August 2006 Medicaid Bulletin


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In This Issue...

All Providers:

Adult Care Home Providers:

Child Service Coordination Providers:

Durable Medical Equipment Providers:

Hosptial Outpatient Departments:

Local Health Departments:

North Carolina Health Choice Providers:

Nursing Facility Providers:

Nurse Practitioners:

Outpatient Behavioral Health Service Providers School Based Health Centers:

Physicians:

Psychiatric Residential Treatment Facilities:




Attention: All Providers

Basic Medicaid Billing Seminars

Seminars for Basic Medicaid billing guidelines are scheduled for October 2006. Registration information and a list of dates and site locations for the seminars will be published in the September 2006 general Medicaid bulletin.

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


Attention: All Providers

Clinical Coverage Policies

The following new or amended clinical coverage policies are now available on the Division of Medical Assistance's website:

These policies supersede previously published policies and procedures.  Providers may contact EDS at 1-800-688-6696 or 919-851-8888 with billing questions.

Clinical Policy and Programs
DMA, 919-855-4260


Attention: All Providers

Citizenship/Identity Changes

First, Medicaid requirements to verify alien status have not changed.  An undocumented alien will still be eligible for only emergency services while documented aliens must still provide verification of their alien status.

Effective September 1, most applicants for medical assistance who state they are United States citizens must provide citizenship/identity verification.  Exceptions are:  current and former SSI recipients and current and former Medicare recipients.  Children in the NCHC program, ages 6 to 18, do not have to verify citizenship/identity.  Medicaid applicants will not be approved until all eligibility requirements, including proof of citizenship/identity, are provided.

For those currently receiving Medicaid, citizenship and identity must be verified at next redetermination scheduled on or after September 1.  This includes the newborn children automatically eligible for Medicaid.  If verifications is not provided during redetermination process, the recipient will be recertified and given 3 months to provide proof of citizenship/identity.  Children eligible in foster care will be considered recipients and given 3 months to verify citizenship/identity.

If applicant/recipient requests help in obtaining the documents, the county department of social services must help, especially if there is a fee involved. 

Many counties have electronic data matches with the local register of deeds to verify births.  CMS has said we can allow data matches.  The State is currently working with State Vital Records to do an electronic match.  However, that won’t be ready by September 1. 

Copies of certified birth certificates are acceptable.

Another program’s evidence of citizenship/identity, such as Food Stamps, can be used to verify citizenship/identity for Medicaid.

There is a chart on the DMA website under county links, letters to county directors that gives the hierarchy on how CMS wants states to verify citizenship/identity.  CMS will monitor states to ensure the lowest hierarchy is not always used to verify citizenship. 

Hospitals or the companies they have hired to take applications must not hold these applications if they wish to pursue verification of citizenship/identity.  Several companies now try to manipulate the date of application for the company’s benefit rather than the applicant’s benefit.  This violates federal regulations in 42 CFR 435.906 that provides individuals must have the right to apply for medical assistance without delay.  While county agencies and the applicants appreciate assistance in pursuing verifications, an applicant’s right to apply without delay must not be impeded.  These verifications can be provided at a later date.

Eligibility Unit
DMA, 919-855-4000



Attention: All Providers

National Provider Identifier (NPI)

Beginning September 1, 2006, the N.C. Medicaid Program will begin collecting the National Provider Identifier(s) (NPI) from currently enrolled Medicaid providers.  The N.C. Medicaid NPI form will be published in the September general Medicaid bulletin and will also be available on DMA’s website.  The form can be returned by fax or mail to the address listed on the form.  Providers must also include with the NPI form a copy of the notification letter from the National Plan and Provider Enumeration System (NPPES). 

DMA is pursuing options for e-mail, web-based and electronic batch submission.  Details will be provided in future bulletins.

Providers are encouraged to apply for their NPI immediately.  Please go to the NPPES website.  Please indicate North Carolina as your state name and include your Medicaid provider number(s).  Claims submitted after May 23, 2007, will deny without an NPI number. 

Remember, applying for an NPI does not replace any enrollment or credentialing processes for N.C. Medicaid. 

