In This Issue..
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All Providers:
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Criterion #5 Services: Optical Providers: Prescribers: Psychiatric Residential Treatment Facility Services: Residential Treatment Services: UB-92 Billers: |
EDS, 1-800-688-6696 or 919-851-8888
| Electronic Cut-Off Schedule | Checkwrite Schedule |
|---|---|
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August 30, 2002
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September 4, 2002
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September 6, 2002
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September 10, 2002
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September 13, 2002
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September 19, 2002
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October 4, 2002
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October 8, 2002
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October 11, 2002
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October 15, 2002
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October 18, 2002
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October 22, 2002
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October 25, 2002
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October 30, 2002
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EDS, 1-800-688-6696 or 919-851-8888
Retroactive prior approval is only considered when the recipient did not have Medicaid coverage at the time of the surgery and was later approved for Medicaid with a retroactive eligibility date. The recipient must be eligible for Medicaid coverage on the date the surgery was performed. The recipient must meet all medical necessity prior approval criteria before retroactive prior approval can be authorized.
Providers can avoid claim denials for prior approval by utilizing the Automated Voice Response (AVR) system to determine if surgery CPT codes require prior approval. The telephone number for the AVR system is 1-800-723-4337.
Providers rendering services to recipients enrolled in Carolina ACCESS are
required to obtain both the primary care physician's referral and prior
approval for the surgery.
EDS, 1-800-688-6696 or 919-851-8888
Darlene Cagle
Medical Policy Section
Division of Medical Assistance
2511 Mail Service Center
Raleigh, NC 27699-2511
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.
Darlene Cagle, Medical Policy Section
DMA, 919-857-4020
CPT code 78990 will remain available for radiopharmaceutical diagnostic imaging
agents, not otherwise classified, and must also be billed with an invoice.
EDS, 1-800-688-6696 or 919-851-8888
Only the following ICD-9-CM diagnoses are covered. The diagnosis can be primary or secondary.
151.0 - 151.9
162.2 - 162.9
171.0 - 171.9
174.0 - 175.9
183.0 - 183.9
200.00 - 202.98
EDS, 1-800-688-6696 or 919-851-8888
Only the following ICD-9-CM diagnoses are covered:
Representatives will be available from 8:30 a.m. to 5:00 p.m. for 30-minute
sessions at the dates and locations listed below. Providers may schedule a consultation
by completing and returning the request form below.
|
County
|
Location
|
Date
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|---|---|---|
| Pasquotank | College of the Albemarle Small Business Center Seminar Room E-121A US 17 North Elizabeth City, NC 27909 |
October 8, 2002 |
| Brunswick | Brunswick Community College Room 120/121, Bldg. D 50 College Road NE Bolivia, NC 28462 |
October 9, 2002 |
| Buncombe | Mountain AHEC Classroom 2 501 Biltmore Ave. Asheville, NC 28801 |
October 14, 2002 |
| Wilkes | Wilkes Community College Thompson Hall, Room 209 1328 Collegiate Drive Highway 268 Wilkesboro, NC 28697 |
October 15, 2002 |
If you are interested in scheduling a session, please complete and return the Medicaid Provider Consultation Request form by September 27, 2002 to the address listed below:
Lisa Laur
EDS
P.O. Box 300009
Raleigh, NC 27622
Fax: 919-851-4014
EDS, 1-800-688-6696 or 919-851-8888
EDS Provider Enrollment
P.O. Box 300009
Raleigh, NC 27622
Fax: 919-851-4014
To report a change of ownership, name, address, tax identification number changes,
group member, or licensure status, please use the Notification
of Change in Provider Status form. Managed Care providers (Carolina ACCESS,
ACCESS II, ACCESS III, and HMO Risk Contracting) must also report changes in
daytime or after-hours phone numbers and should report changes using the Carolina
ACCESS Provider Information Change form.
EDS, 1-800-688-6696 or 919-851-8888
Effective September 1, 2002, Carolina ACCESS (CA) overrides will no longer be approved when an enrollee has failed to establish a medical record with the primary care provider (PCP) designated on the enrollee's Medicaid identification (MID) card. The CA contract requires PCPs to coordinate care for their enrollees. This means that PCPs must either schedule an appointment for enrollees based on the standards of appointment availability or authorize another provider to treat the enrollee. The contract defines the standards of appointment availability as:
| Emergency | immediately upon presentation or notification |
| Urgent | within 24 hours of presentation or notification |
| Routine sick care | within 3 days of presentation or notification |
| Routine well care | within 90 days of presentation or notification (15 days if pregnant) |
It is the responsibility of the treating provider to obtain authorization for treatment from the PCP listed on the recipient's MID card prior to treatment. If authorization is requested after services have been rendered, the PCP may refuse to authorize. This will result in denied claims. No override will be considered unless the PCP has been contacted and refused to authorize treatment.
Override requests must be submitted to EDS using the Carolina ACCESS Override Request form within six months of the date of service. EDS has 30 days to evaluate the request. The Override Request form has been revised to simplify the evaluation process. Please use the revised Override Request form for requests submitted to EDS after September 1, 2002. This form is also available in the Carolina ACCESS PCP Provider Manual and on DMA's website.
