In this issue................................

All Providers:

• Change in Medicaid Co-payments
• Checkwrite Schedule
• Clinical Coverage Policies
• Directions and Registration to the OB/GYN Medicaid Billing Seminar
• Directions to the Medicaid Family Planning Waiver Seminar
• Intracranial Neurostimulator Procedures
• Medicaid Family Planning Waiver Seminar Registration
• New Dates for the OB/GYN Seminars
• North Carolina Health Choice Children Age 0-5 Moving to Medicaid
• OB/GYN Medicaid Billing Seminar Schedule
• Requests for Corrected 1099 Action Required by March 1, 2006
• Tax Identification Information
• Updated EOB Crosswalk to HIPAA Standard Codes

Community Alternatives Program for Children Providers:

• CAP/C Program Changes

Chiropractors:

• Provider Enrollment

Dentists:

• Provider Enrollment

Durable Medical Equipment Providers:

• Change in Rate Methodology for HCPCS Code E0781

Enhanced Mental Health Services:

• Enhanced Mental Health Services Seminar Schedule
• Enhanced Mental Health Services Seminar Directions and Registration

Home Infusion Therapy Providers:

• Change in Rate Methodology for HCPCS Code E0781

Nursing Facility Providers:

• Adjustments Associated With Unsupported MDS Information 2005-2006

Optometrists:

• Provider Enrollment

Osteopaths: 

• Provider Enrollment

Orthotic and Prosthetic Device Providers: 

• Change to Reimbursement Rates for Certain HCPCS Codes

Prescriber Providers: 

• Policy and Procedures for Prescribing Synagis for RSV Season 2005-2006

Pharmacy Providers: 

• Medicare Part D: Implications for North Carolina’s Pharmacists and Senior Citizens
• Medicare Part D Provider Marketing Guidelines Now Available
• Providing Compounded Prescriptions for Medicaid Recipients
• Over-The Counter Nicotine Replacement Therapy Medications Covered by Medicaid
• Policy and Procedures for Prescribing Synagis for RSV Season 2005-2006

Physicians:

• Gastric Bypass Prior Approval Documentation
• Physicians Drug Program Pricing List Update
• Provider Enrollment

Podiatrists:

• Provider Enrollment

Attention:  Nursing Facility Providers

Adjustments Associated With Unsupported MDS Information 2005-2006

The first year of the Minimum Data Set (MDS) Validation Review program for nursing facilities ended September 30, 2005.  This first year of reviews was designated as an educational year.  Nursing facilities receive the results of the MDS reviews at the exit conference with the MDS review nurses.  The results indicate the information on the MDS that was not supported by documentation in the resident’s file. 

Beginning October 1, 2005 through September 30, 2006, if  the facility has a MDS Validation Review that results in a greater than 40 percent unsupported documentation rate, then the affected MDS's will be recalculated and assigned the appropriate Resource Utilization Group (RUG-III) category.  If the recalculation establishes a new Case Mix Index (CMI) number, the facility’s CMI for the quarter under review will be recalculated.  The facility will be assessed a retrospective rate adjustment for that quarter with recoupment of the Medicaid overpayment to the nursing facility. 

The documentation requirements are specified in the Supportive Documentation Guidelines (SDGs) set forth by the Division of Medical Assistance (DMA) for all MDS documentation reviews.  The Guidelines are available on DMA’s web site at: http://www.dhhs.state.nc.us/dma/prov.htm.

A reconsideration review may be requested if a nursing facility disagrees with the findings of the MDS Validation Review.  The procedure is as follows:

1.  A summary letter of the review is sent by the MDS nurse reviewers to the facility within 10 business days after the exit conference date of the documentation review.

2. Within 15 business days of the receipt of the MDS review findings letter, the facility must submit a written request for a Reconsideration Review. The request is sent to the DMA Facility Services Manager at the address listed in the letter.

3.  The DMA facility services manager assigns a facility services staff member to re-examine the original  review results.

4.  DMA staff reviews the findings in question and renders a decision.  The decision is sent in writing from DMA to the facility within 20 business days of the receipt of the request for reconsideration.

5.  If the facility still disagrees with DMA’s decision, the facility can notify the facility services manager within  ten business days of receipt of the reconsideration decision.  The information will be reviewed again by a DMA staff member and a final decision is rendered to the facility in writing within 30 days. 

6.  No further reconsideration is available to the facility.

Contacts for questions related to the MDS or MDS Validation Program are:

     Myers and Stauffer’s Help Desk

     1-800-763-2278

     North Carolina MDS Help Line

     Cindy DePorter, State RAI/MDS Coordinator

      919-715-1872

      MDS Validation Program

      Peggy Scott, RN, Nursing Facility Consultant

      DMA, 919-855-4350

Nursing Services Facility

DMA, 919-855-4350

Attention: All Providers

Clinical Coverage Policies

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

5A – Durable Medical Equipment

5B – Orthotics and Prosthetics

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

Intracranial Neurostimulator Procedures (61850-61888) Covered ICD-9-CM Codes

Effective with date of service October 1, 2005, the list of ICD-9-CM codes covered by N.C. Medicaid for intracranial neurostimulator procedures 61850 through 61888 were changed or updated according to the 2005 edition of the ICD-9-CM diagnosis codes. 

