Providers are responsible for informing their billing agency for information in this bulletin.
In this Issue:
|
All Providers:
Adult Care Home Providers: Carolina ACCESS Providers:
Durable Medical Equipment Providers: Independent Practitioner Service Providers: |
Nursing Facility Providers:
Optometrists and Opthalmologists: Outpatient Hospital Providers: Physicians: Prescribers:
|
The Division of Medical Assistance (DMA) and EDS will be closed on Friday, November 10, in observance of Veteran's Day, and on Thursday, November 23 and Friday, November 24, in observance of Thanksgiving.
EDS, 1-800-688-6696 or 919-851-8888
The following table is an updated list of FDA approved injectable drugs currently covered by the North Carolina Medicaid program when administered in a physician's office for the FDA approved indications. This list replaces the list published in October, 1999. Newly covered drugs are effective with date of service October 1, 2000. Immunizations that are billed using Current Procedural Terminology (CPT) codes are not included on this list.
Physicians will continue to bill on the HCFA-1500 claim form using the appropriate drug code and indicating the number of units administered. Physicians are to bill their usual and customary charge.
(*) Designates newly covered drugs.
(**) Designates an invoice is required to accompany the HCFA-1500 claim form.
Payment is based on the invoice price.
(^^) Designates special pricing.
| Procedure Codes | Description | |
|---|---|---|
| J0130 | Abciximab 10 mg | |
| J1120 | Acetazolamide Sodium, up to 500 mg (Diamox) | |
| J0150 | Adenosine I.V. (Adenocard I.V.) 6 mg. | |
| J0151 | Adenosine (Adenoscan) 90 mg | |
| J0170 | Adrenalin, Epinephrine, up to 1 ml ampule | |
| Q0156 | Albumin Infusion 5%/500ml | |
| Q0157 | Albumin Infusion 25%/50ml | |
| J0205 | Alglucerase, per 10 units (Ceredase) | |
| J0256 | Alpha 1 Proteinase Inhibitor Human A (Prolastin) 10 mg. | |
| J9015 | Aldesleukin (Proleukin, Interleuken II 22 million IU (SDV) | |
| J2996 | Alteplase Recombinant, per 10 mg (Activase) | |
| J0207 | Amifostine 500 mg. | |
| W5181 | Amikacin Sulfate (500 mg) | |
| J0280 | Aminophyllin, up to 250 mg | |
| J1320 | Amitriptyline HCL, up to 20 mg (Elavil, Enovil) | |
| J0300 | Amobarbital, up to 125 mg (Amytal) | |
| J0285 | Amphotericin B (50 mg) | |
| J0286 | Amphotericin B Any Lipid Formulation (50 mg) | |
| J0295 | Ampicillin Sodium/Sulbactam Sodium, per 1.5 gm | |
| J0290 | Ampicillin, up to 500 mg (Omnipen, Polycillin-N, Totacillin-N) | |
| J0350 | Anistreplase, per 30 units (Eminase) | |
| J7197 | Antithrombin II (human) per I.U. | |
| J0395 | Arbutamine HCL (1 mg) | |
| J9020 | Asparaginase, 10,000 units (Elspar) | |
| J0460 | Atropine Sulfate, up to 0.3 mg | |
| J2910 | Aurothioglucose, up to 50 mg (Solganal) | |
| W5156 | Azithromycin, oral suspension 1 unit = 1 gm packet (Zithromax), only oral drug on list | |
| * | J0456 | Azithromycin, 500 mg. (Zithromax) |
| J0475 | Baclofen, Kit 1*20 ml. Amp. (10 mg/20ml. 500 meg/ml.) | |
| W5170 | Baclofen, Kit 2*5 ml. Amp. (10 mg./5 ml. 2000 meg./ml.) | |
| W5169 | Baclofen, Kit 4*5 ml. Amp. (10 mg./5ml. 2000 meg./ml.) | |
| J0476 | Baclofen (for intrathecal Trial) 50 mcg | |
| J9031 | BCG (intravesical) per installation (Tice, TheraCys) | |
| J0510 | Benzquinamide HCL, up to 50 mg (Emete-CON) | |
| J0702 | Betamethasone Acetate and Betamethasone Sodium Phosphate, per 3 mg | |
| J0704 | Betamethasone Sodium Phosphate, per 4 mg | |
| J0520 | Bethanechol Chloride up to 5 mg (Urecholine) | |
| ** | J0190 | Biperiden, Akineton 5 mg |
| J9040 | Bleomycin Sulfate, 15 units (Blenoxane)/2 ml | |
| J0585 | Botulinum toxin type A, per unit | |
| J0945 | Brompheniramine Maleate , 10mg | |
| J0635 | Calcitriol, 1 mcg amp.(Calcijex) | |
| J0610 | Calcium Gluconate, up to 10 ml (Kaleinate) | |
| J0620 | Calcium Glycerophosphate and Calcium Lactate, per 10 ml (Calphosan) | |
| J9045 | Carboplatin, 50 mg (Paraplatin) | |
| J9050 | Carmustine, 100 mg (Bicnu) | |
| J0690 | Cefazolin Sodium, up to 500 mg (Ancef, Kefzol, Zolicef) | |
| W5185 | Cefepime HCL (Maxipime HCL) 500 mg | |
| J0695 | Cefonicid Sodium, 1 gram (Monocid) | |
| J0698 | Cefotaxime Sodium, per gm (Claforan) | |
| J0694 | Cefoxitin Sodium, 1 gm (Mefoxin) | |
| J0713 | Ceftazidime per 500 mg | |
| J0715 | Ceftizoxime Sodium, per 500 mg (Cefizax) | |
| J0696 | Ceftriaxone Sodium, per 250 mg (Rocephin) | |
| J0697 | Cefuroxime Sodium, per 750 mg (Kefurox, Zinacef) | |
| J1890 | Cephalothin Sodium, up to 1 gm (Keflin) | |
| J0710 | Cephapirin Sodium, up to 1 gm (Cefadyl) | |
| J0720 | Chloramphenicol Sodium Succinate, up to 1 gm | |
| J1990 | Chlordiazepoxide HCL, up to 100 mg (Librium) | |
| J2400 | Chlorprocaine HCL 30 ml | |
| J0390 | Chloroquine HCL, up to 250 mg | |
| J1205 | Chlorothiazide Sodium 500 mg. | |
| J0730 | Chlorpheniramine Maleate, per 10 mg | |
| J3230 | Chlorpromazine HCL, 50 mg (Thorazine, Ormazines) | |
| J3080 | Chlorprothixene, up to 50 mg (Taractan) | |
| J0725 | Chorionic Gonadotropin, per 1,000 usp units | |
| J0740 | Cidofovir 375 mg. | |
| J0743 | Cilastatin Sodium; Imipenem, per 250 mg | |
| W5176 | Cimetadine HCL (Tagamet) (300 mg) | |
| W5183 | Ciprofloxacin (Cipro) 200 mg. | |
| J9062 | Cisplatin, 50 mg (Plantinol, Platinol AQ) | |
| J9060 | Cisplatin, 10 mg (Platinol, Plantinol AQ) | |
| J9065 | Cladribine, per 1 mg (Leustatin) | |
| J0735 | Clonidine Hydrochloride (1 mg) | |
| J0745 | Codeine Phosphate, per 30 mg | |
| J0760 | Colchicine, 1 mg | |
| J0770 | Colistimethate Sodium, up to 150 mg (Coly-Mycin M) | |
| J0800 | Corticotropin, up to 40 units (Acthor, ACTH) | |
| J0810 | Cortisone Acetate, up to 50 mg | |
| J0835 | Cosyntropin, per 0.25 mg (Cortrosyn) | |
| J3420 | Cyanocobalamin, B 12 1000 mcg | |
