|
|
NPI:
All Providers:
Anesthesia Providers:
CCNC/CA Primary Care Providers:
CAP Case Managers:
CAP/MR-DD Providers:
Durable Medical Equipment Providers:
Enhanced Behavioral Health Services
(Community Intervention Services) Providers:
Home Health Agencies:
Hospital Outpatient Clinics:
Hospitals:
Institutional (UB-04/837I) Billers:
Local Management Entities:
Nurse Practitioners:
Outpatient Behavioral Health Providers:
Pharmacists:
Physicians:
Private Duty Nursing Providers:
Psychiatrists:
Residential Child Care Treatment Facilities:
The Department of Health and Human Services, Division of Medical Assistance hereby provides notice of its intent to amend the Medicaid State Plan for the purpose of revising rate methodology language to reflect an inflationary adjustment factor of zero (0) percent for SFY 2009 – 2010 to all Medicaid private and public providers with the following exceptions: federally qualified health clinics, rural health centers, State institutions, outpatient hospitals, pharmacies and the noninflationary components of the case-mix reimbursement system for nursing facilities. Medicaid rates predicated upon Medicare fee schedules shall follow Medicare reductions but not Medicare increases unless federally required. Inflationary increases for Medicaid providers paying provider fees (private ICF-MRs and nursing facilities) can occur if the State share of the increases can be funded with provider fees.
A public notice will be issued for any future rates adjustments for SFY 2009 – 2010.
This amendment will become effective July 1, 2009.
The annual estimated state fiscal impact of this change is:
A copy of the proposed amendment(s) may be viewed at the county department of social services. Questions, comments and requests for copies of the proposed State Plan amendment should be directed to the Division of Medical Assistance at the address listed below.
Craigan L. Gray, MD, MBA, JD
Medicaid Director
Division of Medical Assistance
2501 Mail Service Center
Raleigh, NC 27699-2501
Effective with date of processing May 1, 2009, the 7-digit Carolina ACCESS Medicaid Provider Referral Number is no longer accepted on paper or electronic claims. In order to receive payment and avoid denials, submit ONLY the Carolina ACCESS National Provider Identifier (NPI) referral number in block 17b on the CMS-1500 claim form or on the left side of form locator 78 on the UB-04 claim form.
To determine the recipient’s primary care provider (PCP) and whether to obtain the group NPI or individual NPI for the Carolina ACCESS referral authorization, refer to the recipient’s Medicaid identification (MID) card or the Automated Voice Response (AVR) system. When calling the AVR system for PCP information, select option 6 for eligibility, and then option 2 for enrollment.
Tips on Submitting Claims for Carolina ACCESS Recipients
Note: Qualifiers are required only when billing paper claims. They are not required when using the NCECSWeb Tool. Providers using a software vendor or clearinghouse, should contact them to verify whether qualifiers are required.
The N.C. Medicaid National Provider Identifier (NPI) mapping solution uses both billing (accounting) and service facility ZIP codes to map claims. Providers with one NPI that represents multiple Medicaid provider numbers at different locations must submit the ZIP+4 that is on file for the appropriate provider number, in order for claims to map properly.
Also, within the ZIP code mapping step, the accounting ZIP+4 is considered first. If no match is found, it moves to service facility ZIP+4. Providers may need to add an accounting address to additional provider numbers for mapping purposes.
To verify your provider information, visit the NPI and Address Database on DMA's website.
Always include your service facility ZIP+4 when completing your claim. On the NCECSWeb Tool there is a specific field for the service facility ZIP code. On the CMS-1500, the service facility ZIP+4 is entered in block 32. On the UB-04, the service facility ZIP+4 is entered in form locator 1 as the “attending physician” ZIP.
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
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 DMA’s HIPAA web page.
With the implementation of standards for electronic transactions mandated by 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 Medicaid bulletins.
EDS, 1-800-688-6696 or 919-851-8888
As a cost-saving measure and to increase efficiency, the N.C. Medicaid Program will require all providers to file claims electronically. Providers will be notified of the implementation date for this requirement in a future Medicaid bulletin.
By submitting claims electronically, providers have the advantage of expedited claims processing and improved cash flow. Electronic claims software includes time-saving features such as automatic insertion of required claims information, retrieval of previously submitted claims from backup files, and generation of lists of commonly used billing codes. Claims submitted electronically by 5:00 p.m. on the cut-off date are processed in the following checkwrite.Electronic Claims Submission Agreement
Providers who did not complete an Electronic Claims Submission (ECS) Agreement at the time of their enrollment must now complete and submit an ECS Agreement. Effective with this requirement, all providers enrolling in the N.C. Medicaid Program will be required to complete and submit the ECS Agreement in their Provider Enrollment Packet. Providers who are already filing claims electronically do not need to resubmit an ECS Agreement.