The changes to the diagnosis list for CPT codes 61850 through 61886 are:

Diagnoses 345.10 through 345.81 are updated to include the 5^th digit

The new diagnosis auditing list for CPT codes 61850 through 61886 include:

The changes to the diagnosis list for CPT code 61888 are:

Addition of diagnoses 332.0, 333.1, and 345.10 through 345.81

The new diagnosis auditing list for CPT codes 61888 include:

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

Attention: All Providers

New Dates for the Medicaid Family Planning Waiver Seminar

Seminars and Teleconference on the Medicaid Family Planning Waiver program have been rescheduled for October 2005.  The seminars focus on recipient eligibility, covered services, and billing for family planning services covered through the waiver program.  

Preregistration is required.  Unregistered providers are welcome to attend if space is available.  Lunch will not be provided at the seminars.

Providers may register for the training by completing and submitting the registration form or by registering online at http://www/dhhs/state.nc.us/dma/prov.htm. 

Providers may choose to attend either the morning session or the afternoon session for land sites.  The morning session begins at 9:00 a.m. and ends at 12:00 p.m.  The afternoon session begins at 1:30 p.m. and ends at 4:30 p.m.  Please arrive 30 minutes prior to the beginning of the seminar to complete registration. 

Providers may choose to attend the teleconference sites which will only be available in the mornings. The morning session begins at 9:00 a.m. and ends at 12:00 p.m.  Please arrive 30 minutes prior to the beginning of the teleconference to complete registration.  Please indicate on the registration form the session you plan to attend.

Providers must print the PDF version of the August 2005 Special Bulletin, Medicaid Family Planning Waiver Program from DMA’s web site at http://www.dhhs.state.nc.us/dma/bulletin.htm and bring it to the training.

Workshop Locations

Teleconference Locations

The teleconference is accessible from each of the sites listed below on Monday, October 24, 2005 and Monday, October 31, 2005.

Directions to the Medicaid Family Planning Waiver Seminar Sites

Catawba Valley Technical College, Auditorium – Hickory

Take I-40 to exit 125. Travel approximately ½ mile to Highway 70.  Travel east on Highway 70.  The college is located approximately 1 ½ miles on the right.  Ample parking is available in the rear lower parking areas.  The entrance to the auditorium is between Student Services and the Maintenance Center.  Follow sidewalk (toward satellite dish) and turn right to auditorium entrance. 

Hilton Charlotte University Place – Charlotte

Exit from I-85 North or South at exit 45 A, W.T. Harris Boulevard East. Hilton Charlotte University Place is 1/4 mile on the left in the University Place complex. The hotel is the highrise building in the complex, totally visible from Harris Boulevard. The left turn at J M Keynes Drive goes directly into the hotel.

Hilton Hotel -  Greenville

Take Highway 264 east to Greenville.  Turn right onto Allen Road in Greenville.  Travel approximately 2 miles.  Allen Road becomes Greenville Boulevard/Alternate 264.  Follow Greenville Boulevard for 2 ½ miles to the Hilton Greenville, which is located on the right.

Directions to the Medicaid Family Planning Waiver Teleconference Sites

(Maps and directions can also be accessed online at http://www.sph.unc.edu/phtin/locations/index.cfm.)

Albemarle Regional Health Services – Elizabeth City

Take US 17 north to Elizabeth City.  Take US 17 Business (Ehringhaus Street) to Halstead Boulevard (beside Burger King).  Turn right on Halstead Boulevard and travel approximately ¾ miles to Roanoke Avenue.  Turn left onto Roanoke Avenue and travel approximately ½ mile.  The Albemarle Regional Health Services building is located on the right.

Catawba County Health Department – Hickory

Take I-40 to Hickory.  Take Exit 128 onto Fairgrove Church Street.  Travel approximately ¾ miles to the second stoplight.  Turn left onto Eleventh Avenue Drive.  The Catawba County Health Department is located on the right just past the Catawba Memorial Hospital.  Parking is available in the first parking lot in front of the building.  Teleconference room 117 is located at the end of the first hallway on the right.

Cooper Building – Raleigh

Traveling East on I-40

Take I-40 into Raleigh.  After the Harrison Boulevard exit, get into the right-hand lane and follow the signs for Wade Avenue.  Follow Wade Avenue until it ends at Capital Boulevard.  Exit to the right onto Capital Boulevard.  Capital Boulevard becomes Dawson Street.  Stay in the left lane and continue around the curve to the second stoplight.  Turn left onto Jones Street.  Travel one block and then turn left onto McDowell Street.  The visitor’s parking lot is located on the right just past the intersection of McDowell Street and Lane Street.  The Cooper Building is located on the corner of McDowell Street and Lane Street adjacent to the parking deck.

Traveling West on I-40

Take I-440 Beltline to exit 289, Wade Avenue.  Turn right at the bottom of the exit ramp.  Follow Wade Avenue until it ends at Capital Boulevard.  Exit to the right onto Capital Boulevard.  Capital Boulevard becomes Dawson Street.  Stay in the left lane and continue around the curve to the second stoplight.  Turn left onto Jones Street.  Travel one block and then turn left onto McDowell Street.  The visitor’s parking lot is located on the right just past the intersection of McDowell Street and Lane Street.  The Cooper Building is located on the corner of McDowell Street and Lane Street adjacent to the parking deck.

