November 2002 Medicaid Bulletin title image

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In This Issue..

All Providers:

Durable Medical Equipment Providers: Independent Practitioners: Local Education Agencies:
Nurse Practitioners: Optical Providers: Personal Care Services (in Private Residences) Providers: Physicians: Podiatrists: Prescribers and Pharmacists:


Attention: All Providers

Holiday Observance

The Division of Medical Assistance and EDS will be closed on Monday, November 11 in observance of Veteran's Day, and on Thursday, November 28, and Friday, November 29 in observance of Thanksgiving.

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


Attention: All Providers

Provider Information Update

The N.C. Medicaid program is updating provider files to include a fax number and e-mail address. These two methods of communication will complement the already existing methods of communication and provide a quick avenue for providers to receive information. Because only one e-mail address and one fax number can be entered for a provider number, please submit the most appropriate information for the provider number given. Please complete and return the Provider Update Form to EDS Provider Enrollment at the address listed below.

To report a change of ownership, name, address, tax identification number changes, group member, or licensure status, please use the Notification of Change in Provider Status form. Managed Care providers (Carolina ACCESS, ACCESS II, and ACCESS III) must also report changes in daytime or after-hours phone numbers and should report changes using the Carolina ACCESS Provider Information Change form.

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


Attention: All Providers

Routine Newborn Circumcision Coverage Policy

Effective with date of service December 1, 2002, optional newborn circumcisions will not be covered by the N.C. Medicaid program. Medically necessary circumcisions will continue to be covered for males of all ages. Providers must bill the most appropriate ICD-9-CM diagnosis code that supports medical necessity. Examples of medical necessity include: Claims without a diagnosis supporting medical necessity will be denied.

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


Attention: All Providers

Proposed Medical Coverage Policies

In accordance with Session Law 2001-424, Senate Bill 1005, proposed new or amended Medicaid medical coverage policies are available for review and comment on DMA's website. To submit a comment related to a policy, refer to the instructions on the website. Providers without Internet access can submit written comments to the address listed below.

Darlene Creech
Medical Policy Section
Division of Medical Assistance
2511 Mail Service Center
Raleigh, NC 27699-2511

The initial comment period for each proposed policy is 45 days. An additional 15-day comment period will follow if a proposed policy is revised as a result of the initial comment period.

Darlene Creech, Medical Policy Section
DMA, 919-857-4020


Attention: All Providers

Revised Medicaid Claim Adjustment Request Form

The Medicaid Claim Adjustment Request form has been revised. The revision of the "EDS Use Only" field was necessary to accommodate placement and scanning of the internal claim number (ICN) that is assigned when processing adjustments. Please begin using this revised form when submitting claim adjustments. A copy of the revised Medicaid Claim Adjustment Request Form on DMA's website. Providers may contact EDS Provider Services with questions about processing adjustment requests.

Medicaid Claim Adjustment Request Form

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


Attention: All Providers

Synagis/RespiGam Coverage Criteria

The N.C. Medicaid program requires prior authorization for the drugs Synagis (palivizumab) 50 mg or 100 mg vials and RespiGam (respiratory syncytial virus immune globulin human) for respiratory syncytial virus (RSV) prophylaxis.

The following criteria are used to determine eligibility for receiving prior approval for either of these drugs:

1.    The patient must be:

    1. an infant less than 24 months of age at the start of the RSV season with chronic lung disease (CLD) that necessitated treatment within the last six months, or
    2. a neonate born between 28 weeks and 32 weeks gestation without CLD who is less than 6 months of age at the start of the RSV season, or
    3. a neonate born at 28 weeks gestation or less without CLD who is less than 12 months of age at the start of the RSV season, or
    4. a neonate born between 32 weeks and 35 weeks gestation without CLD who is less than 6 months of age at the start of the RSV season and who has other medical illnesses or two or more risk factors that predispose the patient to respiratory complications such as:
and
2.    The drug must be used for prevention of RSV and not for treatment.

3.    Acyanotic congenital heart disease is not a contraindication.

4.    The drug is approved for once-a-month administration for up to six doses during the RSV season as documented by the Center for Disease Control's annual guidelines (generally November through March or April).