Group providers must submit the name and Medicaid Provider Number for each individual provider affiliated with their group for whom they will be submitting claims using their group provider number. This is required even if there is only one provider in the group. The Electronic Claims Submission Agreement for the group must be signed by each individual provider, which authorizes the group to use the individual's National Provider Identifier to bill Medicaid for services provided.
To obtain a copy of this agreement for either a group or an individual, visit CSC's Provider Forms web page.
Trading Partner Agreement
Providers and clearinghouses that bill HIPAA-compliant transactions directly to N.C. Medicaid are required to complete and submit a Trading Partner Agreement (TPA) to N.C. Medicaid. The TPA stipulates the general terms and conditions by which the partners agree to exchange information electronically. The form is available on DMA's Provider Forms web page.
Electronic Claim Exceptions
The following list outlines some of the situations in which a claim must be billed on paper.
Only claims that comply with the exceptions listed above may be submitted on paper. All other claims are required to be submitted electronically. This list will be maintained on the DMA's Electronic Claims Exceptions web page. Providers will be notified of updates to the list through the Medicaid Bulletin.
EDS, 1-800-688-6696 or 919-851-8888
As a cost-saving measure and to increase efficiency, the N.C. Medicaid Program will require all providers to receive payments electronically. Providers will be notified of the implementation date for this requirement in a future Medicaid Bulletin.
By receiving payments electronically, providers eliminate the possibility of their paper checks’ being lost, stolen, misrouted, damaged or returned to sender. Electronic funds transfers (EFT) also eliminate delays incurred in receipt of Medicaid payment for the mailing and delivery of the check, which can take 5 to 7 business days. EFT payments are deposited through a secure transaction into the provider-designated checking or savings bank account. EFT provides payment in a timely and safe manner and supports an increased cash flow to the provider’s business operation.To initiate the automatic deposit process, providers must complete and return the Electronic Funds Transfer Authorization Agreement for Automatic Deposit form and attach a voided check to confirm the provider's account number and bank transit number. A separate EFT form must be submitted for each provider number. Providers must submit a new EFT form if they change banks or bank accounts. A copy of the form can be obtained on DMA's Provider Forms web page.
To initiate the automatic deposit process, providers must complete and return the Electronic Funds Transfer Authorization Agreement for Automatic Deposit form. A separate EFT form must be submitted for each provider number. Providers must submit a new EFT form if they change banks or bank accounts. A copy of the form can be obtained on DMA's Provider Forms web page. Instructions on completing the form as well as documentation requirements can be found on the EFT form. Documentation includes attaching a voided check to confirm the provider’s account number and bank transit number.
Completed forms can be returned by fax to the EDS financial unit at 919-816-3186 or by e-mail to NCXIXEFT@eds.com. Providers will continue to receive paper checks until automatic deposits begin or resume to a new bank account. When the EFT process for automatic deposits has been completed, the top left corner of the last page of the Remittance and Status Report will show “EFT number” rather than “check number.”EDS, 1-800-688-6696 or 919-851-8888
Electronic Funds Transfer Authorization Agreement for Automatic Deposit Form
As a cost-saving measure and to increase efficiency, the N.C. Medicaid Program may begin issuance of no more than one Medicaid identification (MID) card per year to each recipient. The proposed annual cards would be printed on white stock; DMA would no longer have blue, pink, green, and buff colored MID cards. The cards would include, at a minimum, the recipient’s name, MID number, and managed care primary care provider information (if applicable).
If implemented, this change would mean that the MID card will no longer serve as proof of recipient eligibility. Providers must verify the cardholder’s current eligibility at each visit. Once providers have verified eligibility during a particular month, the provider may assume that the cardholder remains eligible for the remainder of that month.An exception to the one card per year rule would be made for those managed care recipients who change their primary care physician or change their name. A recipient would also be able to ask the county department of social services to submit a request for a replacement card, if needed.
Should the proposed legislation be implemented, providers will be notified of the change in future Medicaid Bulletins and through Remittance and Status Report banner messages, e-mail blasts, and the DMA Budget Initiative web page.Medicaid Eligibility Unit
DMA, 919-855-4000
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 ProgramsEffective January 1, 2007, Section 6023 of the Deficit Reduction Act (DRA) of 2005 requires providers receiving annual Medicaid payments of $5 million or more to educate employees, contractors, and agents about federal and state fraud and false claims laws and the whistleblower protections available under those laws.
Each year DMA will notify those providers who received a minimum of $5 million in Medicaid payments during the last federal fiscal year (October 1 through September 30) that they must submit a Letter of Attestation to Medicaid in compliance with the DRA. (A complete list of providers who meet this requirement will be available on DMA’s False Claims Act Database web page.) This minimum amount may have been paid to one N.C. Medicaid provider number or to multiple Medicaid provider numbers associated with the same tax identification number. A separate notification will be mailed for each Medicaid provider number.Providers must complete and submit a copy of the Letter of Attestation Form within 30 days of the date of notification. Upon completion, submit the Letter to EDS by fax or by mail.