E. Newton Smith Public Health Center, Cumberland County Health Department – Fayetteville

Traveling South on I-95

Take I-95 south to Fayetteville.  Near Fayetteville, bear right onto I-95 Business/US 301 Business.  Travel on I-95 Business/US 301 Business to E. Russell Street (third stoplight).  Turn right onto E. Russell Street and follow it to the end.  Turn left onto McIver Street.  Bear right onto McGilvary Street.  Turn right at the first street to the right onto Fountainhead Lane.  The Public Health Center is the four-story, tan building on the right.

Traveling North on I-95

Take I-95 north to I-95 Business/US 301 Business.  Turn left onto Gillespie Street. Turn left onto W. Russell Street and follow it to the end.  Turn left onto McIver Street.  Bear right onto McGilvary Street.  Turn right at the first street to the right onto Fountainhead Lane.  The Public Health Center is the four-story, tan building on the right.

Community Services Building, Jackson County Health Department – Sylva

From Asheville, take I-40 west to Waynesville.  From Waynesville, take US 19/US 23 South/US 74 West to Sylva.  Take exit 78.  Travel approximately 3 miles to Harris Regional Hospital and turn right.  Travel approximately ½ miles to the Community Services Building on the right.  The teleconference center is located in the brown colonial-style modular unit beside the main building.

UNC School of Public Health, Michael Hooker Research Center – Chapel Hill

Take I-40 to Chapel Hill.  Exit onto NC 54 West, exit 273-B.  Travel west on NC 54.  At the NC 54 Business/Bypass split, NC 54 becomes Raleigh Road.  Follow Raleigh Road onto the University campus.  At the top of the hill, after the intersection of Raleigh Road and Country Club Road, the road changes names to South Road.  Follow South Road through campus.  After crossing S. Columbia Street, turn left onto Pittsboro Street.  Travel past the Tate-Turner-Kuralt Building on the left, then past McGavran-Greenberg Hall.  Be ready to bear to the left-there’s a stoplight-and to recross S. Columbia Street onto Manning Drive.  Travel on Manning Drive to the second stoplight.  Turn right onto East Drive.

Paid parking ($.75 per hour) is available on the Dogwood Deck of the visitor’s parking lot.  The parking lot entrance is located to the right of East Drive.  The teleconference center is connected to the Rosenau Hall and McGavran-Greenberg Hall.

Wilson County Health Department – Wilson

Take US 264 east to Wilson.  After crossing I-95, turn at the third stoplight onto Forest Hill Road.  Turn left at the second stoplight onto Tarboro Street.  Turn right at the first stoplight onto Glendale Drive.  The Wilson County Health Department is located immediately after the next stoplight.  Turn into the second drive after the stoplight.  Enter the building through the doors under the blue awning.  The teleconference room is located on the right.

Attention:  All Providers

North Carolina Health Choice Children Age 0-5 Moving to Medicaid

 During the 2005 session, the General Assembly passed legislation that will move children ages birth through five from the North Carolina Health Choice (NCHC) program to the North Carolina Medicaid program. Effective January 1, 2006, children birth through five years of age with family income equal to or less than 200% of the federal poverty limit will be eligible for Medicaid. Children birth through five years of age currently enrolled in North Carolina Health Choice will be moved to the Medicaid program effective January 1, 2006. The North Carolina Health Choice program will continue to cover children between the ages of six through eighteen.

Some of the children moving from NCHC to Medicaid will have NCHC cards with expiration dates after January 1, 2006. These cards will no longer be valid for those children from birth through age five. A blue monthly Medicaid card will be issued for these children beginning January 2006.

Medicaid Eligibility Unit
DMA, 919-855-4000

Attention:  All Providers

Requests for Corrected 1099 - Action Required by March 1, 2006

Providers receiving Medicaid payments of more than $600 annually receive a 1099 MISC tax form from EDS.  The 1099 MISC tax form is generated as required by IRS guidelines.  It will be mailed to each provider no later than January 31, 2006.  The 1099 MISC tax form will reflect the tax information on file with Medicaid as of the last Medicaid checkwrite cycle cutoff date, December 16, 2005.

If the tax name or tax identification number on the annual 1099 MISC you receive is incorrect, a correction to the 1099 MISC must be requested.  This ensures that accurate tax information is on file with Medicaid and is sent to the IRS annually.  When the IRS receives incorrect information on your 1099 MISC, it may require backup withholding in the amount of 28 percent of future Medicaid payments.  The IRS could require EDS to initiate and continue this withholding to obtain correct tax data.

A correction to the original 1099 MISC must be submitted to EDS by March 1, 2006 and must be accompanied by the following documentation:

·A copy of the original 1099 MISC.

·A signed and completed IRS W-9 form clearly indicating the correct tax identification number and tax name.  (Additional instructions for completing the W-9 form can be obtained at www.irs.gov under the link "Forms and Pubs.").

Fax both documents to:

919-816-3186,
Attention: Corrected 1099 Request - Financial

Or

Mail both documents to:

EDS
Attention: Corrected 1099 Request - Financial
4905 Waters Edge Drive
Raleigh, NC 27606

A copy of the corrected 1099 MISC will be mailed to you for your records.  All corrected 1099 MISC requests will be reported to the IRS. In some cases, additional information may be required to ensure that the tax information on file with Medicaid is accurate. Providers will be notified by mail of any additional action that may be required to complete the correction to their tax information.

