In This Issue...........................................

All Providers:

• 2006 Checkwrite Schedule
• Gadolinium-Based Magnetic Resonance Contrast Agent, per ml - Billing Guidelines
• Non-Covered Services
• Physician Drug Program Pricing List Update
• Policy and Procedures for Prescribing Synagis for 2006-2007 Respiratory Syncytial Virus Season
• Quarterly Update to the 2006 Physician Fee Schedule Database
• Tetanus, Diphtheria Toxoids and Acelluar  Pertussis Vaccine (TDAP) – HCPCS Code 90715

Adult Care Home Providers:

• Fee Schedule for Adult Care Home Special Care Unit for Persons with Alzheimer’s and Related Disorders

CMS-1500 Billers:

• Medicare Health Maintenance Organization (HMO)

Children’s Developmental Service Agencies (CDSAs):

• Outpatient Specialized Therapies Prior Authorization Process – Update to New Web Site and Submission Process

Durable Medical Equipment Providers:

• Durable Medical Equipment Rental Items

Health Departments:

• Outpatient Specialized Therapies Prior Authorization Process – Update to New Web Site and Submission Process

Home Health Agencies:

• Outpatient Specialized Therapies Prior Authorization Process – Update to New Web Site and Submission Process

Hospital Outpatient Clinics:

• Outpatient Specialized Therapies Prior Authorization Process – Update to New Web Site and Submission Process

ICF-MR Providers:

• ICF-MR Provider Assessment Database

Independent Practitioners:

• Outpatient Specialized Therapies Prior Authorization Process – Update to New Web Site and Submission Process

Local Management Entities:

• Outpatient Specialized Therapies Prior Authorization Process – Update to New Web Site and Submission Process

Nursing Facility Providers:

• Minimum Data Set Validation Review Update

Optical Service Providers:

• Introducing the New Request for Prior Approval for Visual Aids Form (372-017) and Instructions

Personal Care Services and Personal Care Services – Plus Providers:

• Personal Care Services Provider Training Session II

Physicians:

• Outpatient Specialized Therapies Prior Authorization Process – Update to New Web Site and Submission Process

UB-92 Billers:

• Medicare Health Maintenance Organization  (HMO)

Attention:  All Providers

Gadolinium-Based Magnetic Resonance Contrast Agent, per ml, (HCPCS Procedure Code Q9952) – Billing Guidelines

The NC Medicaid Bulletin dated November 2005 informed providers that for dates of service April 1, 2005, and after, HCPCS procedure codes Q9945 through Q9951 must be billed for low osmolar contrast media (LOCM) used in radiologic diagnostic studies.  Recognizing that Q9952 (gadolinium-based magnetic resonance contrast agent) is frequently billed for MRI studies, Medicaid will reimburse for Q9952 effective with date of service January 1, 2006.

For Medicaid billing, one unit of Q9952 equals 1 ml.  The maximum reimbursement rate per unit of Q9952 is $2.89.  Providers who have had claims denied because of billing HCPCS procedure code Q9952 for dates of service on or after January 1, 2006, may resubmit the claims for processing.

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

Attention:  All Providers

Non-Covered Services

The following services have been determined by Divisional of Medical Assistance (DMA) to be experimental or investigational and are not covered.  Please note that this is not an inclusive list of all Medicaid non-covered services.  When these services are billed to Medicaid, reimbursement will be denied.  Providers are reminded that it is fraudulent to bill for non-covered services using a covered CPT code.

According to the Basic Medicaid Billing Guide, March 2006:  “When a non-covered service is requested by a recipient, the provider must inform the recipient either orally or in writing that the requested service is not covered under the Medicaid program and will, therefore, be the financial responsibility of the recipient. This must be done prior to rendering the service.”  The billing guide is available online at the DMA Web site at http://www.dhhs.state.nc.us/dma/prov.htm.

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

Attention:  All Providers

Physician Drug Program Pricing List Update

Effective with date of service October 1, 2006, the maximum reimbursement rates for procedure codes in the Physician Drug Program have been updated.  Rates are based on the 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%) of the lowest generic.

