October 2010 Medicaid Bulletin

HP Enterprise Services
1-800-688-6696 or 919-851-8888

Attention:  All Providers

Provider Enrollment Application Process

Recent reports indicate improvements in CSC’s processing times for provider enrollment.  DMA will continue to monitor the process and to work with CSC to identify areas for improvement.

To ensure that provider enrollment applications continue to be processed in a timely manner, applicants are reminded to complete all required fields and to fully answer all of the required disclosure questions.  Please refer to the online help text when completing the application. 

Complete information is critical to ensuring an accurate background check [as required by PL 111-148 Subtitle E, Section 6401(b)].  Applicants are reminded that

• Individual information requested on the application must match the applicant’s federal tax form.
• If applicable, the full middle name should be indicated.
• Social Security Numbers are required.

Information about Managing Relationships between the applicant and any employee who exercises operational or managerial control of the provider agency or who directly or indirectly conducts the day-to-day operations of the provider agency must be disclosed (see 42 CFR 1002.3).  Company officers, directors, general managers, business managers, and office administrators, as well as any personnel authorized for electronic funds transfers, are considered to be a managing relationship.

• Please enter the individual’s full middle name, if applicable.
• The individual’s Social Security Number and date of birth are required.
• The business relationship to the provider must be indicated.

Ownership information for any applicant that is a corporation, partnership or non-profit organization must be disclosed (see 42 CFR 1002.3).  Applicants must report all Ownership Information for each owner/shareholder with 5% or more direct or indirect controlling interest in the applicant’s organization.

• For individual owners, enter the full name (including full middle name, if applicable), Social Security Number, and date of birth.
• For corporate owners, enter the complete legal name of the business and the Employer Identification Number.

All applicants must answer each question in the Exclusion Sanction Information section of the application.

• For each question that is answered with a “yes,” applicants must attach or submit a complete copy of the applicable criminal complaint or disciplinary action, Consent Order, documentation regarding recoupment/repayment/settlement actions, and/or final disposition clearly indicating the final resolution as applicable.  A written explanation in lieu of supporting documentation is not acceptable.
• Disclosure is not time-limited; all adverse legal actions must be reported regardless of whether any records were expunged or any appeals are pending.

Disclosure of adverse legal actions may not preclude participation with the N.C. Medicaid Program; however, full and accurate disclosure is critical to determining an applicant’s eligibility for participation with the N.C. Medicaid Program and is required by federal law (see 42 CFR Chapter IV, part 455, Subpart B).

Provider Services
DMA, 919-855-4050

Attention:  All Providers

Pregnancy Medical Home Project

DMA is working in partnership with Community Care of North Carolina (CCNC) and other community stakeholders including providers, local health departments, and the Division of Public Health, to create a program that provides pregnant Medicaid recipients with a pregnancy medical home (PMH).  The goal is to improve the quality of perinatal care given to Medicaid recipients thereby improving birth outcomes and reducing Medicaid spending.  This will be done by modeling the PMH after the enhanced primary care case management (PCCM) program developed by CCNC.

If a pregnant Medicaid recipient’s aid program category covers pregnancy services, they are eligible to participate in this program.  This program is NOT just for recipients of Medicaid for Pregnant Women (MPW).  Pregnant Medicaid patients will receive care management (population management).  High-risk pregnant women in a PMH will receive case management services.  The level of service provided will be in proportion to the individual’s identified needs.  Case managers are expected to closely monitor the pregnancy through regular contact with the physician and patient to promote a healthy birth outcome. 

To qualify for participation as a PMH, the provider must agree to the following:

• Ensuring that no elective deliveries are performed before 39 weeks of gestation by agreement with all professional providers
• Engaging fully in the 17P project in each pregnancy medical home
• Decreasing the cesarean section rate among nulliparous women
• Completing a high-risk screening on each pregnant Medicaid recipient in the program and integrating the plan of care with local care/case management
• Open chart audits

In exchange for meeting the program expectations described above, the PMH will receive the following incentives:

• Exemption from prior approval on ultrasounds
• $50 for completing a high risk screening tool at initial visit
• $150 incentive for the postpartum visit per Medicaid recipient
• Increased rate for a vaginal delivery

Any provider who bills global, package or individual pregnancy procedures is eligible to participate in this program as long as he/she agrees to the program requirements.  It is NOT just for obstetric providers.

Please watch for additional information in future Medicaid bulletins.

Managed Care Section
DMA, 919-855-4780

Attention:  All Providers

Procedures for Prescribing Synagis for RSV Season 2010/2011

Effective with date of service, November 1, 2010, through March 31, 2011, the N.C. Medicaid Program reimburses for respiratory syncytial virus (RSV) immune globulin (Synagis) ONLY through the Outpatient Pharmacy Program.  Synagis is not covered when billed through the Physician Drug Program or when billed on institutional claims by outpatient hospitals.  This does not include outpatient hospital pharmacy billing through point of sale (POS).