Mail toOR
Fax to
919-851-4014
Attn: PVS-False Claims Act
Compliance with Section 6023 of the DRA is a condition of receiving Medicaid payments. Medicaid payments will be denied for providers who do not submit a signed Letter of Attestation within 30 days of the date of notification. Providers may resubmit claims once the signed Letter is submitted to and received by EDS.
EDS, 1-800-688-6696 or 919-851-8888DMA will implement a number of changes in response to proposed legislated budget reductions. Providers will be notified of operational changes and coverage, and policy changes via the Medicaid Bulletin. These changes will also be listed on DMA’s Budget Initiatives web page.
Provider ServicesThe Medicaid provider enrollment process includes the completion of the Internal Revenue Service’s (IRS) W-9 form. The N.C. Medicaid Program must collect this information in order to correctly report income paid to the provider. The W-9 form is retained by the N.C. Medicaid Program 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 that 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 on the Internal Revenue Service website.)
Some individual providers who are also associated with a group practice submitted their W-9 with the group’s TIN listed instead of their social security number (SSN). Now that the N.C. Medicaid Program 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-9s at any time by sending a completed Medicaid Provider Change Form with a corrected W-9 attached to the form to the address listed below.N.C. Medicaid Provider Enrollment
CSC
PO Box 300020
Raleigh NC 27622-8020
Earnings reported on the 1099 form are based on the provider number associated with the National Provider Identifier 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 their Remittance and Status Report (RA) to verify that the claim is submitted properly and income is reported to the correct TIN.
Monica T. Jones, Provider Services
DMA, 919-855-4050
Internal Revenue Service Website
Effective with date of service November 1, 2008, the unit limitation for CPT procedure code 72295 (discography, lumbar, radiological supervision and interpretation) was changed to five units per day. Modifiers 76 (repeat procedure by the same physician) or 77 (repeat procedure by another physician) should no longer be used when billing 72295. Providers who received a denial with EOB 5201 (diagnostic procedure allowed once per day unless billed with appropriate modifiers) or EOB 5202 (repeat diagnostic procedure allowed twice per day) for procedure code 72295 for dates of service on or after November 1, 2008, may resubmit the denied charges as a new claim (not as an adjustment request) for processing.
EDS, 1-800-688-6696 or 919-851-8888Effective with date of service July 1, 2009, the following changes have been made to the dental benefits for
N.C. Health Choice.
There will be coverage for selected new extraction codes, as follows:
| Code |
Description |
|---|---|
| D7111 |
Extraction, coronal remnants - deciduous tooth - Allowed for teeth A through T and AS through TS. |
| D7140 |
Extraction, erupted tooth or exposed root (elevation and/or forceps removal) - Allowed for |
| D7250 |
Surgical removal of residual tooth roots (cutting procedure) - Allowed for A through T, |
There is no coverage for third molar extractions: teeth numbers 1, 16, 17, and 32.
There will be coverage for space maintainers, as follows:
| Code |
Description |
|---|---|
| D1510 |
Space maintainer - fixed - unilateral - Allowed for UR, UL, LL, and LR |
| D1515 |
Space maintainer – fixed - bilateral - Allowed for UP and LO |
There will be coverage for selected endodontic codes, as follows:
| Code |
Description |
|---|---|
| D3310 |
Endodontic therapy, anterior tooth (excluding final restoration) - allowed for teeth #'s |
| D3330 |
Endodontic therapy, molar (excluding final restoration) -- allowed for teeth #'s 3, 14, 19, and 30 only |
No prior review is required for the extraction, space maintainer, and endodontic codes listed above.
Orthognathic surgery will be covered to correct functionally impairing malocclusions when orthodontia was approved and initiated while the child was covered by Medicaid and the need for orthognathic surgery was documented in the orthodontic treatment plan.The following orthognathic surgery codes that may be covered if considered medically necessary:
| Code | Description |
|---|---|
| D7940 | Osteoplasty - for orthognathic deformities |
| D7941 | Osteotomy - mandibular rami |
| D7943 | Osteotomy - mandibular rami with bone graft; includes obtaining the graft |
| D7944 | Osteotomy - segmented or subapical |
| D7945 | Osteotomy - body of mandible |
| D7946 | LeFort I (maxilla - total) |
| D7947 | LeFort I (maxilla - segmented) |
| D7948 | LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) - without bone graft |
| D7949 | LeFort II or LeFort III - with bone graft |
| D7950 | Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report |
| D7955 | Repair of maxillofacial soft and/or hard tissue defect |
Prior review is required for all orthognathic surgery.
N.C. Health ChoiceEffective with date of service January 1, 2008, CMS added modifier 51 (multiple procedures) as an appropriate modifier when billing the following CPT procedure codes:
System changes have been completed. Providers who received a denial with EOB 24 (Procedure code, procedure/modifier combination or revenue code is missing, invalid or invalid for this bill type. Correct and rebill denied detail as a new claim.) when billing CPT procedure code 93541, 93542 or 93543 with modifier 51 for dates of service on or after January 1, 2008, may resubmit the denied charges as a new claim (not an adjustment request) for processing as long as filing has been kept timely.