Provider Services
DMA, 919-855-4050


Attention: All Providers

Tetanus and Diphtheria Toxoids (Td, CPT Code 90718) – Ending Coverage

Effective with date of service November 1, 2006, the N.C. Medicaid program will no longer recognize CPT code 90718 (the old Td vaccine) as a VFC vaccine, nor reimburse for the administration fee (CPT codes 90471, 90472, 90465, or 90466) for this vaccine for VFC recipients through 18 years of age.  Effective with date of service November 1, 2006, DMA will no longer recognize CPT 90718 for recipients over 18 years of age nor reimburse for the administration of this vaccine.  Providers who report CPT 90718 for VFC recipients or bill for the administration of the vaccine after date of service October 31, 2006, and those who bill for the vaccine and administration fee for recipients over 18 years of age after date of service October 31, 2006, will have those claims denied.

Refer to the December 2005 general Medicaid bulletin for coverage information on DECAVAC (the new Td preservative-free vaccine), CPT code 90714.

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



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:  All Providers

Updates to HIPAA 835 Transactions for Medicare Crossovers

Beginning September 1, 2006, Medicare crossover claims will be reported differently on the HIPAA 835 transaction set, the Unsolicited 277 transaction set and the HIPAA 277 Claim Status Response transaction set for North Carolina Medicaid.  It may be necessary for providers to work with their software vendors regarding this change.  

Medicare Part B crossover claims are processed in the Medicaid system using a billed amount that is built during claims adjudication.  This billed amount consists of the Medicare coinsurance and deductible.  Currently, this is the billed amount being reported on the 835 transaction.  Providers have had difficulty reconciling their records because this is not the amount they actually billed Medicaid.  Claims received and processed for the first checkwrite cycle in September will begin to report the actual billed amount on the claim. 

In addition, the Claim Status Indicator (CLP02) will also be modified to reflect if Medicaid processed the claim as primary, secondary, or tertiary on paid claims.  These codes are represented in the 835 as follows:

o       1 – Processed as Primary

o       2 – Processed as Secondary

o       3 – Processed as Tertiary

Other Claim Status Indicator codes used will remain unchanged.

Older Medicare crossover claims that adjudicated prior to September 1, 2006, that are being reported as reversed on HIPAA 835 transactions due to an adjustment, or that are being reported on the 277 Claim Status Response transactions, will continue to have their Billed Amount data element set to the NC Medicaid billed amount.

Medicare crossover claims that adjudicate on or after September 1, 2006 can be found using the Original Billed Amount specified in the 276 transaction only if it matches the claims’ Original Billed Amount.  Medicare crossover claims that adjudicated prior to September 1, as well as all non-crossover claims, will continue to be found using the Original Billed Amount specified in the 276 transaction only if it matches the NC Medicaid Original Billed Amount.

Please reference the chart below:

Medicare Crossover Claims

 

Prior to September 1, 2006

September 1, 2006 and after

835 Transaction will report

Medicaid Bill amount

Medicare Billed Amount

Unsolicited 277 Transaction

Medicaid Bill Amount

Medicare Billed Amount

Regular 276/277 using “Amount Billed” as search criteria use

Medicaid Bill Amount

Medicare Billed Amount

Paid claims with no TPL, Claim Status Code on 835 will report

1 = Primary

2 = Secondary

Paid claims with other TPL, Claim Status Code on 835 will report

1 = Primary

3 = Tertiary

Non – Crossover Claims

 

Prior to September 1, 2006

September 1, 2006 and after

835 Transaction will report

Medicaid Billed Amount

Medicaid Billed Amount

Unsolicited 277 Transaction

Medicaid Billed Amount

Medicaid Billed Amount

Regular 276/277 using “Amount Billed” as search criteria use

Medicaid Billed Amount

Medicaid Billed Amount

Claims with no TPL, Claim Status Code on 835 will report

1 = Primary

1 = Primary

Claims with Medicare TPL and/or other TPL, the Claims Status Code on 835 will report