5.    The physician must include the following information in his/her own handwriting on the face of the prescription:

6.    To expedite the process and allow for immediate discussion, the prior authorization request must be made by the physician's office.

ACS State Healthcare administers the Medicaid Drug Prior Approval program. Providers may call ACS toll free at 866-246-8505 for additional information. The ACS State Healthcare website can be accessed at http://www.ncmedicaidpbm.com.

Melissa Weeks, Medical Policy Section
DMA, 919-857-4020


Attention: Durable Medical Equipment Providers

Return Address on Certificate of Medical Necessity and Prior Approval Form

Effective November 1, 2002, all three copies of each Certificate of Medical Necessity and Prior Approval (CMN/PA) form submitted to EDS for review must include the provider's return address in block 29 on the form. CMN/PA forms without the return address on all three copies will not be reviewed and will be returned to the provider for correction.

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


Attention: Optical Providers

Billing Dispensing Fees for Glasses that Cannot be Dispensed

Because EDS no longer retains the top copy of the Request for Prior Approval for Visual Aids, providers must include a copy of the request form along with the glasses, the claim, and required documentation when billing dispensing fees for glasses that cannot be dispensed.

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


Attention: Podiatrists, Physicians, and Nurse Practitioners

Modifier YR - Routine Foot Care

Effective with date of service December 1, 2002, state-created modifier YR will be end-dated to comply with the implementation of national codes mandated by the Health Insurance Portability and Accountability Act (HIPAA). Routine foot care in the absence of qualifying conditions remains non-covered. Refer to the June 1999 and November 1999 general Medicaid bulletins for complete information on qualifying circumstances and class findings required for coverage.

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


Attention: Personal Care Services (in Private Residences) Providers

Change in Monthly Limit for Medicaid Personal Care Services in Private Residences

Effective with date of service December 1, 2002, the N.C. Medicaid program will cover no more that 240 units (60 hours) per calendar month of Personal Care Services (PCS) in a private residence for a client. This change is due to a provision in the state budget. There is no change to the maximum daily limit of 14 units (3.5 hours). Any time billed for a registered nurse (RN) will continue to count against the daily and monthly limits. PCS providers are to follow the instructions in this article to make any amendments to the PCS plan of care that are required to implement this change.

Guidance on care plan changes is found in subsection 6.8, Changing the Plan of Care, of the N.C. Medicaid Community Care Manual. The procedures in subsection 6.8 are modified as follows to reduce the paperwork for providers and physicians when implementing the new monthly limit. The modifications apply only to this implementation. Providers must follow the guidance in subsection 6.8 for all other care plan changes.

Physician Signature Requirement

Physician orders are not required by the Division of Medical Assistance (DMA) for the following changes to implement the new monthly limit:

Physician orders are required by DMA for a change that deletes a personal care or medical monitoring task. If all of the personal care tasks are eliminated from a visit, the visit does not qualify for Medicaid reimbursement as PCS. The primary purpose of each PCS visit must be to perform personal care for the client.

Implementing the Change

Providers may begin initiating the paperwork for any changes required in the plan of care, including any required physician orders. Providers must ensure that all of the paperwork clearly shows the effective date of the change. If a change unrelated to the implementation of the new monthly limit is needed, providers must follow the procedures in subsection 6.8 of the N.C. Medicaid Community Care Manual.

Example: A provider completes all of the documentation for the December 1, 2002, date of service change on November 12, 2002. On November 15, 2002, the provider learns that the client needs a change to the current plan of care. The provider makes the November 15 change for the balance of November according to subsection 6.8 of the manual, including the physician's signature requirements in that subsection. If the November 15 plan of care needs to be revised to implement the new monthly limit, the provider may apply the modifications included in this article to make that change.

Other Documentation Requirements

Providers are reminded to be sure each of their PCS clients meets the criteria for the service, the tasks performed for the client are allowed by Medicaid policy, and the time billed to Medicaid is appropriate for the performed tasks.