The clinical criteria utilized by N.C. Medicaid for the 2010/2011 RSV season are consistent with published guidelines in the Red Book:  2009 Report of the Committee on Infectious Diseases, 28th Edition.  Prior authorization is required for Medicaid coverage of Synagis during the upcoming RSV season.  The coverage season is November 1, 2010, through March 31, 2011.   

The Prior Authorization Synagis Drug Request Form is required for all Synagis requests.  This includes requests for children meeting the explicit clinical criteria such as date of birth (DOB) and estimated gestational age (EGA).  The Prior Authorization Synagis Drug Request Form should also be used when requesting Synagis for a child not meeting the clinical criteria.  Complete the justification of medical need section of the form for those requests.  Please ensure the person completing the Prior Authorization Synagis Drug Request Form has verified that the conditions exist and are accurately reported.

Submit requests for coverage of Synagis doses exceeding policy or for coverage outside of the defined coverage period on the Non-Covered State Medicaid Plan Services Request Form for Recipients Under 21 Years of Age.  The form is available on DMA’s EPSDT webpage.

N.C. Medicaid will begin coverage of Synagis on November 1, 2010.  During the season, Medicaid will cover up to five monthly doses of Synagis.  The number of doses billed to Medicaid should be in accordance with policy and adjusted if an infant received the first dose prior to a hospital discharge.  Delays in request processing can occur if a Medicaid identification number is not provided or the form is not complete.

The Prior Authorization Synagis Drug Request Form 
The Prior Authorization Synagis Drug Request Formmust be signed by the prescriber and submitted to ACS, DMA’s pharmacy prior authorization vendor.  Fax the completed Prior Authorization Synagis Drug Request Form to ACS at 1-866-246-8507.  The Prior Authorization Synagis Drug Request Form is available on DMA’s Synagis web page.

N.C. Medicaid does not participate in RSV Connection.  The Prior Authorization Synagis Drug Request Form should not be submitted to RSV Connection.  It is important for a pharmacy to ensure that Synagis is approved prior to billing Medicaid.  A claim transmitted at POS will be denied if a prior authorization request was not submitted by the provider or if the request was not approved.  Limited claims for Synagis may be approved through Smart PA when submitted electronically.  Please refer to the guidance below when submitting a request for Synagis. 

The Prior Authorization Synagis Drug Request Form includes a prescription section at the bottom.  Use of the prescription section is optional.  It is the responsibility of the provider to ensure that the pharmacy has a prescription for Synagis.  It is the responsibility of the pharmacy to ensure that all prescription requirements are met.   

Maximum of Five Doses
An EPDST medical necessity review will be performed for all Synagis requests.  Please describe the severity of diagnoses to help justify the medical need for Synagis.  The clinical information section of the Prior Authorization Synagis Drug Request Form can be used to provide supplemental information for all requests.  Up to five doses during the season will be approved for chronic lung disease (CLD) and hemodynamically significant congenital heart disease (HSCHD) for infants and children less than two years of age.  Use of an ICD-9-CM code is encouraged to help ensure that accurate information is processed from the form. 

For CLD, please specify the diagnosis causing the long-term respiratory problems to help to establish the severity of the condition.  Please indicate treatments received in the six months before the start of the season such as supplemental oxygen, bronchodilator, diuretic or chronic corticosteroid therapy.

For HSCHD, please specify the diagnosis causing the condition and identify medications prescribed for the condition.  Infants not at increased risk from RSV who generally should not receive immunoprophylaxis include those with hemodynamically insignificant heart disease, such as secundum atrial septal defect, small ventricular septal defect (VSD), pulmonic stenosis, uncomplicated aortic stenosis, mild coarctation of the aorta, patent ductus arteriosus (PDA), lesions adequately corrected by surgery unless the infant continues on medication for CHF, or mild cardiomyopathy not requiring medication. 

In addition to the two conditions listed above, a premature infant (prematurity must be counted to the exact day) may qualify for five doses as follows:

• Born at an EGA of ≤28 weeks 6 days and DOB is on or after November 2, 2009;
• Born at an EGA of 29 weeks 0 days to 31 weeks 6 days and DOB is on or after May 2, 2010; or
• Born at an EGA of ≤34 weeks 6 days and DOB is after March 31, 2010, and also has severe neuromuscular disease that compromises handling of respiratory secretions; or congenital abnormalities of the airways that compromises handling of respiratory secretions.

Please specify the specific diagnosis to justify severe neuromuscular disease or congenital airway abnormalities.  