EDS, 1-800-688-6696 or 919-851-8888Background
In 2005, the North Carolina Legislature passed enabling legislation (Article 5E. North Carolina Controlled Substances Reporting System Act § 90-113.70-76) to establish a prescription monitoring program. The stated purpose of the Act is to “improve the State’s ability to identify controlled substance abusers or misusers and refer them for treatment, and to identify and stop diversion of prescription drugs in an efficient and cost-effective manner that will not impede the appropriate medical utilization of licit controlled substances.” This legislation was in response to the newly recognized epidemic of unintentional fatal poisonings sweeping the nation and the state, resulting primarily from the increasing misuse and abuse of prescription opioids. The new, centralized database created by the Act was named the Controlled Substances Reporting System (CSRS), as it includes information only on outpatient prescriptions for controlled substances, not on other types of medications that are prescribed and dispensed in North Carolina. In July 2007, the N.C. Department of Health and Human Services (DHHS) put the CSRS into production.
In addition, DHHS shall report unusual patterns of prescribing to the Attorney General. An independent multidisciplinary advisory committee has been formed to provide ongoing guidance to DHHS on the CSRS. The committee establishes reviews and revises objective criteria as to what constitutes an unusual pattern.
Legal MandateEpidemiologic Profile of Outpatient Controlled Substances
Almost half of the prescriptions in the CSRS database are for narcotic analgesics (mostly opioids). In 2008, more than 16 million outpatient prescriptions were dispensed for controlled substances. Of these, the most frequently prescribed were products with hydrocodone (4,146,484 prescriptions), benzodiazepines (3,782,112 prescriptions), oxycodone (2,029,604 prescriptions) and products to treat insomnia (1,416,840 prescriptions). The prescription rates varied greatly by county, with the highest prescription rates occurring most often (but not always) in our state’s most rural areas (see Figure 1).
Enrolling in the CSRS
Medicaid and other medical providers who are practitioners with a current DEA registration and licensed pharmacists may easily apply for access to the CSRS by completing a short enrollment application available on the CSRS website. Print, complete, sign and notarize the form and mail it to the CSRS at the address on the form. E-mail confirmation of access is often received in less than two weeks. The CSRS link is also available on the DMA Outpatient Pharmacy web page under “Related Sites.” Because of the strict confidentiality provisions in the Act, only the registered practitioner may access the system. The law prohibits other members of the practice from using it. Additionally, it is unlawful to disclose CSRS findings with anyone (including other practitioners) except the patient. (Pending legislation could change this provision.)
The CSRS was not designed as a means by which to “fire” a patient because of a less-than-optimal prescription profile. Because the CSRS is new and the potential for error always exists, the system cannot be assumed to be infallible. Always discuss the findings with the patient. If the patient contests the findings or the practitioner is concerned about the validity of the profile or has other questions, the practitioner may contact John Womble or William Bronson, at the Division of Mental Health, Developmental Disabilities and Substance Abuse Services, Drug Control Unit (telephone 919-733-1765, Monday through Friday between 9:00 a.m. and 5:00 p.m.).
William D. Bronson, ManagerCatherine (Kay) Sanford
Injury Epidemiology Consultant
Susan Albert, MD, Medical Director
Wilkes County Health Department
CSC is ready to begin the 12-month process to verify information and credential enrolled Medicaid providers who have not been credentialed in the last 18 months. CSC will notify providers by mail when verification and credentialing activities will begin for their provider types. The notification packet will be mailed to the provider's billing/accounting address and will include a pre-printed report of information currently on file with N.C. Medicaid plus a checklist of credentialing-related documents that must be returned to CSC. (Providers may verify their billing/accounting address via the DMA Provider Services NPI and Address Database or by calling the EVC Call Center.)
The pre-printed NC MMIS Verification Form includes demographic data and NPI information currently on file with N.C. Medicaid and also contains space for providers to enter license/certification numbers, type of ownership, and contact information. Providers must complete the form, attach copies of documents required for credentialing, and return the verification packet to CSC within 30 days of the date of receipt. Failure to respond to the notification may result in termination of Medicaid participation.
The verification process will take up to three weeks from the time CSC receives the correct and complete verification packet from the provider; the return of incomplete or incorrect information will prolong the verification process. CSC will review the information and conduct credentialing activities that include criminal background checks, queries of practitioner databases, and verification of licensure, certification, and endorsement.
DMA and CSC will continue to inform providers of various events and changes through the General Medicaid Bulletin, the DMA Replacement MMIS web page, and the EVC Call Center website.