1 = Primary

2 = Secondary

Or

3 = Tertiary

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



Attention: Adult Care Home Providers

Prior Approval Process for Medicaid Payment for Recipients Residing in an Adult Care Home (ACH) Special Care Unit for Persons with Alzheimer’s and Related Disorders (SCU-A)

Session Law 2005- 276 provided for additional Medicaid funding for the care of residents residing in Special Care Units for Persons with Alzheimer’s and Related Disorders (SCU-A) located in Adult Care Homes.  Effective with the date of service October 1, 2006, the N.C. Medicaid Program will implement a special care rate for ACH providers Operating Special Care Units for Persons with Alzheimer’s and Related Disorders.

Medicaid will reimburse providers according to the following procedure:

  1. ACH providers who admit Medicaid recipients who receive State and County Special Assistance and have an Ambulation Code of “C” on their eligibility file are eligible to apply for prior approval to receive a special Medicaid enhanced service rate through the Division of Medical Assistance when that recipient is admitted to a SCU-A.
  1. Providers must obtain prior approval from DMA  before admitting a new resident to a SCU-A. No retroactive prior-approval will be provided.
  1. Providers must obtain prior approval from DMA within 7 days of admitting a Resident who currently resides in another unit of the ACH into the home’s SCU-A in order to receive the SCU-A rate from the date of admission. Otherwise, if approved, prior approval will be effective retroactive to the date received by DMA.
  1. Providers must send the following information to obtain prior approval from DMA:
    1. Completed DMA SCU-A Prior Approval Request Form.
    2. Current FL-2, signed by a physician, with a primary diagnosis of Alzheimer’s and Related Disorders.
    1. Copy of the Pre-Admission Screening by the facility to evaluate the appropriateness of an individual’s placement in the SCU-A as required by current rule.
    1. Copy of current 3050R if resident is not new to the home.
    2. Copy of the Provider’s current ACH License with SCU-A designation.
    3. Copy of Provider’s current ACH SCU-A Disclosure statement.

5.    Providers send the requested information via US Mail to:

 DMA ACH Unit
 NC DHHS
 Division of Medical Assistance
 Facility and Community Care Section
 1985 Umstead Drive
 2501 Mail Service Center
 Raleigh, NC 27699-2501

Other important information for ACH Providers to know related to the Prior Approval for SCU-A Payment:

  1. Providers will not receive payment for Enhanced ACH/PCS services for a recipient receiving payment for SCU-A.

2.   Recipients must receive Basic PCS at the same time as SCU-A services.

3.   DMA will mail a decision notice to the ACH provider within 15 working days of receipt of prior approval request.

4.   DMA will contact fiscal agent and authorize Medicaid reimbursement for days approved.

5.   In order to avoid payment processing delays, beginning August 1, 2006, providers may begin to submit the required prior approval information to DMA for residents who currently reside in a SCU-A and are expected to remain until October1, 2006.  Upon approval, the new rate will begin effective with date of service October 1, 2006.

Instructions for completing the Adult Care Home SCU-A form:

1.  This form is only to be used by Adult Care Homes with Special Care Unit Designations.

2.  Print clearly.

3.  All copies of items submitted must be legible.

4.  The complete facility information is only due once per year- as per schedule or upon facility status change or as otherwise needed.

5.  This is a HIPAA requirement: The completed form and information must be sent in a sealed envelope with “confidential” written in red and then placed in another envelope and addressed as in #6 belowDMA will not accept faxed records.

6.  Completed form must be sent via US Mail to the following address:

NC DHHS – DMA
ACH Unit
Facility and Community Care
1985 Umstead Drive
2501 Mail Service Center, Raleigh, NC  27699-2501

7.    For questions contact:  Nancy Roberts @ 919-855-4116 or  Julie Budzinski @ 919-855-4368 or Julie.Budzinski@dhhs.nc.gov.

Clinical Policy and Programs
DMA, 919-855-4116 and /or 919-855-4368



Attention:  Child Service Coordination Providers

Infant-Toddler Program Referrals

Effective July 1, 2006, the new eligibility definition for the North Carolina infant-toddler program at should be used when determining the appropriateness of a referral to the program.  Clinical Coverage Policy #1M-1, Child Service Coordination, has been updated to direct providers to the North Carolina early intervention services webpage for eligibility requirements.