Adelle Kingsberry, Community Care Section, Medical Policy
DMA, 919-857-4021


Attention: Prescribers and Pharmacists

"Medically Necessary" Replaces "Dispense as Written"

Effective January 1, 2003, the words "medically necessary" written on a prescription will be necessary to dispense a trade or brand name drug, except for antipsychotic drugs and drugs listed in the narrow therapeutic index. "Dispense as written" will no longer be valid. Senate Bill 1115, Section 21.19(h) Dispensing of Generic Drugs mandates this change.
 
Section 21.19(h) Dispensing of Generic Drugs. - Notwithstanding G.S. 90-85.27 through G.S. 90-85.31, or any other law to the contrary, under the Medical Assistance Program (Title XIX of the SSA), and except as otherwise provided in this subsection for atypical antipsychotic drugs and drugs listed in the narrow therapeutic index, a prescription order for a drug designated by a trade or brand name shall be considered to be an order for the drug by its established or generic name, except when the prescriber has determined, at the time the drug is prescribed, that the brand name drug is medically necessary and has written on the prescription order the phrase "medically necessary." An initial prescription order for an atypical antipsychotic drug or a drug listed in the narrow therapeutic drug index that does not contain the phrase "medically necessary" shall be considered an order for the drug by its established or generic name, except that a pharmacy shall not substitute a generic or established name prescription drug for subsequent brand or trade name prescription orders of the same prescription drug without explicit oral or written approval of the prescriber given at the time the order is filled. Generic drugs shall be dispensed at a lower cost to the Medical Assistance Program rather than trade or brand name drugs. As used in this subsection, "brand name" means the proprietary name the manufacturer places upon a drug product or on its container, label, or wrapping at the time of packaging; and "established name" has the same meaning as in section 502(e) (3) of the Federal Food, Drug, and Cosmetic Act as amended, 21 U.S.C. § 352 (e) (3).


Please note that the pharmacist is not required to call the prescriber to substitute a generic drug if "medically necessary" is absent from the prescription unless the prescription is for an atypical antipsychotic drug or a drug listed in the narrow therapeutic drug index.

Melissa Weeks, Medical Policy Section
DMA, 919-857-4020


Attention: Prescribers and Pharmacists

Senior Care Drug Assistance Program

The North Carolina Health and Wellness Trust Fund Commission is implementing a senior prescription drug assistance and medication management program called Senior Care. The Senior Care program will be funded for three years. It is estimated that over 50,000 senior enrollees will receive assistance through the program. Senior Care will cover 60 percent of the first $1,000 of the cost of drugs needed for the treatment of COPD, cardiovascular disease or diabetes mellitus. The program employs an open formulary.

Applications are available at distribution points throughout the state such as local senior centers, departments of social services, departments of public health, hospitals, health centers, and pharmacies. Adults over the age of 65 residing in North Carolina who meet specific income criteria are eligible to apply for the Senior Care program. Senior adults who have third party insurance coverage or are enrolled with Medicaid are not eligible to apply for Senior Care. Seniors who apply and are deemed eligible can begin using their Senior Care card on November 1, 2002.

Senior Care has contracted with ACS to serve as the pharmacy benefit manager for the program. ACS will process enrollment applications, pay claims, contract with pharmacies, and provide customer service. ACS is currently in the process of contracting with pharmacies throughout the state to participate in their network for Senior Care.

Pharmacists can contact at ACS at 1-866-226-1388.

Michael Keough
Office of Rural Health, 919-733-2040


Attention: Independent Practitioners and Local Education Agencies

Independent Practitioners and Local Education Agencies Seminars

Seminars for Independent Practitioners (IPs) and Local Education Agencies (LEAs) are scheduled for December 2002. The seminars will consist of four service-specific sessions and will focus on the claim filing process and Y code conversions to standard national codes as mandated by the Health Insurance Portability and Accountability Act (HIPAA).

Due to limited seating and fire code restrictions, preregistration is required and limited to two staff members per office. Unregistered providers are welcome to attend if space is available. Providers may register for the IP and LEA seminars by completing and submitting the Independent Practitioners and Local Education Agencies Seminars Registration form, or providers can register online beginning November 1, 2002. Please indicate on the registration form the session(s) you plan to attend.

Providers must access and print the PDF version of the December 2002 Special Bulletin VII, HIPAA Code Conversion for Independent Practitioners and Local Education Agencies and bring it to the seminar. Providers may choose to print only those sections that pertain to the specific service session they plan to attend.