Maximum of Three Doses; Last Dose Administered at Three Months of Age (90 Days of Life)
Infants meeting clinical criteria as follows may be approved for up to three doses of Synagis during the season: 

• Born at an EGA of 32 weeks and 0 day to 34 weeks 6 days, and DOB is on or after August 2, 2010, and has at least one of the two following defined risk factors:
• Attends child care [defined as a home or facility where care is provided for any number of infants or young toddlers (toddler age is up to the third birthday)].
• Has a sibling younger than five years of age in the home.

Requesting Synagis for RSV Prophylaxis when Clinical Criteria Are Not Met
Use the Prior Authorization Synagis Drug Request Form for these requests.  Clinical information must be provided to justify the medical need for Synagis for infants or children not meeting any of the above the criteria.  A medical necessity review will determine if medical need is justified based on the information provided.  Provide the information in the section of the form for clinical information.  Use ICD-9-CM codes to ensure that accurate information is processed from the form. 

Generally, the following diagnoses do not singularly justify medical necessity for Synagis prophylaxis:

• a positive RSV episode during the current season
• repeated pneumonia
• sickle cell
• multiple birth with approved sibling
• apnea or respiratory failure of newborn 

Submitting Prior Approval Requests
All prior approval requests should be submitted on the Prior Authorization Synagis Drug Request Form.  Fax the form to ACS at 1-866-246-8507.  The Prior Authorization Synagis Drug Request Form is for all requests for Synagis during the season.  ACS will fax approval notifications to the provider and pharmacy.

Use the Non-Covered State Medicaid Plan Services Request Form for Recipients Under 21 Years of Ageto request Synagis doses exceeding policy or for Synagis administration outside the defined coverage period.  A medical necessity review will be done under EPSDT; if the information provided justifies medical need, the request will be approved and an approval notification will be faxed to the provider and pharmacy.

Medicaid will allow Synagis claims processing to begin on October 26, 2010, to allow sufficient time for pharmacies to provide Synagis by November 1, 2010.  Payment of Synagis claims prior to October 26, 2010, and after March 31, 2011, will not be allowed.  Pharmacy providers should always indicate an accurate days’ supply when submitting claims to N.C. Medicaid.  Claims for Synagis doses that include multiple vial strengths must be submitted as a single compound drug claim.  Synagis doses that require multiple vial strengths that are submitted as individual claims will be subject to recoupment by DMA Program Integrity.  Physicians and pharmacy providers are subject to audits of patient records by DMA Program Integrity.

Pharmacy Distributor Information
ACS will fax the approval notification to the pharmacy identified on the Prior Authorization Synagis Drug Request Form.  Please ensure that approval notification is received before billing Synagis claims to Medicaid.  The prior approval notification should be maintained according to required record keeping time frames.  

HP Enterprise Services
1-800-688-6696 or 919-851-8888

Attention:  All Providers

Enrollment Fee Update:  Reminders

As mandated by Session Law 2009-451, beginning September 1, 2009, the N.C. Medicaid Program implemented a $100 enrollment fee for all new enrollments and at 3-year intervals when providers are re-credentialed. 

APPLICANTS SHOULD NOT SUBMIT PAYMENT WITH THEIR APPLICATION.  Upon receipt of your enrollment application, an invoice will be mailed to you if the fee is owed.  An invoice will only be issued if the tax identification number in the enrollment application does not identify the applicant as a currently enrolled Medicaid provider. 

Providers are reminded that payment

• is due immediately upon receipt of an invoice for the enrollment fee; 
• should be remitted to the address on the invoice and not directly to CSC; and  
• is accepted by check or money order made payable to DMA. 

Please make every effort to remit payment promptly.  Applications will not be processed if payment is not received.  If payment is not received after 30 business days, your application will be voided.

CSC, 1-866-844-1113

Attention:  All Providers

Copayment Changes

On November 1, 2010, DMA will implement two new copayment requirements.  A copayment of $3.00 will be charged for clinic and outpatient services including local health department visits and outpatient behavioral health services.  A $6.00 copayment will be charged for non-emergency visits to a hospital emergency room. 

Providers are reminded that they may not charge copayments for

• Dental services provided in a health department
• Family planning services
• Federally Qualified Health Center (FQHC) core services
• Health Check (EPSDT)-related services
• Emergency visits to a hospital emergency department services, including physician services delivered in the emergency department
• Rural Health Clinic (RHC) core services
• Services covered by both Medicare and Medicaid
• Services provided to Community Alternatives Program participants
• Services related to pregnancy
• Services to individuals under the age of 21

Refer to Section 2 of the Basic Medicaid Billing Guide for a complete list of copayments and copayment exemptions.