Providers must continue to bill electronically or 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 Physician Drug Program is available on DMA’s Web site at http://www.dhhs.state.nc.us/dma/fee/fee.htm. 

For procedure codes J3490, J3590, and J9999, providers must continue to submit a copy of the original 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, less shipping and handling.

Financial Management

DMA, 919-855-4200

Attention: All Providers

Policy and Procedures for Prescribing Synagis for 2006–2007 Respiratory Syncytial Virus Season

On October 15, 2006, N.C. Medicaid will begin coverage of Synagis prescriptions for respiratory syncytial virus (RSV).  This year, Synagis prescriptions will not require prior approval.  However, health care and pharmacy providers are expected to ensure the appropriate usage of Synagis.  The clinical criteria utilized in this policy are consistent with currently published American Academy of Pediatrics guidelines at http://aappolicy.aappublications.org/cgi/content/full/pediatrics.

Please ensure that either

·      the conditions exist and are accurate, and are verified by completion and submission of the Synagis for RSV Prophylaxis Form (“in-criteria form”) at http://www.dhhs.state.nc.us/dma/Forms/SynagisCriteriaForm.pdf, or

·      the patient does not fit the published criteria, but the Request for Medical Review for Synagis Outside of Criteria Form at http://http://www.dhhs.state.nc.us/dma/Forms/SynagisMedicalReview.pdf

      has been completed and submitted.

Note:  Processing delays can occur if the patient does not have a Medicaid identification number or the form is not complete.

Note:  During the RSV season, no more than five monthly doses of Synagis can be obtained for each recipient by using these forms.  The number of doses should be adjusted if an infant received the first dose prior to a hospital discharge.

Submitting the In-Criteria Form

Infants born on or after October 15, 2004, meet the medical criteria for Synagis if they have one or more of the following conditions:

Other infants may meet the medical criteria for Synagis as follows:

When it has been verified that one or more of the above conditions exist and are accurate, submit the in-criteria form by doing the following:

·         Prescriber signs and submits to the pharmacy distributor of choice (not to DMA).

·         Pharmacy distributor must maintain the form on site.

·         Every week, pharmacy distributor must send DMA copies of the forms submitted that week.

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

o        Or submit high-volume Synagis claims on a diskette. Please call Charlene Sampson at (919) 855-4306 to coordinate this process.

Submitting the Request for Medical Review Form

When a patient does not explicitly meet the guidelines but the provider still wishes to prescribe Synagis, submit the Request for Medical Review Form by doing the following:

·         Prescriber completes the form, including the medical necessity justification, sign it, and fax it to  DMA at 919-715-1255.  This is the only form that prescribers should fax to DMA.

·          The request will be reviewed and either approved or denied.  Notification of the result will be sent

        to prescribers.

·            Pharmacy distributor maintains a copy of the approval letter on site.

Medicaid will allow Synagis claims processing to begin on October 10, 2006, to allow sufficient time for pharmacies to provide Synagis by October 15, 2006.  Payment of Synagis claims prior to October 10, 2006, and after March 31, 2007, will not be allowed.  Pharmacy providers should always indicate an accurate days’ supply when submitting claims to N.C. Medicaid.  Physicians and pharmacy providers are subject to audits of Synagis records by DMA Program Integrity. 

Pharmacy and Ancillary Services

DMA, 919-855-4300

Attention: All Providers

Quarterly Update to the 2006 Physician Fee Schedule Database

The Centers for Medicare and Medicaid Services (CMS) develops payment files annually based upon the Medicare Physician Fee Schedule Final Rule.  CMS issues quarterly updates as deemed necessary.  Based on the quarterly updates, the N.C. Medicaid program has made the following changes effective with date of service October 1, 2006.  The CPT codes listed below are valid codes with N.C. Medicaid.  All applicable edits, audits, limitations, and modifier combinations continue to apply to these codes.  