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

Attention: All Providers

Tax Identification Information

The N.C. Medicaid program must have the correct tax information on file for all providers.  This ensures that 1099 MISC forms are issued correctly each year and that correct tax information is provided to the IRS.  Incorrect information on file with Medicaid can result in the IRS withholding 28 percent of a provider’s Medicaid payments.  The individual responsible for maintenance of tax information must receive the information contained in this article.

How to Verify Tax Information

The last page of the Medicaid Remittance and Status Report (RA) indicates the tax name and number on file with Medicaid for the provider number listed.  Review the Medicaid RA throughout the year to ensure that the correct tax information is on file for each provider number.  If you do not have access to a Medicaid RA, call EDS Provider Services at 919-851-8888 or 1-800-688-6696 to verify the tax information on file for each provider.

How to Correct Tax Information

All providers are required to complete a W-9 form for each provider for which incorrect information is on file.  Please go to http://www.irs.gov/pub/irs-pdf/fw9.pdf to obtain a copy of a W-9 form.  Correct information is due by December 16, 2005.  The procedure for submitting corrected tax information to the Medicaid program is outlined below:

All providers,who identify incorrect tax information, must submit a completed and signed W-9 forms, along with a completed and signed Medicaid Provider

Change form or Carolina ACCESS Provider Information Change Form, to the address listed below:

Division of Medical Assistance
Provider Services
2501 Mail Service Center
Raleigh, NC 27699-2501

Refer to the following instructions for completing the W-9.  Additional instructions can be found on the IRS web site at www.irs.gov under the link "Forms and Pubs."

·List the N.C. Medicaid provider number in the block titled "List account number(s) here."

·List the N.C. Medicaid provider name in the block titled "Business Name."  It should appear exactly as the IRS has on file.

·Indicate the appropriate type of business.

·Fill in either a social security number or a tax identification number.  Indicate the number exactly as the IRS has on file for the provider’s business.  Do not insert a social security number unless the business is a sole proprietorship or individually owned and operated.

·An authorized person must sign and date this form or it will be returned as incomplete and the tax information on file with Medicaid will not be updated.

Change of Ownership

·All providers, including Managed Care providers, must report changes to DMA Provider Services using the Medicaid Provider Change form.

·Carolina ACCESS providers must also report changes to DMA Provider Services using the Carolina ACCESS Provider Information Change form.

·DMA Provider Services will assign a new Medicaid provider number, if appropriate, and will ensure the correct tax information is on file for Medicaid payments.

If DMA is not contacted and the incorrect tax identification number is used, that provider will be liable for taxes on income not necessarily received by the provider’s business.  DMA will assume no responsibility for penalties assessed by the IRS or for misrouted payments prior to written receipt of notification of ownership changes.

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 web site at http://www.dhhs.state.nc.us/dma/prov.htm.

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: Community Alternatives Program for Children Providers

CAP/C Program Changes

The Centers for Medicare and Medicaid (CMS) has granted approval for North Carolina Medicaid’s Community Alternatives Program for Children (CAP/C) Waiver program for an additional five years effective July 1, 2005 through June 30, 2010.  The following changes in CAP/C were approved:

1.       New Forms:

• Revised Referral Form
• New Physician’s Request Form (required by physician at initial assessment and at annual CNR for nursing services)
• Revised Assessment and Plan of Care (electronic and paper versions  available)  

The CAP/C forms can be found DMA’s web site at http://www.dhhs.state.nc.us/dma/forms.html and are effective immediately.

2.       The revised Plan of Care reflects a revised Client Statement which serves to ensure that the client or responsible party understands the benefits and limitations of the CAP/C program.

3.       The Assessment and Plan of Care now may be completed solely by the registered nurse case manager, or the provider agency may optionally choose for the social work case manager to assist with portions of the Assessment and Plan of Care.

4.       Respite Care In-Home Nursing is a new CAP/C service with a limit of 168 hours per calendar year.  The service is billed using HCPCS code T1005 and is billed in 15 minute increments.  CAP/C providers must complete a new enrollment application indicating that the application is an amendment to “Add New Service” if they wish to provide this additional service.  The application is available on DMA’s web site.

Facility and Community Care
DMA, 919-855-4380

Attention: Durable Medical Equipment Providers and Home Infusion Therapy Providers

Change in Rate Methodology for HCPCS Code E0781

Effective with date of service October 1, 2005, HCPCS code E0781, ambulatory infusion pump, will be paid as a monthly rate instead of a daily rate.  The maximum monthly rate is $264.87.  Providers are reminded to bill their usual and customary rate.

Clinical coverage criteria remains unchanged.  Refer to Clinical Coverage Policy 5A, Durable Medical Equipment and Section 5, Home Infusion Therapy, of the Community Care Provider Manual on DMA’s web site at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm for detailed coverage and billing information.

