November 2009
Medicaid Bulletin

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In This Issue . . .

• Checkwrite Schedule
• EPSDT Applicability to Medicaid Services and Providers
• Proposed Clinical Coverage Policies

All Providers:

• Dietary Evaluation and Counseling
• EDS Announces New Name
• Electronic Claim Submission EOB Code
• Electronic Funds Transfer
• Influenza A (H1N1) 2009 Monovalent Vaccine and Reimbursement Guidelines for 2009/2010
• North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool
• Notice of Medicaid Identification Card Changes
• Obtaining Informed Consent on Sterilization Consent Forms
• Paper Claim Submissions
• Prior Authorization for Non-emergency Outpatient High-tech Radiology and Ultrasound Procedures:  Update
• Retroactive Eligibility for Family Planning Waiver
• Suspension of New Enrollment for At-Risk Case Management Providers
• Urine Drug Testing

CAP/MR-DD Providers:

• Mental Health Cost Report Training Sessions

Children’s Developmental Service Agencies:

• Changes to Outpatient Specialized Therapies

Durable Medical Equipment Providers:

• Coverage for Servicing and Repairing Durable Medical Equipment
• Coverage for Standers
• Medically Necessary Incontinence, Ostomy, and Urological Supplies
• Prodigy Diabetic Supplies Under the Durable Medical Equipment and Pharmacy Programs

Enhanced Behavioral Health (Community Intervention) Services Providers:

• Mental Health Cost Report Training Sessions
• Provider Verification and Credentialing Activities

Health Departments:

• Changes to Outpatient Specialized Therapies

Home Health Agencies:

• Changes to Outpatient Specialized Therapies

Hospital Outpatient Clinics:

• Changes to Outpatient Specialized Therapies

Independent Practitioners:

• Changes to Outpatient Specialized Therapies

Local Education Agencies:

• Changes to Outpatient Specialized Therapies

Local Management Entities:

• Changes to Outpatient Specialized Therapies
• Mental Health Cost Report Training Sessions

Nurse Practitioners:

• Canakinumab Single-use Vials (180 mg) (Ilaris, HCPCS Code J3590): Billing Guidelines
• Infliximab (Remicade, HCPCS Code J1745) and Rituximab (Rituxan, HCPCS Code J9310): New Billing Guidelines

Pharmacists:

• New Prior Authorization Requirements for Leukotriene Modifiers
• Prodigy Diabetic Supplies Under the Durable Medical Equipment and Pharmacy Programs

Physicians:

• Canakinumab Single-use Vials (180 mg) (Ilaris, HCPCS Code J3590): Billing Guidelines
• Changes to Outpatient Specialized Therapies
• Infliximab (Remicade, HCPCS Code J1745) and Rituximab (Rituxan, HCPCS Code J9310): New Billing Guidelines

Prescribers:

• New Prior Authorization Requirements for Leukotriene Modifiers

Residential Child Care Treatment Facilities:

• Mental Health Cost Report Training Sessions

Attention:  All Providers

EDS Announces New Name

In August 2008, Hewlett-Packard (HP) acquired EDS, fiscal agent for the N.C. Medicaid Program.  As a result of this acquisition, EDS is changing its name to HP Enterprise Services.

North Carolina Medicaid providers will not be affected by this change and will probably notice very few changes.  Providers will begin to see the HP logo or the HP Enterprise Services name on correspondence and forms.  The mailing address is not changing but providers should address the mail to HP Enterprise Services.  E-mail correspondence will come from an “@hp.com” e-mail address rather than an “@eds.com” e-mail address.  And, providers will hear the HP name when contacting the Raleigh call center.  Think of it as a sports team changing jerseys.  The same players are on the field working hard to deliver the outstanding Medicaid services you’ve come to expect from a trusted business ally.

The new name reflects HP’s commitment to the longtime success of its clients.  It also reminds our clients of the enhanced value they now get from the combination of EDS’ proven operational excellence PLUS the best-in-class technology of HP.

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

Attention:  All Providers

Electronic Funds Transfer

The N.C. Medicaid Program will no longer issue paper checks for claims payments.  All payments will be made electronically by automatic deposit to the account specified in the provider's Electronic Funds Transfer (EFT) Authorization Agreement for Automatic Deposits.

Providers must complete and submit an EFT Authorization Agreement immediately to ensure that there is no disruption to payments.  Claims will suspend if an EFT Authorization Agreement has not been submitted to and processed by the N.C. Medicaid Program.