Codes Billed with Modifier 51, Multiple Procedures

· CPT codes 20926 and 29873 are no longer valid services when billed in combination with Modifier 51.  If billed with Modifier 51 for date of service on or after October 1, 2006, these codes will be denied.

· CPT code 50320 is now a valid service when billed in combination with Modifier 51.

Codes Billed with Modifier 50, Bilateral

· The following CPT codes are no longer valid services when billed in combination with Modifier 50:

If billed with Modifier 50 for date of service on or after October 1, 2006, the above codes will be denied.

· The following CPT codes are now valid services when billed in combination with Modifier 50:

Codes Billed with Modifier 62, Co-surgery

· CPT codes 63304 and 63308 are now valid services when billed in combination with Modifier 62.

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

Attention:  All Providers

Tetanus, Diphtheria Toxoids and Acelluar Pertussis Vaccine (TDAP) - HCPCS Code 90715

The reimbursement rate for the HCPCS code 90715 has been changed to reflect the AWP minus 10% effective March 1, 2006.  The new rate is $38.21.

Prior claims submitted for HCPCS code 90715 will not be adjusted.

Financial Management

DMA, 919-855-4200

Attention:  Adult Care Home Providers

Fee Schedule for Adult Care Home Special Care Unit for Persons with Alzheimer’s and Related Disorders

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

The applicable HCPCS codes and daily rates are as follows:

Please note:

1.                  Recipients must receive, and providers must bill for, Basic PCS at the same time as SCU-A services.

2.                  Providers will not receive payment for Enhanced ACH services for  recipients in a SCU-A.

3.                  The SCU-A rate is only for those residents that receive prior approval from DMA.

Direct questions regarding rates to:

Patricia “Trish” Harper @919-855-4216 or trish.harper@ncmail.net

Elizabeth Grady @919-855-4207 or elizabeth.grady@ncmail.net

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

Attention:  Children’s Developmental Service Agencies, Home Health Agencies, Hospital Outpatient Clinics, Independent Practitioners, Health Departments, Local Management Entities, and Physicians

Outpatient Specialized Therapies Prior Authorization Process – Update to New Web Site and Submission Process

As indicated in the July 2006 N.C. general Medicaid bulletin, testing of the Web-based electronic submission process for prior approval has been completed by members of the Therapy Advisory Group. Based on feedback from the pilot sites, modifications were made to improve user friendliness and decrease the amount of data required.

The biggest change is to the evaluation component. When the new process is implemented, the required evaluation information will be reduced to the following:

·        Date of the evaluation

·        Relevant medical history supporting the need for therapy

·        Measurable goals and objective baselines determined at evaluation

The medical necessity determination will be based on the medical history and measurable goals with objective baselines or, in the case of reauthorizations, objective progress. Supplemental information will be requested only if medical necessity cannot be determined from the required data.

Through the Web site, providers will also have the option to submit authorizations using a file transfer protocol (FTP).  However, FTP will be the last component to be completed in the new system. Since the providers’ IT vendors will need to create a data format to transfer the information, the process and data fields must first be finalized. Once the system is in place for a few months and any identified changes have been completed, a file format will be provided.  For providers who choose to continue submitting prior authorization requests via fax or mail, a new form has been created to mirror the format and data fields of the Web site.

Although still required for therapy, copies of the following documentation will no longer be required at the time of prior authorization submission:

Instead, all required documentation will be submitted by completing the new form, which is composed of the following sections:

1. Recipient Demographics
2. Provider Demographics
3. Requested Dates of Service/Units or Visits
4. Order for Therapy
5. Treatment Plan of Care
6. ICD-9 Codes
7. Evaluation

8. Goals
9. Progress Towards Goals

The system changes will be pilot tested by Therapy Advisory Group members in early October. Following review of the pilot feedback, an implementation date for the new system will be determined.  The provider community will be notified through bulletin articles, faxed communication from the Carolinas Center for Medical Excellence (CCME), and information on CCME’s Web site available at http://www.mrnc.org.

