by telephone, the pharmacist must document the following information on the prescription:
EDS, 1-800-688-6696 or 919-851-8888
The Centers for Medicare and Medicaid Services (CMS) has announced an exception to the 60-day limit on locum tenens billing for physician members of a reserve component of the Armed Forces who are called to active duty. CMS implemented this exception in accordance with section 116 of the Medicare, Medicaid, and SCHIP Extension Act of 2007, enacted on December 29, 2007.
DMA has adopted this exception for dates of service January 1, 2008 through June 30, 2008. Physicians may bill for services provided in their offices by a locum tenens physician using modifier Q6 appended to the procedure code.
Locum tenens services meeting the following requirements are identified by appending modifier Q6 to the procedure code:
If an extension of this exception is approved, providers will be notified through a future general Medicaid Bulletin article.
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service February 14, 2008, the N.C. Medicaid program added the FDA-approved diagnosis of Crohn’s disease to the required list of diagnoses for natalizumab (Tysabri) when billed through the Physician’s Drug Program. Tysabri is also covered for a diagnosis of multiple sclerosis.
One of the following ICD 9-CM diagnosis codes is required when billing for Tysabri:
|
ICD-9-CM Diagnosis Code |
Description |
|---|---|
|
340 |
multiple sclerosis |
|
555.0, 555.1, 555.2, or 555.9 |
Crohn’s disease |
EDS, 1-800-688-6696 or 919-851-8888
Medically necessary private duty nursing (PDN) services, as defined by the Code of Federal Regulations (42CFR440.80) the North Carolina Administrative Code (10A NCAC 220.0122) and the Medicaid State Plan may be provided when prescribed by a physician and prior approved by DMA. The care must be medically necessary and require a licensed nurse to provide substantial, complex, and continuous nursing care.
A Medicaid recipient with a medical condition that necessitates PDN services normally is unable to leave the home without being accompanied by a licensed nurse because leaving the home requires a considerable and taxing effort. The nurse may accompany the recipient outside of his or her residence during those approved hours when the recipient’s normal life activities take the recipient out of the home. During activities that occur outside of the recipient’s residence, the licensed nurse may not provide transportation. (Recipients may contact their local department of social services for medically related transportation options.)
The need for nursing care to participate in activities outside of the home is not a basis for authorizing PDN services. It is the responsibility of the provider to ensure there is a continuous need for nursing care, and to report significant changes in the recipient’s condition that might indicate a need to discontinue services when the recipient’s condition improves to a level that no longer supports the need for continuous nursing care. The agency is responsible for providing a factual “Medical Update” with each 60-day certification period that summarizes the performance and frequency of nursing assessments and interventions based on the required physician’s orders. DMA may request nursing documentation or additional information to support the request for ongoing PDN services.
Home Care Initiatives
DMA, 919-855-4390
The last date of service that will be covered for Synagis pharmacy claims according to the 2007/2008 Synagis policy is March 31, 2008. Synagis claims processing for the 2007/2008 RSV season began on October 10, 2007. All Synagis requests must be completed on the criterion-specific forms.
No more than five monthly doses of Synagis can be obtained using these forms. Copies of the submitted N.C. Medicaid Synagis for RSV Prophylaxis forms should be mailed by pharmacy distributors to DMA. Please mail the forms to:
N.C. Division of Medical Assistance
Pharmacy Program
2501 Mail Service Center
Raleigh, NC 27699-2501
Pharmacy distributors with a large volume of Synagis claims should submit scanned copies of the N.C. Medicaid Synagis for RSV Prophylaxis forms on a diskette. All diskettes must be sent to DMA by May 31, 2008. Please call Charlene Sampson at 919-855-4306 if you need assistance with the coordination of this process or if you have any questions.
A Notice of Approval of Service Request letter was provided by DMA for Early Periodic Screening, Diagnostic and Treatment (EPSDT) requests for Synagis. These would include requests for a sixth dose in March or an April dose of Synagis. A copy of the Notice of Approval of Service Request letter should be maintained on file at the pharmacy.
The N.C. Medicaid program should not be billed for Synagis unless one of the following items is on file at the pharmacy:
Payment of Synagis claims will be reviewed and may be subject to recoupment by DMA Program Integrity if the appropriate forms or approval letters are not on file.
Charlene Sampson, Pharmacy Program
DMA, 919-855-4306
Service limitations on scope, amount, duration, frequency, location of service, and other specific criteria stated in this publication may be exceeded or may not apply to recipients under 21 years of age if the provider's documentation shows that
This applies to both proposed and current limitations. Providers should review any information in this publication that contains limitations in the context of EPSDT and apply that information to their service requests for recipients under 21 years of age. A brief summary of EPSDT follows.
EPSDT is a federal Medicaid requirement (42 U.S.C. § 1396d(r) of the Social Security Act) that requires the coverage of services, products, or procedures for Medicaid recipients under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination (including any evaluation by a physician or other licensed clinician).
This means that EPSDT covers most of the medical or remedial care a child needs to
Medically necessary services will be provided in the most economic mode possible, as long as the treatment made available is similarly efficacious to the service requested by the recipient’s physician, therapist, or other licensed practitioner; the determination process does not delay the delivery of the needed service; and the determination does not limit the recipient’s right to a free choice of providers.
EPSDT does not require the state Medicaid agency to provide any service, product, or procedure that is unsafe, ineffective, experimental, or investigational; that is not medical in nature; or that is not generally recognized as an accepted method of medical practice or treatment.
If the service, product, or procedure requires prior approval, the fact that the recipient is under 21 years of age does not eliminate the requirement for prior approval.
For important additional information about EPSDT, please visit the following websites:
In accordance with NCGS §108A-54.2, 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 Proposed Clinical Coverage Policies web page. Providers without Internet access can submit written comments to the address listed below.
Loretta Bohn
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.
|
Month |
Electronic Cut-Off Date |
Checkwrite Date |
|---|---|---|
|
May |
05/01/08 |
05/06/08 |
|
05/08/08 |
05/13/08 |
|
|
05/15/08 |
05/20/08 |
|
|
05/22/08 |
05/29/08 |
|
|
June |
06/05/08 |
06/10/08 |
|
06/12/08 |
06/17/08 |
|
|
06/19/08 |
06/26/08 |
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.
| William W. Lawrence, Jr. M.D. Acting Director Division of Medical Assistance Department of Health and Human Services |
Melissa Robinson |