Below are fax numbers available for providers to send EFT Authorization Agreements to HP Enterprise Services (EDS):

• 919-816-3186
• 919-816-3181
• 919-816-4399

The e-mail address for submitting EFT Authorization Agreements to HP Enterprise Services (EDS) is NCXIXEFT@eds.com.

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

Attention:  All Providers

Electronic Claim Submission EOB Code

Effective with date of processing October 2, 2009, the N.C. Medicaid Program requires all providers to file claims electronically.  Claims received on or after October 2, 2009, are subject to denial if the claim is not in compliance with the electronic claim mandate.  Information on the electronic claim mandate, originally published in the July 2009 Medicaid Bulletin, is available on DMA’s Budget Initiatives web page.

Prior to submitting electronic claims, providers must have an Electronic Claim Submission (ECS) Agreement on file with N.C. Medicaid.  If an ECS Agreement is not on file, providers may obtain the form on the NC Tracks Provider Forms web page.

To prepare for the electronic claim submission requirement, providers should familiarize themselves with the following EOB code.

EOB 8700 – Per legislative mandate this Medicaid claim must be filed electronically for adjudication.

If a paper claim is submitted and is not included on the list of ECS exceptions, the claim will be denied.  The list of exceptions to the requirement for electronic claim submissions has been revised and is available on DMA’s ECS Exceptions web page.  Only claims that comply with these exceptions may be submitted on paper.  All other claims are required to be submitted electronically.

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

• Budget Initiatives Web Page
• ECS Exceptions Web Page
• Electronic Claim Submission, July 2009 Medicaid Bulletin
• NC Tracks Provider Forms Web Page

Attention: All Providers

Paper Claim Submissions

If a claim meets one of the exceptions to the electronic claims submission requirement, providers should submit the original claim and not a carbon copy or photocopy of the claim.  Because paper claims are manually keyed into the system, submitting the original will decrease the number of denials that providers receive due to keying errors.

When completing the paper claim form, use black ink only.  Do not submit carbon copies or photocopies.  HP Enterprise Services (EDS) uses optical scanning technology to store an electronic image of the claim and the scanners cannot detect carbon copies, photocopies, highlighted data or any color of ink other than black.  For auditing purposes, all claim information must be visible in an archive copy.  Carbon copies, photocopies, and claims containing a color of ink other than black will not be processed and will be returned to the provider.

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

ECS Exceptions Web Page

Attention:  All Providers

Urine Drug Testing

Providers are reminded to use the appropriate codes when billing for urine drug testing.  Providers must use CPT code 80100 (drug screen, qualitative; multiple drug classes chromatographic method, each procedure) or CPT code 80101 (single drug class method [eg, immunoassay, enzyme assay], each drug class) for initial drug screenings. 

CPT code 80102 (drug confirmation, each procedure) must be used by laboratories for drug confirmation.  When sending a urine drug test to an outside laboratory for confirmation, the provider should specify the positive results of the drug screen that need to be confirmed.  The laboratory should confirm only the drugs that were positive and bill CPT code 80102 with the correct number of units. 

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

Attention:  All Providers

Obtaining Informed Consent on Sterilization Consent Forms

DMA has become aware that some providers have been referring Medicaid recipients to the local department of social services (DSS) to complete the federally mandated Sterilization Consent form and to obtain informed consent prior to a sterilization procedure.  According to Clinical Coverage Policy 1E-3, Sterilization Procedures, “Providers must complete a valid sterilization consent form prior to rendering a sterilization procedure.” 

Moreover, review of federal guidelines located in 42 CFR 441.257 and 441.258 indicates that an individual who can answer specific questions about the procedure and potential complications should be counseling the recipient.  Therefore, it is the medical provider’s responsibility to obtain informed consent and this should not be delegated to DSS. 

Beginning December 1, 2009, consent forms cannot be completed by DSS.  Any consent form completed by a DSS agency on which the date completed is on or after December 1, 2009, will be considered an invalid consent.  Claims submitted with these consent forms on file will be denied.

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

Attention:  All Providers

Suspension of New Enrollment for At-Risk Case Management Providers

DMA has temporarily suspended enrollment for providers of Case Management Services for Children and Adults Who Are at Risk for Abuse, Neglect or Exploitation.  Due to this action, the Division of Aging and Adult Services (DAAS) is not currently accepting applications for certification as an “At Risk Case Management Certified Agency” from any provider agencies except local county departments of social services.  This policy will be evaluated at the conclusion of the work of the Consolidated Case Management Task Force and subsequent payment study.  We apologize for any inconvenience due to these actions.

