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In This Issue…

All Providers:

• Compliance Date for HIPAA Electronic Transactions
• NCLeads Update
• Pediarix
• Provider Services and Enrollment Change of Address
• Updated EOB Code Crosswalk to HIPPAA Standard Codes

Adult Care Home Providers:

• Medicaid ACH-PCS Therapeutic Leave

Children’s Development Service Agencies (CDSA):

• Outpatient Specialized Therapies CCNC Pilot Project

DD Targeted Case Management Providers:

• DD Targeted Case Management Billing Seminar Schedule
• Seminar Directions

Durable Medical Equipment Providers:

• Code Conversions for Power Wheelchair Electronics, Wheelchair Components, and Enteral Nutrition  Products
• Orthotic and Prosthetic Code Changes
• Medicare Crossovers and Spanning Dates

General Hospitals:

• Revenue Codes

Home Health Providers:

• Outpatient Specialized Therapies CCNC Pilot Project

Home Infusion Therapy (HIT) Providers:

• Billing the Nursing Component for HIT Therapy

Hospital Providers:

• Outpatient Pathology

Independent Practitioner Providers:

• Outpatient Specialized Therapies CCNC Pilot Project

Local Health Departments:

• Outpatient Specialized Therapies CCNC Pilot Project

Local Management Entities (LME):

• Outpatient Specialized Therapies CCNC Pilot Project

Nursing Facility Providers:

• Nursing Facility Capital Reimbursement

Orthotic and Prosthetic Providers:

• Orthotic and Prosthetic Seminar Schedule
• Provider Enrollment
• Seminar Directions

Outpatient Hospital Clinics:

• Outpatient Specialized Therapies CCNC Pilot Project

Personal Care Services Providers:

• New PCS/PCS-Plus Training

Physician Services:

• Outpatient Specialized Therapies CCNC Pilot Project

Compliance Date for Health Insurance Portability Accountability Act (HIPAA) Electronic Transactions

Effective October 1, 2005, the N.C. Medicaid program will cease acceptance of non-HIPAA compliant transaction formats.  Providers currently filing on non-HIPAA compliant formats need to make the necessary changes to ensure compliance.  The following article includes information regarding the Health Insurance Portability and Accountability Act (HIPAA), the importance of compliance and recommendations to become compliant.

HIPAA legislation requires the standardized transmission of electronic information. Covered entities were required to comply with these standards by October 16, 2003. Covered entities are defined in HIPAA as:

1. Health plans.
2. Health care clearinghouses or vendors.
3. Health care providers who transmit any health information in electronic format in connection with a transaction covered in the HIPAA Transaction Rule. These terms are defined in detail in 45 CFR 160.103.

The N.C. Medicaid program, as a covered entity, satisfied the  HIPAA compliance date by implementing the American National Standard Institute (ANSI) Accredited Standards Committee (ASC) X12N standards, Version 4010A1 on October 13,2003, for the following transactions:

• Health Care Claim (Professional, Institutional, Dental) – 837 Transaction
• Health Care Claim Payment/Advice – 835 Transaction
• Health Care Claim Status Request and Response – 276/277 Transaction
• Benefit Enrollment and Maintenance – 834 Transaction
• Payroll Deducted and Other Group Premium Payment for Insurance Products – 820 Transaction
• Eligibility Benefit Inquiry and Response – 270/271 Transaction
• Health Care Services Review-Request for Review and Response – 278 Transaction

The N.C. Medicaid program also implemented the National Council for Prescription Drug Programs (NCPDP), Versions 1.1 Batch and 5.1 Point-of-Sale, in accordance to HIPAA legislation, as the standard for all retail pharmacy transactions.

Although the compliance date mandated by HIPAA was October 16, 2003, CMS allowed payers, including the N.C. Medicaid program, to continue accepting non-compliant formats to minimize financial hardship for the associates with whom they exchange transactions.  The N.C. Medicaid program has been accepting both compliant and non-compliant transactions since October 13, 2003.  October 1, 2005 marks the date the N.C. Medicaid program will cease accepting transactions on non-compliant electronic formats.

Currently, there are no billing policy changes related to this date.  Should changes to billing policy become necessary, they will be communicated in future bulletin articles. 