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

Attention: Orthotic and Prosthetic Device Providers

Changes to Reimbursement Rates for Certain HCPCS Codes

Effective with date of service October 1, 2005, the maximum reimbursement rate for some orthopedic shoes changed.  The change is required since the rates for orthotics and prosthetics are based on Medicare’s rates.  Refer to DMA’s web site at http://www.dhhs.state.nc.us/dma/fee.htm. for a copy of the Orthotic and Prosthetic Fee Schedule.

Providers are reminded to bill their usual and customary rates.

EDS, 1-800-688-6696 or 919-851-8888 

Attention: Pharmacists and Pharmacy Technicians

Medicare Part D:  Implications for North Carolina’s Pharmacists and Senior Citizens

This fall, the North Carolina Association of Pharmacists (NCAP), North Carolina Senior Care, and the UNC-CH School of Pharmacy are co-sponsoring Medicare Part D continuing education programs for pharmacists and pharmacy technicians.  Ten programs are scheduled to be held across the state between September 15, 2005 and October 18, 2005. Most programs will be held in AHEC facilities, with one conducted on Sunday evening, October 16, 2005, at the NCAP Annual Convention (Sheraton Imperial Hotel, Durham). The UNC-CH School of Pharmacy is serving as the Accredited Continuing Pharmacy Education accredited provider for continuing education credit.

The goal of this program is to describe the intent of Medicare Part D and the prescription drug benefit. North Carolina pharmacists who are Medicare experts will discuss the role of the pharmacist and how this historical reform will affect pharmacy as a profession.

Please visit http://www.ncpharmacists.org/calendar.cfm to view the brochure and register for the Medicare Part D program in your area or call the North Carolina Association of Pharmacists at 919-967-2237.

North Carolina Association of Pharmacists

919-967-2237

Attention: Pharmacy Providers

Medicare Part D Provider Marketing Guidelines Now Available

The final version of the Medicare Part D Marketing Guidelines is now available from the Centers for Medicare and Medicaid Services and can be found at http://www.cms.hhs.gov/pdps/.  The Guidelines include information on what pharmacists can and cannot do when assisting beneficiaries with prescription drug plan (PDP) selection.

Pharmacy providers contracted with Plans and their subcontractors can:

• Provide the names of Plans with which they contract and/or participate.
• Provide information and assistance in applying for the limited income subsidy.
• Provide objective information on specific Plan formularies, based on a particular patient’s medications and health care needs.
• Provide objective information regarding specific Plans, such as covered benefits, cost sharing, and utilization management tools.
• Distribute PDP marketing materials, including enrollment application forms.
Note: Providers must inform individuals where they can obtain information on all available options
within the service area (i.e., 1-800-MEDICARE or http://www.medicare.gov/).
• Distribute Medicare Advantage (MA) and/or Medicare Advantage-Prescription Drug (MA-PD) marketing materials, excluding enrollment application forms.
Note: Providers must inform individuals where they can obtain information on all available options
within the service area (i.e., 1-800-MEDICARE or http://www.medicare.gov/).
• Refer their patients to other sources of information, such as the State Health Insurance Assistance Programs, Plan marketing representatives, CMS’s web site at http://www.medicare.gov/, or calling 1-800-MEDICARE.
• Print out and share information with patients from CMS’s web site.
• Use comparative marketing materials comparing plan information created by a non-benefit/service providing third party (See Section 10 of the Guidelines under Marketing of Multiple Lines of Business, Non-Benefit/Service-Providing Third Party Marketing Materials).

Pharmacy providers contracted with Plans and their subcontractors cannot:

• Direct, urge or attempt to persuade any prospective enrollee to enroll in a particular Plan or to insure with a particular company based on financial or any other interest of the provider (subcontractor).
• Collect enrollment applications.
• Offer inducements to persuade beneficiaries to enroll in a particular plan or organization.
• Health screen when distributing information to patients, as health screening is a prohibited marketing activity.
• Offer anything of value to induce Plan enrollees to select them as their provider.
• Expect compensation in consideration for the enrollment of a beneficiary.
• Expect compensation directly or indirectly from the Plan for beneficiary enrollment activities.

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

Attention: Pharmacists and Prescribers

Over-The-Counter Nicotine Replacement Therapy Medications Covered by Medicaid

The N.C. Medicaid program has added nicotine replacement therapy (NRT) medications to the list of selected over-the-counter (OTC) medications covered by Medicaid.  The medication must be pursuant to a lawful prescription, the manufacturer of the medication must have a valid rebate agreement with the Centers for Medicare and Medicaid Services and the national drug code (NDC) of the medication must be on the covered OTC list.  The following nicotine replacement therapy medications are on the list of covered OTC medications:

Refer to General Coverage Policy A2, Over-The-Counter Medications, on DMA’s web site at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm for additional information.

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

Attention: Pharmacy Providers

Providing Compounded Prescriptions for Medicaid Recipients

Medicaid pharmacy providers providing compounded prescriptions to the general public may not exclude Medicaid recipients from receiving compounded prescriptions from their pharmacies.  Medicaid pharmacy providers that are the pharmacy of record must take the necessary steps to ensure that Medicaid recipients receive prescribed medications within the month of record including prescribed medications that require compounding. If the ingredients required for the compounded prescription are not available, the pharmacy of record must assist the Medicaid recipient with locating a pharmacy that has the ingredients necessary to fill the prescribed compounded prescription.