Julie Budzinski
DMA, 919-855-4368

Charles Williams
DAAS, 919-733-3818

Attention:  All Providers

North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool

In September 2009, the N.C. Medicaid Program implemented the North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool.  This tool allows providers to access electronic recipient eligibility information via the North Carolina Electronic Claims Submission (NCECS) Web Tool.

Use of this tool allows providers to immediately verify recipient information such as

• Current eligibility
• Medicaid program (benefit category)
• Medicare participation
• CCNC/CA (Carolina ACCESS) participation
• Transfer of asset information
• Other insurance information

This is the same information that providers receive today through the Automated Voice Response (AVR) system but the tool is quicker and easier to use.  In order to use this tool, providers must have access to the NCECSWeb Tool.  DMA encourages you to begin immediately the process of obtaining this access.

Providers who currently have an NCECSWeb logon ID and password can utilize this same logon information to access recipient eligibility verification.  You do not need to take any further action.

Providers who do not currently have access to the NCECSWeb must take the following action.

Step One:

Submit a completed and signed Electronic Claims Submission (ECS) Agreement to CSC.  (Refer to the
NC Tracks Provider Forms web page for a copy of the form and instructions.)

Note:  Providers who have previously submitted the ECS Agreement do not need to resubmit the form.

Step Two:

Contact the HP Enterprise Services (EDS) Electronic Commerce Services Unit (1-800-688-6696 or
919-851-8888, option 1) to obtain instructions and a logon ID and password for the NCECSWeb Tool.

For additional information on verifying recipient eligibility, refer to the Basic Medicaid Billing Guide.  For detailed information on the NCECSWeb Tool, refer to the September 2009 Special Bulletin, North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool Instruction Guide.

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

• Automated Voice Response (AVR) System Instructions
• Basic Medicaid Billing Guide
• North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool
• NC Tracks Provider Forms Web Page
• North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool Instruction Guide, September 2009 Special Bulletin

Attention:  All Providers

Notice of Medicaid Identification Card Changes

On September 8, 2009, the N.C. Medicaid Program began issuance of one Medicaid identification (MID) card per year to each recipient (refer to the September 2009 Medicaid Bulletin article titled Notice of Medicaid Identification Card Changes).  The new annual cards (see new card sample) are printed on gray card stock.  The blue, pink, green, and buff-colored MID cards are being phased out.  The new cards include the case head name, recipient name, MID number, issue date, and Community Care of North Carolina/Carolina ACCESS (CCNC/CA) primary care provider information (if applicable).  The new cards do not indicate dates of eligibility, Medicaid program or special coverage.  Recipients who are issued new cards may have been approved for prior months only, the current month only, or an ongoing period of up to 12 months.

Because the new card no longer serves as proof of eligibility, it is essential that at each visit providers verify the recipient’s

• Identity (if an adult)
• Current eligibility
• Medicaid program, including restrictive coverage such as Family Planning Waiver and Medicaid for Pregnant Women
• Special coverage (Community Alternatives Program, Program of All-inclusive Care for the Elderly)
• CCNC/CA primary care provider information
• Other insurance information

To verify eligibility, a provider can choose to use the North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool (NCECSWeb Tool), the real time or batch Eligibility Verification System (EVS), or the HP Enterprise Services (EDS) Automated Voice Response (AVR) system.  Information on how to enroll and use the NCECSWeb tool can be found in the September 2009 Special Bulletin, North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool Instruction Guide.  For information regarding real-time and batch eligibility, contact the HP Enterprise Services (EDS) ECS Unit at 1-800-688-6696 (option 1).  Information about the AVR system is available in the July 2001 Special Bulletin, Automated Voice Response (AVR) System Provider Inquiry Instructions.  To access the AVR system, call HP Enterprise Services (EDS) at 1-800-723-4337. 

The methods listed above will not only serve to verify eligibility, but also to inform the provider as to whether the recipient is entitled to any special services, such as the Program of All-inclusive Care for the Elderly (PACE) or the Community Alternatives Program, or enrolled in a restrictive program, such as the Family Planning Waiver or Medicaid for Pregnant Women.  Recipients enrolled in PACE receive their medical care exclusively through the PACE organization.  When using the AVR system, it is, therefore, important that providers listen to the entire recorded message and follow the prompts as directed or important parts of eligibility information may be missed.

Each year a recipient will receive a new card.  The new card will be issued on the anniversary of the issuance of the previous card.  When the recipient receives the card depends on the month in which the recipient received the previous card.  Recipients should be referred to their local department of social services to request a replace card, if needed.