Compliance Options
Providers currently submitting claims via non HIPAA-compliant formats have several options for meeting the compliance date indicated above.  These options are briefly detailed below:

1. Vendor - Providers may purchase HIPAA compliant software, from a vendor, which allows the creation of HIPAA compliant transactions.  Providers who exercise this option will be required to have a Trading Partner Agreement on file, and are required to complete transaction testing before submitting transactions in production to N.C. Medicaid.
2. Clearinghouse – Providers may contract for the services of a clearinghouse.  A clearinghouse acts as a middle-man between the provider and payer.  Providers submit claims to the clearinghouse; in turn, the clearinghouse forwards the transactions to payers for adjudication.  Under this option, the Trading Partner Agreement exists between the clearinghouse and the fiscal agent for N.C. Medicaid program since the clearinghouse is the actual entity submitting transactions to N.C. Medicaid on behalf of the provider.
3. In-House – Providers with technical staff or services may create their own transactions based on the standard electronic formats. As with the vendor solution, providers are required to have a Trading Partner Agreement on file and test with N.C. Medicaid before transactions can be filed in production.
4. NCECSWeb -  Providers may file claims directly to N.C. Medicaid using NCECSWeb. NCECSWeb replaces all previous versions of N.C. Medicaid created claims filing software such as NECS and NCECS.   NCECSWeb is a claims filing tool only and is only compatible with N.C. Medicaid.  NCECSWeb complies with the data content standards required by HIPAA.

Providers are encouraged to begin the transition to one of these HIPAA-compliant formats immediately to ensure ample time to test and address compliance errors, if necessary.  Regardless of the option selected, all providers who wish to file claims electronically will be required to have an Electronic Claims Submission Agreement on file for their provider number. 

Providers should ensure that vendors, clearinghouses, and other associates with whom they conduct business are HIPAA-compliant. Providers must also be aware that HIPAA is federal legislation and impacts more than N.C. Medicaid. It may be necessary for providers to make changes in claims filing practices with all associated health plans.

Additional Information
Implementation guides for the ASC X12N and NCPDP (Pharmacy) transactions listed in this bulletin article have been established as the standard for HIPAA compliance.

The implementation guides for ASC X12N transactions are available at http://www.wpc-edi.com. The NCPDP implementation guide is available at http://www.ncpdp.org. The guides offer a detailed layout for standard transaction formats.  In addition,  to ensure a seamless transition from non-compliant electronic formats to HIPAA standard formats, companion guides have been published. These guides provide the specifics requirements necessary to successfully exchange transactions electronically with the N.C. Medicaid program in ASC X12 and NCPDP standard formats. The information contained in the guides is for billing providers, their technical staff, clearinghouses or vendors.  N.C. Medicaid companion guides are available on DMA's HIPAA web page.

Please visit the website on a regular basis to see if changes have been made to the companion guides that may impact your electronic transaction exchange with EDS.

Additional helpful information regarding HIPAA legislation can be found at:

• Centers for Medicare and Medicaid Services' HIPAA page: http://www.cms.hhs.gov/
• Workgroup for Electronic Data Interchange (WEDI) — HIPAA page: http://www.wedi.org
• June 2003, Special Bulletin II, HIPAA Update

For questions or a list of vendors and clearinghouses, please contact EDS Electronic Commerce Services at 1-800-688-6696, or 919-851-8888, option 1. 

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

Attention: All Providers

NCLeads Update

Information related to the implementation of the new Medicaid Management Information System, NCLeads, scheduled for implementation in mid-2006 can be found online at http://ncleads.dhhs.state.nc.us.  Please refer to this website for information, updates, and contact information related to the NCLeads system.

Thomas Liverman, Provider Relations
Office of MMIS Services,
919-647-8315

Attention: All Providers

Pediarix, (Diphtheria, Tetanus Toxoids, Acellular Pertussis Vaccine, Hepatitis B and Poliovirus Vaccine, Inactivated) (DTaP-HepB-IPV) (CPT 90723) - Coverage in the UCVDP/VFC Program and Billing Guidelines

Effective with date of service January 1, 2005, Pediarix was added to the list of vaccines covered through the Universal Childhood Vaccine Distribution Program (UCVDP) Vaccines for Children (VFC) program.  This program provides all vaccines required by the Advisory Committee of Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC).  UCVDP/VFC covered vaccines are available to children birth through 18 years of age. Pediarix is licensed for the 3-dose primary series of DTaP, IPV, and Hepatitis B for children six weeks to seven years of age. Pediarix is not FDA approved for doses four or five of the DTaP series. The CDC and American Academy of Pediatrics still encourage that infants receive their first dose of hepatitis B vaccine at birth.