HP Enterprise Services
1-800-688-6696 or 919-851-8888

Attention: All Providers

Implementation of the National Correct Coding Initiative

This bulletin article provides initial guidance regarding DMA’s implementation of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), as amended by the Health Care and Education Recovery Act of 2010 (P.L. 111-152), together referred to as the Affordable Care Act (ACA).  Specifically, this article is regarding Title VI – Transparency and Program Integrity, Subtitle F – Additional Medicaid Program Integrity Provisions, Section 6507 – Mandatory State Use of National Correct Coding Initiative (NCCI). 

Implementation of the NCCI according to the ACA by the N.C. Medicaid Program will be retroactive to date of processing October 1, 2010.  The NCCI edits supersede the Medicaid State Plan, all N.C. Medicaid policies, bulletin articles, and other previous guidance provided on procedure-to-procedure and units-of-service edits.

DMA will notify providers through the Medicaid Bulletin when NCCI system changes are complete.  At that time, DMA may recoup claims for dates of processing on or after October 1, 2010, when they are adjudicated through the NCCI edits. 

HP Enterprise Services
1-800-688-6696 or 919-851-8888

Attention:  All Providers

Influenza Vaccine and Reimbursement Guidelines for 2010/2011

The N.C. Medicaid Program reimburses for vaccines in accordance with guidelines from the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP).  Each year, scientists try to match the viruses in the influenza vaccine to those most likely to cause flu that year.  This season’s vaccine is comprised of the following three strains: an A/California/7/2009 (H1N1)-like virus; an A/Perth/16/2009 (H3N2)-like virus; and a B/Brisbane/60/2008-like virus.  There will be NO single-antigen H1N1 vaccine manufactured this season because it is one of the three antigens included in the seasonal formulation for all seasonal vaccine products, as stated above.  ACIP recommendations on 2010/2011 influenza can be found on the CDC website.  Note that there is an update and an erratum to the recommendations.

North Carolina Immunization Program/Vaccines for Children
The N.C. Immunization Branch distributes all required childhood vaccines to local health departments, hospitals, and private providers under North Carolina Immunization Program/Vaccines for Children (NCIP/VFC) guidelines.  For the 2010/2011 influenza season, NCIP/VFC influenza vaccine is available at no charge to providers for children aged 6 months through 18 years who are eligible for the VFC program.  Providers wishing to immunize children who are not VFC-eligible and adult patients must purchase vaccine for those groups.  The current NCIP coverage criteria and definitions of VFC categories may be found on the NCIP website.  Refer also to the new influenza page on the NCIP website for helpful information regarding this season’s influenza vaccine.

Billing/Reporting Influenza Vaccines
The following tables indicate the vaccine codes that can be either reported or billed for influenza vaccine, depending on the age of the recipient and the formulation of the vaccine.  The tables also indicate the administration codes that can be billed, depending on the age of the recipient.

Note:  The information in the following tables is not detailed billing guidance.  Specific information on billing all immunization administration codes for the Health Check recipients can be found in the April 2010 Special Bulletin, Health Check Billing Guide 2010.

Table 1:  Influenza Billing Codes for Recipients Less Than 19 Years of Age

Note: In the tables below, the + sign indicates an add-on code.

Table 2:  Influenza Billing Codes for Recipients 19 and 20 Years of Age

Use the following codes to bill Medicaid for an influenza vaccine purchased and administered to recipients 19 through 20 years of age. 

Table 3:  Influenza Billing Codes for Recipients 21 Years of Age and Older

Use the following codes to bill Medicaid for an influenza vaccine purchased and administered to recipients 21 years of age and older. 

Note: In the tables below, the + sign indicates an add-on code.

For a recipient 21 years of age or older receiving an influenza vaccine, an evaluation and management (E/M) code cannot be reimbursed to any provider on the same day that injection administration fee codes (90471 or 90471 and +90472) are reimbursed, unless the provider bills an E/M code for a separately identifiable service by appending modifier 25 to the E/M code.

Note: 
For federally qualified health centers (FQHCs) and rural health clinics (RHCs), for recipients 0 through 20 years of age, if the vaccine was obtained at no cost to the clinic, the clinic may bill only for the administration costs under the C suffix provider number.  For recipients 21 years of age and older, the costs of the vaccine and its administration may be included on the cost report and not billed to Medicaid.

Private providers, FQHCs, and RHCs may bill Medicaid for the vaccine and administration fees for the influenza vaccine administered to Medicaid Pregnant Women (MPW) recipients.  Refer to the above guidelines. 