Medicaid Eligibility Unit
DMA, 919-855-4000

• Automated Voice Response (AVR) System
• Automated Voice Response (AVR) System Provider Inquiry Instructions, July 2001 Special Bulletin
• CCNC/CA Primary Care Provider Information
• Example of New Medicaid Identification Card
• North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool
• Notice of Medicaid Identification Card Changes, September 2009 Medicaid Bulletin
• Family Planning Waiver
• Medicaid for Pregnant Women
• Community Alternatives Program
• Program of All-inclusive Care for the Elderly

Attention:  All Providers

Influenza A (H1N1) 2009 Monovalent Vaccine and Reimbursement Guidelines for 2009/2010

The N.C. Medicaid Program reimburses for vaccines in accordance with guidelines from the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP).  ACIP recommendations on 2009/2010 H1N1 influenza vaccine can be found on the CDC website at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5810a1.htm?s_cid=rr5810a1_e.

N.C. Distribution Program for the H1N1 Vaccine

The federal government has purchased the H1N1 influenza vaccines to distribute for administration to persons of all ages, based on the established priority groups.  H1N1 vaccine will not be available for providers to purchase.  The majority of the H1N1 vaccine manufactured is expected to be injectable, with the balance being intranasal.  The N.C. Immunization Branch of the Division of Public Health will distribute the H1N1 vaccines to providers.

Reporting the H1N1 Influenza Vaccine and Billing for Administration Costs

The H1N1 vaccine, regardless of formulation, CANNOT be billed to Medicaid.  The CPT code for all formulations of the H1N1 vaccine is 90663.  All providers are required to report the vaccine code, with a charge of $0.00.  Providers may bill the N.C. Medicaid Program for the administration costs of the vaccines.  Because the live intranasal seasonal (FluMist, CPT code 90660) AND live intranasal H1N1 influenza vaccines (CPT code 90663) CANNOT be administered simultaneously (same day), Medicaid cannot cover these two procedure codes billed on the same day.

The following tables indicate the vaccine code that must be reported for all of the formulations of the H1N1 influenza vaccine.  The tables also indicate the administration codes that can be billed by providers, depending on the age of the recipient.  The ICD-9-CM diagnosis for H1N1 influenza vaccine, V04.81, may be billed, as appropriate.

Note:  The information in the following tables is not detailed billing guidance.  Specific information on billing all immunization administration codes for recipients 0 through 20 years of age (6 months through 20 years of age for influenza vaccines) can be found in the April 2009 Special Bulletin, Health Check Billing Guide 2009.

Table 1:  H1N1 Influenza Billing Codes for Recipients Age 6 Months through 20 Years of Age

All Providers

Use the following CPT procedure code to report (with a charge of $0.00) the H1N1 vaccine administered to a recipient 6 months through 20 years of age. 

Private Providers, Federally Qualified Health Centers, Rural Health Clinics, and Local Health Departments

The table below includes options for billing H1N1 as the ONLY vaccine administered on that day to a recipient 6 months through 20 years of age that day or as an additional vaccine administered that day.  An injectable vaccine administered on the same day as an oral or intranasal vaccine should be considered the primary administration code.

Table 2:  H1N1 Influenza Billing Codes for Recipients 21 Years of Age and Older

All Providers

Use the following CPT procedure code to report an H1N1 influenza vaccine administered to a recipient 21 years of age and older.

Private Providers and Local Health Departments

Use the following codes to bill for an administration fee for recipients 21 years of age or older.  The table below includes options for billing H1N1 as the ONLY vaccine administered that day or as an additional vaccine administered that day.  An injectable vaccine administered on the same day as an oral or intranasal vaccine should be considered the primary administration code.

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

Note:   In addition to local health departments and other identified providers, the federal government is supplying the H1N1 vaccine to federally qualified health centers (FQHCs) and rural health clinics (RHCs) at no charge.  Therefore, FQHCs and RHCs cannot bill Medicaid for the cost of the vaccine for any recipient.  Follow the guidelines in the April 2009 Special Bulletin, Health Check Billing Guide 2009 for instructions on billing administration codes for recipients 0 through 20 years of age (6 months through 20 years of age for influenza vaccines) under the C suffix provider number for H1N1 influenza vaccine.  For recipients 21 years of age and older seen in an FQHC or RHC, the cost of the administration may be included on the cost report for those recipients.