EVC Call Center Contact Information
|
EVC Call Center Toll-Free Number |
866-844-1113 |
|
EVC Call Center Fax Number |
866-844-1382 |
|
EVC Call Center E-Mail Address |
|
|
EVC Call Center Mailing Address |
N.C. Medicaid Provider Enrollment |
|
EVC Call Center Site Address |
N.C. Medicaid Provider Enrollment |
|
EVC Call Center Website |
Refer to DMA's Replacement MMIS web page for more information about CSC and the development and implementation of the Replacement Medicaid Management Information System (MMIS).
Linda Pruitt
DMA, 919-855-4106
Federal guidelines require that all Medicaid claims, except hospital inpatient and nursing facility claims, must be received by EDS within 365 days of the first date of service in order to be accepted for processing and payment. All Medicaid hospital inpatient and nursing facility claims must be received within 365 days of the last date of service on the claim. If a claim was filed within the 365-day time period, providers have 18 months from the remittance advice (RA) date to refile a claim.
If the claim is a crossover from Medicare or any other third-party commercial insurance, regardless of the date of service on the claim, the provider has 180 days from the date listed on the explanation of benefits (EOB) to file the claim to Medicaid from that insurance (whether the claim was paid or denied). The provider must include the Medicaid Resolution Inquiry Form, copy of the claim, and a copy of the Third-Party or Medicare EOB in order to request a time limit override with EDS.Claims initially received for processing within the 365-day time limit may be resubmitted to EDS on paper or electronically. The claim information must match exactly to the original claim for the recipient Medicaid identification number (MID), provider number, from date of service, and total billed. Claims that do not have an exact match to the original claim in the system will be denied for one of the following Explanation of Benefits (EOB):
The Medicaid Resolution Inquiry Form is used to submit claims for Time Limit Overrides. The instructions for completing the Medicaid Resolution Inquiry Form can be found in the Basic Medicaid Billing Guide in Section Eight – Resolving Denied Claims on page nine.
When submitting inquiry forms, always attach the claim and a copy of any paper RAs related to the inquiry form, as well as any other information related to the claim (provider-generated RAs or electronic RAs are not acceptable). Each inquiry request requires a separate form and copies of documentation (vouchers and attachments). Because these documents are scanned for processing, attach only single-sided documents to the inquiry request. Do not attach double sided documents to the inquiry request. A copy of the Medicaid Resolution Inquiry Form is on DMA’s Provider Forms web page.
Retro Eligibility and Retroactive Prior Approval
In some instances an application for Medicaid benefits is initially denied and then later approved due to a reversal of a disability denial, a state appeal, or a court decision. A time limit override may be needed in some cases; the county department of social services (DSS) is responsible for requesting this override base on date of approval. When a time limit override is warranted, the county department of social services will provide written notice to the recipient outlining the specific dates of service when the Time Limit Override is approved. Recipients are instructed to immediately notify the provider of retroactive approval. When this occurs, providers can file claims for these specific dates of service outlined in the recipient letter. The provider must file these claims within six months of determination as outlined in the recipient letter.
Retroactive prior approval is considered when a recipient, who does not have Medicaid coverage at the time of the procedure, is later approved for Medicaid with a retroactive eligibility date. Because some of these appeals and reversals are not final for many months, the county DSS can request an override of the claims filing time limit from DMA.
EDS, 1-800-688-6696 or 919-851-8888Effective with date of service May 5, 2009, the N.C. Medicaid Program added the FDA-approved diagnosis of glioblastoma to the required list of diagnoses for bevacizumab (Avastin) when billed through the Physician’s Drug Program. Avastin is indicated as a single agent for patients whose glioblastoma progressed despite prior therapy.
Certain ICD-9-CM diagnosis codes are required when billing for Avastin.
There was an error in the table published in the April 2009 Medicaid Bulletin article that provided guidance on the ICD-9-CM diagnosis codes required when billing bendamustine (Treanda, HCPCS procedure codes J9999 and J9033) for non-Hodgkin’s lymphoma. For “other malignant neoplasms of lymphoid and histiocytic tissue,” the range of codes should have been listed as 202.00 through 202.98.
Refer to the corrected table below when billing for Treanda.