HP Enterprise Services
1-800-688-6696 or 919-688-6696

Attention:  Nurse Practitioners and Physicians

Cabazitaxel Injection (Jevtana, HCPCS Code J9999):  Billing Guidelines

Effective with date of service July 15, 2010, the N.C. Medicaid Program covers cabazitaxel (Jevtana) for use in the Physician’s Drug Program when billed with HCPCS code J9999 (not otherwise classified, antineoplastic drugs).  Jevtana is available in a 60-mg/1.5-ml single-dose vial kit.  Jevtana  is a microtubule inhibitor indicated in combination with prednisone for the treatment of patients with hormone-refractory metastatic prostate cancer previously treated with a docetaxel-containing treatment regimen.  Jevtana should not be used in patients with a neutrophil counts of ≤ 1,500/mm3.  Jevtana is contraindicated in patients who have a history of severe hypersensitivity reactions to Jevtana or to other drugs formulated with polysorbate 80.

The individual dosage of Jevtana is based on the calculation of the Body Surface Area (BSA) and is 25 mg/m2 administered as a 1-hour intravenous infusion every three weeks in combination with oral prednisone (10 mg) administered daily throughout Jevtana treatment.  Jevtana should be administered under the supervision of a qualified physician experienced in the use of antineoplastic medicinal products.  Appropriate management of complications is possible only when the adequate diagnostic and treatment facilities are readily available.  The

Jevtana dose should be reduced to 20 mg/m2 if patients experience certain adverse reactions.  Full prescribing information >>

Jevtana injection single-use vial requires two dilutions prior to administration.  Jevtana should not be mixed with any other drugs.

Premedication is suggested at least 30 minutes prior to each dose of Jevtana with the following intravenous medications to reduce the risk and/or severity of hypersensitivity:

• antihistamine (dexchlorpheniramine 5 mg or diphenhydramine 25 mg or equivalent antihistamine)
• corticosteroid (dexamethasone 8 mg or equivalent steroid)
• H2 antagonist (ranitidine 50 mg or equivalent H2 antagonist)

Antiemetic prophylaxis is recommended and can be given orally or intravenously as needed.  Refer to the full prescribing information at the web address listed above.

For Medicaid Billing

• The ICD-9-CM diagnosis code required for billing Jevtana is 185 (malignant neoplasm of prostate).
• Providers must bill Jevtana with HCPCS code J9999 (not otherwise classified, antineoplastic drugs).
• Providers must indicate the number of HCPCS units.
• One Medicaid unit of coverage is one 60-mg/1.5-ml single-dose vial kit.  The maximum reimbursement rate per 60-mg single-dose vial kit is $5,760.00.
• Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units.  The NDC units for Jevtana should be reported in “MLs.”  To bill for the entire 60-mg/1.5-ml injection of Jevtana, report the NDC units as “ML1.5.”  If the drug was purchased under the 340-B drug pricing program, place a “UD” modifier in the modifier field for that drug detail.
• Refer to the March 2009 Special Bulletin, National Drug Code Implementation, Phase III, for additional instructions.
• Providers must bill their usual and customary charge.

The fee schedule for the Physician’s Drug Program is available on DMA’s Fee Schedule web page.

HP Enterprise Services
1-800-688-6696 or 919-851-8888

Attention:  Nurse Practitioners and Physicians

Zoledronic Acid (Reclast, HCPCS Code J3488):  Update to Billing Guidelines

The N.C. Medicaid Program covers the FDA-approved indications for Reclast.  These include

1. treatment of Paget’s disease;
2. treatment of osteoporosis in postmenopausal women (PMO) (to reduce the incidence of fractures or to reduce the incidence of new clinical fractures in patients with low-trauma hip fracture);
3. treatment of osteoporosis in men (to increase bone mass);
4. treatment and prevention of glucocortocoid-induced osteoporosis [in patients initiating or continuing prednisone ≥7.5 mg/day (or equivalent) and expected to remain on glucocorticoids for at least
   12 months]; and
5. prevention of osteoporosis in postmenopausal women.

Effective with date of service June 1, 2009, the N.C. Medicaid Program added the FDA-approved diagnosis of prevention of osteoporosis in post-menopausal women to the list of covered ICD-9-CM diagnosis codes when billed through the Physician’s Drug Program.  Effective with date of service March 16, 2009, the indication for treatment and prevention of glucocorticoid-induced osteoporosis was added to the list of covered diagnoses.