| J9096 | Cyclophosphamide Lyophilized 1 gm (Cytoxan Lyophilized) | |
| J9093 | Cyclophosphamide Lyophilized, 100 mg (Cytoxan Lyophilized) | |
| J9091 | Cyclophosphamide, 1.0 gm (Cytoxan, Neosar) | |
| J9070 | Cyclophosphamide, 100 mg (Cytoxan, Neosar) | |
| J9092 | Cyclophosphamide, 2.0 gm (Cytoxan, Neosar) | |
| J9080 | Cyclophosphamide, 200 mg (Cytoxan, Neosar) | |
| J9090 | Cyclophosphamide, 500 mg (Cytoxan, Neosar) | |
| J9094 | Cyclophosphamide, Lyophilized, 200 mg (Cytoxan Lyophilized) | |
| J9095 | Cyclophosphamide, Lyophilized, 500 mg (Cytoxan Lyophilized) | |
| J9097 | Cyclophosphamide Lyophilized 2gm | |
| J9100 | Cytarabine 100 mg (Cytosar U) | |
| J9110 | Cytarbine 500 mg | |
| J9130 | Dacarbazine 100 mg | |
| J9140 | Dacarbazine 200 mg | |
| J7513 | Daclizumab (Zenapax) 25 mg. | |
| J9120 | Dactinomycin .5 mg (Cosmegen) | |
| J1645 | Dalteparin (Fragmin) per 2500 I.U./.2 ml. | |
| J9150 | Daunorubicin HCL, 10 mg (Cerubidine) | |
| J9151 | Daunorubicin Citrate Liposomal 10 mg | |
| J0895 | Deferoxamine, Mesylate 500 mg per 5cc (Deferal) | |
| W5195 | Denileukin Diftitox 9 mcg (Ontak) | |
| J1000 | Depoestradiol Cypionate, up to 5 mg | |
| J1095 | Dexamethasone Acetate 8 mg | |
| J2597 | Desmopression Acetate per 1 mcg | |
| J1100 | Dexamethosone Sodium, up to 4mg/ml | |
| J1190 | Dexrazoxane HCL 250 mg | |
| J7110 | Dextran 75 | |
| J7042 | Dextrose/Normal Saline - 5% (500 ml = 1 unit) | |
| J7070 | Dextrose/Water - 5% (1000 cc = 1 unit) | |
| J7060 | Dextrose/Water - 5% (500 ml = 1 unit) | |
| J3360 | Diazepam, up to 5 mg (Valium, Zetran) | |
| J1730 | Diazoxide, up to 300 mg (Hyperstat IV) | |
| J0500 | Dicyclomine HCL up to 20 mg (Bentyl, Dilomine, Antispas) | |
| J9165 | Diethylstilbestrol Diphosphate, 250 mg (Stilphostrol) | |
| J1160 | Digoxin, up to 0.5 mg (Lanoxin) | |
| J1110 | Dihydroergotamine, up to 1 mg | |
| J0470 | Dimecaprol, up to 100 mg | |
| J1240 | Dimenhydrinate, 50 mg | |
| J1200 | Diphenhydramine HCL, up to 50 MG (Benadryl) | |
| J1245 | Dipyridamole, per 10 mg (Persantine IV) | |
| J1212 | DMSO, Dimethyl Sulfoxide, 50%, 50 ml | |
| J1250 | Dobutamine HCL, 250 mg | |
| J9170 | Docetaxel (20 mg) | |
| J1260 | Dolasetron Mesylate (10 mg) | |
| J9001 | Doxil 10 mg/ml | |
| J9000 | Doxorubicin HCL, 10 mg (Adriamycin Rubex) | |
| J1810 | Droperidol and Fentanyl Citrate, up to 2 ml ampule (Innovar) | |
| J1790 | Droperidol, up to 5 mg (Inapsine) | |
| J1180 | Dyphylline, up to 500 mg | |
| J0600 | Edetate Calcium Disodium up to 1000 mg | |
| J1650 | Emoxaparin Sodium (Lovenox) 10 mg | |
| Q9920 | EPO, per 1000 units, Patient HCT 20 or less | |
| Q9921 | EPO, per 1000 units, Patient HCT 21 | |
| Q9922 | EPO, per 1000 units, Patient HCT 22 | |
| Q9923 | EPO, per 1000 units, Patient HCT 23 | |
| Q9924 | EPO, per 1000 units, Patient HCT 24 | |
| Q9925 | EPO, per 1000 units, Patient HCT 25 | |
| Q9926 | EPO, per 1000 units, Patient HCT 26 | |
| Q9927 | EPO, per 1000 units, Patient HCT 27 | |
| Q9928 | EPO, per 1000 units, Patient HCT 28 | |
| Q9929 | EPO, per 1000 units, Patient HCT 29 | |
| Q9930 | EPO, per 1000 units, Patient HCT 30 | |
| Q9931 | EPO, per 1000 units, Patient HCT 31 | |
| Q9932 | EPO, per 1000 units, Patient HCT 32 | |
| Q9933 | EPO, per 1000 units, Patient HCT 33 | |
| Q9934 | EPO, per 1000 units, Patient HCT 34 | |
| Q9935 | EPO, per 1000 units, Patient HCT 35 | |
| Q9936 | EPO, per 1000 units, Patient HCT 36 | |
| Q9937 | EPO, per 1000 units, Patient HCT 37 | |
| Q9938 | EPO, per 1000 units, Patient HCT 38 | |
| Q9939 | EPO, per 1000 units, Patient HCT 39 | |
| Q9940 | EPO, per 1000 units, Patient HCT 40 | |
| J1325 | Epoprostenol (.5 mg) | |
| Q0136 | Epotin Alpha (for non ESRD use) P/1000 units | |
| J1330 | Ergonovine Maleate, up to 0.2 mg | |
| J1362 | Erythromycin Gluceptate, per 250 mg | |
| J1364 | Erythromycin Lactobionate, per 500 mg | |
| J1380 | Estradiol Valerate, up to 10 mg | |
| J1390 | Estradiol Valerate, up to 20 mg | |
| J0970 | Estradiol Valerate, up to 40 mg | |
| J1410 | Estrogen Conjugated, per 25 mg (Premarin Intravenuous) | |
| J1435 | Estrone, per 1 mg | |
| J1436 | Etidronate Disodium, per 300 mg (Didronel) | |
| J9181 | Etoposide, 10 mg (Vepesid) | |
| J9182 | Etoposide, 100 mg (Vepesid) | |
| J3010 | Fentanyl Citrate, up to 2 ml (Sublimaze) | |
| J7190 | Factor VIII (anti-hemophilic factor) (human) per IU (Hemofil M) | |
| J7191 | Factor VIII (anti-hemophilic factor) Porcine per IU | |
| J7192 | Factor VIII (anti-hemophilic factor) Recombinant- per IU | |
| J7194 | Factor IX - (Benefix 1 IU) | |
| Q0160 | Factor IX (Antihemophilic Factor, Purified, non-recombinant) - per I.U. | |
| Q0161 | Factor IX (Antihemophilic Factor, recombinant) - per I.U. | |
| J1440 | Filgrastim , 300 mcg (Neupogen) | |
| J1441 | Filgrastim , 480 mcg (Neupogen) | |
| J9200 | Floxuridine, 500 mg (FUDR) | |
| J9185 | Fludarabine Phosphate, 50 mg (Fludara) | |
| J9190 | Fluorouracil, 500 mg (Adrucil) | |
| J2680 | Fluphenazine Decanoate, up to 25 mg (Prolixin Decanoate) | |
| J1455 | Foscarnet Sodium, per 1000 mg | |
| J1940 | Furosemide, up to 20 mg (Lasix, Furomide M.D.) | |
| J1460 | Gamma Globulin, Intramuscular, 1 cc | |
| J1470 | Gamma Globulin, Intramuscular, 2 cc | |
| J1480 | Gamma Globulin, Intramuscular, 3 cc | |
| J1490 | Gamma Globulin, Intramuscular, 4 cc | |
| J1500 | Gamma Globulin, Intramuscular, 5 cc | |
| J1510 | Gamma Globulin, Intramuscular, 6 cc | |
| J1520 | Gamma Globulin, Intramuscular, 7 cc | |
| J1530 | Gamma Globulin, Intramuscular, 8 cc | |
| J1540 | Gamma Globulin, Intramuscular, 9 cc | |
| J1550 | Gamma Globulin Intramuscular 10 cc | |
| ^^ | J1560 | Gamma Globulin, Intramuscular, over 10 cc (use correct combinations of services) |
| J1570 | Ganciclovir Sodium, 500 mg (Cytovene) | |