| Dates of Service |
HCPCS Procedure Code |
ICD-9-CM Diagnosis Code |
ICD-9-CM Diagnosis Code Description |
|---|---|---|---|
| March 1, 2008, through September 30, 2008 |
J9999 |
V58.11 |
Encounter for antineoplastic chemotherapy |
| AND |
|||
| 204.10 through 204.11 |
Lymphoid leukemia, chronic, without mention of remission, in remission |
||
| October 1, 2008, through October 31, 2008 |
J9999 |
V58.11 |
Encounter for antineoplastic chemotherapy |
| AND |
|||
| 204.10 through 204.12 |
Lymphoid leukemia, chronic, without mention of remission, in remission or in relapse |
||
| November 1, 2008, through December 31, 2008 |
J9999 |
V58.11 |
Encounter for antineoplastic chemotherapy |
| AND |
|||
| 204.10 through 204.12 |
Lymphoid leukemia, chronic, without mention of remission, in remission or in relapse |
||
| OR one of these non-Hodgkin’s lymphoma diagnosis codes: |
|||
|
Lymphosarcoma and reticulosarcoma and other specified malignant tumors of lymphatic tissue |
||
|
Other malignant neoplasms of lymphoid and histiocytic tissue |
||
| January 1, 2009, and after |
J9033 |
V58.11 |
Encounter for antineoplastic chemotherapy |
| AND |
|||
| 204.10 through 204.12 |
Lymphoid leukemia, chronic, without mention of remission, in remission or in relapse |
||
| OR one of these non-Hodgkin’s lymphoma diagnosis codes: |
|||
|
Lymphosarcoma and reticulosarcoma and other specified malignant tumors of lymphatic tissue |
||
|
Other malignant neoplasms of lymphoid and histiocytic tissue |
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service July 1, 2009, the N.C. Medicaid Program covers factor VIII (antihemophilic factor, recombinant) (Xyntha) per IU for use in the Physician’s Drug Program when billed with HCPCS procedure code Q2023. Xyntha is available in vials containing 250, 500, 1000, and 2000 IUs.
Xyntha is indicated for patients with hemophilia A. Xyntha, administered intravenously, may be used for the control and prevention of bleeding episodes or for surgical prophylaxis.
For Medicaid BillingThe fee schedule for the Physician’s Drug Program is available on DMA’s Fee Schedule web page.
EDS, 1-800-688-6696 or 919-851-8888Zero and null values will not be accepted. This requirement will apply only to new prescriptions and will not apply to refills. The information entered into the prescription origin code field is required to assist with auditing processes.
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service July 1, 2009, the N.C. Medicaid Program covers lacosamide injectable (Vimpat) for use in the Physician’s Drug Program when billed with HCPCS procedure code J3490 (unclassified drugs). Vimpat is available as 200-mg/20-ml single-use vials with a concentration of 10 mg/ml. Vimpat is indicated as adjunctive therapy in the treatment of partial-onset seizures when oral administration is temporarily not feasible.
Vimpat is initially administered intravenously with a dosage of 50 mg twice daily. The dosage may be increased at weekly intervals by 100 mg/day and is administered intravenously as two divided doses up to the recommended maintenance dosage of 200 to 400 mg/day. This recommended maintenance dosage is based on individual patient response and tolerability. When switching from oral to IV lacosamide, the initial total daily IV dosage of lacosamide should be equivalent to the total daily dosage and frequency of oral lacosamide and should be infused intravenously over a period of 30 to 60 minutes.For Medicaid Billing
The fee schedule for the Physician's Drug Program is available on DMA's Fee Schedule web page.
EDS, 1-800-688-6696 or 919-851-8888Effective with date of service July 1, 2009, the N.C. Medicaid Program covers golimumab injectable (Simponi) for use in the Physician’s Drug Program when billed with HCPCS code J3590 (unclassified biologicals). Simponi is available as either pre-filled syringes (50 mg per 0.5 ml) or pre-filled SmartJect autoinjectors (50 mg per 0.5 ml).
Simponi is a human monoclonal antibody that is indicated for the treatment of active moderate-to-severe rheumatoid arthritis (RA), active psoriatic arthritis (PsA), and active ankylosing spondylitis (AS).Simponi is administered as a subcutaneous (SC) injection once a month. The recommended dose for Simponi is 50 mg.
Prior to initiating Simponi and periodically during therapy, patients should be evaluated for active tuberculosis and tested for latent infection. For patients with RA, Simponi should be given in combination with methotrexate; for patients with PsA or AS, Simponi may be given with or without methotrexate or other non-biologic disease-modifying antirheumatic drugs (DMARDs). For patients with RA, PsA, or AS, corticosteroids, non-biologic DMARDs, and/or nonsteroidal anti-inflammatory drugs (NSAIDs) may be continued during treatment with Simponi.For Medicaid Billing
The fee schedule for the Physician's Drug Program is available on DMA's Fee Schedule web page.
EDS, 1-800-688-6696 or 919-851-8888Effective date of service July 17, 2009, insulin syringes will be covered as an over-the-counter product in the N.C. Medicaid Outpatient Pharmacy Program. Recipients must have a prescription for the insulin syringes and there must be an insulin prescription on file within the last 90 days in order to bill using the pharmacy point-of-sale system. Syringes are supplies that must be billed in multiples of 10 and a National Drug Code (NDC) must be used when billing through point-of-sale. Rates apply to syringes; therefore, no copayments or dispensing fees apply. Medicare Part D continues to cover insulin syringes for dual eligible recipients.
Syringes do not have to be purchased at the same pharmacy as the insulin unless the patient is locked into a pharmacy. Recipients identified for the Focused Risk Management (FORM) Program who require more than 11 unduplicated prescriptions each month are restricted to a single pharmacy. In these cases, the insulin syringes must be purchased at the same pharmacy.
Insulin syringes will no longer require authorization by a recipient’s CCNC/CA primary care provider. Lancets and strips will not be paid through point-of-sale. These items will continue to require authorization by a recipient’s CCNC/CA primary care provider.