Clinical Policy and Programs
DMA, 919-855-4260


Attention:  Durable Medical Equipment Providers

Addition of Adjustable Wheelchair Cushion Codes to DME Fee Schedule

Effective with date of service August 1, 2006, the following codes are added to the capped rental section of the Durable Medical Equipment (DME) Fee Schedule:

K0734

Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth

K0735

Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth

K0736

Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any depth

K0737

Skin protection and positioning wheelchair seat cushion, adjustable, with 22 inches or greater, any depth

The codes may be covered if the recipient has a diagnosis or a condition that may cause breakdown of the skin due to immobility and sitting in a wheelchair for long periods of time.  The recipient must be wheelchair bound. The codes do not require prior approval, however, medical necessity must be documented on the Certificate of Medical Necessity/Prior Approval (CMN/PA) form  The lifetime expectancy for all these codes is 3 years. 

For current pricing on these and all DME codes, refer to DMA’s Fee Schedule web page.

For all billings, providers are reminded to bill their usual and customary rates.  Do not automatically bill the established maximum reimbursement rate.  Payment will be the lesser of the billed usual and customary rate or the maximum reimbursement rate.

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



Attention: Durable Medical Equipment Providers

Fee Schedule Changes for Interim Rates and Other Rate Changes

Effective with dates of service on or after August 1, 2006, rates have been changed for the Durable Medical Equipment (DME) HCPCS code below previously added with an interim rate.  Medicare pricing has now become available for this code:

E0705

TRANSFER BOARD OR DEVICE, ANY TYPE, EACH

Effective with the same date, other DME rates have changed based on the normal annual review of DME rates.

For current pricing on all DME codes, refer to DMA's Fee Schedule web page.

For all billings, providers are reminded to bill their usual and customary rates.  Do not automatically bill the established maximum reimbursement rate.  Payment will be the lesser of the billed usual and customary rate or the maximum reimbursement rate.

Rate Setting
DMA, 919-855-4200


Attention: North Carolina Health Choice Providers

State Health Plan Delay in Payments

Due to the recent notification of changes in the professional fees and code schedule for Medicaid, which became effective July 1, the State Health Plan of North Carolina will be delayed in processing payments for July 2006 dates of service.  We apologize for any inconvenience this has caused.

Becky Murray
North Carolina State Health Plan, 919-881-2300



Attention:  Nursing Facility Providers

Electronic Records – Supplement to Supportive Documentation Guidelines

Nursing Facilities that choose to keep resident records electronically must meet the following requirements to facilitate the Minimum Data Set (MDS) Validation Review process:

1. The facility must have an electronic signature policy. The reviewer may request to see the policy.
2. The facility must have an identified procedure for making corrections to electronic entries.
3. Computer access to the residents’ information must be available to the reviewer.
4. Hard copies of documentation are not routinely required; however, the State reserves the right to request that certain records be printed or produced at the time of the review.
5. All Supportive Documentation Guidelines must be followed, including signatures, initials, and dates.
6. The entire medical record is subject to review.
7. The facility must have written policies in place to ensure the privacy and integrity of the record.

Clinical Policy and Programs
MDS Validation Review Consultant
DMA, 919-855-4356



Attention:  Outpatient Behavioral Health Service Providers School Based Health Centers, Local Health Departments and Hospital Outpatient Departments

Reminders Regarding the Referral Process for Outpatient Behavioral Health Services

Prior to the initial outpatient behavioral health visit, recipients under the age of 21 require a referral by a Carolina Access (CA) Primary Care Provider (PCP), the LME or a Medicaid enrolled psychiatrist.  Practitioners who are employed and working for a CA Primary Care Physician or Medicaid enrolled psychiatrist billing under the “incident to” guidelines will not need a referral.  Services provided by a physician do not require a referral.

