August 2004 Medicaid Bulletin

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In This Issue . . .

All Providers:

  • Medicare Crossovers
  • Medicare Crossover Reference Request Form
  • NCMMIS Update
  • Updated EOB Crosswalk to HIPAA Standard Codes
  • Checkwrite Schedule
  • Electronic Cut-Off Schedule
  • Ambulatory Surgical Centers:

  • Deflux Injectable Gel for the Treatment of Standard Vesicoureteral Reflux - Coverage Notice
  • Community Alternatives Program Case Managers:

  • Reimbursement Rate Increase for Case Management
  • Dental Providers:

  • Dental Seminars
  • Durable Medical Equipment Providers:

  • Addition of HCPCS Code E1161 to the DME Fee Schedule
  • Health Departments:

  • Dental Seminars
  • Hospitals:

  • Correct Billing of Inpatient Hospital Transfers
  • Deflux Injectable Gel for the Treatment of Standard Vesicoureteral Reflux - Coverage Notice
  • Essure Permanent Sterilization Procedure - Coverage Notice
  • Nursing Facility Providers:

  • Nursing Facility Level of Care Billing
  • Physicians:

  • Deflux Injectable Gel for the Treatment of Standard Vesicoureteral Reflux - Coverage Notice
  • Essure Permanent Sterilization Procedure - Coverage Notice

  • 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 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 Remittance and Status Report (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: All Providers

    NCMMIS Update

    ACS is currently working with the State to review the new North Carolina Medicaid Management Information System (NCMMIS) business requirements that will best meet North Carolina's needs. As mentioned in last month's bulletin, we will be soliciting provider participation in testing the system next year as we prepare for implementation in June 2006.

    ACS is using many components of their recently-certified Mississippi MMIS to customize for use in North Carolina. The NCMMIS will be called NCLeads. One Mississippi provider, Mr. Jamey Boudreaux, Executive Director of the Louisiana-Mississippi Hospice and Palliative Care Organization, has this to say about Mississippi's MMIS:

    "ACS has been very responsive in terms of trying to resolve issues - much more responsive than other states. I get calls from Fred Hinds [ACS Account Manager] on a regular basis and I know when I attend national meetings, other directors do not have that kind of relationship or response from their fiscal intermediaries."

    Remember - while you can continue to submit claims using any current method(s) with the new system, you can also enter and adjudicate claims online ("real time" processing instead of overnight processing) in the new system. If you have questions about the NCLeads implementation, please contact Provider Relations.

    Thomas Liverman, NCMMIS Provider Relations
    919-855-3112

    A Word from ACS

    In June 2006, North Carolina will "go live" with a new Medicaid Management Information System (MMIS) developed and managed by Affiliated Computer Services (ACS). The change to ACS not only enables the development of a modern, efficient, and cost effective technology system for the State, but also means improvements in the way providers interact with the Medicaid program.

    ACS understands that there is often apprehension and concern about the quality and efficiency of service when changing MMIS systems and vendors. This situation is particularly understandable due to the longevity of the current vendor. EDS has been the N.C. Medicaid claims processing provider for nearly three decades, and many of you have come to rely on their service. You have my commitment that we will work closely and collaboratively with our EDS counterparts to ensure that you receive uninterrupted service throughout the transition to the new system. While there are normally challenges during the deployment of a new and large system, my pledge to you is that we will be responsive to your concerns and issues and will work diligently to quickly address them as they arise.

    ACS is a national leader in Medicaid claims processing. We process 400 million health claims a year worth $50 billion in payments to several hundred thousand healthcare providers in 12 states and the District of Columbia.

    ACS, in partnership with the state of North Carolina, is committed to building on a legacy of excellence in delivering the highest level of service to the State's Medicaid recipients and providers. As the North Carolina Medicaid claims processor, ACS will be accountable to manage nearly 90 million healthcare claims a year worth more than $7 billion in payments to 65,000 health providers across the State. We take the responsibility for providing the system that serves 1.3 million North Carolinians very seriously.

    Please know that one of our primary objectives is to ensure that the North Carolina provider community is ready for the new system and that the new system processes claims in an accurate and timely manner. To keep you informed of our progress over the next two years, we will be using a number of communication methods, including the general Medicaid bulletin. In future editions of this newsletter, ACS will be providing you information about the status of the new system, the features and benefits it will offer providers and the State, and other related matters that will keep you up-to-date on this important project.

    We will also be telling you about ways you can become actively involved in the evaluation of the system prior to implementation. Specifically, we will need a wide variety of providers to participate in system testing. Be on the lookout for additional information on this topic in future newsletter features.

