In This Issue...

All Providers:

• Additions to Covered Diagnostic and Therapeutic Radiopharmaceuticals
• Checkwrite Schedule
• Clinical Coverage Policies
• Low Osmolar Contrast Media – Billing  Guidelines
• Medicare Part D Web Page
• North Carolina Health Choice Children Age 0-5 Moving to Medicaid
• Seniors Health Insurance Information Program (SHIIP) “Train the Trainer” Sessions for Medicare Part D Prescription Drug Plan Benefit

Children’s Developmental Service Agencies:

• Correction to the September 2005 Bulletin Article

County Departments of Social Services:

• Level I Preadmission Screening Annual Resident Review (PASARR) Screens

Durable Medical Equipment (DME) Providers:

• Reimbursement Rate for HCPCS Code A4259, Lancets

Dialysis Providers:

• End-Stage Renal Disease

Health Choice Providers:

• Reimbursement Rate Changes

Home Health Providers:

• 2005 Home Health Fee Schedule
• Reimbursement Rate for HCPCS Code A4259, Lancets

Home Infusion Therapy Providers: 

• 2005 Home Infusion Therapy Fee Schedule

Hospice Providers: 

• Medicaid Reimbursement Rates for Hospice Services

Hospitals: 

• Level I Preadmission Screening Annual Resident Review (PASARR) Screens

Nursing Facility Providers:

• Level I Preadmission Screening Annual  Resident Review (PASARR) Screens

Personal Care Services (PCS) In Home Providers: 

• Directions to the Statewide Training for the New Personal Care Services Policy
• Statewide Training for the New Personal Care Services Policy

Pharmacy Providers:

• Access to Over-the-Counter Medications Covered by N.C. Medicaid
• Inaccurate Billing of Pharmacy Claims
• New Prior Authorization Procedures for OxyContin and Oxycodone Extended-Release Products
• Reporting Changes of Address and Contact Information

Prescribers:

• New Prior Authorization Procedures for OxyContin and Oxycodone Extended-Release Products

Providers of Targeted Case Management Services for Mentally Retarded/Developmentally Disabled Individuals:

• Updated Provider Qualifications and Documentation Requirements

Attention: All Providers

Additions to Covered Diagnostic and Therapeutic Radiopharmaceuticals

Effective with date of service December 31, 2004, CPT code 78990, provision of diagnostic radiopharmaceutical(s), was end dated by the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA).

The January 2005 general Medicaid bulletin listed diagnostic radiopharmaceutical agents to be billed with new HCPCS codes instead of CPT code 78990.  Please add the following agents with their appropriate codes to this list.  These agents are also covered effective with date of service January 1, 2005.

Additionally, CPT code 79900, Provision of therapeutic radiopharmaceutical therapy, was also end dated effective with date of service December 31, 2004.  Please use the following HCPCS codes, effective with date of service January 1, 2005, to bill for these therapeutic radiopharmaceuticals:

Providers must attach an invoice to the claim form when billing for each of the six agents listed above. An invoice must be submitted with each claim.  The paper invoice must indicate the name of the recipient, the recipient’s Medicaid identification (MID) number, the name of the agent, the dosage administered, and the cost per dose. 

Claims submitted without this information on the invoice will be denied.  Reimbursement is based on the actual invoice price of the agent only (less the shipping and handling).

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

Attention: All Providers

Clinical Coverage Policies

The following new or amended clinical coverage policies are now available on the Division of Medical Assistance’s web site:

• 3C – Personal Care Services
• 8C – Outpatient Behavioral Health Services Provided by Direct Enrolled Providers
• 8B – Inpatient Behavioral Health Services
• 9 – Outpatient Pharmacy Program
• 12A – Case Management Services for Adults and Children At-Risk for Abuse, Neglect or Exploitation

These policies supersede previously published policies and procedures.  Providers may contact EDS at 1-800-688-6696 or 919-851-8888 with billing questions.

Clinical Policy and Programs
DMA, 919-855-4260

Attention: All Providers

Medicare Part D Web Page

The Division of Medical Assistance has developed a new web page for the information about the Medicare Part D program.  Information for providers, counties, and Medicaid recipients.