Referrals may be made by telephone, fax or in writing to the mental health provider.  The referring provider will give the mental health provider a referral number that must be placed in block 19 of the CMS 1500 claim form in order for the claim to be paid.  Failure to put the referral number on the claim when filing will result in denial of payment.

Recipients age 21 and over do not require a referral.

Behavioral Health Services
DMA, 919-855-4290



Attention: Physicians and Nurse Practitioners

Cetuximab (Erbitux, J9055) – Update to Billing Guidelines

The N.C. Medicaid program covers cetuximab (Erbitux) for use in the Physician’s Drug Program for the diagnosis of colorectal carcinoma.  Recently, the Food and Drug Administration also approved Erbitux for the diagnosis of head and neck carcinoma.

In accordance with the new FDA approved diagnoses for Erbitux, the following ICD-9-CM diagnosis codes are required when billing for Erbitux:

and

1.      153.0 through 154.8

2.      140.0 through 149.9

3.      160.0 through 161.9

4.      195.0

5.      162.0

6.      171.0

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



Attention: Physicians and Nurse Practitioners

Triptorelin Pamoate (Trelstar Depot and Trelstar LA, J3315) Billing Guidelines

Effective with date of service July 1, 2006, the N.C. Medicaid program covers triptorelin pamoate (Trelstar Depot for injection and Trelstar LA for injection) for use in the Physician’s Drug Program, when billed with HCPCS code J3315.  Triptorelin is a synthetic hormone that stops the production of testosterone. It is approved by the FDA for palliative treatment of advanced prostrate cancer.  It is an alternative treatment for prostrate cancer when orchiectomy or estrogen replacement administration is either not indicated or not acceptable to the patient. It is available in two forms as described below.

Drug name

HCPCS Code

Dosage

Frequency of Administration

Billing Unit

Trelstar Depot

J3315

3.75 mg

Monthly

1 unit

Trelstar LA

J3315

11.25 mg

Once every 12 weeks (3 months)

3 units

Both forms of Trelstar are to be reconstituted with sterile water only and administered as single intramuscular injections. Both forms are also available in the Clip’N’Ject single-dose delivery system use.  ICD-9-CM diagnosis code 185, malignant neoplasm of prostate, must be billed with Trelstar Depot or Trelstar LA.

Billing Requirements:

Example

21

Diagnosis

24A

Date(s) of Service

24B

Place of Service

24D

Procedures, Services or Supplies

24F

Charges

24G

Units

185

08212006

11

J3315

$

1 Unit

For Medicaid billing, one unit of coverage is 3.75 mg.  The maximum reimbursement rate per unit is $260.23.

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



Attention: Psychiatric Residential Treatment Facilities

Direct Enrollment and Direct Billing

Effective September 1, 2006, local management entities (LMEs) will begin to endorse Level II (program type) and Levels III and IV psychiatric residential treatment facilities that have one, two, or three beds.  As each facility obtains this endorsement, providers should submit an enrollment packet to DMA to obtain a Medicaid provider number.  With the Medicaid provider number, providers may begin direct billing.

EDS will offer two workshops in September to train these providers on billing and the authorization process.  Registration information will be published in the September general Medicaid bulletin.

Behavioral Health
DMA, 919-855-4290


NCLeads Update

Information related to the implementation of the new Medicaid Management Information System, NCLeads, can be found online.  Please refer to the NCLeads website for information, updates, and contact information related to the NCLeads system.

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.  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

Month
Electronic Cut-Off Date
Checkwrite Date

July (d)

06/30/06

07/06/06

 

07/07/06

07/11/06

 

07/14/06

07/18/06

 

07/21/06

07/27/06

August

08/04/06

08/08/06

 

08/11/06

08/15/06

 

08/18/06

08/22/06

 

08/25/06

08/30/06

September (e)

09/01/06

09/06/06

 

09/08/06

09/12/06

 

09/15/06

09/19/06

 

09/22/06

09/28/06

 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.



_____________________   _____________________
Mark T. Benton, Senior Deputy Director and
Chief Operating Officer
  Cheryll Collier
Division of Medical Assistance   Executive Director
Department of Health and Human Services   EDS