Attention: All Providers

Clinical Coverage Policy Update

All of the Division of Medical Assistance’s clinical coverage policies have been updated to include the web address where providers can access DMA’s policy statement on Early and Periodic Screening, Diagnostic, and Treatment (EPSDT). The policy statement is located on DMA’s website at http://www.dhhs.state.nc.us/dma/prov.htm.

The clinical coverage policies are available on DMA’s website at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm.

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

Early Periodic Screening, Diagnostic and Treatment and Health Check

Information related to the federal requirements for Early Periodic Screening, Diagnostic and Treatment (EPSDT) and the Health Check program is available in the December 2005 Special Bulletin, Medicaid for Children.

Clinical Policy and Programs

DMA, 919-855-4260

Attention: All Providers

DECAVAC – Tetanus and Diphtheria Toxoids (Td) Adsorbed, Preservative Free, for use in Individuals Seven Years or Older, for Intramuscular Use, (CPT 90714) – Coverage in the UCVDP/VFC Program and Billing Guidelines

Effective with date of service July 1, 2005, the N.C. Medicaid program recognizes the new preservative-free tetanus vaccine, DECAVAC. This vaccine is covered in the Universal Childhood Vaccine Distribution Program (UCVDP)/Vaccines for Children (VFC) program. UCVDP covers Td for all children seven through 18 years of age.

Due to the availability of these vaccines, Medicaid does not reimburse for UCVDP/VFC vaccines for children that are covered under the UCVDP/VFC program. As with other injectable vaccines covered in this program, an administration fee will be reimbursed by Medicaid, if applicable. ICD-9-CM diagnosis code V03.7 should be used when billing DECAVAC. Health Check providers should refer to the April 2005 Special Bulletin III, Health Check Special Billing Guide 2005, for additional billing information on billing Medicaid for vaccines and to the article titled, “CPT Codes 90465 and 90466 – New Immunization Administration Codes for Recipients Under Eight Years of Age,” in the July 2005 general Medicaid bulletin.

Certain adults may receive state-supplied DECAVAC. The ACIP Coverage Criteria states that UCVDP Td:

Can be given to any person of any age entering a North Carolina college/university (where Td is required by NC Immunization Law) for the first time who has not had a booster in 10 years.
Any adult can receive Td at the local health department, hospital, federally qualified health center (FQHC) or rural health center (RHC). Medicaid also does not reimburse for the Td state-supplied vaccine that is provided to those providers for administration to recipients over 18 years of age. However, an administration fee will be reimbursed by Medicaid, if applicable. Medicaid will reimburse for Td purchased vaccine when it is medically necessary. An administration code will also be reimbursed, if applicable.

Billing Guidelines:

The procedure code for billing DECAVAC is CPT 90714.

Effective with date of service July 1, 2005, report the vaccine code, CPT 90714, with no modifier for vaccine that was state-supplied and administered to a Medicaid recipient through 18 years of age. Bill a charge of $0.00. An administration fee may be billed to Medicaid, if appropriate.

Effective with date of service July 1, 2005, bill CPT 90714 with modifier SC for purchased vaccine given to those Medicaid recipients over 18 years of age. Bill the usual and customary charge.

Effective with date of service July 1, 2005, report CPT 90714 with no modifier for state-supplied vaccine given to those Medicaid recipients over 18 years of age at health departments, FQHCs and RHCs. Bill a charge of $0.00.

ICD-9-CM diagnosis code V03.7 should be used when billing for DECAVAC.

The maximum reimbursement rate for purchased DECAVAC per unit (0.5 ml) is $ 18.90. Add this vaccine to the list published in the November 2004 general Medicaid bulletin.

Note: The remaining tetanus vaccine containing a preservative provided by the UCVDP program which is still viable should be billed with CPT code 90718. The last expiration date of the preservative-containing tetanus vaccine that will be reimbursed for those recipients under 19 years of age as part of the UCVDP/VFC program will be June 30, 2006. Until this date, Medicaid will continue to reimburse for the administration of CPT 90718 with codes 90741or 90472 as explained in the April 2005 Special Bulletin III, Health Check Special Billing Guide 2005. Providers should refer also to the article titled “CPT Codes 90465 and 90466 – New Immunization Codes for Recipients under Eight Years of Age” in the July 2005 general Medicaid bulletin regarding reimbursement for those administration codes. A future bulletin will discuss how to bill for CPT 90718 that is purchased and administered after the VFC vaccine has been exhausted.

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

Attention: All Providers

Influenza Vaccine and Reimbursement Guidelines

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). Information pertinent to influenza disease and vaccine and recommendations regarding who should receive the vaccine can be found at:

Influenza ACIP recommendations for flu season 2004-2005: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5408a1.htm.

Influenza tier in vaccine shortage: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5430a4.htm.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a4.htm.

Additional information regarding vaccine supply and prioritization can be found at http://www.cdc.gov/flu/.

The North Carolina Immunization Branch distributes childhood vaccines to local health departments, hospitals, and private providers under guidelines of the North Carolina Universal Distribution Program/Vaccine for Children (UCVDP/VFC).