Debbie Pittard, Medicare Part D Project Manager
DMA, 919-855-4000

Attention: All Providers

Low Osmolar Contrast Media - Billing Guidelines

Effective January 1, 2005, the N.C. Medicaid program covers low osmolar contrast media (LOCM) for all medically necessary radiological procedures furnished to non-hospital patients.  LOCM agents will continue to be covered in hospital outpatient and inpatient settings, billed with revenue codes.  LOCM is used in radiological diagnostic studies where, due to certain medical conditions, the use of other contrast material could be detrimental to a patient’s health.

For dates of service January 1, 2005 through March 31, 2005, providers must bill the following HCPCS codes for LOCM. Services billed with these codes after date of service March 31, 2005, will be denied.

Effective with date of service March 31, 2005, HCPCS codes A4644 through A4646 were end-dated and replaced with the following HCPCS codes.  For dates of service April 1, 2005 and after, the following codes must be billed for LOCM:

Providers must attach an invoice to the claim form when billing for four of the agents listed above, A4644, A4645, A4646 and Q9951. An invoice must be submitted with each claim.  The paper invoice must indicate the name of the recipient, the recipient’s Medicaid identification (MID) number, the name of the agent, the dosage administered, and the cost per dose. 

Claims submitted without this information on the invoice will be denied.  Reimbursement is based on the actual invoice price of the agent only (less the shipping and handling).

Effective with date of service October 31, 2005, HCPCS code A4648 will be end-dated. Claims billed with A4648 after date of service October 31, 2005, will be denied.

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

Attention: All Providers

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

During the 2005 session, the General Assembly passed legislation which will move children ages birth through five from the North Carolina Health Choice (NCHC) program to the North Carolina Medicaid program.  Effective January 1, 2006, children birth through five years of age with family income equal to or less than 200% of the federal poverty level will be eligible for Medicaid.  Children birth through five years of age currently enrolled in North Carolina Health Choice will be moved to the Medicaid program effective January 1, 2006.  The North Carolina Health Choice program will continue to cover children between the ages of six through eighteen with family income between 100% to 200% federal poverty level.

Some of the children moving from NCHC to Medicaid will have NCHC cards with expiration dates after January 1, 2006.  These cards will not be valid after December 31, 2005.  A blue monthly Medicaid card will be issued for these children in late December for January 2006.

For more information, refer to the December 2005 Special Bulletin, North Carolina Health Choice (NCHC) Children Ages Birth through 5 Move to Medicaid on DMA’s web site.

Medicaid Eligibility Unit
DMA, 919-855-4000

Attention: All Providers

SHIIP “Train the Trainer” Sessions for Medicare Part D Prescription Plan Benefit

The Seniors’ Health Insurance Information Program (SHIIP) in cooperation with the Area Agencies on Aging will be offering “Train the Trainer” sessions through November 9, 2005 for interested professionals, medical providers, aging network representatives, SHIIP volunteers, and anyone else that will be assisting with Medicare Part D Prescription Drug Plan enrollments or answering questions about plan enrollment.  Participants will learn about the general benefit regulations and about companies offering this program in North Carolina.  A demonstration of the internet-based tools provided by Medicare will also be provided during the training sessions.

For detailed information on scheduled sessions go to http://www.ncshiip.com and link to “Medicare Part D:  Train the Trainer.”  Space is limited, so please reserve a place by consulting the list of training sites, times and contact information.  Training materials will be made available.  There is no cost for the sessions.

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

Attention: Children’s Developmental Service Agencies

Correction to the September 2005 Bulletin Article

The attention line on the bulletin article “Clarification of First Treatment Date for Outpatient Specialized Therapies” incorrectly identified Children's Developmental Service Agencies as Community Development Service Agency.  We apologize for any inconvenience.

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

Attention: County Departments of Social Services, Hospitals, and Nursing Facility Providers

Level I Preadmission Screening Annual Resident Review (PASARR) Screens

It is the responsibility of the provider to ensure that PASARR Level I screens are received for evaluation by First Health Services Corporation (FHSC) and that PASARR Level I numbers are assigned.  Providers who utilize Provider Link to submit Level I screens must use an alternate method of submission if the Provider Link web site is down.  Providers may also submit Level I screens to FHSC through their web site or by fax (1-800-272-1752). 

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

Attention: Durable Medical Equipment and Home Health Providers

Reimbursement Rate for HCPCS code A4259, Lancets

Effective with date of service November 1, 2005, the maximum reimbursement rate for HCPCS code A4259, lancets, per box of 100, was changed to $12.06.  The change is required because Medicaid’s reimbursement rate to durable medical equipment suppliers for this item is based on Medicare’s rates for home health supplies.  Providers are reminded to bill their usual and customary rates.