| J7310 | Ganciclovir, Long-acting Implant (4.5 mg) | |
| J9201 | Gemcitabine HCl. 200 mg | |
| J1580 | Gentamicin (Garamycin Sulfate) 80 mg | |
| J1610 | Glucagon Hydrochloride, per 1 mg | |
| J1600 | Gold Sodium Thiomaleate, up to 50 mg | |
| J1620 | Gonadorelin Hydrochloride, per 100 mcg | |
| J9202 | Goserelin Acetate Implant, per 3.6 mg (Zoladex) | |
| J1626 | Granisetron Hydrochloride (100 mcg) | |
| J1631 | Haloperidol Decanoate, per 50 mg (Haldol Decanoate - 50 or 100) | |
| J1630 | Haloperidol, up to 5 mg (Haldol) | |
| J1642 | Heparin Sodium, (Heparin Lock Flush), per 10 units | |
| J1644 | Heparin Sodium, per 1000 units | |
| J9355 | Herceptin (Trastuzumab) 10 mg | |
| J7315 | Hyalgan (Sodium Hyaluronate) 20 mg. (Series of 5 weekly injections) | |
| J3470 | Hyaluronidase, up to 150 units (Wydase) | |
| J0360 | Hydralazine HCL, up to 20 mg (Apresoline) | |
| J2480 | Hydrochlorides of Opium Alkaloids, up to 20 mg (Pantopon) | |
| J1700 | Hydrocortisone Acetate, up to 25 mg | |
| J1710 | Hydrocortisone Sodium Phosphate, up to 50 mg | |
| J1720 | Hydrocortisone Sodium Succinate, up to 100 mg | |
| J1170 | Hydromorphone, up to 4 mg (Dilaudid) | |
| J1739 | Hydroxyprogesterone Caproate 125 mg/ml | |
| J1741 | Hydroxyprogesterone Caproate, 250 mg/ml | |
| J3410 | Hydroxyzine HCL, up to 25 mg (Vistaril, Vistaject-25, Hyzine-50) | |
| J7320 | Hylan G-F 20 (Synvisc) 16 mg/ 2 ml Series of 3 weekly injections | |
| J1980 | Hyoscyamine Sulfate, up to 0.25 mg (Levsin) | |
| J7130 | Hypertonic Saline Solution (50 or 100 meq, 20 cc vial) | |
| J1742 | Ibutilide Fumarate (1 mg.) | |
| J9211 | Idarubicin Hydrochloride, 5 mg | |
| J9208 | Ifosfamide, 1 gm | |
| J1785 | Imiglucerase, per unit (Cerezyme) | |
| ** | J3270 | Imipramine HCL, up to 25 mg (Tofranil) |
| J1561 | Immune Globulin, Intravenous, per 500 mg (Gammar IV) | |
| J1745 | Infliximab 5 mg (Remicade) | |
| J1820 | Insulin, up to 100 units (Pork Regular) | |
| J9213 | Interferon, Alfa-2A, recombinant, 3 million units (Roferon) | |
| J9214 | Interferon, Alfa-2B, Recombinant, 1 million units (Intron A) | |
| J9215 | Interferon, Alfa-N3, 250,000 IU | |
| J9212 | Interferon, Alfacon-1, Recombinant, 1 mcg | |
| J9216 | Interferon, Gamma 1-B, 3 million units (Actimmune) | |
| J9206 | Irinotecan (20 mg) | |
| J1750 | Iron Dextran, Infed 50 mg | |
| J1840 | Kanamycin Sulfate, 500 mg (Kantrex, Klebcil) | |
| J1850 | Kanamycin Sulfate, 75 mg (Kantrex, Klebcil) | |
| J1885 | Ketorolac Tromethamine, per 15 mg (Toradol) | |
| J1910 | Kutapressin, up to 2 ml | |
| J0640 | Leucovorin Calcium, per 50 mg | |
| J9217 | Leuprolide Acetate (for depot suspension), 7.5
mg (Lupron)
(22.5 mg allowed for DX 185 only) |
|
| J1950 | Leuprolide Acetate (for depot suspension), per
3.75 mg (Lupron) Leuprolide Acetate (for depot suspension), per 11.25 mg(Lupron) (3 months) |
|
| J9218 | Leuprolide Acetate, per 1 mg (Lupron) | |
| J1955 | Levocarnitine per 1 gm | |
| J1956 | Levofloxacin (250 mg) | |
| J1960 | Levorphanol tartrate, up to 2 mg | |
| J2000 | Lidocaine HCL, 50 cc | |
| J2010 | Lincomycin HCL, up to 300 mg (Lincocin) | |
| J2060 | Lorazepam, 2 mg (Ativan) | |
| W5128 | Lupron Depot Pediatric 11.25 mg | |
| W5129 | Lupron Depot Pediatric 15 mg | |
| W5127 | Lupron Depot Pediatric 7.5 mg | |
| J3475 | Magnesium Sulfate, 500 mg, injection | |
| J2150 | Mannitol, 25% in 50 ml | |
| J9230 | Mechlorethamine Hydrochloride (Nitrogen Mustard), 10 mg | |
| J1055 | Medroxyprogesterone Acetate for Contraceptive Use, 150 mg (Depo-Provera) | |
| J1050 | Medroxyprogesterone Acetate, 100 mg (Depo-Provera) | |
| J9245 | Melphalan Hydrochloride 50 mg (Alkeran) | |
| J2180 | Meperidine and Promethazine HCL, up to 50 mg (Mepergan Injection) | |
| J2175 | Meperidine Hydrochloride, per 100 mg (Demerol HCL) | |
| J3450 | Mephentermine, up to 30 mg | |
| J0670 | Mepivacaine (Carbocaine) 10 ml | |
| J9209 | Mesna, 200 mg (Mesnex) | |
| J0380 | Metaraminol Bitartrate 10 mg (Aramine) | |
| J1230 | Methadone HCL, up to 10 mg | |
| J2970 | Methicillin Sodium, up to 1 gm (Staphcillin) | |
| J2800 | Methocarbamol, up to 10 ml (Robaxin) | |
| J9250 | Methotrexate Sodium, 5 mg | |
| J9260 | Methotrexate Sodium, 50 mg | |
| J1970 | Methotrimeprazine, up to 20 mg | |
| J3390 | Methoxamine, up to 20 mg (Vasoxyl) | |
| J0210 | Methyldopate HCL, up to 250 mg (Aldomet) | |
| J2210 | Methylergonovine Maleate, up to 0.2 mg (Methergine) | |
| J1020 | Methylprednisolone Acetate, 20 mg (Depo Medrol) | |
| J1030 | Methylprednisolone Acetate, 40 mg | |
| J1040 | Methylprednisolone Acetate, 80 mg | |
| J2930 | Methylprednisolone Sodium Succinate, up to 125 mg (SoluMedrol, Anetha Pred) | |
| J2920 | Methylprednisolone Sodium Succinate, up to 40 mg (Solu Medrol, Anetha Pred) | |
| J2765 | Metoclopramide HCL, up to 10 mg (Reglan) | |
| J2250 | Midozolem HCL (Versed) per 1 mg | |
| J2260 | Milrinone Lactate, per 5 ml (Primacor) | |
| J9290 | Mitomycin, 20 mg (Mutamycin) | |
| J9291 | Mitomycin, 40 mg (Mutamycin) | |
| J9280 | Mitomycin, 5 mg (Mutamycin) | |
| J9293 | Mitoxantrone Hydrochloride, per 5 mg (Novantrone) | |
| J2275 | Morphine Sulfate (preservative-free sterile solution), per 10 mg | |
| J2270 | Morphine Sulfate, up to 10 mg | |
| J2271 | Morphine Sulfate (100 mg) | |
| J2310 | Nalaxone Hydrochloride (Narcan) per 1 mg | |
| J2300 | Nalbuphine Hydrochloride, 10 mg | |
| J2321 | Nandrolone Decanoate, up to 100 mg | |
| J2322 | Nandrolone Decanoate, up to 200 mg | |
| J2320 | Nandrolone Decanoate, up to 50 mg | |
| J0340 | Nandrolone Phenpropionate, up to 50 mg (Duradolin) | |
| J9390 | Navelbine 10 mg | |
| J2710 | Neostigmine Methylsulfate, up to 0.5 mg (Prostigmine) | |
| J7030 | Normal Saline Solution, 1000 cc, infusion | |
| J7050 | Normal Saline Solution, 250 cc, infusion | |
