In This Issue...........................................

All Providers:

• Applying for the National Provider Number
• Checkwrite Schedule
• Clarification for Completing the W-9
• Clinical Coverage Policies
• Outpatient Pharmacy Program Special Bulletin

Adult Care Home Providers: 

• Medicaid Payments for Recipients Residing in an Adult Care Home Special Care Unit for Persons with Alzheimer’s and Related Disorders

AQUIP Users:

• Quarterly Automated Quality Utilization and Improvement Program Training Seminar

CAP/DA Lead Agencies:

• Quarterly Automated Quality Utilization and Improvement Program Training Seminar

Community Health Providers:

• Preadmission Screening and Annual Resident Review (PASARR) Seminars

Dental Providers:

• Dental Rate Change

Federally Qualified Health Centers (FQHCs):

• Preadmission Screening and Annual Resident Review (PASARR) Seminars

Health Departments:

• Dental Rate Change
• Preadmission Screening and Annual Resident Review (PASARR) Seminars

Home Health Agencies:

• Preadmission Screening and Annual Resident Review (PASARR) Seminars

Hospice:

• Preadmission Screening and Annual Resident Review (PASARR) Seminars

Hospitals:

• Preadmission Screening and Annual Resident Review (PASARR) Seminars

Nurse Practitioners:

• Daptomycin Injection, 1 mg (Cubicin, J0878) – Billing Guidelines
• Preadmission Screening and Annual Resident Review (PASARR) Seminars

Nursing Facilities:

• Preadmission Screening and Annual Resident Review (PASARR) Seminars

Pharmacists and Prescribers:

• Outpatient Pharmacy Program Special Bulletin

Physicians:

• Daptomycin Injection, 1 mg (Cubicin, J0878) – Billing Guidelines

Rural Health Centers (RHCs):

• Preadmission Screening and Annual Resident Review (PASARR) Seminars

Social Services:

• Preadmission Screening and Annual Resident Review (PASARR) Seminars

Attention: All Providers

Applying for the National Provider Identifier

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of a standard unique identifier for healthcare providers.  The final rule for the National Provider Identifier (NPI) was issued on January 23, 2004, and adopts the NPI as this national standard.

Healthcare providers can apply now for their NPI at the following website: https://nppes.cms.hhs.gov.  All HIPAA-covered physicians, suppliers, and other health care providers must apply for and be issued an NPI by May 23, 2007.  In addition, all health plans must be able to accept the NPI instead of the plan specific provider identifiers on all HIPAA standard transactions by May 23, 2007.  In other words, after this date claims submitted to Medicaid must be billed with your NPI number instead of your current Medicaid provider number.

ALERT:   When applying for an NPI, you are urged to include all Medicaid provider numbers on the NPI application form.  Be sure to indicate North Carolina as your state name.  It is our understanding that at some point CMS will make enumeration information available to states.  At that time, this information will assist DMA in the development of crosswalks between your NPI and your Medicaid provider numbers. 

The Division of Medical Assistance has initiated its NPI project.  Please look for future bulletins regarding procedures for gathering NPIs and taxonomies.

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

Attention: All Providers

Clarification for Completing the W-9

The Medicaid provider enrollment process includes the completion of the Internal Revenue Service’s (IRS) W-9 form.  The Division of Medical Assistance (DMA) must collect this information in order to correctly report income paid to the provider.  The W-9 form is retained by DMA and is not sent to the IRS.  The instructions that the IRS provides with the W-9 form explain that payments you receive may be subject to backup withholding if you do not report your correct tax identification number (TIN).  The instructions further explain the TIN provided must match the name given on Line 1.  Failure to provide your correct TIN may result in a penalty.  (The W-9 form and instructions for completing the form are available at http://www.irs.gov.) 

Some individual providers who are also associated with a group practice submitted their W-9 with the group’s TIN listed instead of their SSN.  Now that DMA is aware of this issue, the IRS instructions and guidelines for completion of the W-9 form will be followed.  Providers who have supplied incorrect TINs in the past may correct their W-9 at any time by completing a Provider Change Form and attaching a corrected W-9.

Earnings reported on the 1099 form are based on the provider number entered on the claim form. If incorrect earnings are reported it may be because claims are incorrectly filed without the group number, which results in income being reported to the individual (attending) provider number entered on the claim.  Incorrect earnings are NOT reported based on the W-9.  It is important that all providers carefully review the Financial Section of Remittance and Status Report (RA) to verify that the claim is submitted properly and income is reported to the correct TIN. 