Due to the availability of the UCVDP/VFC vaccines, Medicaid does not reimburse for those vaccines that are covered under that program; however, an administration fee may be billed to Medicaid, if applicable.  Diagnosis code V06.8 should be used when billing for Pediarix if appropriate.  Providers should refer to the April 2005 Special Bulletin III, Health Check Billing Guide 2005 for additional information on billing Medicaid for vaccines. 

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

Attention: All Providers

Provider Services and Enrollment Change of Address

The Provider Services and Enrollment Section of the Division of Medical Assistance has moved.

Certified mail, UPS, or Federal Express deliveries that require a street address should be sent to the following address:

DMA Provider Services
Attn: First Name Last Name
801 Ruggles Drive
Raleigh, NC 27603

The mailing address and telephone numbers will remain the same:

DMA Provider Services
Attn: First Name Last Name
2501 Mail Service Center
Raleigh, NC 27600-2501
919-855-4050

Provider Services
DMA, 919-855-4050

Attention: All Providers

Updated EOB Code Crosswalk to HIPAA Standard Codes

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). An updated version of the list is available on the Division of Medical Assistance’s HIPAA web page.

With the implementation of standards for electronic transactions mandated by the Health Insurance Portability and Accountability Act (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 list is current as of the date of publication. Providers will be notified of changes to the list through the general Medicaid bulletin.

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

Attention: Adult Care Home Providers

Medicaid ACH-PCS Therapeutic Leave

Effective July 1, 2005 entitlement to Therapeutic Leave is not applicable in the case of the Medicaid Adult Care Home Personal Care Services (ACH-PCS) program. The Center for Medicare Medicaid Services (CMS) regional office has ruled that ACH-PCS is to be paid only when Basic Personal Cares Services have been provided. The North Carolina Administrative Code (NCAC) 10A, Attachment 4.19-C, Section 1 (j), Page 1 has been added to read as follows:

"Effective July 1, 2005 entitlement to Therapeutic Leave is not applicable in the case of the Medicaid Adult Care Home Personal Care Services (ACH-PCS) program."

Finance Management, Rate Setting Section
DMA, 919-855-4200

Attention: DD Targeted Case Management Providers

DD Targeted Case Management Billing Seminar Schedule

DD Targeted Case Management Billing seminars are scheduled for July 2005.  Seminars are intended for providers who meet the approval and endorsement criteria to bill for DD Targeted Case Management on or after July 1, 2005.  Topics to be discussed will include, but are not limited to, provider enrollment requirements, eligibility issues, billing instructions, and clinical coverage policies.  Those who will be billing for these services to N.C. Medicaid are encouraged to attend. 

The seminars are scheduled at the locations listed below.  Pre-registration is required.  Due to limited seating, registration is limited to two staff members per office.  Unregistered providers are welcome to attend if space is available.

Providers may register for the DD Targeted Case Management Billing seminars by completing and submitting the registration form available on the next page or by registering online.  Please indicate the session you would like to attend on the registration form.  Seminars begin at 10:00 a.m. and will end at 1:00 p.m.  Providers are encouraged to arrive by 9:45 a.m. to complete registration.  Refreshments will not be provided during the seminar.

Providers must print the PDF version of the July 2005 Special Bulletin VI DD Targeted Case Management and bring it to the seminar.  This will be available to providers on the website beginning July 1, 2005.

DD Targeted Case Management providers who meet the endorsement and enrollment criteria and would like to provide this service must direct enroll with the N.C. Medicaid program.  You may access Medicaid enrollment information by going to DMA’s website.  Enrollment applications can be found at this location.

Directions to the DD Targeted Case Management Billing Seminars

Holiday Inn Conference Center – Salisbury, North Carolina
Traveling South on I-85
Take exit 75. Turn right onto Jake Alexander Boulevard. Travel approximately ½ mile. The Holiday Inn is located on the right.