The Division of Medical Assistance (DMA) sends a monthly enrollment report to each PCP to assist in identification of their enrollees. DMA also sends a monthly referral report to each PCP so they can verify the validity and accuracy of the referrals. PCPs must document all referrals in the patient record. It is the responsibility of the PCP to review the reports and report discrepancies to their regional Managed Care consultant for investigation.
Managed Care Section
DMA, 919-857-4022
The survey results indicate that the majority of PCPs are meeting their contractual requirements. Please review the following requirements for participation with your staff to ensure that all PCPs are meeting the needs of their enrollees.
Coordination of Care
PCPs must either schedule an appointment for enrollees based on the standards
of appointment availability or authorize another provider to treat the
enrollee. DMA sends a monthly enrollment report to each PCP to assist in the
identification of their enrollees. It is the responsibility of the PCP to review
the report and report discrepancies to their regional Managed Care consultant.
The PCP must continue to coordinate care until the error is reported and the
PCP number is changed in the system.
Standards of Appointment Availability
| Emergency | immediately upon presentation or notification |
| Urgent | within 24 hours of presentation or notification |
| Routine sick care | within 3 days of presentation or notification |
| Routine well care | within 90 days of presentation or notification (15 days if pregnant) |
Office Hours
CA PCPs must have a provider available in the office at a minimum of 30 hours
per week to see patients.
Hospital Admitting Privileges
CA PCPs must establish and maintain age-appropriate hospital admitting privileges
or have a Carolina
ACCESS Patient Admission Agreement on file indicating a formal, written
agreement with another physician or group practice for management of inpatient
hospital admission of enrollees. Unassigned call doctors with the hospital are
not an acceptable option.
Patient Disenrollment
If it becomes necessary to disenroll a recipient due to repeated non-compliance,
medication abuse or missed appointments, the PCP must follow this procedure:
If there are questions or comments, contact your regional Managed Care consultant.
This information is also available in the Carolina
ACCESS Primary Care Provider manual on DMA's website.
Laurie Giles, Managed Care Section
DMA, 919-857-4022
EDS, 1-800-688-6696 or 919-851-8888
Electronic claim submissions are not affected by this change. Continue to submit
electronic claims in the same format.
Laurie Giles, Managed Care Section
DMA, 919-857-4022
A prescriber Medicaid identification number (ID) will be issued in lieu of the DEA number. The ID number follows the same format as the DEA number and will always begin with a Z (for example, ZF1234567).
Prescribers must enter this number on their Medicaid prescriptions. This number is referred to as a PRESCRIBER MEDICAID IDENTIFICATION NUMBER only, and should not be referred to as a DEA number.
If updated information has not been submitted to EDS Provider Enrollment, please copy, complete, and return the DEA Number form for each prescriber in your practice. Please send the information to the following address:
EDS Provider Enrollment Unit
P.O. Box 300009
Raleigh, North Carolina 27622
Fax: 919-851-4014
EDS, 1-800-688-6696 or 919-851-8888
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Residential Services Level II-IV
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PRTF
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Criterion # 5
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|---|---|---|---|
| Bill Type | |||
| First Claim | 842 Interim | 892 Interim | 142 Interim |
| Continuing Claim | 843 Interim | 893 Interim | 143 Interim |
| Last Claim | 844 Interim | 894 Interim | 144 Interim |
| Revenue Code | 902 | 911 | 902 |
| Procedure Code | Appropriate Y code to denote level of care | N/A | Y2343 |
Because multiple claims are submitted during a recipient's stay, using the
correct bill type codes will accurately indicate the status of the claim.
Carol Robertson, Behavioral Health Services, Medical Policy Section
DMA, 919-857-4020
DMA
Medical Policy Section
2511 Mail Service Center
Raleigh, NC 27699-2511
ATTN: Angela Langston
Bill Hottel, Adult Care Home Services
DMA, 919-857-4020
Area mental health programs are responsible for the admission and the initial length of stay up to 120 days or 30 days and may give this authorization(s) in increments of time up to the 120 or 30 days. Area mental health programs are not permitted to authorize time beyond these trigger points.
The 120 days follows the child. If the child is moved from Level II to Level III or to different homes within the same level that does NOT restart the clock. Note: An updated RAF must be submitted to both ValueOptions and EDS when there is a change in the level of care or a change in homes to ensure that ValueOptions knows where the child is located and that EDS makes the proper claims payment. The clock is only stopped if the child is discharged home and remains there for 15 days or more without readmission to a residential facility.
ValueOptions assumes responsibility for authorizing continued stay when:
Carol Robertson, Behavioral Health Services
DMA, 919-857-4020
| September 4, 2002 | October 8, 2002 | November 5, 2002 |
| September 10, 2002 | October 15, 2002 | November 13, 2002 |
| September 19, 2002 | October 22, 2002 | November 19, 2002 |
| October 30, 2002 | November 26, 2002 |
| August 30, 2002 | October 4, 2002 | November 1, 2002 |
| September 6, 2002 | October 11, 2002 | November 8, 2002 |
| September 13, 2002 | October 18, 2002 | November 15, 2002 |
| October 25, 2002 | November 22, 2002 |
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.
| _____________________ | _____________________ | |
| Nina M. Yeager, Director | Ricky Pope | |
| Division of Medical Assitance | Executive Director | |
| Department of Health and Human Services | EDS |
| DMA Home | |