Adequate time between notification and implementation will be given for providers to access the Web-based training and become familiar with the new prior authorization forms. Training on CCME’s Web site will include audio-video clips demonstrating the electronic submission process and Web site options, FAQs, helpful hints, and a help desk for technical support.

While the prior approval submission process will be changing, DMA’s Clinical Coverage Policy 10A, Outpatient Specialized Therapies, is not is available at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm.  Continue to follow all current policy guidelines.  All services are subject to post-payment review.

CCME, 1-800-228-3365, ext 2045

Attention: CMS-1500 Billers

Medicare Health Maintenance Organization (HMO)

In order for Medicaid to consider payment for Medicare Health Maintenance Organization, providers are requested to bill only the co-payment amount shown on the Medicare Explanation of Benefits (EOB).   Medicaid liability is only for the Medicare HMO co-payment. When filing on the CMS-1500 the following blocks must be completed:

·     Blocks 24F, 28, and 30 should reflect the Medicare HMO co-payment amount only.  If blocks 24F, 28, and 30 do not reflect the Medicare HMO co-payment amount the claim will be returned to the provider to correct the CMS-1500 claim form.

·     Block 29 should reflect third party insurance payments only. Providers are not to indicate the Medicare HMO payment in this block.  If the recipient does not have a third party insurance payment, the block should be left blank.  If the Medicare HMO payment is indicated in block 29, the claim will be returned back to the provider to correct the CMS-1500 claim form. 

All CMS-1500 Medicare HMO claims should be submitted with the Medicaid Resolution Inquiry Form indicating that the claim attached is a Medicare HMO. The Medicaid Resolution inquiry form as well as the CMS-1500 claim form and Medicare HMO EOB should be mailed to:

EDS

PO Box 300009

Raleigh, NC 27622.

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

Attention: UB-92 Billers

Medicare Health Maintenance Organization (HMO)

In order for Medicaid to consider payment for Medicare Health Maintenance Organization, providers are requested to bill all charges on the UB-92. The claims should not be altered for processing purposes.  The claim should be billed to Medicaid as it was billed to Medicare Health Maintenance Organization. Medicaid liability is only for the Medicare HMO co-payment. The following information is required for claim processing:

·        The claims must be submitted with a Medicare EOB.  Please ensure that the Medicare EOB attached.  If the EOB is on multiple pages, please submit all pages with the claim form.

·        All charges should be reflected on the UB-92.  Do not combine or destroy the integrity of the claim by rolling up the charges into one revenue code.

·        If the recipient has patient monthly liability or deductible, the information should be reflected on inpatient stays if applicable.

·        Co-payment amount should be indicated in FL 55 (Estimated Amount Due). 

·        Form locator 84 should indicate “This is a Medicare HMO claim”.

The UB-92 claim form and Medicare HMO EOB should be mailed to:

DMA/Third Party Recovery

2508 Mail Service Center

Raleigh, NC  27699-2508.

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

Attention:  Durable Medical Equipment Providers

Durable Medical Equipment Rental Items

Durable medical equipment providers are reminded that the reimbursement for rental items includes service, delivery, assembly, set-up, repairs, and supplies.  Refer to Clinical Coverage Policy #5A, Durable Medical Equipment, sections 1.1, 7.1, and 8.1, for additional information.  The policy is available on the Web at http://www.dhhs.state.nc.us/dma under Provider Links, Provider Information, Clinical Coverage Policies and Provider Manuals.

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

Attention: Nursing Facility Providers

Minimum Data Set Validation Review Update

Beginning with Federal fiscal year 2007 (October 1, 2006), DMA will exercise the right to re-review the documentation of the nursing facilities that fail their minimum data set (MDS) validation review.  The facility’s documentation will not be reviewed any earlier than 120 days following the exit interview of the failed MDS validation review.

DMA’s right to re-review is stated in the Nursing Facilities Provider Manual (chapter 5, p. 3, MDS review process #10).  The manual is available on the Web at http://www.dhhs.state.nc.us/dma/nursingfacility.htm.