| J7040 | Normal Saline Solution, Sterile (500 ml=1 unit), infusion | |
| J2405 | Ondansetron Hydrochloride, per 1 mg (Zofran) | |
| J2355 | Oprelvekin (Newmega) 5 mg | |
| J2360 | Orphenadrine Citrate, up to 60 mg | |
| J2700 | Oxacillin Sodium, up to 250 mg (Bactocile, Prostaphlin) | |
| J2410 | Oxymorphone HCL, up to 1 mg | |
| J2460 | Oxytetracycline HCL, up to 50 mg (Terramycin IM) | |
| J2590 | Oxytocin, 10 units/1ml (Pitocin, Syntocinon) | |
| J9265 | Paclitaxel, 30 mg (Taxol) | |
| J2430 | Pamidronate Disodium, per 30 mg (Aredia) | |
| J2440 | Papaverine HCL, up to 60 mg | |
| J9266 | Pegaspargase (Onscospar) Single Dose vial (5 ml/ SDV) | |
| J0540 | Penicillin G Benzathine and Penicillin G Procaine, up to 1,200,000 units | |
| J0550 | Penicillin G Benzathine and Penicillin G Procaine, up to 2,400,000 units | |
| J0530 | Penicillin G Benzathine and Penicillin G procaine, up to 600,000 units | |
| J0570 | Penicillin G Benzathine, up to 1,200,000 units (Bicillin L-A, Permapen) | |
| J0580 | Penicillin G Benzathine, up to 2,400,000 units (Bicillin L-A, Permapen) | |
| J0560 | Penicillin G Benzathine, up to 600,000 units (Bicillin L-A, Permapen) | |
| J2540 | Penicillin G Potassium, up to 600,000 units | |
| J2510 | Penicillin G Procaine, Aqueous, up to 600,000 units | |
| ** | J2512 | Pentagastrin, per 2 ml (Peptavlon) |
| J2545 | Pentamidine (Pentam 300) | |
| W5192 | Pentamidine Isethionate, 300 mg | |
| J3070 | Pentazocine HCL, up to 30 mg (Talwin) | |
| J2515 | Pentobarbital Sodium (Nembutal Sodium Solution) 50 mg | |
| J9268 | Pentostatin, 10 mg | |
| J2543 | Piperacillin Sodium 4 gm (Pipracil) | |
| J3310 | Perphenazine, up to 5 mg (Trilafon) | |
| J2560 | Phenobarbital Sodium, up to 120 mg | |
| J2760 | Phentolamine Mesylate, up to 5 mg (Regitine) | |
| J2370 | Phenylephrine HCL, up to 1 ml (NeoSynephrine) | |
| J1165 | Phenytoin Sodium (Dilantin) | |
| J9270 | Plicamycin, (Mithracin) 2.5 mg | |
| J9600 | Porfimer Sodium (75 mg) | |
| J3480 | Potassium Chloride 2 meq. | |
| J2730 | Pralidoxime Chloride, up to 1 gm (Protopam Chloride) | |
| J2650 | Prednisolone Acetate, up to 1 ml | |
| J2640 | Prednisolone Sodium Phosphate, to 20 mg | |
| J1690 | Prednisolone Tebutate, up to 20 mg | |
| J2690 | Procainamide HCL, up to 1 gm (Pronestyl) | |
| J0780 | Prochlorperazine Edisylate 10 mg Compazine, Cotranzine, Compa-Z, Ultrazine-10 | |
| J2675 | Progesterone, per 50 mg | |
| J2950 | Promazine HCL, up to 25 mg (Sparine, Prozine-50) | |
| J2550 | Promethazine HCL, up to 50 mg (Phenergan, Phenazine) | |
| J1930 | Propiomazine HCL, up to 20 mg | |
| J1800 | Propranolol HCL, up to 1 mg (Inderal) | |
| J2720 | Protamine Sulfate, per 10 mg | |
| J2725 | Protirelin, per 250 mg | |
| J2780 | Rantidine (Zantac) 25 mg. | |
| J2994 | Reteplase (37.6 mg/ 2 SDV) | |
| J7120 | Ringers Lactate Infusion, up to 1000 cc | |
| J9310 | Rituximab (Rituxan) 100 mg./ 10ml. | |
| W5198 | Sandostatin (Octreotide Acetate) 50 mcg | |
| * | J2352 | Sandostatin (Octreotide Acetate) LAR Depot 1 mg (10 or 20 mg) (30 mg. ^^) |
| J2820 | Sargramostim (GM-CSF), (Leukine, Prokine) 50 mcg | |
| J2860 | Secobarbital Sodium, up to 250 mg (Seconal) | |
| Y1856 | Sodium Bicarbonate 7.5% up to 50 ml | |
| J2912 | Sodium Chloride 9% per ml | |
| J3320 | Spectinomycin-Dihydrochloride, up to 2 gm (Trobicin) | |
| X1270 | Stadol | |
| J7051 | Sterile Saline or Water (up to 5cc) | |
| J2995 | Streptokinase, per 250,000 IU | |
| J3000 | Streptomycin 1 gm | |
| J9320 | Streptozocin, 1 gm (Zanosar) | |
| J0330 | Succinycholine Chloride, up to 20 mg (Anectine, Quelicin, Surostrin) | |
| J9170 | Taxotere 20 mg | |
| J3105 | Terbutaline Sulfate, up to 1 mg (Brethine) | |
| J1060 | Testosterone Estradiol Cypionate, 50 mg | |
| J1080 | Testosterone Estradiol Cypionate, 200 mg | |
| J1090 | Testosterone Cypionate, 50 mg | |
| J1070 | Testosterone Estradiol Cypionate, 100 mg | |
| J0900 | Testosterone Enanthate and Estradiol Valerate 1 cc | |
| J3120 | Testosterone Enanthate, 100 mg | |
| J3130 | Testosterone Enanthate, 200 mg | |
| J3150 | Testosterone Propionate, 100 mg | |
| J3140 | Testosterone Suspension, 50 mg | |
| ** | J0120 | Tetracycline, up to 250 mg (Achromycin) |
| J3280 | Thiethylperazine Maleate, 10 mg (Norzine, Torecan) | |
| J9340 | Thiotepa Triethylenthiophosphoromide, 15 mg | |
| J2330 | Thiothixene, up to 4 mg (Navane) | |
| J3240 | Thyrotropin Alfa (Thyrogen) 0.9 mg | |
| J3260 | Tobramycin Sulfate, up to 80 mg (Nebcin) | |
| J9350 | Topatecan (4 mg.) | |
| J3265 | Torsemide 10 mg/ml | |
| J2670 | Tolazoline HCL, up to 25 mg (Priscoline HCL) | |
| J3301 | Triamcinolone Acetonide, per 10 mg | |
| J3302 | Triamcinolone Diacetate, per 5 mg | |
| J3303 | Triamcinolone Hexacetonide, per 5 mg | |
| J3400 | Triflupromazine HCL, up to 20 mg | |
| J0400 | Trimethapan Camsylate up to 500 mg | |
| J3250 | Trimethobenzamide HCL, up to 200 mg (Tigan) | |
| J3305 | Trimetrexate Glucoronate 25 mg | |
| J3350 | Urea, up to 40 gm | |
| J3365 | Urokinase, 250,000 i.u. vial | |
| J3364 | Urokinase, 5000 iu vial | |
| J9357 | Valstar (Valvubicin) 200 mg | |
| J3370 | Vancomycin HCL, up to 500 mg | |
| J9360 | Vinblastine Sulfate, 1 mg | |
| J9370 | Vincristine Sulfate, 1 mg (Oncovin, Vincasar PFS) | |
| J9375 | Vincristine Sulfate, 2 mg | |
| J9380 | Vincristine Sulfate, 5 mg (Oncovin, Vincasar PFS) | |
| J3430 | Vitamin K, Phytonadione 1 mg/0.5ml | |
| J2500 | Zemplar (Paricalcitol) 5 mcg |
EDS, 1-800-688-6696 or 919-851-8888
Facsimiles (FAXes) and electronic signatures that meet the Division of Medical Assistance (DMA) requirements listed below are acceptable for supporting Medicaid claims. This policy does not exempt a provider from meeting licensure, certification, enrollment, and accreditation requirements, or other legal and regulatory requirements.