Provider Services

DMA, 919-855-4050          

Attention: All Providers

Clinical Coverage Policies

The following new or amended clinical coverage policies are now available on the Division of Medical Assistance’s Web site at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm:

• 7 – Hearing Aid Services
• 8D-2 – Residential Treatment Services
• 9 – Outpatient Pharmacy Program
• 10B – Independent Practitioners
• 10C – Local Education Agencies

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: Adult Care Home Providers

Medicaid Payments for Recipients Residing in an Adult Care Home Special Care Unit for Persons with Alzheimer’s and Related Disorders

Session Law 2005-276, passed during the 2004–2005 legislative session, provided additional funding for special care units for persons with Alzheimer’s and related disorders located in adult care homes (SCU-A). As part of that legislation, effective October 1, 2005, an enhanced state and county special assistance rate became available to cover an increased room and board charge in a SCU-A.

The legislation also requires the N.C. Medicaid program to implement an enhanced personal care service rate for Medicaid recipients in the SCU-A. Effective with date of service October 1, 2006, the N.C. Medicaid program will implement this SCU-A, enhanced personal care service rate. Providers must obtain prior approval from Medicaid before admitting a Medicaid resident to a SCU-A and receiving this new enhanced rate. The prior approval process will be explained in an article in the July 2006 general Medicaid bulletin.

Clinical Policy and Programs

DMA, 919-855-4360

Attention: CAP/DA Lead Agencies and AQUIP Users
Quarterly Automated Quality Utilization and Improvement Program Training Seminar

The second quarterly Automated Quality Utilization and Improvement Program (AQUIP) training seminar for new AQUIP users in a CAP/DA Lead Agency is scheduled for June 27, 2006, at the Hilton Charlotte University Place.

Attendance at this meeting is of the utmost importance for new AQUIP users.  CAP/DA lead agency contacts have been informed via e-mail of any identified new AQUIP users in their counties who should attend this session.  Any current AQUIP users who would like to attend the session may do so if space permits.

The AQUIP seminar is scheduled to begin at 9:00 a.m. (registration 8:30 to 9:00 a.m.) and end at 4:00 p.m.  The morning session will focus on how to accurately complete the Client Information Sheet, Data Set Assessment, and Plan of Care.  After a break for lunch (on your own), the afternoon session will address the system overview and use.

Preregistration is required.  Contact your CAP/DA lead agency to verify if your name is on the required attendance list.  You may register for the seminar online by going to https://www2.mrnc.org/aquip and clicking on Registrations.  You will receive a computer-generated confirmation number, which you should bring to the seminar.

Driving Directions

Hilton Charlotte University Place—Charlotte

Exit from I-85 North or South at exit 45A, W.T. Harris Boulevard East.  Hilton Charlotte University Place is 0.25 mile on the left in the University Place complex.  The hotel is the high-rise building in the complex, totally visible from Harris Boulevard.  The left turn at J.M. Keynes Drive goes directly into the hotel parking lot.

Facility and Community Care
DMA, 919-855-4360

Attention:  All Dental Providers Including Health Department Dental Clinics

Dental Rate Change

Effective with dates of service October 1, 2005, reimbursement rates for the following dental procedures were increased.  The rate changes were entered into the MMIS system on May 5, 2006; therefore, claims processed after this date will pay with these new rates.  Claims that processed prior to May 5, 2006, will be automatically reprocessed through system adjustments to pay the additional reimbursement.  Providers will be notified through the general Medicaid bulletin and/or a banner message on the remittance advice regarding the scheduled date for system adjustments.  No adjustments will be accepted from providers for these dental rate changes.  Providers are reminded to bill their usual and customary charges rather than the Medicaid rate.

Effective with dates of service July 1, 2006, reimbursement rates for the following dental procedures will be changed:

For current pricing on these and all dental codes, refer to DMA’s Website at http://www.dhhs.state.nc.us/dma/fee/fee.htm.  For coverage criteria and additional billing guidelines, please refer to Clinical Coverage Policy 4A, Dental Services.

Dental Program

DMA, 919-855-4280

Attention: Hospitals, Nursing Facilities, Hospice, Dept. of Social Services, Physicians, Home Health Agencies, Health Departments, Federally Qualified Health Centers (FQHCs), and Rural Health Centers (RHCs) 

Preadmission Screening and Annual Resident Review (PASARR) Seminars

Seminars for the PASARR program are scheduled for June and July 2006.  The seminars are designed to educate providers on the changes to procedures for processing PASARR.

Preregistration for this seminar is required.  Providers register for the seminar by completing and submitting the registration form or by registering online beginning June 1st at http://www.dhhs.state.nc.us/dma/prov.htm.  A confirmation notice will be mailed to each registered participant.  The deadline for registration is the date of each seminar.

The seminars begin at 10:00 am. and end at 1:00 p.m.  Providers should arrive at least 30 minutes early to complete the registration process.  Lunch will not be served.

Providers must print a copy of the Special Bulletin, PASARR Program and Training from the DMA website, http://www.dhhs.state.nc.us/dma/bulletin.htm, and bring it to the seminar.