Private providers, local health departments, FQHCs, and RHCs may bill Medicaid for the administration fee for the H1N1 vaccine administered to Medicaid Pregnant Women (MPW) recipients.  Refer to the guidelines above. 

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

Attention:  All Providers

Dietary Evaluation and Counseling

Providers are reminded that the diagnosis codes listed in Attachment A of the Clinical Coverage Policy 1-I, Dietary Evaluation and Counseling, must be used when a pregnant or postpartum recipient is 21 years of age or older. Children ages 0 through 20 years are not limited to the diagnosis list in Attachment A of the policy.

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

Attention:  All Providers

Prior Authorization for Non-emergency Outpatient High-tech Radiology and Ultrasound Procedures:  Update

Prior authorization will be required for non-emergency outpatient high-tech radiology and ultrasound procedures.  The recipient categories exempt from this requirement been updated to include:

• Recipients with emergency coverage for approved dates of service
• Undocumented or documented refugees
• Recipients incarcerated or confined in a mental institution
• Recipients enrolled in Aid to the Aged, Special Assistance for the Blind, and Special Assistance to the Aged

The other recipient categories exempt from prior authorization are:

• Recipients who are dually eligible for Medicare and Medicaid
• Recipients with third-party insurance
• Recipients with PACE
• Recipients with Health Choice
• Recipients with Family Planning Waiver
• Recipients in the Health Insurance Premium Payments Program

Dates related to the implementation of prior authorization (PA) of high-tech radiology and ultrasound procedures are as follows:

MedSolutions will accept authorization requests by web, phone, and fax.  Please visit the MedSolutions website to register for PA services and to view MedSolutions’ imaging guidelines. 

The ordering physician is required to obtain the PA.  This authorization should be obtained before the testing is scheduled.  The authorization number should be provided to the facility performing the test.  The authorization is good for 30 days following its issuance.

Procedures performed during an inpatient stay, during an emergency department visit, during an observation stay or as a referral from a hospital emergency department do not require PA.  Refer to the following information on billing for procedures provided in these circumstances.

The following procedure codes require prior approval:

Positron Emission Tomography (PET) Scans

Computed Tomography Angiography (CTA)

Computed Tomography (CT) Scans

Magnetic Resonance Angiography (MRA)

Magnetic Resonance Imaging (MRI)

Ultrasound

Other

Revenue Codes

A policy will be posted on DMA's Radiology Services web page prior to implementation. 

Practitioner and Clinic Services
DMA, 910-355-1883

• MedSolutions Website
• Radiology Services Web Page

Attention:  All Providers

Retroactive Eligibility for Family Planning Waiver

As of November 1, 2009, there will no longer be retroactive eligibility for Family Planning Waiver (FPW).  Medicaid applicants with a medical need in the three months prior to the month of application will be evaluated for eligibility for all other Medicaid programs.

Medicaid Eligibility Unit
DMA, 919-855-4000

Attention:  Pharmacists and Prescribers

New Prior Authorization Requirements for Leukotriene Modifiers

Effective with date of service of October 28, 2009, the N.C. Outpatient Pharmacy Program began requiring prior authorization for Leukotriene Modifiers.  Prescribers can request prior authorization by contacting ACS at 1-866-246-8505 (telephone) or 866-246-8507 (fax).  The criteria and PA request form for these medications are available on the N.C. Medicaid Enhanced Pharmacy Program website.  Medications that now require prior authorization include Accolate, Singulair, and Zyflo.

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

Attention:  CAP/MR-DD Providers, Enhanced Behavioral Health (Community Intervention) Services Providers, Local Management Entities, and Residential Child Care Treatment Facilities

Mental Health Cost Report Training Sessions

Training is being offered for those providers who have a fiscal year end of September 30, 2009, or December 31, 2009.  The training is being offered at several locations across the state during the month of December 2009 and January 2010.  Those providers with a fiscal year end of March 31, 2010, or June 30, 2010, should wait to go to training when sessions are offered next summer.

To learn more about training, locations, times, and information on how to register for training, visit the Office of the Controller's website and click on the link to the click on Mental Health Cost Report Training Memo.  The memo also provides the link to the website where you can register.

For questions concerning this training or the Mental Health Cost Report, contact Wilma Marrow at Wilma.marrow@dhhs.nc.gov or 919-855-3681.  

Wilma Marrow
Office of the Controller, 919-855-3681

Attention:  Durable Medical Equipment Providers

Coverage for Servicing and Repairing Durable Medical Equipment

Effective with date of service October 31, 2009, the following HCPCS code was end-dated and removed from the Durable Medical Equipment (DME) Fee Schedule on DMA's Fee Schedule web page. 