Fax Copies
Providers may furnish FAX copies of physicians' orders and certifications for Medicaid services, provided prior arrangements for sending FAX information have been made. (Unsolicited items faxed to EDS may not reach the appropriate destination.) Although providers are not required to have original physician signatures on file, it is the provider's responsibility to produce the document with the original signature in the event that additional information is needed during a review of documentation related to the Medicaid claim.
Electronic Signatures
Providers that maintain patient records by computer rather than hard copy may use electronic signatures on valid supporting documentation for Medicaid claims if such entries are appropriately authenticated and dated. The following requirements apply:
Effective with dates of service April 1, 2000, North Carolina Medicaid began covering CPT codes 92992, atrial septectomy or septostomy, transvenous method; and 92993, atrial septectomy or septostomy, blade method.
Providers who have received denial code 009 on procedure code 92992 or 92993 for dates of service April 1, 2000 to present may request an adjustment through the adjustment section at EDS.
EDS, 1-800-688-6696 or 919-851-8888
Effective January 1, 2001, all nursing facility residents must have a First Health Services (formerly First Mental Health) PASARR number. Residents who were "grandfathered" in with PASARR forms used prior to February 1994, must be screened and receive a PASARR number from First Health Services (FHS) by the effective date.
Tracking forms must be sent to FHS for all new admissions in order for the receiving facility to obtain a copy of the Level I and, if appropriate, the Level II results. Level I and Level II documentation must be kept in the resident's medical record.
FHS authorization numbers end with an "alpha" character. The following is an explanation of the alpha characters:
A Nursing facility placement appropriate, does not meet target population for mental illness (MI), mental retardation (MR), or related condition (RC).
B Nursing facility placement appropriate, no specialized services required. An annual resident review is required.
C Nursing facility placement appropriate, specialized services required. An annual resident review is required.
D Represents 7-day time-limited approvals.
E Represents 30-day time-limited approvals.
F Represents 60-day time-limited approvals.
J Residents approved for admission only to state psychiatric hospitals.
Z Denial for placement in a nursing facility.
NOTE: The D, E, and F alphas indicate time-limited stays and the EDS prior approval number (PA) for level of care is also time-limited. Payment will be denied when the PA number is end-dated. Residents who have PASARR numbers with these alpha characters must be closely monitored. If a resident needs to remain in the facility beyond the specified time limit, a Level II screening must be initiated through FHS. Payment will be denied for each day past the time-limited stay. For time-limited stays E and F, a new FL2 must be submitted to EDS as soon as the facility receives the new PASARR number.
Margaret O. Langston, RN, Institutional Services, Medical Policy Section
DMA, 919-857-4020
EDS currently offers Electronic Funds Transfer (EFT) as an alternative to paper check issuance. EFT enables the receipt of Medicaid payments through automatic deposit at a bank while the provider continues to receive the Remittance and Status Report (RA) at the current mailing address. This process guarantees payment in a timely manner and prevents checks from being lost or stolen.
Frequently Asked Questions about Automatic Deposit:
Q. What is the automatic deposit process?
A. EDS generates a list of deposits on an electronic
wire, which represents payments to providers who have chosen automatic deposit.
This electronic wire is sent to the Federal Reserve Bank, which makes the transactions
to the providers' bank. Simultaneously, the EDS account is debited for the funds.
Q. What are the advantages to automatic deposit?
A. The major advantage is that automatic deposit eliminates
needless worry about check delays and checks lost in the mail. It generally
takes 2 to 3 weeks to reissue a lost check.
Q. How do I enroll for EFT?
A. Providers must complete an EFT Agreement form. A
copy of the form follows this article or can be obtained by calling EDS at 1-800-688-6696
(select option "1"). The form is also available online at www.dhhs.state.nc.us/dma.
A separate form must be completed for each provider number your organization
plans to enroll. A deposit slip or voided check for each bank account must
be attached to verify the account number and bank transit number.
Q. Where do I send my completed forms?
A. Mail completed form along with a deposit slip or
voided check for each bank account to:
EDS, 4905 Waters Edge Dr., Raleigh, NC 27606, ATT: Finance-EFT
Or fax to: EDS, ATT: Finance-EFT, 919-859-9703
Q. How will I know when my form has been processed
and direct deposit begins?
A. The last page of the RA indicates the method of payment
for that checkwrite. A "check number" or an "EFT number" is indicated in the
top left corner beneath the provider number.
Q. When will funds be deposited into my account?
A. Funds are automatically deposited within four days
of the checkwrite date. Refer to the back of the Medicaid Bulletin for each
month's checkwrite dates.
Q. How can I be sure my bank received the money?
A. Once EDS initiates the transfer, it is each individual
bank's responsibility to receive the funds and post them to your account. Transfers
can be confirmed by calling your bank's automatic clearinghouse department.