Contacts for questions about the MDS validation review are as follows:

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, R.N., CRNAC, Nursing Facility Consultant

DMA, 919-855-4356

Margaret Comin, R.N., Facility Services Manager

DMA, 919-855-4355

Facilities Services

DMA, 919-855-4350

Attention:  Optical Service Providers

Introducing the New Request for Prior Approval for Visual Aids Form (372-017) and Instructions

The Request for Prior Approval for Visual Aids form (372-017) has been updated.  The current form will not expire; therefore providers should exhaust current supplies and the new form will be introduced gradually, as the warehouse supply of old forms is depleted.

While obsolete sections have been removed, several new sections have been added to incorporate information that must be maintained in the recipient’s visual aid medical record.  Revisions were implemented to provide more thorough medical records, improved clarity, and ease of use for providers, the optical contractor laboratory, and the Division of Medical Assistance.   Please pay special attention to the areas that require signatures and dates.

Providers must continue to retain the fourth copy of this four-part form for office records.

The back of the form contains new provider information, including pertinent Web sites.

An example of the new Request for Prior Approval for Visual Aids form (372-017) and instructions follow.

Please use the following link for a copy of the forms.

NOTE: All sections with asterisks (*) require documentation.

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

Attention:  Personal Care Services and Personal Care Services-Plus Providers

Personal Care Services Provider Training Session II

The Carolinas Centers for Medical Excellence (CCME), formerly Medical Review of North Carolina (MRNC), under contract with the Division of Medical Assistance (DMA), will continue quarterly Personal Care Services (PCS) training sessions statewide.

The training will be for registered nurses, agency administrators, and agency owners.  A complete agenda will be finalized and posted in the November N.C. general Medicaid bulletin.  Please choose the training session that is most convenient for you from among those listed below.

December 1, 2006

Charlotte

Hilton Charlotte Executive Park

5624 Westpark Drive

Charlotte NC 28217

704-527-8000

December 4, 2006

Winston-Salem

Benton Convention Center

301West Fifth Street

Winston-Salem NC 27101

336-727-2976

December 5, 2006

Cary

Embassy Suites/RTP

201 Harrison Oaks Boulevard

Cary NC 27513

919-677-1840

December 7, 2006

Wilmington/Wrightsville Beach

Shell Island Resort

2700 North Lumina Avenue

Wrightsville Beach NC 28480

910-256-8696

December 8, 2006

New Bern

Sheraton Hotel

One Bicentennial Park

New Bern NC 28560

252-638-3585 

Pre-registration is required. Space is limited to the first 200 participants at each site. To register online, go to http://www.mrnc.org/mrnc_web/mrnc/medicaid.aspx?ID=Registration and follow the instructions for registration. A computer-generated confirmation number will confirm your registration.

To register via fax, complete the attached registration form and fax it to the attention of Jennifer Manning at 919-380-9457. A member of the PCS team will call you with a confirmation number.

Registration began Tuesday, September 5, 2006, for all sites and will close Friday, November 17, 2006.  If you need to cancel at any time, please contact Jennifer Manning at 919-380-9860, x2018.

Check-in for each session begins at 8:30 a.m.; the trainings are scheduled from 9:00 a.m. to 4:00 p.m.  Lunch will be on your own.

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

Attention: ICF-MR Providers

ICF-MR Provider Assessment Database

The Division of Medical Assistance (DMA) provider assessment database will go live on October 1, 2006.    The purpose of the provider assessment database is to enhance the providers’ ability to correctly complete their monthly assessment sheets via the Internet. By utilizing the available technology, providers will be able to file monthly assessments that are currently due and manage historical transactions by viewing completed assessments from prior months for all facilities within their management company. 

If you would like to obtain additional information regarding your facility utilizing the assessment database, please contact Mishawn Davis or Stacey Crute at (919)855-4200.

Rate Setting
DMA, 919-855-4200

NCLeads Update

Information related to the implementation of the new Medicaid Management Information System, NCLeads, 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.

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 Web site at http://www.ncdhhs.gov/dma/prov.htm.  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

      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.