Traveling North on I-85
Take exit 75. Turn left onto Jake Alexander Boulevard. Travel approximately ½ mile. The Holiday Inn is located on the right.

Jane S. McKimmon Center – Raleigh, North Carolina
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.

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

Attention: Durable Medical Equipment Providers

Code Conversions for Power Wheelchair Electronics, Wheelchair Components, and Enteral Nutrition Products

In order to comply with the Centers for Medicare and Medicaid Services (CMS) HCPCS coding changes, the following codes are replacing code K0108/W4151, specialty controls with hardware, and are effective with date of service July 1, 2005. 

Note:  HCPCS codes with an asterisk require prior approval.

Additionally, the following code conversions are effective with date of service July 1, 2005.

Note:  HCPCS codes with an asterisk require prior approval.

Effective with date of service July1, 2005, the following HCPCS code was added to the DME fee schedule.  Please refer to the Palmetto GBA-SADMERC Enteral Nutrition Product Classification List at http://www.palmettogba.com for coding guidelines.

The coverage criteria for these items have not changed.  Refer to Clinical Coverage Policy #5A, Durable Medical Equipment for detailed coverage and billing information.  A Certificate of Medical Necessity and Prior Approval form must be completed for all items regardless of the requirement for prior approval.

Providers are reminded that these are maximum reimbursement rates.  Providers must bill their usual and customary rate for all DME. 

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

Attention: Durable Medical Equipment Providers

Medicare Crossovers and Spanning of Dates

Effective with date of processing May 16, 2005, Durable Medical Equipment (DME) providers are now able to submit Medicare crossover claims to Medicaid with a span of dates.  This includes both DME rentals and DME purchases that require a span of dates on the claim.  Providers with a claim that has been denied due to the change of accepting Medicare crossovers effective September 6, 2004 that span the September 6 date, can now submit the claim for payment.

Example #1: DME rental during the month of September 2004

Providers are now able to bill spanning the days of the month for this claim and will receive the designated percentage of coinsurance and deductible for the dates before and after the change date of September 6, 2004.

Example #2: DME purchase that Medicare requires a span of dates (i.e. diabetic supplies)

Providers are now able to submit their claims with the span of dates over multiple calendar months on one detail line after the “To” Date of Service has passed.  The claims will be paid the designated percentage of coinsurance and deductible for all dates of service.

Note:  Claims with a detail line with a “To” Date of Service before September 6, 2004 and a detail line with a “To” Date of Service after September 6, 2004 will be denied.  Claims with these different “To” dates will need to be billed as two separate claims.

EDS, 1-800-688-6696 or 919-851-8888 

Attention: General Hospitals and Psychiatric Hospitals

Revenue Codes

Effective July 1, 2005, hospitals will be allowed to bill the following Revenue Codes for Behavioral Health Treatments/Services on a UB-92 claim form.  The services will be reimbursed at the facility rate when provided in an outpatient setting.  The professional component must be billed on a CMS-1500 claim form.

Behavioral Health Treatments/Services

Note: 909 and 910 are no longer covered and can not be billed on the UB-92 claim form.                                                                                      

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

Attention: Hospital Providers

Outpatient Pathology Services

The N.C. Medicaid program covers pathology laboratory procedures that have a technical and professional component when the service is performed in an outpatient hospital setting.

The hospital is reimbursed for the technical component and must bill using the UB-92 claim form with an appropriate revenue code and the CPT code.  Hospitals that employ pathologists must bill the professional component on the CMS-1500 claim form under the hospital’s professional number. 

The following table includes a list of pathology codes for which payment for the technical component may be made.

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

Attention: Durable Medical Equipment Providers

Orthotic and Prosthetic Code Changes

In order to comply with the Centers for Medicare and Medicaid Services (CMS) HCPCS code changes, the following HCPCS codes were end-dated and removed from the Orthotic and Prosthetic Fee Schedule effective with date of service May 31, 2005.

Also, effective with date of service May 31, 2005, HCPCS codes L6895, “addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated” and L7500, “repair of prosthetic device, hourly rate” were end-dated and removed from the Orthotic and Prosthetic Fee Schedule.  HCPCS code L7520; “repair of prosthetic device, labor component, per 15 minutes” is effective on June 1, 2005 and was added to the Orthotic and Prosthetic Fee Schedule.  The maximum allowable reimbursement rate for code L7520 is $23.02.  HCPCS code L7520 requires prior approval.