The bank will need your account number, the checkwrite date, and the amount
of money EDS paid on the checkwrite date. The transfer amount can be obtained
by calling the Automated Voice Response System at 1-800-723-4337.
Q. How do I report changes in my banking service?
A. Providers must complete and submit a new EFT agreement
with the new information. Providers receive paper checks during the interim
period of two checkwrites before automatic deposit begins to the new account.
Q. Will recoupments ever be withdrawn from my bank
account?
A. No. EFT cannot withdraw money from your account.
It can only make deposits to your account.
Q. What if I have a question or concern regarding
my automatic deposit?
A. EDS will be glad to address any questions or concerns
regarding automatic deposit. You may contact Provider Services by calling 1-800-688-6696.
EDS, 1-800-688-6696 or 919-851-8888
Electronic Funds Transfer (EFT) Form
Effective January 1, 2001, all Utilization Review (UR) FL2 forms must have a First Health Services (formerly First Mental Health) Preadmission Screening and Annual Resident Review (PASARR) number documented in block 10. Recommended level of care (LOC) changes will not be processed and approved if the PASARR number is not on the FL2.
All UR FL2s and their transmittal sheets (FL12s) must be mailed to the
Division of Medical Assistance (DMA). Note below the appropriate DMA mailing
addresses for UR FL2 and FL12 forms:
| REGULAR MAIL Division of Medical Assistance Medical Policy 2511 Mail Service Center Raleigh, NC 27699-2511 ATTN: Utilization Review |
FEDEX/PRIORITY/OVERNIGHT Division of Medical Assistance Medical Policy 1985 Umstead Drive Raleigh, NC 27603 ATTN: Utilization Review |
The correct prior approval (PA) number and current LOC must be documented on the UR FL2. (If you are unsure of the correct number, check with your nursing facility billing office or call the resident's county of eligibility.)
If you have a UR LOC change request already in the UR process, do not call EDS for an LOC change and new PA number. This will result in denial of payment if the incorrect PA number is used on the claim.
The correct and complete responsible party's name and address and the correct and complete attending physician's name and address must be noted on the UR FL2. When this information is incomplete, staff at DMA and Medical Review of North Carolina must contact the nursing facility to obtain the correct information, causing a delay in the facility receiving approval for LOC recommendations as well as a delay in appropriate payment. In addition, if the LOC change letter is sent to the incorrect responsible party or address, letters may be received late, interfering with the resident's right to appeal.
When a resident or responsible party appeals a LOC change, the resident must remain at the LOC until the hearing is held and a decision is made by the hearing officer. Do not submit a LOC change through EDS PA or DMA UR for a resident who has requested an appeal. If there is a major change in the resident's condition, the resident is hospitalized or the resident expires, you must notify the DMA Hearing Office at 919-857-4016.
Utilization Review, Medical Policy Section
DMA, 919-857-4020
Effective January 2, 2001, all mail to the Division of Medical Assistance (DMA) must be addressed to the appropriate Mail Service Center address. Mail sent to any address other than the Mail Service Center addresses will not be forwarded and will be returned to the sender. Refer to the table below for DMA's Mail Service Center addresses.
UPS, FEDEX, Airborne, and other freight companies will continue to deliver to DMA's physical address, 1985 Umstead Drive, Raleigh NC, 27626. Include the DMA employee's name and section with the address to ensure that the delivery is routed correctly.
If you are using forms that have not been updated with DMA's Mail Service Center
addresses, refer to the table below for the correct Mail Service Center address.
| Administration and Regulatory Affairs Division of Medical Assistance 2504 Mail Service Center Raleigh, NC 27699-2504 |
Audit Division of Medical Assistance 2507 Mail Service Center Raleigh, NC 27699-2507 |
| Carolina ACCESS; Managed Care Division of Medical Assistance 2516 Mail Service Center Raleigh, NC 27699-2516 |
Claims Analysis and Medicare Buy-In Division of Medical Assistance 2519 Mail Service Center Raleigh, NC 27699-2519 |
| Community Care Division of Medical Assistance 2502 Mail Service Center Raleigh, NC 27699-2502 |
DHHS Accounts Receivable Division of Medical Assistance 2022 Mail Service Center Raleigh, NC 27699-2022 |
| Director or Deputy Director Division of Medical Assistance 2517 Mail Service Center Raleigh, NC 27699-2517 |
Eligibility Unit Division of Medical Assistance 2512 Mail Service Center Raleigh, NC 27699-2512 |
| Financial Operations Division of Medical Assistance 2509 Mail Service Center Raleigh, NC 27699-2509 |
Hearing Office Division of Medical Assistance 2505 Mail Service Center Raleigh, NC 27699-2505 |
| Information Services Division of Medical Assistance 2514 Mail Service Center Raleigh, NC 27699-2514 |
Mail Management Division of Medical Assistance 2513 Mail Service Center Raleigh, NC 27699-2513 |
| Medicaid Mgt. Info. System (MMIS) Division of Medical Assistance 2510 Mail Service Center Raleigh, NC 27699-2510 |
Medical Policy/Utilization Control Division of Medical Assistance 2511 Mail Service Center Raleigh, NC 27699-2511 |
| Program Integrity Division of Medical Assistance 2515 Mail Service Center Raleigh, NC 27699-2515 |
Provider Services Division of Medical Assistance 2506 Mail Service Center Raleigh, NC 27699-2506 |
| Quality Control Division of Medical Assistance 2518 Mail Service Center Raleigh, NC 27699-2518 |
Third Party Recovery or Health Insurance Premium
Payment Program (HIPP) Division of Medical Assistance 2508 Mail Service Center Raleigh, NC 27699-2508 |
If you do not know which DMA section or unit's address to use, send your correspondence to the following general address:
(Name of DMA employee)Clarence Rogers, Financial Operations
Division of Medical Assistance
2501 Mail Service Center
Raleigh, NC 27699-2501
Effective November 1, 2000, all Carolina ACCESS primary care providers (PCPs) must adhere to the following office-wait time limits:
Program Operations, Managed Care Section
DMA, 919-857-4022
The Division of Medical Assistance (DMA) is upgrading and enhancing the Medicaid Management Information System (MMIS). The goals of the renovation, as noted in the April, 2000 Bulletin, are:
Changes to the following parts are detailed in the Provider Impact section of this article.
Part I - Remittance and Status Advice
Part II - Adjustment Requests - NEW FORM
Part III - Prior Approval (PA)
Part IV - Automated Voice Response (AVR) System and Eligibility Verification
System (EVS)
Implementation Schedule
Updated Implementation Date: The implementation of system changes for the ITME project has been extended to February 9, 2001. The revised date of February 9, 2001 supercedes the original implementation date reflected in the September and October, 2000 ITME bulletin articles. Please note that all references to effective dates in the remainder of this article have been revised to reflect the extended date of February 9, 2001.
The RA will reflect the changes noted in Part I beginning February 9, 2001.
Part II reflects the new N.C. Medicaid adjustment form. Use of this form is
required as of February 9, 2001. Part III provides new instructions for submitting
services that have been prior approved. Part IV addresses changes to the AVR
System and EVS resulting from this enhancement.
Provider Impact
Part I: Remittance and Status Advice (RA) - See Example
1
RA modifications/format changes will be kept to only those that are necessary in conjunction with the ITME project. Overall, the RA will look very similar to the current format. Please note the format changes on the RA sample following this article (Example 1).