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

Attention: Dialysis Providers

End-Stage Renal Disease

Effective with date of service November 1, 2005 the Division of Medical Assistance implemented a Medicaid composite rate change for Hemodialysis/Peritoneal Dialysis and Continuous Ambulatory Peritoneal Dialysis/Continuous Cycling Peritoneal Dialysis (CAPD/CCPD) – Inpatient or Home.

The rate change is based on CMS Manual System Pub. 100-02 Transmittal 27, Change Request 3554.  End stage renal disease (ESRD) composite rates are billed using codes RC821 (Hemoglobin), RC831 (Peritoneal, RC841 (CAPD) and RC 851 (CCPD).  The new ESRD composite rates reflect an 8.7 percent increase.

Adjustments will not be made to previously processed claims.

Note:  This increase corresponds with the Medicaid transition to the pricing of the Physician Drug Program from Average Wholesale Price minus 10% to Average Selling Price +6%, which is also effective November 1, 2005.

Sherrill Johnson, Rate Analyst
DMA, 919 855-4209

Attention: Health Choice Providers

Reimbursement Rate Changes

Effective January 1, 2006, the Health Choice reimbursement rates will be 115% of the Medicaid rates.  Effective July 1, 2006, the reimbursement rates will be 100% of the Medicaid rates.  This change will be implemented as a result of legislation passed in Session Law 2005-276.  The rate change only affects the services that are covered by the Medicaid program and will not affect the benefit package these clients are currently receiving.  Blue Cross/Blue Shield of N.C. continues to be the intermediary for the processing of these claims.

North Carolina Health Choice
1-800-422-4658

Attention: Home Health Providers

2005 Home Health Fee Schedule

The Home Health Fee Schedule will be posted November 1, 2005 and will include both the new codes added effective August 1, 2005 and those that have been updated effective November 1, 2005.  Because of the rate freeze, the rates will not increase; some rates could decrease to match the Medicare rate.  The Ostomy Codes (negotiated rates) will not be reduced to the Medicare rate until 01/01/2006.  The updated Home Health Fee Schedule will follow in the next Medicaid Bulletin article.

Rate Setting
DMA, 919-855-4200

Attention: Home Infusion Therapy Providers

2005 Home Infusion Therapy Fee Schedule

The Home Infusion Therapy rates have been updated as of November 1, 2005.  Because of the rate freeze the rates did not change so there are no changes to the Home Infusion Therapy Fee schedule except for the HCPCS code E0781 (ambulatory infusion pump which is now showing as a monthly rate instead of a daily rate).  As published in the October Medicaid Bulletin article, the maximum monthly rate is $264.87.  The actual fee schedule will appear in the next Medicaid Bulletin.

Rate Setting
DMA, 919-855-4200

Attention: Hospice Providers

Medicaid Reimbursement Rates for Hospice Services

Effective with date of service October 1, 2005, the maximum allowable rate for the following hospice services are as follows:

Note: At this time, the rate for RC 659 is still reimbursed at $131.14

Key to the Hospice Rate Table:

1.    A minimum of eight hours of continuous home care per day must be provided.

2.    There is a maximum of five consecutive days including the date of admission but not the date of discharge for inpatient respite care.  Bill for the sixth day and any subsequent days at the routine home care rate.

3.    When a Medicare/Medicaid recipient is in a nursing facility, Medicare is billed for routine or continuous home care, as appropriate, and Medicaid is billed for the appropriate long-term care rate.  When a Medicaid only hospice recipient is in a nursing facility, the hospice may bill for the appropriate long-term care rate in addition to the home care rate provided in RC 651 or RC 652.

4.    The hospice refunds any overpayments to the Medicaid program.

5.    Date of Discharge:  For the day of discharge from an inpatient unit, the appropriate home care rate must be billed instead of the inpatient care rate unless the recipient expires while inpatient.  When the recipient is discharged as deceased, the inpatient care rate (general or respite) is billed for the discharge date.

6.    Providers are expected to bill their usual and customary charges.  Adjustments will not be accepted for previously processed claims.

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

Attention: Personal Care Services

Statewide Training for the New Personal Care Services Policy

The Division of Medical Assistance (DMA) has scheduled training on the new Personal Care Services Policy for RN’s, Agency Administrators, and Owners during the month of November for registered nurses, agency administrators and agency owners. Please visit our web site for additional information.