    We are excited about this opportunity and look forward to working with you-not only during the transition period but also after implementation of the new North Carolina Medicaid claims processing system.

    Joe Wewerka
    ACS Account Manager

    About Joe Wewerka

    Joe Wewerka brings more than 35 years of experience to the North Carolina Medicaid claims processing project and has been with ACS since 1998. Before joining ACS, he spent 29 years at EDS. He has lived in North Carolina for more than 20 years and directed EDS' North Carolina Medicaid work for four years.


    Attention: Ambulatory Surgical Centers, Hospitals, and Physicians

    Deflux Injectable Gel for the Treatment of Vesicoureteral Reflux - Coverage Notice

    The N.C. Medicaid program is in the process of implementing system changes to allow providers to submit claims for reimbursement for Deflux, an FDA approved injectable gel indicated for the treatment of children with grades II through IV vesicoureteral reflux.

    Providers will be notified of the implementation date and of detailed billing instructions in an upcoming general Medicaid bulletin.

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


    Attention: Community Alternatives Program Case Managers

    Reimbursement Rate Increase for Case Management

    Effective with date of service July 1, 2004, the Medicaid maximum reimbursement rate for CAP/AIDS, CAP/C, and CAP/DA case management is $13.82 per 15-minute unit.

    Providers must continue to bill their usual and customary charges.

    Robyn Slate, Financial Operations
    DMA, 919-857-4015


    Attention: All Providers

    Medicare Crossovers

    The N.C. Medicaid program will return to processing all crossover claims billed on a CMS-1500 form or as an 837 professional transaction as direct crossovers from Medicare. The expected date for this transition is September 6, 2004.

    In anticipation of this change, providers should verify that their Medicare provider numbers are cross-referenced to their Medicaid provider numbers. Providers can verify this by contacting EDS Provider Services at 1-800-688-6696 or 919-851-8888.

    If your Medicaid and Medicare provider numbers are not cross-referenced, please complete and submit the following form by fax or mail to EDS at the address indicated on the form. Additional information on crossover claims will be published in upcoming general Medicaid bulletins.

    Medicare Crossover Reference Request Form

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


    Attention: Dental Providers and Health Departments Dental Clinics

    Dental Seminar Schedule

    Seminars for dental providers are scheduled for September 2004. This seminar will focus on upcoming changes to the clinical coverage policy for dental services and will include guidelines for completing the ADA claim form, changes in covered procedure codes, the most common denials for dental claims, and other general Medicaid issues. Medicaid billing personnel, supervisors, and office managers are encouraged to attend.

    The seminars will begin at 10:00 a.m. and end at 1:00 p.m. Providers are encouraged to arrive by 9:45 a.m. to complete registration. Lunch will not be provided at the seminars. 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 seminars by completing and submitting the Dental Services Seminar Registration Form or through online registration. Please indicate on the registration form the session you plan to attend.

    Special Bulletin VI, Dental Services Coverage Policy and Billing Guidelines, will be used as the primary training document for the seminar. The special bulletin will be available on DMA's website beginning September 1, 2004. Please print the special bulletin and bring it to the seminar.

    Because the seminar also will briefly address the general Medicaid billing guidelines, providers may wish to bring a copy of the General Medicaid Billing/Carolina ACCESS Policies and Procedures Guide to the seminar.

    Seminar Locations

    Wednesday, September 8, 2004
    Jane S. McKimmon Center
    1101 Gorman Street
    Raleigh, NC

    Thursday, September 23, 2004
    Park Inn Gateway Conference Center
    909 Highway 70 SW
    Hickory, NC

    Tuesday, September 28, 2004
    Coast Line Convention Center
    501 Nutt Street
    Wilmington, NC

    Thursday, September 30, 2004
    Holiday Inn Conference Center
    530 Jake Alexander Blvd., S
    Salisbury, NC

    Directions to the Dental Seminars

    Jane S. McKimmon Center - Raleigh

    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.

    Park Inn Gateway Conference Center - Hickory

    Take I-40 to exit 123. Follow signs to US 321 North. Take the first exit (Hickory exit) and follow the ramp to the stoplight. Turn right at the light onto US 70. The Gateway Conference Center is on the right.

    Coast Line Convention Center - Wilmington

    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.