The 2005 fee schedule is available on DMA's Fee Schedule web page.

EDS, 919-851-8888 or 1-800-668-6696

Attention: Home Infusion Therapy (HIT) Providers

Billing the Nursing Component for HIT Therapy

Home Infusion Therapy providers are reminded that Medicaid reimbursement for drug infusion therapy is at a per diem rate that includes the therapy, supplies, IV pump and pole, and the nursing component.  The nursing component (T1030) must be included for each day of service when billing the charges for the therapy, antibiotic therapy (S9494), pain management (S9325), or chemotherapy (S9329).  The reimbursement rate for the nursing charge is prorated to cover all nursing services provided during the course of treatment regardless of the dates of service the visits are made.  When billing concurrent therapies the nursing component is billed once, only with the primary therapy.

Claims submitted with either the drug therapy code or the nursing component code billed separately will be denied.

EDS, 919-851-8888 or 1-800-668-6696

Attention: Nursing Facility Providers

Nursing Facility Capital Reimbursement Information Request

On April 29, 2005, the Division of Medical Assistance (DMA) Audit Section e-mailed and sent by regular mail a letter to all Medicaid Nursing Facility providers requesting information that is needed to develop a new Fair Rental Value reimbursement system for property costs.  A form (with instructions) in Excel format was attached to the e-mailed letter and providers were instructed to complete the form and return it to DMA no later than May 31, 2005.  Submission of this information is critical to developing a system that will accurately reflect each facility’s building costs and to properly account for any additions/improvements made to your facility.  Failure to report the information requested may result in a “default” mechanism being used to determine your facility’s rate. 

Providers who have not yet received the letter, or with any questions related to completing or submitting the form, may contact Frank Dziepak, DMA Audit Manager at the number listed below.

Frank Dziepak, Audit Manager
DMA, 919-647-8068

Attention: Personal Care Services Providers

New PCS/PCS-Plus Training

The Division of Medical Assistance (DMA) has scheduled combined Personal Care Services (PCS) and PCS-Plus training sessions beginning in July 2005.  The sessions will be held in the DMA Office in Raleigh.  The purpose of this training is to provide a policy orientation for Registered Nurses (RNs) who conduct PCS and/or PCS-Plus assessments for Medicaid recipients.  The training includes a review of the policy guidelines for both the PCS and PCS-Plus programs.  Attendees will learn the correct way to conduct and document a PCS assessment and how to develop a PCS plan of care.  There will also be time for attendees to ask questions related to the program.  The trainings are scheduled for the first and third Thursday of each month.

The training sessions begin at 9:00 a.m. and end at 1:00 p.m.  Attendance is limited to 15 RNs per session on a first-come, first-serve basis.  Preregistration is required.  To register, please complete the attached Class Registration Form and fax it to (919) 715-2628.  A mailing address is also provided on the Registration Form if preferred.  Registration by phone is not permitted.  Providers will receive enrollment confirmation with the date of the training session and directions to the DMA office.

Tracy Colvard, Acting Manager for PCS/PCS-Plus
DMA, 919-855-4360 

Attention: Orthotic and Prosthetic Providers

Orthotic and Prosthetic Billing Seminar Schedule

Orthotic and Prosthetic Billing seminars are scheduled for July 2005.  Seminars are intended for providers who will be billing for orthotic and prosthetic devices on or after July 1, 2005.  Topics to be discussed will include, but are not limited to, provider enrollment requirements, eligibility issues, billing instructions, and clinical coverage policies.  Persons who will be billing for these services to N.C. Medicaid are encouraged to attend. 

The seminars are scheduled at the locations listed below.  Preregistration is required.  Due to limited seating, registration is limited to two staff members per office.  Unregistered providers are welcome to attend if space is available.

Providers may register for the Orthotic and Prosthetic Billing seminars by completing and submitting the registration form or by registering online.  Please indicate the session you would like to attend on the registration form.  Seminars begin at 10:00 a.m. and end at 1:00 p.m.  Refreshments will not be provided.  Providers are encouraged to arrive by 9:45 a.m. to complete registration.

Providers must print the PDF version of the July 2005 Special Bulletin V, Orthotic and Prosthetic Devices from DMA’s website and bring it to the seminar.  This will be available to providers on the website beginning July 1, 2005.