The seminars in Hickory and Greenville are scheduled to begin at 9:30 a.m. and end at 1:15 p.m. Two seminars are scheduled in Raleigh. The first seminar is scheduled to begin at 8:30 a.m. and end at 11:30 a.m. The second session is scheduled to begin at 1:00 p.m. and end at 4:00 p.m. Only one session will be provided on Respiratory Therapy. It is scheduled to being at 11:30 a.m. and end at 12:00 p.m. Providers may register for the morning seminar and stay through 12:00 p.m. for the Respiratory Therapy session or providers may register for the afternoon seminar and arrive at 11:30 a.m. for the Respiratory Therapy session.

Hickory, Tuesday, December 3, 2002
Greenville, Wednesday, December 4, 2002
Session Time
Respiratory Therapy  9:30 a.m. to 10:00 a.m. 
Speech/Language and Audiology  10:15 a.m. to 11:30 a.m. 
Physical and Occupational Therapy  11:45 a.m. to 12:30 p.m. 
Psychological Therapy  12:45 p.m. to 1:15 p.m. 

Raleigh, Friday, December 6, 2002
Morning Session Time
Speech/Language and Audiology  8:30 a.m. to 9:45 a.m. 
Physical and Occupational Therapy  10:00 a.m. to 10:45 a.m. 
Psychological Therapy  11:00 a.m. to 11:30 a.m. 
Only Session Time
Respiratory Therapy  11:30 a.m. to 12:00 p.m. 
Afternoon Session Time
Speech/Language and Audiology  1:00 p.m. 2:15 p.m. 
Physical and Occupational Therapy  2:30 p.m. to 3:15 p.m. 
Psychological Therapy  3:30 p.m. to 4:00 p.m. 

Directions to the Independent Practitioners and Local Education Agencies Seminars

Hickory - Park Inn Gateway Conference Center
909 US Highway 70 SW
Take I-40 to exit 123. Follow signs to Highway 321 North. Take the first exit (Hickory exit) and follow the ramp to the stoplight. Turn right at the light onto Highway 70. The Gateway Conference Center is on the right.

Greenville - Brody Auditorium
Brody Medical Science Building, 600 Moye Boulevard
From Highway 264 (becomes Stantonsburg Road into Greenville), turn onto Moye Boulevard. Turn left onto North Campus Loop. The Brody Building is the nine-story complex. At the front entrance, walk through the lobby and take the first left to the Auditorium.

Raleigh - Andrews Conference Center
WakeMed, 3000 New Bern Avenue
Driving and Parking Directions
Take the I-440 Raleigh Beltline to exit 13A, New Bern Avenue.

Paid parking ($3.00 maximum per day) is available on the top two levels of parking deck P3. To reach the parking deck, turn left at the fourth stoplight on New Bern Avenue, and then turn left at the first stop sign. Parking for oversized vehicles is available in the overflow lot for parking deck P3. Handicapped accessible parking is available in parking lot P4, directly in front of the conference center.

To enter the Andrews Conference Center, follow the sidewalk toward New Bern Avenue past the Medical Office Building to entrance E2 of the William F. Andrews Center for Medical Education.

Illegally parked vehicles will be towed. Parking is not permitted at East Square Medical Plaza, Wake County Human Services or in parking lot P4 (except for handicapped accessible parking).

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



 
 

Checkwrite Schedule
November 5, 2002  December 10, 2002 
November 13, 2002  December 17, 2002 
November 19, 2002  December 27, 2002 
November 26, 2002   

Electronic Cut-Off Schedule
November 1, 2002  December 6, 2002 
November 8, 2002  December 13, 2002 
November 15, 2002  December 20, 2002 
November 22, 2002 

Electronic claims must be transmitted and completed by 5:00 p.m. on the cut-off date to be included in the next checkwrite. Any claims transmitted after 5:00 p.m. will be processed on the second checkwrite following the transmission date.
 
 
 
_____________________ _____________________
Nina M. Yeager, Director Ricky Pope
Division of Medical Assitance Executive Director
Department of Health and Human Services EDS

 
 
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