    Holiday Inn Conference Center - Salisbury

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

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


    Attention: Durable Medical Equipment Providers

    Addition of HCPCS Code E1161 to the DME Fee Schedule

    HCPCS code E1161, "manual adult size wheelchair, includes tilt-in space" was added to the Capped Rental category of the DME Fee Schedule effective with date of service January 1, 2004. The maximum reimbursement rates are:

    The lifetime expectancy is three years. Prior approval is required. The medical coverage criteria are the same as those for a standard manual wheelchair base and the tilt in space component. Thus, the criteria are as follows:

    The documentation requirements are the same for requests to renew approval.

    Clinical Coverage Policy #5, Durable Medical Equipment, has been updated to reflect this change.

    DME Fee Schedule

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


    Attention: Hospital Providers

    Correct Billing of Inpatient Hospital Transfers

    This billing reminder is to help that ensure hospitals are filing their claims correctly according to North Carolina Administrative Code and Medicaid policy to help eliminate overpayment to hospitals. A report from the Office of Inspector General (OIG) dated October 8, 2003, indicated a $2,984,289 overpayment to hospitals because of improper coding of discharge/transfers of patients. It was noted in the report that transferred patients were incorrectly coded as discharged patients. The report included a recommendation that the Division of Medical Assistance (DMA) notify and train all hospitals on the proper method of billing Prospective Payment Systems (PPS) transfers. Based on this recommendation, in November 2003, DMA sent a letter to hospital administrators asking them to evaluate their billing systems and to implement appropriate internal processing systems to include audits to identify transfers. This internal processing system should help hospitals to edit their claims before they are submitted to Medicaid. The letter also reminded hospitals that Medical Review of North Carolina will continue to conduct appropriate post-payment audits of inpatient hospital transfers throughout the State.

    General acute care inpatient hospital claims (excluding inpatient psychiatric and rehabilitation services) are reimbursed by Diagnosis Related Grouping (DRG) Rate Setting Methodology in accordance with North Carolina Administrative Code10A NCAC 22G.0200 and the State Medicaid Plan.

    Refer to the following guidelines from Section 8 of the N.C. Medicaid Hospital Services Manual when billing for hospital transfers.

    Prorated DRG
    When patients must be transferred from one acute care facility to another, both the transferring facility and the receiving facility will be paid. The transferring facility is entitled to a prorated DRG amount. If the required days of the acute care stay are greater than or equal to the average length of stay assigned for the DRG, the transferring facility is eligible for the entire amount. If the required days of the acute care stay do not exceed the average length of stay assigned for the DRG, the prorated payment is calculated this way:

    DRG prorated payment = [(DRG payment x Actual Length of Stay) / DRG Average Length of Stay]

    The receiving facility will receive the usual DRG payment unless the patient is transferred again.

    Note: Patient status (Block 22) must reflect "02," patient transfer.

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


    Attention: Nursing Facility Providers

    Nursing Facility Level of Care Billing

    After June 1, 2004, nursing facility (NF) reimbursements will only be approved at the NF-level of care. Claims for residents approved at the NF-level of care must be billed using the provider's current skilled nursing facility (SNF) provider number and skilled level bill type. If the FL-2 was approved prior to June 1, 2004, the provider must bill using the level of care approved on the FL-2. For example, if the resident was approved at the intermediate care facility (ICF) level of care, then the provider must use their ICF provider number and the ICF bill type. If the resident was approved at the SNF level of care, then the provider must use their SNF provider number and the SNF bill type.

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


    Attention: Hospitals and Physicians

    Essure Permanent Sterilization Procedure - Coverage Notice

    The N.C. Medicaid program is in the process of implementing system changes to allow providers to submit claims for reimbursement for Essure, the permanent hysteroscopic sterilization procedure.

    Providers will be notified of the implementation date and of detailed billing instructions in an upcoming general Medicaid bulletin.

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


    Proposed Medical Coverage Policies

    In accordance with Session Law 2003-284, proposed new or amended Medicaid medical 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
    Medical 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.


    Checkwrite Schedule

    August 10, 2004

    September 8, 2004

    October 5, 2004

    August 17, 2004

    September 14, 2004

    October 12, 2004

    August 26, 2004

    September 23, 2004

    October 19, 2004

    Electronic Cut-Off Schedule

    August 6, 2004

    September 3, 2004

    October 1, 2004

    August 13, 2004

    September 10, 2004

    October 8, 2004

    August 20, 2004

    September 17, 2004

    October 15, 2004

    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 precessed on the second checkwrite following the transmission date.

    2004 Checkwrite Schedule


    _____________________
    _____________________
    Gary H. Fuquay, Director
    Cheryll Collier
    Division of Medical Assitance
    Executive Director
    Department of Health and Human Services
    EDS

     

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