Persons who are board-certified to provide orthotic and prosthetic devices and would like to enroll in the N.C. Medicaid program can enroll using the Orthotic and Prosthetic application.

Directions to the Orthotic and Prosthetic Billing Seminars

Greenville Hilton – Greenville, North Carolina
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 Hilton Greenville is located on the right.

Coast Line Convention Center – Wilmington, North Carolina
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.

Blue Ridge Community College, Bo Thomas Auditorium – Flat Rock, North Carolina
Take I-40 to Asheville.  Travel east on I-26 to exit 53, Upward Road.  At the end of the ramp, turn right onto Upward Road.  At the second light, turn right onto S. Allen Drive.  Turn left at the sign onto College Drive.  The first building on the right is the Sink Building.  The Bo Thomas Auditorium is on the left side of the Sink Building.

Holiday Inn Conference Center – Salisbury, North Carolina
Traveling South on I-85
Take exit 75. Turn right onto Jake Alexander Boulevard. Travel approximately½ mile. The Holiday Inn is located on the right.

Traveling North on I-85
Take exit 75. Turn left onto Jake Alexander Boulevard. Travel approximately½ mile. The Holiday Inn is located on the right.

Jane S. McKimmon Center – Raleigh, North Carolina
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.

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

Attention: Local Management Entities (LME), Children’s Development Service Agencies (CSDA), Home Health Providers, Outpatient Hospital Clinics, Independent Practitioner Providers, Local Health Departments, Physician Services

Outpatient Specialized Therapies CCNC Pilot Project

Effective June 1, 2005, the Community Care of NC (CCNC) pilot program for therapy services in Cabarrus and Pitt Counties was discontinued.  Therapy providers serving Medicaid recipients in these two counties should submit all therapy prior approval requests directly to Medical Review of North Carolina (MRNC).

Medicaid providers serving Medicaid children in Pitt County and Medicaid adults and children in Cabarrus County enrolled in the Community Care of North Carolina (CCNC – formerly known as Access II and III) Program have been piloting a local interdisciplinary team approach to the care management of ancillary services.  For the last two years, the CCNC networks have been reviewing and coordinating ancillary services for their Medicaid enrollees in their communities. 

We appreciate your efforts and support in making this pilot a success and in working with us as we explore processes that improve the quality and coordination of care provided to our Medicaid population. 

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

Attention: All Orthotic and Prosthetic Service Providers

Provider Enrollment

Effective July 1, 2005 Medicaid will direct enroll practitioners who provide Orthotic and
Prosthetic Devises. Only Medicaid approved and enrolled providers with the appropriate board certification will be reimbursed for orthotic and prothetic devises with dates of service effectve July 1, 2005.

Pratitioners who wish to enroll with Medicaid must meet the qualifications as outlined below for their appropriate provider type.

• Orthotist – certification from the American Board for Certification (ABC) or the Board of Certification (BOC)
• Prosthetist - certification from the American Board for Certification(ABC) or the Board of Certification (BOC)
• Prosthetist/Orthotist- certification from the American Board for Certification(ABC) or the Board of Certification (BOC)
• Pedorthotics - certification from the Board for Certification in Pedorthotics- Certified Pedorthotist
• Ocularists - certification from the National Examining Board of Ocularists
• Registered Fitter/Orthotics - certification from the American Board for Certification in Orthotics and Prosthetics (ABC)
• Certified Orthotic Fitter – certification from the Board for Orthotist/Prosthetist (BOC)
• Registered Fitter-Mastectomy – certification from the American Board for Certification in Orthotics and Prosthetics (ABC)
• Certified Mastectomy Fitter- certification from the Board for Orthotist/Prosthetist (BOC)
• Registered Fitter-Orthotics Mastectomy – certification from the American Board for Certification in Orthotics and Prosthetics (ABC)

Pratitioners who bill for Orthotics and Prothetics will be required to be affiliated with a Medicaid enrolled DME dispensing provider agency or must apply and meet the enrollment guidelines as a DME dispensing provider. For additional information on DME agency enrollment please access our application.

Provider Enrollment
DMA, 919-855-4050

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.

2005 Checkwrite Schedule

2005 Checkwrite 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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