One of the following ICD-9-CM diagnosis codes must be billed with Reclast, HCPCS code J3488:

1. For Paget’s disease

• 731.0 (osteitis deformans without mention of bone tumor)

2. For the treatment of postmenopausal women with osteoporosis and men with osteoporosis

• 733.01 (senile osteoporosis)

3. For glucocorticoid-induced osteoporosis treatment

• 733.09 (osteoporosis, other)
• The following secondary code should also be used:
  • E932.0 (drugs, medicinal and biological substances causing adverse effects in therapeutic use, adrenal cortical steroids)

4. For the prevention of PMO

• 733.90 (disorder of bone and cartilage, unspecified)

5. For the prevention of glucocorticoid-induced osteoporosis due to long-term steroid

• 733.90 (disorder of bone and cartilage, unspecified)
• The following secondary code should also be used:
  • V58.65 [long-term (current) use of steroids]

HP Enterprise Services
1-800-688-6696 or 919-851-8888

Attention:  Nurse Practitioners and Physicians

Ranibizumab (Lucentis, HCPCS Code J2778):  Update to Billing Guidelines

Effective with date of service June 22, 2010, the N.C. Medicaid Program added the FDA-approved diagnosis of macular edema following retinal vein occlusion to the already covered diagnosis of wet age-related macular degeneration for Lucentis when billed through the Physician’s Drug Program. 

One of the following ICD-9-CM diagnosis codes must be billed with Lucentis, HCPCS code J2778:

1. For wet age-related macular degeneration

• 362.52 (exudative senile macular degeneration)
  

OR

2. For macular edema following retinal vein occlusion

• 362.83 (retinal edema)
  
  PLUS, EITHER
  • 362.35 (central retinal vein occlusion)
    OR
  • 362.36 [venous tributary (branch) occlusion]

HP Enterprise Services
1-800-688-6696 or 919-851-8888

Attention: Institutional (UB-04/837I) Billers

Non-Monetary Value Codes

Paper claims received by HP Enterprise Services are now processed using Optical Character Recognition (OCR) technology.  To maximize the functionality of this technology, data elements must be aligned properly on the paper claims as they are processed. Providers should refer to the National Uniform Billing Committee (NUBC) UB manual for claim form instructions. 

Value Codes 80 through 83 represent days and are non-monetary value codes.  When billing N.C. Medicaid, the value for these codes should be entered as the number of units (1 unit = 1 day).  The proper placement of these non-monetary value codes are to the left of the dollars/cents delimiter.  The number of units should be
right-justified; zeros should not be entered to the right of the delimiter.    

HP Enterprise Services
1-800-688-6696 or 919-851-8888

Attention:  Nurse Practitioners and Local Management Entities

Injectable Drugs:  Update to Billing Guidelines

The N.C. Medicaid Program covers the following psychotropic injectable drugs for use by nurse practitioners and local management entities (LMEs).

1. J1630    [haloperidol, up to 5 mg (Haldol)]
2. J1631    [haloperidol decanoate, per 50 mg (Haldol Decanoate-50)]
3. J2680    [fluphenazine decanoate, up to 25 mg (Prolixin)]
4. J2794    [risperidone, long acting, 0.5 mg (Risperdal Consta)]
   Refer to the April 2010 Medicaid Bulletin for additional information.
5. J3230    [chlorpromazine HCl, up to 50 mg (Thorazine)]
6. J3490    (unclassified drugs)
   Note:  Olanzapine extended release formulation (Zyprexa Relprevv) is billed under J3490.  Refer to the May 2010 Medicaid Bulletin for additional information.
7. S0166   [olanzapine, 2.5 mg (Zyprexa)]
   Refer to the May 2010 Medicaid Bulletin for additional information.

For Medicaid Billing

• Providers must bill with 11-digit National Drug Codes (NDCs) and appropriate NDC units.
• Only rebatable NDCs will be reimbursed.
• If the drug was purchased under the 340-B drug pricing program, place a “UD” modifier in the modifier field for that drug detail.
• Refer to the March 2009 Special Bulletin, National Drug Code Implementation, Phase III, for additional instructions.
• Providers must bill their usual and customary charge.

HP Enterprise Services
1-800-688-6696 or 919-851-8888

Attention:  Pharmacists

Recipient Management Lock-in Program Emergency Fill

The N.C. Medicaid Program will reimburse an enrolled Medicaid pharmacy for a 4-day supply of a prescription dispensed to a recipient locked into a different pharmacy and prescriber in response to an emergent situation.  The emergency supply is limited to a 4-day supply.  The provider will be paid for the drug cost only, and the recipient will be responsible for the appropriate copayment. A “3” in the Level of Service field (418-DI) should be used to indicate that the transaction is an emergency fill.

Only one emergency occurrence will be reimbursed per lock-in period.  Records of the dispensing of emergency supply medications are subject to review by DMA Program Integrity.  Paid quantities for more than a 4-day supply are subject to recoupment.