The trainings are scheduled from 9:00 a.m. to 3:00 p.m. at each site. There is no registration involved; please choose the training site and date that is most convenient. Seating availability is based on first-come first-served basis. Most of the sites can accommodate 150 to 200 participants. Lunch will not be provided during the training. The training locations and dates to the training sites are included below. The directions are available on the next page.

Directions to the Personal Care Services Training Sites

James Sprunt Community College (Kenansville)
James Sprunt Community College is located on NC Highway 11, one mile south of Kenansville. It is approximately 80 miles south of Raleigh; 60 miles north of Wilmington traveling by Interstate 40. From I-40, use Exit 373. JSCC is about 5 miles from this exit using NC Hwy 903 to NC Hwy 11. Directions are clearly marked to the Hoffler Bldg.
From the Fayetteville:
Take NC Hwy. 24 East through Clinton and Warsaw.
From Jacksonville:
Take NC Hwy. 24Wwest through Richlands and Beulaville.
From the Kinston or Greenville:
Take NC Hwy. 11 South through Pink Hill.
From the Goldsboro:
Take NC Hwy 117 South to Warsaw; then NC Hwy 24-50 East to Kenansville.

Martin Community College (Williamston)
From the East:
Take Highway 64 West to the intersection at McDonald's in Williamston, turn left on Highway 13/17 Bypass, continue straight past the Comfort Inn on the right, after this intersection the highway becomes Old Highway 64 Bypass, continue approximately 2-3 miles, turn left on Kehukee Park Road. The receptionist in the main building #1(by the flag pole) can direct you to building #2.
From the West:
Take US64 East to Exit #512 (Prison Camp Road Exit), turn right on Prison Camp Road, turn left on Kehukee Park Road. College is on the right. The receptionist in the main building #1(by the flag pole) can direct you to building #2.
From the North:
Take Highway 13/17 South to Williamston, continue straight until it becomes Old Highway 64 Bypass, continue approximately 2-3 miles, turn left on Kehukee Park Road. The receptionist in the main building #1(by the flag pole) can direct you to building #2.
From the South:
Take US17 North, turn left to take the US64 ramp, take the Prison Camp Road Exit, turn right on Prison Camp Road, turn left on Kehukee Park Road. College is on the right. The receptionist in the main building #1(by the flag pole) can direct you to building #2.

Johnston Community College (Smithfield)
From Benson/South:
From I-95 North, take exit number 95 towards US-70-Business/Smithfield/Goldsboro. Turn left onto US-70-Business. At the second traffic light, turn left onto College Road. JCC is on the left. Go to the third building on the left and use the second parking lot. (Tallest bldg on campus)
From Wilson/North:
From I-95 South, take exit number 95 towards US-70-Business/Smithfield/Goldsboro. Turn right onto US-70-Business. At the second traffic light, turn left onto College Road. JCC is on the left. Go to the third building on the left and use the second parking lot. (Tallest bldg on campus)
From Raleigh/West:
From US-70 East, take the US-70-Business exit towards Smithfield. Continue on US-70-Business (Market Street) through Smithfield. Proceed under the railroad overpass and at the next traffic light, turn right onto College Road. JCC is on the left. Go to the third building on the left and use the second parking lot. (Tallest bldg on campus)
From Goldsboro/East:
From US-70 West, take the US-70-Business exit towards Smithfield. Continue on US-70-Business and go over I-95. At the second traffic light, turn left onto College Road. JCC is on the left. Go to the third building on the left and use the second parking lot. (Tallest bldg on campus)

Mitchell Community College (Statesville)
From I-77 South (Union Grove/Elkin):
Take Exit 50; turn right on East Broad Street and go approximately 1 mile until reaching the 2nd stoplight; turn left and at next stoplight turn right onto East Front Street and proceed approximately 1 mile; Continuing Education Center located on left.
From I-40 West (Mocksville/Winston-Salem): Take Exit 150; turn left on Hwy. 115 South/ North Center Street and go approximate 1/7 miles until reaching Jct. 64 (corner of Vance Hotel); turn right on West Front Street and proceed approximately .6 miles; Continuing Education Center located on left.
From I-77 North (Mooresville/Charlotte):
Take Exit 49B; turn right on Salisbury Road and go approximately 1.2 miles until reaching 2nd stoplight; turn left on East Front Street and proceed approximately 1 mile; Continuing Education Center located on left.
From I-40 East (Conover/Hickory):
Take Exit 148: turn right at stoplight onto Hwy. 64-90 East; turn left at next stoplight onto West Front Street. Travel approximately 2.3 miles. Continuing Education Center is located on right.
From Highway 70 West (Salisbury/Kannapolis):
Continue into Statesville; approximately 1 mile past J.C. Penney Distribution Center, turn right a stoplight onto Salisbury Road; travel approximately 1 mile; Continuing Education Center is located on left.