Effective with date of service November 1, 2009, the following HCPCS code was added to the DME Fee Schedule. 

The coverage criteria for servicing and repairing DME have not changed.  Prior approval is required.  Refer to Section 5.8 of Clinical Coverage Policy 5A, Durable Medical Equipment.

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

Attention:  Durable Medical Equipment Providers

Coverage for Standers

Effective with date of service November 1, 2009, newly established coverage criteria for standers were implemented.  This policy revision includes the addition of four new codes for standers and coverage of standers for recipients ages 0 through 20 years of age. 

Prior approval guidelines for standers have been added.  Refer to Section 5.3.24 of Clinical Coverage Policy 5A, Durable Medical Equipment for more coverage details. 

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

Attention:  Durable Medical Equipment Providers

Medically Necessary Incontinence, Ostomy, and Urological Supplies

Effective November 1, 2009, durable medical equipment (DME) providers can seek reimbursement for medically necessary incontinence, ostomy, and urological supplies.  Please refer to Clinical Coverage Policy 5A, Durable Medical Equipment for specific coverage details.

DME providers can submit their claims for these supplies (when the recipient meets the coverage criteria) through HP Enterprise Services (EDS). 

Note: Any recipient who currently receives other home health services should continue to receive their incontinence, ostomy, and urological supplies though the home health provider.

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

Attention:  Nurse Practitioners and Physicians

Infliximab (Remicade, HCPCS Code J1745) and Rituximab (Rituxan, HCPCS Code J9310):  New Billing Guidelines

Effective with date of service October 1, 2009, claims billed for Remicade or Rituxan will be checked for a covered diagnosis codes in accordance with the Food and Drug Administration guidelines.  The N.C. Medicaid Program cannot reimburse for drugs or services considered to be investigative or experimental.  

Remicade

The ICD-9-CM diagnosis codes required when billing for J1745 are:

• 555.0 (regional enteritis of the small intestine); or
• 555.1 (regional enteritis of the large intestine); or
• 555.2 (regional enteritis of the small intestine with large intestine); or
• 555.9 (regional enteritis of an unspecified site); or
• 556.0 through 556.9 (ulcerative colitis); or
• 565.1 (anal fistula); or
• 569.81 (fistula of intestine, excluding rectum and anus); or
• 696.0 (psoriatic arthopathy); or
• 696.1 (other psoriasis); or
• 714.0 through 714.2 (rheumatoid arthritis); or
• 720.0 (ankylosing spondylitis and other inflammatory spondylopathies).

Rituxan

The ICD-9-CM diagnosis codes required when billing for J9310 are:

• 200.00 through 200.88 (lymphosarcoma and reticulosarcoma and other specified malignant tumors of lymphatic tissue); or
• 202.00 through 202.98 (other malignant neoplasms of lymphoid and histiocytic tissue); or
• 714.0 through 714.2 (rheumatoid arthritis).

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

Attention:  Nurse Practitioners and Physicians

Canakinumab Single-use Vials (180 mg) (Ilaris, HCPCS Code J3590):  Billing Guidelines

Effective with date of service August 1, 2009, the N.C. Medicaid program covers canakinumab injectable (Ilaris) for use in the Physician’s Drug Program when billed with HCPCS code J3590 (unclassified biologics).  Ilaris is available as single-use vials containing 180 mg of Ilaris as a lyophilized powder for reconstitution.

Ilaris is a monoclonal antibody that blocks the activity of IL-1β.  It is indicated for the treatment of Cryopyrin-Associated Periodic Syndrome (CAPS), including Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS), in adults and children four years of age and older.

A single does of Ilaris should be administered every 8 weeks as a subcutaneous injection.  The dose is 150 mg for adults and children with body weight greater than 40 kg, and 2 mg/kg for patients with body weight between
15 kg and 40 kg. For children between 15 kg to 40 kg with an inadequate response, the dose can be increased to
3 mg/kg. 

For Medicaid Billing

• The ICD-9-CM diagnosis codes required for billing Ilaris are:
  • 708.2 (Urticaria due to cold and heat [FCAS])

  OR

  • 279.4 (Autoimmune disease, not elsewhere classified)

• Providers should bill Ilaris with HCPCS code J3590 (unclassified biologics).
• One Medicaid unit of coverage is one 180-mg vial.  The maximum reimbursement rate, per one 180-mg vial, is $17,812.51.  An entire single-use vial may be billed.
• Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units.  The NDC units for Ilaris should be reported as “units.”  The drug in its original state must be considered, NOT the reconstituted amount.  If billing for the entire 180-mg single-dose vial, report the NDC units as “UN1.”  If the drug was purchased under the 340B Drug Pricing Program, place a “UD” modifier in the modifier field for that drug detail.
• Refer to the March 2009 Special Bulletin, National Drug Code Implementation, Phase III, for additional instructions.
• Medicaid covers only rebatable NDCs.
• Providers must bill their usual and customary charge.