HP Enterprise Services
1-800-688-6696 or 919-851-8888

Attention:  Critical Access Behavioral Health Agencies and Direct-Enrolled Outpatient Behavioral Health Services Providers

Update on Unmanaged Visits for Children

As a result of action by the General Assembly, the 26 unmanaged outpatient behavioral health therapy visits limit for children will decrease to 16 unmanaged visits.  Prior authorization will be required for all outpatient services for children after the 16th visit.  As a reminder, prior authorization will continue to be required for adults after the 8th visit.  To ease the transition for providers and recipients, this change will now be effective January 1, 2011, to correspond with the new benefit year.

Behavioral Health Unit
DMA, 919-855-4290

Attention:  Critical Access Behavioral Health Agencies

Prior Authorization and Billing for Mental Health/Substance Abuse Targeted Case Management

In order for Mental Health/Substance Abuse Targeted Case Management (MH/SA TCM) claims to adjudicate appropriately, when submitting claims for MH/SA TCM, please ensure that prior authorization has been received from the appropriate utilization management vendor (ValueOptions, The Durham Center or Eastpointe LME).  If the authorization request has not been approved, when a claim is submitted, it will be denied.

To request prior authorization for recipients who are being transitioned from the case management component of Community Support Services (CS) to MH/SA TCM, providers must submit a Letter of Attestation to ValueOptions for each recipient who will be transitioned.  Eastpointe and The Durham Center WILL NOT be able to process these attestation requests.  Detailed information on submitting Letters of Attestation can be found in the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services’ Implementation Update #77. 

Critical Access Behavioral Health Agencies (CABHAs) may also submit prior authorization requests for recipients new to case management services.  These would be recipients who are not currently receiving the case management portion of CS.  As a reminder, all initial requests for MH/SA TCM for recipients in The Durham Center's and Eastpointe's catchment areas should be sent to The Durham Center and Eastpointe, respectively IF the provider will not be using the attestation.  To request initial prior authorization for these recipients, providers must submit the inpatient treatment request (ITR), person centered plan (PCP), and a signed service order to the appropriate utilization management vendor for the recipient’s catchment area (ValueOptions, The Durham Center or Eastpointe LME).

Behavioral Health Unit
DMA, 919-855-4290

Attention:  Critical Access Behavioral Health Agencies

Enrollment, Authorization, and Billing Frequently Asked Questions

Based on feedback from participants in the Critical Access Behavioral Health Agency (CABHA) enrollment/authorization/billing seminars that took place in August, DMA, in conjunction with their vendors (CSC, ValueOptions, and HP Enterprise Services), has developed a list of frequently asked questions (FAQs) related to the key areas of enrollment, authorization, and billing. 

Behavioral Health Unit
DMA, 919-855-4290

Attention:  Obstetric Providers and Radiology Services

Updates to Prior Authorization for Obstetrical Ultrasounds

The following prior approval requirements are effective with date of service October 1, 2010.  All obstetrical (OB) ultrasounds must be registered with or authorized by MedSolutions in order for claims to be processed.

1. CPT procedure code 76813 (ultrasound pregnant uterus first trimester fetal nuchal translucency measurement single or first gestation) and 76814 (for each additional gestation):
   1. Allow one fetal nuchal translucency scan per pregnancy without requiring medical necessity indication if performed between 11 through 13 weeks gestation.
   2. This first trimester scan includes an assessment of fetal viability, crown rump measurement for dating, and measurement of nuchal fold thickness.
   3. Register the procedure with MedSolutions.
2. CPT procedure code 76805 (ultrasound pregnant uterus fetal and maternal evaluation after first trimester single or first gestation) and 76810 (for each additional gestation):
   1. Allow one complete ultrasound per pregnancy without requiring medical necessity indication if performed after 16 weeks gestation.
   2. Register the procedure with MedSolutions.
3. CPT procedure code 76811 (ultrasound pregnant uterus fetal and maternal evaluation plus detailed fetal anatomic examination single or first gestation) and 76812 (for each additional gestation):
   1. These procedure codes require medical necessity indication, such as a known or suspected fetal anatomic or genetic abnormality, and can only be performed by:
1. Providers with sub-specialty in Maternal Fetal Medicine (Perinatology) or Radiology; or
2. OB ultrasound providers who are in an American Institute of Ultrasound in Medicine (AIUM) or an American College of Radiology (ACR) accredited practice.

2. Allow one of these detailed anatomic scans per practice (same group practice, same tax identification number, etc.), per pregnancy for appropriate medical necessity indications.
3. These examinations will be audited for report content and practice referral patterns.
4. 76805 and 76811 should not be requested nor billed for the same date of service and should not be requested on the same authorization request.
4. All other OB ultrasound studies are subject to medical necessity review.  If there is an urgent medical need for an OB ultrasound in addition to or at dates/codes not identified above, the ultrasound can be obtained and the request for authorization can be made to MedSolutions within two business days after the date of service.  These requests will be reviewed for both urgent and medical necessity indications.
   Example:  A recipient presents early in pregnancy with bleeding or no fetal heart tones with Doppler at 12 weeks gestation.  The provider can perform the ultrasound and bill for CPT procedure code 76801 (ultrasound pregnant uterus fetal and maternal evaluation first trimester single or first gestation) and 76802 (each additional gestation) and request prior authorization for medical necessity within two business days of the date of service.  The provider can still provide complete ultrasound and bill for CPT procedure code 76805 after 16 weeks gestation without requiring medical necessity.