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

Attention: Pharmacists and Prescribers

Policy and Procedures for Prescribing Synagis for RSV Season 2005-2006 

For the upcoming RSV season, Synagis will not require prior approval (PA) for Medicaid recipients. However, the responsibility for appropriate usage of Synagis will be placed on prescribers and pharmacy providers. The clinical criteria utilized in this policy are consistent with currently published American Academy of Pediatrics guidelines (http://aappolicy.aappublications.org/cgi/content/full/pediatrics; 112/6/1442).

Please ensure that the person completing the Synagis criteria form has verified that the conditions exist and are accurate. If a patient does not fit the published criteria and you still wish to prescribe Synagis, you must submit your request to DMA on the Request for Medical Review for Synagis Outside of Criteria form and fax the request to DMA at 919-657-8843.

The start of the Synagis season is October 15, 2005. No more than 5 monthly doses of Synagis can be obtained by using these forms. The number of doses should be adjusted if an infant received the first dose prior to a hospital discharge. Delays in getting a request processed can occur if the patient does not have a Medicaid identification number or the form is not complete.

The criteria form must be signed by the prescriber and submitted to the pharmacy distributor of choice. The pharmacy distributor must mail a copy of the submitted form to DMA.

Please mail to:
N.C. Division of Medical Assistance
Pharmacy Program
1985 Umstead Drive
2501 Mail Service Center
Raleigh, N.C. 27699

The Request for Medical Review for Synagis Outside of Criteria form must be signed by the prescriber and faxed to DMA at 919-657-8843.

Please refer to the following guidelines when submitting a request:

For the following four diagnoses, DOB must be on or after 10/15/03:

Chronic Lung Disease (Bronchopulmonary Dysplasia)
The infant has Chronic Lung Disease (bronchopulmonary dysplasia) and has necessitated treatment (supplemental oxygen, bronchodilator, diuretic, corticosteroid) in the six months before the start of the season.

Hemodynamically Significant Congenital Heart Disease
Infants less than 12 months of age who are most likely to benefit include those receiving medication to control CHF, moderate to severe pulmonary hypertension, and/or cyanotic heart disease.

Infants NOT at increased risk from RSV who generally should NOT receive immunoprophylaxis include: hemodynamically insignificant heart disease such as
secundum atrial/septal defect, small VSD, pulmonic stenosis, uncomplicated aortic stenosis, mild coarctation of the aorta, PDA, lesions adequately corrected by surgery unless the infant continues on medication for CHF, mild cardiomyopathy where the infant is not receiving medical therapy.

Cystic Fibrosis
The infant has Cystic Fibrosis and either requires chronic oxygen or has been diagnosed with nutritional failure.

Severe Congenital Immunodeficiency
Severe combined immunodeficiency disease or severe acquired immunodeficiency syndrome.

Infant is born at an EGA of:

< 28 weeks and DOB is on or after 10/15/04
29-32 weeks and DOB is on or after 4/15/05

If born between 32 weeks and 1 day and 35 weeks and 0 days gestation, must be less than 6 months of age (DOB on or after 4/15/05) at the start of the season and have two or more defined risk factors:

*School-age Siblings
*Attends Day Care
*Severe Neuromuscular Disease
*Exposure to prolonged wood burning heaters which are the primary source of heat for the family. Tobacco smoke is NOT a risk factor because it can be controlled by the family.
*Congenital abnormalities of the airways.
*Request for Medical Review for Synagis Outside of Criteria

This form will be used for patients who do not explicitly meet the guidelines whose providers still wish to prescribe Synagis. Please fill out the requested information and fax to DMA at 919-657-8843. PLEASE NOTE THAT THIS IS THE ONLY FORM THAT RESCRIBERS SHOULD FAX TO DMA.

Medicaid will allow Synagis claims processing to begin on October 10, 2005 to allow sufficient time for pharmacies to provide Synagis by the start of the season on October 15, 2005. Payment of Synagis claims prior to October 10, 2005 and after March 15, 2006 will not be allowed. Physicians and pharmacy providers are subject to audits of Synagis records by DMA Program Integrity.

The Synagis Criteria Form and the Request for Medical Review for Synagis Outside of Criteria Form are available on the DMA web site at http://www.dhhs.state.nc.us/dma/prov.htm

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

Attention: Physicians

Gastric Bypass Prior Approval Documentation

As indicated in Clinical Coverage Policy #1A-15, Surgery for Clinically Severe Obesity, all of the following medical documentation and information must be included with prior approval requests for surgeries for clinically severe obesity:

1.        Documentation of a continuous six month period or longer of all medical treatment modality therapies attempted by the recipient under the supervision of a physician or in an organized weight loss program to reduce weight, the duration of each therapy and the results of each treatment. 

2.        Documentation of the recipient’s weight for three separate years.

3.        The recipient’s present weight, height, skeletal frame, body mass index and gender.

4.        Medical history of all of the recipient’s diagnoses such as hypertension, heart problems, pulmonary problems, arthritis, joint pains, back problems, etc.

5.        A complete listing of all the recipient’s medications.

6.        Blood pressures, fasting blood sugar levels, pulmonary study results, orthopedic x-ray reports, etc.

7.        Documentation that all correctable causes of obesity have been ruled out with test results of laboratory tests performed, such as thyroid panel, etc.