EDS, 1-800-688-6696 or 919-851-8888
Medicaid coverage of incontinent supplies (i.e., diapers and Chux) is limited to recipients ages 3 years and older. Diapers for recipients under the age of 3 years are age-appropriate and, therefore, do not meet the medical necessity criteria for coverage. All Medicaid-covered medical supplies must meet medical necessity criteria, be specifically ordered by the physician, and be indicated on the recipient’s plan of care. Medical necessity criteria include the item being age-appropriate.
Non-sterile gloves for use by agency staff in providing services to the recipient are considered an administrative cost to the agency and are included in the Medicaid reimbursement rate for the service. The gloves cannot be billed to Medicaid as a separate charge. Non-sterile gloves are covered for family members and similar caregivers only if the caregiver is in contact with the patient’s blood or other potentially infectious body fluids. The gloves must be specifically ordered by the physician in the plan of care. The medical record must contain documentation regarding the condition or illness that requires the medical supplies and reflect usage to support the quantity being delivered.EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service December 1, 2007, DMA implemented the use of anesthesia modifier AD (medical supervision by a physician of more than four concurrent anesthesia procedures). System changes are now complete. The following guidelines must be used when billing the AD modifier.
Anesthesiologists who provide supervision to more than four anesthesia procedures performed by Certified Registered Nurse Anesthetists (CRNAs) will bill for the procedure using only the AD modifier. The QZ modifier (CRNA service: without medical direction by a physician) must be appended to the anesthesia CPT procedure code on the CRNA’s claim. The anesthesiologist will be reimbursed 45 base units for every procedure being supervised, and may bill a one-time 15-minute block of time if the anesthesiologist can document presence at anesthetic induction in the medical record.
ExampleThe anesthesiologist’s claim form will list the procedure code plus modifier AD and 0 (zero) units. The provider will be reimbursed for 45 base units. If present during anesthetic induction: list procedure code plus modifier AD and 15 units. Reimbursement will be for 60 base units. Only one claim detail for each procedure, with either 0 or 15 units appended, will be accepted. All other combinations of AD modifier and number of units will be denied. Medical record documentation must support claims billed. Normal timely filing guidelines apply.
The supervised CRNA’s claim form will list the procedure code and modifier QZ plus the time.
EDS, 1-800-688-6696 or 919-851-8888Direct-enrolled mental health practitioners who provide services to a CCNC/CA enrollee under the age of
21 years must have a referral from the CCNC/CA primary care provider, a Medicaid-enrolled psychiatrist or the Local Management Entity (LME). When the service is provided without an appropriate referral, an override cannot be given by CCNC/CA.
Managed Care
DMA, 919-855-4780
Effective with date of processing July 1, 2009, the N.C. Medicaid Program requires that immune globulins billed on institutional claims using Revenue Codes 250 or 636 plus CPT procedure codes 90281 through 90399 be reported with National Drug Codes (NDCs). Only rebatable NDCs are covered.
Providers must identify 340B drugs dispensed in an outpatient or clinic setting by using the UD modifier. This will allow Medicaid to identify claim details for 340B drugs and exclude them from the rebate collection process. All non-340B drugs are billed using the applicable HCPCS procedure code and NDC pair without the UD modifier.Refer to the article titled UD Modifier and 340B Drugs in the June 2009 Medicaid Bulletin for additional information on billing for 340B drugs.
Refer to the Refer to the March 2009 Special Bulletin, National Drug Code Implementation, Phase III, for additional information on NDC billing.
Medicaid bulletins and special bulletins are available on DMA’s Medicaid Bulletins web page.
EDS, 1-800-688-6696 or 919-851-8888
Training is being offered for those providers who have a fiscal year end of March 31, 2009, or June 30, 2009. The training scheduled at several locations across the state during the month of July. Those providers with a fiscal year end of September 30, 2009, or December 31, 2009, should wait to go to training when sessions are offered this winter.
To learn more about training, locations, times, and information on how to register for training, visit the Office of the Controller’s website and click on the link to the Mental Health Cost Report Training Memo. The memo also provides the link to the website where you can register.For questions concerning this training or the Mental Health Cost Report, contact Bill Caddell at Bill.Caddell@dhhs.nc.gov or 919-855-3681.
Rate SettingThe deadline for coverage of provisionally licensed providers delivering outpatient behavioral health services as a reimbursable service under Medicaid and state funds and billed through the Local Management Entity (LME) has been extended to June 30, 2010. DMA and DMH will continue to pay for services delivered by the provisionally licensed individuals listed above when billed through LMEs under HCPCS procedure codes H0001, H0004, and H0005 until that date.