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

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

Attention:  Durable Medical Equipment Providers and Pharmacy Providers

Prodigy Diabetic Supplies Under the Durable Medical Equipment and Pharmacy Programs

Effective November 15, 2009, Prodigy Diabetes Care, LLC, will be N.C. Medicaid's designated preferred manufacturer for glucose meters, diabetic test strips, control solutions, lancets, lancing devices, and syringes. Beginning on this date of service, only Prodigy test strips, control solutions, lancets, lancing devices, and syringes will be covered by N.C. Medicaid.  This change will apply only to Medicaid-primary recipients (dually eligible and third-party recipients are not affected). Note: These requirements will not apply to private duty nursing and home health providers until February 1, 2010.

The following table lists the National Drug Codes (NDCs) that are included under this program; for meters, please call your wholesaler or Prodigy Diabetes Care, LLC.

In addition, effective November 15, 2009, diabetic test strips, control solutions, lancets, and lancing devices will be added to the list of over-the-counter products covered under the Outpatient Pharmacy Program.  These products will be covered under the pharmacy point-of-sale system with a prescription.  

Billing Instructions for Submitting Claims for Diabetic Supplies under Durable Medical Equipment

Claims for diabetic test strips, control solutions, lancets, lancing devices, and syringes submitted under the Durable Medical Equipment (DME) Program must be billed using the NDC in addition to the HCPCS code. The NDC will be entered in the shaded area of block 24A of the CMS-1500 claim form. (For information on how to bill with NDCs, please refer to the March 2009 Special Bulletin, National Drug Code Implementation, Phase III, on DMA's website. 

Test strips must be billed in units (1 unit = 50 strips) and syringes and lancets must also be billed in units (1 unit = 100 syringes or lancets).

A transition period will be in place from November 15, 2009, through February 15, 2010 (this transition period is not a postponement), in which a one-time, per-recipient, per-product override will be allowed. In addition to modifier NU, DME providers will need to place the SC modifier in block 24D of the CMS-1500 claim form to bypass the requirement to bill for Prodigy NDCs (as listed in the chart above). Following February 15, 2010, this modifier will no longer be acceptable for use with diabetic supplies for DME and only the Prodigy NDCs referenced above will be covered. 

HCPCS codes and supply limits for diabetic supplies remain the same as outlined in Clinical Coverage Policy 5A, Durable Medical Equipment, as indicated below:

Effective November 15, 2009, HCPCS codes E0607 and E2100 will be end-dated.

Note:   These requirements do not apply to private duty nursing and home health providers until February 1, 2010. 

Billing Instructions for Submitting Diabetic Supplies under Pharmacy Point-of-Sale System

Claims for diabetic test strips, control solutions, lancets, lancing devices, and syringes submitted at point-of-sale must be billed using the NDC.  Test strips must be billed in multiples of 50 and syringes and lancets must be billed in multiples of 100.  For Medicaid billing, 1 lancing device = 1 unit. Rates apply to these diabetic supplies; therefore, no copayments and no dispensing fees apply. 

A transition period will be in place from November 15, 2009, through February 15, 2010 (this transition period is not a postponement), in which a one-time, per-recipient, per-product override will be allowed under the pharmacy point-of-sale system for covered diabetic supplies that are not the Prodigy brand.  Pharmacy providers can place a “1” in the prior authorization type code field (461-EU) or a “2” in the submission clarification code field (420-DK) to override the requirement to bill for Prodigy NDCs.  Following February 15, 2010, this override will no longer be available and only the Prodigy NDCs referenced above will be covered.  Diabetic supply limits will be the same as under the DME Program.  Prior authorization requests for additional quantities or for non-Prodigy diabetic supplies must go through the DME Program.

Diabetic supplies do not have to be purchased at the same pharmacy unless the recipient is locked into a pharmacy.  Recipients identified for the Focused Risk Management (FORM) Program who require more than
11 unduplicated prescriptions each month are restricted to a single pharmacy.  In these cases, the diabetic supplies must be purchased at the same pharmacy.  