8.        Documentation of a psychological evaluation assessing the recipient’s suitability for surgery and his/her ability to comply with lifelong dietary changes and medical follow up.  Components of such an assessment should include:  levels of depression, eating behaviors, stress management, cognitive abilities, social functioning, self-esteem, personality factors or other mental health diagnoses that may affect treatment, readiness and ability to adhere to required lifestyle modifications and follow up/social support.

9.        Documentation of a fully developed, 5-year psychosocial, nutritional, and activity-based follow-up plan.

10.    Certification that the recipient has been informed about all surgery risks, surgery sequelae, the need for extensive follow-up care, expectancy of weight loss and a signed statement that the recipient has been informed of the risks and results and still desires a surgical procedure.

11.    Description of the type of gastro-bariatric surgery planned and CPT code that describes the surgery planned.

An increasing number of requests have been submitted without the required documentation of a 5-year follow-up plan and a statement signed by the recipient certifying that he/she has been informed of the risks and results of the surgery and still desires the procedure.

Prior approval requests without all of the required documentation listed above will be returned to the provider.

Please refer to DMA’s web site at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm for a copy of clinical coverage policy 1A-15.

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

Attention:  Physicians

Physicians Drug Program Pricing List Update

Effective November 1, 2005, the maximum reimbursement rates for procedure codes in the Physicians Drug Program have been updated.  Rates are based on Average Sales Price plus six percent (ASP+6%), the pricing point used by Medicare.  For drugs not covered by Medicare and where the ASP+6% price is not available, the rates are based on the Average Wholesale Price less ten percent (AWP-10%).

Providers must continue to bill on the CMS-1500 or UB-92 claim form, as previously instructed, with their usual and customary charge.  Adjustments will not be made to previously processed claims.

The new rate schedule for the Physicians Drug Program is available on DMA’s web site at http://www.dhhs.state.nc.us/dma/fee/fee.htm.

For procedure codes J3490 and J9999, providers must continue to submit a copy of the invoice along with the CMS-1500 claim form as previously instructed.  Providers must write the name of the recipient, the recipient’s Medicaid identification number, the name of the medication, the dosage given, the National Drug Code(s) (NDC) from the vial(s) used, the number of each vial administered, and the cost per dose on the invoice. Payment is based on the invoice cost shipping and handling.

Financial Management

DMA, 919-855-4200

Attention:  Physicians, Chiropractors, Dentists, Optometrists, Podiatrists, and Osteopaths

Provider Enrollment

The Division of Medical Assistance DMA Provider Services Unit is responsible for approving and enrolling both group and individual providers in the N.C. Medicaid program.  Below are helpful hints for completing enrollment as an individual or group practitioners in the N.C. Medicaid Program:

·          Provider enrollment applications are available on DMA’s web site at http://www.dhhs.state.nc.us/dma/provenroll.htm .

·          Individual providers enroll by completing the “Physician In-State and Border” individual application.

·          Group practices complete the “Physician In-state and Border” group application. If a group has more than one location, each location must enroll to obtain a NC Medicaid provider number specific to that location.

·          Group providers are required to disclose all ownership interest in the practice or group that represent a five percent or greater ownership interest.

·          Individual providers must submit the required information and documentation that reflect their related information, not the information of the practice, hospital or group(s) with which they are affiliated.

·          Individual providers are linked to group practices during the application process or on request via a Medicaid Provider Change Form http://www.dhhs.state.nc.us/dma/Forms/changeprovstatus.pdf

·          Once an individual provider is enrolled, the individual Medicaid provider number assigned shall follow the provider and shall remain the providers attending number when billing for Medicaid reimbursable services, regardless of affiliation(s).

·          Active providers joining a new practice are not required to re-enroll.  All changes to a practice that do not effect ownership, changes to practice address, linking of a provider to a practice, or deleting  a provider from a practice must be reported to DMA using the Medicaid Provider Change Form at http://www.dhhs.state.nc.us/dma/Forms/changeprovstatus.pdf.

·          Providers should assure that accurate information is maintained in their records by reporting changes to the DMA Provider Services Unit in a timely manner.

·          Providers whose records become inactive for a period greater than 90 days may be required to re-enroll in the N.C. Medicaid Program.

·          Information on contacting Medicaid is available on DMA’s web site at http://www.dhhs.state.nc.us/dma/prov.htm.

Provider Services

DMA, 919-855-4050

Attention: Providers of Enhanced Mental Health Services

Enhanced Mental Health Services Seminar Schedule

Enhanced Mental Health Services seminars have been rescheduled for October 2005.  Seminars are intended for providers who meet the approval and endorsement criteria to bill for Enhanced Mental Health Services on or after the implementation date.  Topics to be discussed will include, but are not limited to, provider enrollment requirements, eligibility issues, billing instructions, and clinical coverage policies.  Those who will be billing for these services to N.C. Medicaid are encouraged to attend. 

The seminars are scheduled at the locations listed below.  Preregistration is required.  It is recommended that the office manager a clinical professional and a billing person from each office attend these seminars.  Due to limited seating, registration is limited to three staff members per office.  Unregistered providers are welcome to attend if space is available.