As outlined in Implementation Update # 32 (on the DMH Enhanced Services Implementation Updates web page), the LME may choose to provide this billing service on behalf of the provisionally licensed professional. If the provisionally licensed professional is employed by an agency, the agency must develop a contract directly with the LME to do this billing for them. If provisionally licensed professionals work independently, they should contact their licensure board prior to developing a contract with the LME to ensure compliance with each profession’s scope of practice.In addition to providing outpatient behavioral health services billed through an LME, there are various other means for provisionally licensed professionals to obtain the clinical experience required by their licensing boards. These include
Catharine Goldsmith, Behavioral Health Section
DMA, 919-855-4290
This is a reminder of current outpatient prior authorization and billing guidelines for outpatient behavioral health services outlined in the June 2009 Implementation Update/Medicaid Bulletin. ValueOptions has revised the current Outpatient Review Form (ORF2). Please see the ValueOptions website for the revised form.
Effective July 1, 2009, providers must use the revised ORF2 for prior authorization requests. Providers should pay special attention to these two fields on the revised form:Both fields must be completed. Prior authorizations will be created for the Billing Provider/Medicaid provider number. Providers must enter the Billing Medicaid provider number associated with the Billing NPI with which they will submit their claims (do not submit NPI on the ORF2).
Prior authorization requests for group providers will cover all providers under that Billing Medicaid provider number. Do not submit a new request for a provider who fills in should the primary provider be absent.After September 1, 2009, ValueOptions will return any request as “Unable to Process” if it is submitted on the old ORF2 form or if the two fields noted above are not completed.
Behavioral Health SectionThis is a clarification of the prior approval guidelines outlined in the March 2009 and May 2009 Medicaid Bulletins. In order to facilitate best practice and integrated care for clients, CPT procedure codes 99408 and 99409 do not require prior authorization. These codes are also used by physicians and other medical professionals for substance abuse assessments and screenings. ValueOptions will not process prior authorization requests submitted for these CPT procedure codes.
Behavioral Health SectionAs a reminder, nurse practitioners must direct enroll with Medicaid to be eligible to provide outpatient behavioral health services to adults and children. Nurse practitioners may also provide services “incident to” a physician if they are employed in a physician’s office or a physician-directed clinic. However, all behavioral health practitioner services billed under “incident to” must meet the guidelines outlined in the May 2005 Special Bulletin, Expansion of Provider Types for Outpatient Behavioral Health Services, Phase II, and the article titled Modification in Supervision When Practicing “Incident To” a Physician, published in the October 2008 Medicaid Bulletin. (The Medicaid Bulletin and the Special Bulletin are available on DMA’s Medicaid Bulletin web page.)
Behavioral Health Section
DMA, 919-855-4290
The Enhanced Behavioral Health Services Provider Seminars scheduled for August 2009 have been cancelled.
EDS, 1-800-688-6696 or 919-851-8888In April 2009, following approval from CNS, DMA implemented Grouper 25/MCE version 24 software for inpatient claim processing. As a result of the retroactive implemenation of the grouper software, a recoup/repay of all hospital inpatient claims with discharge date of service after October 1, 2008, was necessary. These recoup/repays were processed based on the hospital fiscal year end (HFYE) date according to the table below.
| Group | Hospital Fiscal Year End Date | Remittance and Status Report (RA) Dates |
|---|---|---|
Group 1 |
12/31/2008 |
5/28/2009 and 6/9/2009 |
Group 2 |
4/30/2009 and 5/31/2009 |
6/16/2009 and 6/25/2009 |
Group 3 |
6/30/2009 and 7/31/2009 |
6/16/2009 and 6/25/2009 |
Group 4 |
8/31/2009 and 9/30/2009 |
6/25/2009 and 7/7/2009 |
Hospitals began to see these recoup/repays on their remittance status advices starting June 6, 2009.
EDS, 1-800-688-6696 or 919-851-8888
To comply with regulations mandated by HIPAA, in the February 2009 Medicaid Bulletin article titled ICD-9-CM Procedure Codes, DMA announced its intention to limit the use of ICD-9-CM procedure codes to the reporting of inpatient procedures by hospitals and to deny all other claims submitted with ICD-9-CM procedure codes including outpatient, nursing home, adult care homes, home health, hospice, and residential child care treatment facility services.
To allow providers to report surgical procedures previously reported using ICD-9-CM procedure codes, DMA planned to expand the detail level information required for Revenue Codes 36X (Operating Room Services) and 76X (Specialty Room Treatment/Observation Room) to include CPT/HCPCS procedure codes.
Implementation of these changes has been delayed until further notice.
EDS, 1-800-688-6696 or 919-851-8888
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
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 |
| July |
7/2/09 |
7/7/09 |
| 7/9/09 |
7/14/09 |
|
| 7/16/09 |
7/23/09 |
|
| 7/30/09 |
8/4/09 |
|
| August |
8/6/09 |
8/11/09 |
| 8/13/09 |
8/16/09 |
|
| 8/20/09 |
8/27/09 |
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.
| Craigan L. Gray, MD, MBA, JD Director Division of Medical Assistance Department of Health and Human Services |
Melissa Robinson |