5. Obstetrical ultrasound indications for sequential imaging:
   OB ultrasound indications for sequential imaging are based upon the MedSolutions Obstetrical Ultrasound Imaging Guidelines.  Refer to Attachment C, Obstetrical Ultrasound Indications for Sequential Imaging, in Clinical Coverage Policy 1K-7, Prior Approval for Imaging Procedures, which will be used for evaluating requests for OB ultrasounds in certain patients with known or suspected high risk diagnoses with references to the appropriate guidelines.  Some of these patients may require sequential imaging (batching).
   
   1. Verbal approval for these batched authorizations cannot be requested online.  Requests must be submitted by fax (1-888-693-3210) or by phone (1-888-693-3211) to the MedSolutions nurse.  Batched authorizations will be approved at the suggested frequency for a 30-day period.
   2. If ultrasounds or other OB studies that require preauthorization are requested over and above those approved in the batched authorization for the 30-day period, another authorization will need to be started and audits will be conducted to ensure proper coding, billing, and medical appropriateness of these additional studies.
   3. The traditional, single use obstetrical ultrasound CPT codes (76801, 76802, 76805, 76810, 76811, 76812, 76813, and 76814) will not be included in the batching process.

Clinical Coverage Policy 1K-7, Prior Approval for Imaging Procedures, can be accessed from DMA’s Clinical Coverage Policy web page, from the Radiology Services web page or from the OB/GYN Services web page.

Diane Holder, Clinical Policy and Programs
DMA, 910-355-1883

Attention:  Personal Care Services Providers

Independent Assessment Updates and Reminders

Registration forms for the new web-based Provider Interface were due by October 1, 2010.  All registered providers will receive their user name and password by e-mail between October 1 and October 4, 2010.  If you have not submitted Provider Interface registration forms, please do so immediately.  Refer to the Independent Assessment website for forms and instructions.  

Beginning Monday, October 4, 2010, all Personal Care Services (PCS) providers must use the Provider Interface to receive and respond to recipient referrals and to view copies of recipient independent assessments and notices.  Also, beginning October 4, 2010, please discontinue the use of the weekly discharge update form and report recipient discharges using the Provider Interface. 

CCME will offer additional provider regional trainings in October 2010.  The trainings will cover the following topics:

• Using the web-based Provider Interface to receive and respond to recipient referrals, to view recipient assessments and authorization and denial notices, to request change of status reassessments, and to report recipient discharges.
• The recipient appeal process and maintenance of service

Training dates and locations for October 2010 are as follows:

Date	Location
October 19, 2010	Chapel Hill, NC
October 20, 2010	Fayetteville, NC
October 21, 2010	New Bern, NC
October 26, 2010	Greensboro, NC
October 28, 2010	Hickory, NC

Refer to the Independent Assessment website for additional information and to register for an upcoming training in your region.

Continue to visit theIndependent Assessment website regularly for PCS forms, reference documents, educational content, announcements, and updates to frequently asked questions. New educational information on recipient appeals and Maintenance of Service (MOS) will be posted this month.

Questions may be directed to the CCME Independent Assessment Help Line at 1-800-228-3365 and by e-mail to PCSAssessment@thecarolinascenter.org.  Please note that the Help Line call center capacity has been increased.  Please direct questions regarding recipient status or referrals to the Help Line for faster response and to avoid the transmission of PHI over e-mail.

CCME, 1-800-228-3365

Attention:  HIV Case Management Providers

HIV Case Management Provider Training Sessions

The Carolinas Center for Medical Excellence (CCME) is pleased to announce that comprehensive Provider Certification and HIV Case Management Trainings are scheduled for November and December 2010 (see schedule below).  At this time, training is limited to those providers who are currently enrolled with Medicaid to provide HIV Case Management.

Date	Session Topic	Required Attendees
November 15, 2010	New Certification/Application Process	The official agency/program administrator (i.e., the agency owner or director)
November 16, 2010	New Certification/Application Process	The official agency/program administrator (i.e., the agency owner or director)
November 17 and 18, 2010	New Policy Requirements	HIV CM Program supervisors
December 14 and 15, 2010	New Policy Requirements	HIV CM Program supervisors