For additional information, providers may call Prodigy Diabetic Care, LLC at 1-866-540-4816, DMA Clinical Policies and Programs at 919-855-4310 (DME) or 919-855-4300 (Pharmacy).

Durable Medical Equipment Program
DMA, 919-855-4310

Outpatient Pharmacy Program
DMA, 919-855-4300

Attention: Enhanced Behavioral Health (Community Intervention) Services Providers

Provider Verification and Credentialing Activities

As noted in the July 2009 Medicaid Bulletin, the process to re-verify information and to credential enrolled Medicaid Community Intervention Services providers is scheduled to begin immediately. CSC will be notifying providers by mail and sending the notification packet to the provider's billing/accounting address. This will include a pre-printed report of information currently on file with N.C. Medicaid plus a checklist of credentialing-related documents that must be returned to CSC. (Providers may verify their billing/accounting address via the DMA Provider Services NPI and Address Database or by calling the EVC Call Center at 1-866-844-1113.)

The pre-printed NC MMIS Verification Form includes demographic data and NPI information currently on file with N.C. Medicaid and also contains space for providers to enter license/certification numbers, type of ownership, and contact information. Providers must complete the form, attach copies of documents required for credentialing, and return the verification packet to CSC within 30 days of the date of receipt. The verification process will take up to three weeks from the time CSC receives the correct and complete verification packet from the provider; the return of incomplete or incorrect information may lead to an interruption in enrollment. Lack of compliance in these procedures could result in suspension of enrollment and eventual termination.

Please pay special attention to the designation for Community Support Team. Community Support Team providers are required to submit the verification packet with appropriate credentials, including all current Notifications of Endorsement Actions, to qualify for enrollment as a provider of Community Support Team services. This will effectively separate Community Support Child (H0036 HA), Community Support Adult (H0036 HB), and Community Support Group (H0036 HQ) services from Community Support Team services.

Behavioral Health Section
DMA, 919-855-4290

Early and Periodic Screening, Diagnosis and Treatment and Applicability to Medicaid Services and Providers

Service limitations on scope, amount, duration, frequency, location of service, and other specific criteria stated in this publication may be exceeded or may not apply to recipients under 21 years of age if the provider's documentation shows that

• the requested service is medically necessary to correct or ameliorate a defect, physical or mental illness, or health problem; and

• all other Early and Periodic Screening, Diagnosis and Treatment (EPSDT) criteria are met.

This applies to both proposed and current limitations. Providers should review any information in this publication that contains limitations in the context of EPSDT and apply that information to their service requests for recipients under 21 years of age. A brief summary of EPSDT follows.

EPSDT is a federal Medicaid requirement (42 U.S.C. § 1396d(r) of the Social Security Act) that requires the coverage of services, products, or procedures for Medicaid recipients under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination (including any evaluation by a physician or other licensed clinician).

This means that EPSDT covers most of the medical or remedial care a child needs to

• improve or maintain his or her health in the best condition possible OR
• compensate for a health problem OR
• prevent it from worsening OR
• prevent the development of additional health problems

Medically necessary services will be provided in the most economic mode possible, as long as the treatment made available is similarly efficacious to the service requested by the recipient's physician, therapist, or other licensed practitioner; the determination process does not delay the delivery of the needed service; and the determination does not limit the recipient's right to a free choice of providers.

EPSDT does not require the state Medicaid agency to provide any service, product, or procedure that is unsafe, ineffective, experimental, or investigational; that is not medical in nature; or that is not generally recognized as an accepted method of medical practice or treatment.

If the service, product, or procedure requires prior approval, the fact that the recipient is under 21 years of age does not eliminate the requirement for prior approval.

For important additional information about EPSDT, please visit the following websites:

• Basic Medicaid Billing Guide (especially sections 2 and 6)
• Health Check Billing Guide
• EPSDT provider information

Proposed Clinical Coverage Policies

In accordance with NCGS §108A-54.2, 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 Proposed Clinical Coverage Policies web page.  Providers without Internet access can submit written comments to the address listed below.

Lorie Williams
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.

2009 Checkwrite Schedule

Month	Electronic Cut-Off Date	Checkwrite Date
November	11/5/09	11/10/09
	11/12/09	11/19/09
	11/25/09	12/1/09
December	12/3/09	12/8/09
	12/10/09	12/15/09
	12/17/09	12/23/09

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.

Craigan L. Gray, MD, MBA, JD Director Division of Medical Assistance Department of Health and Human Services

Melissa Robinson Executive Director EDS, an HP Company

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