Addition of Financial Payer Code
A financial payer code follows the claim internal control number (ICN) in the first line of the claim data reflected on the RA. This financial payer code denotes the entity responsible for payment of the claims listed on the RA. Upon implementation, N.C. Medicaid will be the only financially responsible payer; therefore, the N.C. Medicaid payer code of NCXIX (five characters) will be reflected.
Addition of Population Group Payer Code
The RA reflects the population payer code for each claim detail. The population payer code is printed at the beginning of each claim detail line on the RA. The population payer code denotes the special program/population group from which a recipient is receiving Medicaid benefits. Examples of population payer codes are as follows:
| Code | Name | Description |
|---|---|---|
| CA-I | Carolina ACCESS | All recipients enrolled in Medicaid's Carolina ACCESS program |
| CA-II | ACCESS II | All recipients enrolled in Medicaid's ACCESS II program |
| CAB | ACCESS III - Cabarrus County | All recipients enrolled in Medicaid's ACCESS III program for Cabarrus County |
| PITT | ACCESS III - Pitt County | All recipients enrolled in Medicaid's ACCESS III program for Pitt County |
| HMOM | Health Management Organization (HMO) | All recipients enrolled in Medicaid's HMO program |
| NCXIX | Medicaid | All recipients not enrolled in any of the above noted population payer programs. Any recipient not identified with Carolina ACCESS, ACCESS II, ACCESS III, or HMO will be assigned the NCXIX population payer code to identify them with the Medicaid fee-for-service program. |
Other population payers may be designated by DMA in the future.
Addition of new totals following the current claim total line
An additional line is added following each claim total line of the paid and
denied claim sections of the RA for the following claim types: Medical (J),
Dental (K), Home Health, Hospice and Personal Care (Q), Medical Vendor (P),
Outpatient (M), and Professional Crossover (O). This additional line reflects
original claim billed amount, original claim detail count, and total number
of financial payers. Upon implementation February, 2001, N.C. Medicaid will
be the only financial payer; these new totals will reflect the submitted claim
totals.
These additional totals do not appear for claim types Drug (D), Inpatient (S), Nursing Home (T), and Medicare Crossover (W) since they are not processed at the claim detail level and will not have multiple financial payers assigned, based on current N.C. Medicaid billing policy.
Addition of a new summary page at end of RA
For each Medicaid population payer identified on the paper RA, a new summary
page showing total payments by population payer is provided at the end of the
RA. This provides population payer detail information for tracking and informational
purposes.
New specifications for Tape RA
Updated specifications have been mailed to all Tape RA Providers. If you are
currently receiving a Tape RA and have not received the updated specifications,
or have questions regarding the changes, please contact Glenda Raynor, Manager
of EDS Electronic Commerce Services, at 919-851-8888 extension 5-3099.
Part II: Adjustment Requests - NEW FORM (Example 2)
The N.C. Medicaid program will begin using a new RA format in February, 2001. This new format affects the way adjustment request forms are completed by the provider and processed by EDS. The appropriate "financial payer" information found on the new RA will be required on all adjustment request forms after February 9, 2001. DMA and EDS have implemented a new adjustment request form to help with these changes. One of the predominant changes is in the "claim number" field. This area is now identified with twenty boxes, each box for one number of the referenced claim number. Until February 9, 2001, there will be five empty boxes at the end of the claim number. After the February 9, 2001 implementation of the MMIS enhancements, these spaces will be used for the financial payer code information. Providers may begin using this new adjustment request form now if it facilitates implementing these changes. (Refer to example of claim field below.) Please contact EDS Provider Services with questions about the new format and processing of an adjustment request.
|
Claim #:
|
# | # | # | # | # | # | # | # | # | # | # | # | # | # | # |
|
Claim #:
|
# | # | # | # | # | # | # | # | # | # | # | # | # | # | # | N | C | X | I | X |
Effective February 9, 2001, entering the prior approval number on the claim form by the provider to receive payment for services rendered will no longer be required. This holds true for all prior approved Medicaid services, regardless of the entity giving the prior approval.
Prior approval requirements and the criteria for approval of services have not changed. Those services that previously required prior approval before the implementation of the enhanced MMIS will continue to require prior approval. If a service was approved prior to February 9, 2001 but was not provided or billed until after February 9, 2001, the original prior approval is still valid. The MMIS will verify that prior approval was obtained before claims payment can occur. If the services being submitted on the claim form require prior approval, and approval has not been obtained, that claim will be denied. The only change is that the input of the prior approval number is no longer required on the claim form by the provider as of February 9, 2001.
Part IV: Automated Voice Response (AVR) System and Eligibility Verification System (EVS)
These systems will be enhanced with new messages that will explain under which
special Medicaid program or programs a recipient is enrolled as a participant.
Additional information regarding these system enhancements will be provided
in subsequent bulletin articles.
EDS, 1-800-688-6696 or 919-851-8888
Remittance and Status Advice Samples
Medicaid Claim Adjustment Request Form
Outpatient hospital providers who meet the requirements for "Certificate of Recognition" from the American Diabetes Association may bill for Outpatient Diabetes Self-management Training. Refer to the November 1999 North Carolina Medicaid Bulletin for additional information. Revenue code (RC) 942 and the appropriate CPT code 99404, individual counseling, or 99412, group counseling, must be used to bill the service. North Carolina Medicaid covers RC 942 only for Diabetes Self-management Training.
If you received claim denials for dates of service on or after November 1, 1999 that stated the service is noncovered, refile the claim using the appropriate RC and CPT code combination.
EDS, 1-800-688-6696 or 919-851-8888
Alert - Tax Update Requested
North Carolina Medicaid must have the proper tax information for all providers. This ensures correct issuance of 1099 MISC forms each year and that the correct tax information is provided to the IRS. Inappropriate information on file can result in the IRS withholding 31% of a provider's Medicaid payments. Be sure the individual responsible for maintenance of tax information receives the following information.
How to Verify Tax Information
The last page of the Medicaid Remittance and Status Advice (RA) indicates the provider tax name and number that Medicaid has on file. Refer to the Medicaid RA throughout the year for each provider number to ensure Medicaid has the correct tax information on file. The tax information needed for a group practice is as follows: (1) Group tax name and group tax number (2) Attending Medicaid provider numbers in the group. If a Medicaid RA is needed, call EDS Provider Services 919-851-8888 or 1-800-688-6696 to verify the tax information on file for each provider number.
Providers should complete a Special W-9 for all provider numbers with incorrect information on file. Instructions for completing the Special W-9 are listed below.
EDS
4905 Waters Edge Drive
Raleigh, NC 27606
Attention: Provider Services
OR
FAX to 919-851-4014
Attention: Provider Services
Change of Ownership
Contact DMA Provider Services at 919-857-4017 to report all changes in business
ownership. If necessary, a new Medicaid provider number will be assigned and
Provider Services will ensure the correct tax information is on file for Medicaid
payments.
If DMA is not contacted and the incorrect provider 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.
Group Practice Changes
When a physician leaves or a physician is added to a group practice, contact
DMA Provider Services to update Medicaid enrollment and tax information.
Remember, without notifying DMA Provider Services, the incorrect tax information could remain on file and your business could become liable for taxes on Medicaid payments you did not receive.
EDS, 1-800-688-6696 or 919-851-8888
During the month of October, Public Consulting Group, Inc. (PCG) and the Division of Medical Assistance, Third Party Recovery Section forwarded to hospitals a list of Medicare claims with a December 31, 2000 filing deadline date. A separate mailing will be issued for Medicare claims with a December 31, 2001 filing deadline date.
Please direct all questions to Jennifer Malchak with PCG.