Mountain Area Health Education Center (Asheville)
From I-40 Eastbound:
Take Exit 50 and turn left onto Hendersonville Road (Biltmore Avenue). Or, from I40 Westbound, take Exit 50B onto Hendersonville Road (Biltmore Avenue). Stay in the right-hand lane through five (5) traffic lights. At the sixth (6) traffic light, turn left at the Mission Hospital emergency entrance. Turn right and then immediately right again into the deck. Drive up to the gate, press the speaker button and let the receptionist know you are here for a MAHEC program.
From 19-23 (I-26):
Take 240 East to Exit 5B (Charlotte Street). Exit right onto Charlotte Street. At the 4th light, make a left onto Biltmore Avenue. Proceed through 3 traffic lights. At the 4th light turn right into the Mission Hospitals Emergency entrance. Take the first right and then another immediate right into the MAHEC parking deck.

Attention: Pharmacy Providers

Access to Over-the-Counter Medications Covered by N.C. Medicaid

Pharmacy providers who do not have access to over-the-counter (OTC) medications covered by the NC Medicaid program may request that a specific OTC medication in one of the covered therapeutic drug classes be placed on the list. NC Medicaid will only consider requests for OTC medications for which the manufacturer has a rebate agreement with the Centers for Medicare and Medicaid Services. Please contact Sharon Greeson with EDS at Sharon.Greeson@eds.com to make your requests. Please indicate the current AWP and package size of the product being requested.

Refer to General Clinical Coverage Policy #A2 for a copy of the covered OTC drug list.

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

Attention: Pharmacy Providers

Inaccurate Billing of Pharmacy Claims

Providers of pharmacy services must price and bill all prescriptions for N.C. Medicaid recipients in accordance with N.C. Medicaid program policies.  Overpayments and invalid payments due to provider error are subject to recoupment.  Therefore, it is important that accurate pharmacy claims are submitted to prevent recoupments and delays in payment.  The Division of Medical Assistance monitors pharmacy providers who repeatedly fail to submit pharmacy claims in agreement with N.C. Medicaid pharmacy policy.  Repeated violators are subject to revocation of N.C. Medicaid provider status.

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

Attention: Pharmacists and Prescribers

New Prior Authorization Procedures for OxyContin and Oxycodone Extended-Release Products

Effective November 1, 2005, prior authorization requests for OxyContin and Oxycodone extended-release products will be accepted by fax only.  The signature of the prescriber on the request form continues to be required as an important safeguard against fraud and abuse.  Prior authorization criteria and request forms are available online at http://www.ncmedicaidpbm.com.

ACS, 1-866-246-8505
Fax:  1-866-246-8507

Attention: Pharmacy Providers

Reporting Changes of Address and Contact Information

Pharmacy providers must report changes of ownership, address and telephone number to the Division of Medical Assistance (DMA) using the Provider Change Form on DMA’s web site.

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

Attention: Providers of Targeted Case Management Services for Mentally Retarded/Developmentally Disabled Individuals

Updated Provider Qualifications and Documentation Requirements

The provider qualifications and documentation requirements listed in the July 2005 Special Bulletin for Targeted Case Management for Mentally Retarded/Developmentally Disable (MR/DD) Individuals have been revised. 

Behavioral Health Services
DMA, 919-855-4290

NCLeads Update

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

Thomas Liverman, Provider Relations
Office of MMIS Services,
919-647-8315

Proposed Clinical Coverage Policies

In accordance with Session Law 2005-276, proposed new or amended Medicaid clinical 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 web site.  Providers without Internet access can submit written comments to the address listed below.

Gina Rutherford
Division of Medical Assistance
Clinical Policy Section
2501 Mail Service Center
Raleigh, NC 27699-2501

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

2005 Checkwrite Schedule

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

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