Providers may register for the Enhanced Mental Health Services seminars by completing and submitting the registration form available or by registering online at http://www.dhhs.state.nc.us/dma/prov.htm.  The seminars will begin at 9:00 a.m. and will end at 4:45 p.m. with a break for lunch from 12:00 p.m. to 1:00 pm.  Providers are encouraged to arrive by 8:45 a.m. to complete registration.  Refreshments will not be provided during the seminar.

Providers must print the PDF version of the August 2005 Special Bulletin Providers of Enhanced Mental Health Services from DMA’s web site at http://www.dhhs.state.nc.us/dma/bulletin.htm and bring it to the seminar.

Providers of Enhanced Mental Health Services who meet the endorsement and enrollment criteria and would like to provide these services must direct enroll with the N.C. Medicaid program.  You may access Medicaid enrollment information by going to DMA’s web site.

Enrollment applications can be found at this location.

Directions to the Enhanced Mental Health Services Seminars

Holiday Inn – Asheville, North Carolina
I-40 Eastbound, Exit 55. Turn left, at light turn right. Hotel drive is on the left.
I-40 Westbound, Exit 55. Turn right, at light turn right. Hotel drive is on the left.

Holiday Inn - Statesville, North Carolina
I-77 North or South to Exit 49A

Rocky Mount location- Rocky Mount, North Carolina
From Raleigh (West)
Take 64 East . Take the Red Oak exit. Turn right off ramp at stop sign (Old Carriage Rd). Go approximately 1/4 mile. Nash Community College will be on your right.
From Rocky Mount (East)
Take 64 West. Take the Red Oak Exit (exit past the 95 overpass). Turn left off ramp at stop sign. Go approximately 1/4 mile. Nash Community College will be on your right.

Robeson Community College- Lumberton, North Carolina
I-95 to exit 22. Turn onto Fayetteville Rd.

Jane S. McKimmon Center – Raleigh, North Carolina
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.

Attention: All Providers

Change in Medicaid Co-payments

The NC General Assembly, Session Law 2005-276, authorized the Division of Medical Assistance to implement the federal law maximum co-payments for several Medicaid services.

Below is a list of changes in co-pay amounts effective November 1, 2005:

Medicaid recipients are responsible for co-pay amounts, but providers cannot refuse to treat a patient if they are unable to pay this amount.

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

OB/GYN Medicaid Billing Seminar

OB/GYN Medicaid billing seminars are scheduled for November 2005.  Seminars are intended for providers who provide OB/GYN services.  Topics to be discussed will include, but not limited to Baby Love, obstetrics, gynecology, billing instructions and denial resolution.

The seminars are scheduled at the locations listed below.  Preregistration is required.  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 OB/GYN Medicaid billing seminars by completing and submitting the registration form available or by registering online at http://www.dhhs.state.nc.us/dma/prov.htm. Please indicate the session you plan to attend on the registration form.  There will be two sessions, one for hospital providers and one for physicans providers.  The session for hospitals will begin at 9:00 a.m. and end at 12:00 p.m.  The session for physicans will begin at 1:00 p.m. and end at 4:00 p.m.  Providers are encouraged to arrive by 8:45 a.m. for the first session to complete registration and 12:45 p.m. for the second session.  Refreshments will not be provided. 

Providers must print the PDF version of the October 2005 OB/GYN Special Medicaid Billing Guide and bring it to the seminar.

The seminar will also reference the Basic Medicaid billing guidelines, so please bring a copy of the Basic Medicaid Billing Guide to the seminar. 

Directions to the OB/GYN Medicaid Billing Seminars

Coastline Convention Center – Wilmington, North Carolina                                                                         

Take I-40 east to Wilmington. Take the US 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, North Carolina

Traveling South on I-85

Take exit 75.  Turn right on Jake Alexander Boulevard.  Travel approximately ½ mile.  The Holiday Inn is located on the right.

Traveling North on I-85

Take exit 75.  Turn left on Jake Alexander Boulevard.  Travel approximately ½ mile.  The Holiday Inn is located on the right.

Jane S. McKimmon Center – Raleigh, North Carolina

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.

Greenville Hilton – Greenville, North Carolina

Take US 64 east to US 264 east.  Follow 264 east to Greenville.  Once you enter Greenville, turn right on Allen Road.  After traveling approximately 2 miles, Allen Road becomes Greenville Boulevard/Alternate 264.  Follow Greenville Boulevard for approximately 2½ miles.  The Hilton Greenville is located on the right.

NCLeads Update

Information related to the implementation of the new Medicaid Management Information System, NCLeads, scheduled for implementation in mid-2006 can be found online at http://ncleads.dhhs.state.nc.us.  Please refer to this web site for information, updates, and contact information related to the NCLeads system.

Thomas Liverman, Provider Relations

Office of MMIS Services,

919-647-8315

Proposed Clinical Coverage Policies

In accordance with Session Law 2003-284, proposed new or amended Medicaid clinical coverage policies are available for review and comment on DMA’s web site at http://www.dhhs.state.nc.us/dma/prov.htm. To submit a comment related to a policy, refer to the instructions on the web site. 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.

2005 Checkwrite Schedule

      Electronic claims must be transmitted and completed by 5:00 p.m. on the cut-off date to be included in the next checkwrite. 
Any claims transmitted after 5:00 p.m. will be processed on the second checkwrite following the transmission date.

  2005 Checkwrite Schedule

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