Jennifer Malchak
PCG, 1-800-372-0878
Each month a sample of the Utilization Review (UR) FL2s received at the Division of Medical Assistance (DMA) is sent to Medical Review of North Carolina (MRNC), the contractor for level of care (LOC) monitoring. DMA has recently increased the sample number. Therefore, nursing facilities can expect the UR FL2s to be reviewed several times a year.
MRNC nurses review the sample FL2s to determine if the LOC recommended by the UR Committee is appropriate to meet the resident's needs. (This process is outlined in Chapter Seven of the June 2000 Nursing Facility provider manual.) When the documentation on the FL2 is not consistent with the LOC, MRNC will request medical records for the most recent thirty (30) days. If MRNC changes the LOC, written notification will be forwarded to the nursing facility. The new prior approval number will appear in the upper right corner of the notification letter. A copy of the FL2 will not be mailed with the notification letter.
Utilization Review, Medical Policy Section
DMA, 919-857-4020
When a nursing facility resident requires hospitalization, the nursing facility provider must indicate a Discharge Status in form locator 22 and a Discharge Bill Type in form locator 4 on the UB-92 claim form. (Bill Types and Discharge Status Codes are noted in Chapter Eight of the June 2000 Nursing Facility provider manual.)
Payments made to nursing facilities for claims billed with the incorrect bill type will be recouped.
EDS, 1-800-688-6696 or 919-851-8888
The Division of Medical Assistance (DMA) is now requiring DEA numbers on all recipient pharmacy claims instead of UPIN numbers. Providers must have their DEA registration number on file. Failure to do so may result in denied claims. If a prescriber does not have a DEA number and needs to issue prescriptions to recipients served by the Medicaid program, the prescriber should contact the DUR Section at 919-733-3590.
An identification number (ID) will be issued in lieu of the DEA number. The ID number, following the same format as the DEA number, will always begin with a Z (for example, ZF1234567). Prescribers will need to enter this number on their Medicaid prescriptions. This number is referred to as a MEDICAID IDENTIFICATION NUMBER only and should not be referred to as a DEA number.
If EDS Provider Enrollment does not have your updated information, please copy, complete, and return the DEA Number form for each prescriber in your practice. Please send the information to the following address:
EDS Provider Enrollment Unit
P.O. Box 300009
Raleigh, North Carolina 27622
FAX, 919-851-4014
EDS, 1-800-688-6696 or 919-851-8888
Sharman Leinwand, DUR Coordinator, Program Integrity Section
DMA, 919-733-3590 ext. 229
Carolina ACCESS (CA) primary care providers (PCPs) must communicate all pertinent changes made within the practice to the local Managed Care Representative. Changes may involve hospital admitting privileges, the CA contact person for the office, new office hours, new providers added to the practice, etc. The Managed Care Representative will notify the Division of Medical Assistance (DMA) Managed Care Section, and the change will be made to the CA application and agreement on file. If information is needed regarding the best way to contact your Managed Care Representative, please call the DMA Managed Care Section at 919-857-4022.
Kirby Ferguson, Managed Care Section
DMA, 919-857-4022
Carolina ACCESS (CA) welcomes and encourages Medicaid recipients who are also receiving Medicare benefits (Dually Eligible) to enroll in the CA program. If a Dually Eligible recipient chooses to participate in CA, they must select a CA PCP who participates in both Medicare and Medicaid.
CA PCPs electing to care for CA Dually Eligible recipients must participate in both the Medicare and Medicaid programs. In addition, PCPs must report to the Division of Medical Assistance if their participation with Medicare or Medicaid is voluntarily or involuntarily terminated.
Program Operations, Managed Care Section
DMA, 919-857-4022
Effective with date of service October 1, 2000, the October 1999 workshop handout published by EDS will be used as the updated version of DMA's medical policy for IPs until further notice. Updated handouts were provided at the EDS workshops in 1999 and mailed to all enrolled providers.
Please review the October 1999 EDS handout for updates, deletions, and other changes to the medical policy for IP providers. A copy of the handout may be obtained by calling EDS Provider Services at 1-800-688-6696 or 919-851-8888.
EDS, 1-800-688-6696 or 919-851-8888
Diabetic recipients do not generally require more frequent eye refractions or eyeglass lens changes than other recipients. However, retinal disease (diabetic retinopathy, diabetic macular edema, etc.) is the leading cause of blindness in diabetic patients. Therefore, it is important that diabetic recipients are seen annually to evaluate the health of the eye.
For diabetic recipients with no complications, providers should bill for an office visit a minimum of one year from the previous eye exam date. Based on the findings, more frequent evaluation may be indicated. Providers should bill one of the following CPT codes and follow CPT guidelines:
OfficeVisit - New Patient
(No Prior Authorization Required)
99201
99202
99203
99204
99205
Office Visit - Established Patient
(No Prior Authorization Required)
99211
99212
99213
99214
When a diabetic patient is evaluated for retinopathy, documentation of the evaluation should be forwarded to the primary care physician or referring physician.
When a significant change in visual acuity is detected during an office visit, the recipient should be referred back to the medical physician for evaluation of the diabetic condition (stable or unstable). The medical physician should write a referral to the ophthalmologist or optometrist stating the diabetic condition and requesting a new eye refraction. The ophthalmologist or optometrist may request a refraction only by submitting a general Request for Prior Approval form (371-118) and the referring medical physician's letter to the EDS address listed on the top of the form. The optometrist or ophthalmologist should document medical justification for an early refraction in block 7 of the Request for Prior Approval form (i.e., visual acuity with current glasses, pressure changes, current medications, etc.). A minimal change of one diopter in power is required for approval of a new lens(es). Each request for an early refraction will be reviewed on a case-by-case basis.
EDS, 1-800-688-6696 or 919-851-8888
The Division of Medical Assistance (DMA) has implemented a policy to allow Adult Care Home (ACH) providers to make limited corrections to the ACH assessment and care plan form (DMA-3050).
Acceptable Format
Corrections to the DMA-3050 are acceptable when the incorrect information is
lined through once with the new information noted, initialed, and dated by the
assessor. Example: supervise toileting, bh 11/1/00
assist on and off toilet.
Conditions
Effective with date of service December 1, 2000, the following codes have a
maximum reimbursement rate reduction. Please make these changes on the Durable
Medical Equipment Fee schedule dated August 1, 2000. Providers are expected
to bill their usual and customary rate
| CODE | DESCRIPTION | MAXIMUM REIMBURSEMENT RATE |
|---|---|---|
| A4627 | Spacer, Bag or Reservoir, w/ or w/o mask, for use w/ metered dose inhaler | $ 35.37, new |
| A4614 | Peak Expiratory Flow Rate Meter, hand held | $ 25.60, new |
| W4721 | Group 27 Gel Cell Battery, each | $203.00, new |
| W4721 | Group 27 Gel Cell Battery, each | $152.25, used |
| W4721 | Group 27 Gel Cell Battery, each | $ 20.30, rented |
EDS, 1-800-688-6696 or 919-851-8888
| November 7, 2000 | December 5, 2000 | January 9, 2001 |
| November 14, 2000 | December 12, 2000 | January 17, 2001 |
| November 21, 2000 | December 21, 2000 | January 25, 2001 |
| November 30, 2000 |
| November 3, 2000 | December 1, 2000 | January 5, 2001 |
| November 10, 2000 | December 8, 2000 | January 12, 2001 |
| November 17, 2000 | December 15, 2000 | January 19, 2001 |
| November 22, 2000 |
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.
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| Paul R. Perruzzi, Director | John W. Tsikerdanos | ||
| Division of Medical Assistance | Executive Director | ||
| Department of Health and Human Services | EDS | ||
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