Dates and Locations:

Directions:

Flat Rock- Bo Thomas Auditorium

Take I-40 to Asheville. Travel east on I-26 to exit 53, Upward Rd. Turn right and end of ramp. At second light, turn right onto S. Allen Drive. Turn left at sign onto College Drive. First building on right is the Sink Building. Bo Thomas Auditorium is on the left side of the Sink Building.

Salisbury- Holiday Inn

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.

Raleigh- McKimmon Center

Traveling East on I-40
Take exit 295 and turn left onto Gorman Street. Travel approximately 2½ miles.  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 2½ miles.  The McKimmon Center is located on the right at the corner of Gorman Street and Western Boulevard.

Greenville- Hilton Hotel

Take Highway 264 east to Greenville.  Turn right onto Allen Road in Greenville.  Travel approximately 2 miles.  Allen Road becomes Greenville Boulevard/Alternate 264.  Follow Greenville Boulevard for 2½ miles to the Hilton Greenville, which is located on the right.

Wilmington- Coast Line Convention Center

Take I-40 east to Wilmington.  Turn right onto Martin Luther King, Jr., Parkway (U.S. 74 West).  Follow signs for downtown Wilmington; the Parkway becomes Third Street.  At first light on Third Street, turn right on Red Cross Street.  Travel two blocks on Red Cross and turn right onto Nutt Street.  Take the second driveway on the left into the Hotel and Convention Center.

Attention: Pharmacists and Prescribers

Outpatient Pharmacy Program Special Bulletin

Effective May 16, 2006, the Outpatient Pharmacy Program Special Bulletin was updated.  This special bulletin supersedes previously published policies and procedures. For your convenience, highlighting in the bulletin will indicate all new information.

The most significant change is a new telephone number of 1-800-688-6696 or 919-851-8888 to call when requesting changes to pharmacy lock-in providers or when identifying new recipients who are restricted to a single pharmacy and managed through the Medication Management Program. Specialty providers will also have to call this number to register with EDS to be added to the recipient’s lock-in file.

Providers may access the May 2006 Special Bulletin, Outpatient Pharmacy Program Special Bulletin.  Providers should contact EDS with any billing questions.

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

Attention: Physicians and Nurse Practitioners

Daptomycin Injection, 1 mg, (Cubicin, J0878) – Billing Guidelines

The following article is reprinted from the May bulletin because Cubicin was incorrectly coded.

Daptomycin Injection, 1 mg (Cubicin, J0878) - Billing Guidelines

Effective with date of service January 1, 2006, the N.C. Medicaid program covers daptomycin for injection (Cubicin) for use in the Physician’s Drug Program, when billed with HCPCS code J0878.  Cubicin is an antibacterial agent of a new class of antibiotics, the cyclic lipopeptides.  The FDA approved indication for Cubicin is the treatment of complicated skin and skin structure infections caused by susceptible strains of the following Gram-positive microorganisms:

• Staphylococcus aureus (including methicillin-resistant strains)
• Streptococcus pyogenes
• Streptococcus agalactiae
• Streptococcus dysgalactiae subsp. equisimilis
• Enterococcus faecalis (vancomycin-susceptible strains only)

Combination therapy may be clinically indicated if the documented or presumed pathogens include Gram-negative or anaerobic organisms.  Cubicin is not recommended for the treatment of pneumonia.

The FDA indicates that the usual adult dose is 4 mg/kg administered over a 30-minute period by IV infusion in 0.9% sodium chloride injection once every 24 hours for 7-14 days.  Doses of Cubicin higher than 4 mg/kg/day have not been studied in Phase 3 controlled clinical trials.  Cubicin should not be dosed more frequently than once a day.

One of the following ICD-9-CM diagnosis codes is required when billing for Cubicin: 

Billing Requirements:

• Use the CMS-1500 claim form.
• Enter the appropriate ICD-9-CM diagnosis code in block 21.
• Enter the date of service in block 24A.
• Enter the place of service in block 24B.
• Enter HCPCS code J0878 in block 24D.
• Enter the usual and customary charge in block 24F.
• Enter the units given in block 24G (1mg = 1 unit).

Example

For Medicaid billing, one unit of coverage is 1 mg.  The maximum reimbursement rate per unit is $0.29.  The fee schedule for the Physician’s Drug Program is available on DMA’s web site at http://www.dhhs.state.nc.us/dma/fee/fee.htm.

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 at http://ncleads.dhhs.state.nc.us.  Please refer to this web site for information, updates, and contact information related to the NCLeads system.

NCLeads Provider Relations

Office of MMIS Services

919-647-8315

Proposed Clinical Coverage Policies

In accordance with Session Law 2005-276, proposed new or amended Medicaid clinical coverage policies are available for review and comment on DMA’s website at http://www.dhhs.state.nc.us/dma/prov.htm.  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

  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.