UCVDP/VFC influenza vaccine is available at no charge to providers for children who meet one of the following criteria:

All healthy children 6 months through 23 months of age;

All high-risk children 6 months through 18 years of age; and,

Pediatric household contacts (6 months through 18 years of age) of:

a. Any child aged 0 through 23 months or

b. Any high-risk child or adult.

Note: Children > 6 months through 8 years of age who have not received the influenza vaccine in previous years should receive 2 doses, 30 days apart. The recommended dosage for children > 6 months through 35 months is 0.25 ml. The recommended dose for children >3 years is 0.5 ml.

Billing Guidelines:

Medicaid does not cover influenza vaccine that is supplied through

UCVDP/VFC for recipients through 18 years of age.

Private providers may bill for administration fees using CPT® code 90471 or

90471 and 90472 (if more than one vaccine is administered on the same day), with the EP modifier for recipients under 19 years of age. If provider counseling is performed for children under the age of 8 years bill using CPT® code 90465 or 90465 and 90466 (if more than one vaccine is administered on the same day) with the EP modifier. Local health departments may bill CPT® code 90471 or 90465 as appropriate with the EP modifier for any visit other than a Health Check screening. Rural Health Clinics and Federally Qualified Health Centers, using the C suffix, may bill 90471 or 90465 if the immunization administration is during a Health Check visit.

Private providers and local health departments may bill Medicaid for influenza vaccine for high risk adults > 19 years of age using CPT® code 90656 or 90658 along with the administration fee CPT® code 90471. Information pertinent to influenza disease and vaccine recommendations about who should receive the vaccine can be found at http://www.cdc.gov/nip/ACIP/default.htm.

Use the following codes to report an influenza vaccine administered to a recipient less than 19 years of age and to bill for the administration fees. Additional information regarding reporting vaccines and billing for administration fees can be found in the Health Check Billing Guide 2005 at http://www.dhhs.state.nc.us/dma/bulletin/HealthCheck0405.pdf. Information on billing CPT ®codes involving physician counseling can be found in the article entitled, CPT® Codes 90465 and 90466. New Immunization Administration Codes for Recipients Under Eight Years of Age, which appeared in the July 2005 General Medicaid Bulletin. This article is available at http://www.dhhs.state.nc.us/dma/bulletin/0705bulletin.htm#cpt.

CPT® code	Description
90655	Influenza virus vaccine, split virus, preservative free, for children 6-35 months of age, for intramuscular use
90656	Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use
90657	Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use
90658	Influenza virus vaccine, split virus, for use in individuals 3 year of age and above, for intramuscular use
90471	Immunization administration; one vaccine (single or combination vaccine/toxoid)
90471 and 90472	90471 – Immunization administration; one vaccine (single or combination vaccine/toxoid) and 90472 – each additional vaccine (single and combination vaccine/toxoid)
90465	Immunization administration under 8 years of age when physician counsels patient/family; first injection (single or combination vaccine/toxoid), per day
90465 and 90466	90465 – Immunization administration under 8 years of age when physician counsels patient/family; first injection (single or combination vaccine/toxoid), per day and 90466 – each additional injection (single or combination vaccine/toxoid), per day (list separately in addition to code for primary procedure)

For a recipient 19 years and older receiving an influenza vaccine, an Evaluation and Management (E/M) code cannot be reimbursed to any provider on the same day that injection administration fee codes (90471 or 90471 and 90472) are reimbursed, unless the provider bills an E/M code for a separately identifiable service by appending modifier 25 to the E/M code.

Use the following codes to bill Medicaid for an influenza vaccine administered to a recipient 19 years of age or older.

CPT® code	Description
90656	Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use
90658	Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use
90471	Immunization administration; one vaccine (single or combination vaccine/toxoid)
90471 and 90472	90471 – Immunization administration; one vaccine (single or combination vaccine/toxoid) and 90472 – each additional vaccine (single and combination vaccine/toxoid)

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

Attention: All Providers

Informed Decisions-Beneficiary Centered Enrollment Service

Informed Decisions, in collaboration with the National Association of Chain Drug Stores, offers a service called Beneficiary Centered Enrollment (BCE) to inform Medicaid recipients of their Medicare Part D options. BCE enables coordination of Medicaid data and random assignments under Medicare Part D to provide valuable information on the options available to individual Medicaid recipients under Medicare Part D.

Each Medicaid recipient that is eligible for Medicare will be receiving a personalized letter from DMA that includes a scorecard describing how each Prescription Drug Plan (PDP) available under Medicare Part D meets the recipient’s needs in terms of medication regimen and pharmacy network. Each letter will include a sample list of drugs that have been paid for by North Carolina Medicaid for the recipient during 2005. The list of drugs has been compared to recently published information on Medicare PDP options that are available to the recipient for no cost other than co-payment. The letter includes the name of each of the recipient’s drugs, the name of each of the no cost PDP's available and whether or not the PDP covers the drug. Pharmacy network information is also included.

An online BCE website will also be available to pharmacists and prescribers that identifies the plan each Medicaid recipient has been auto-enrolled in along with 
details of the plan. A sign-on ID and password will be provided for access to this website.  Additional information about the BCE website, including training information, will be provided in the future.

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

Attention: All Providers

Medicaid Coverage Information for the Excluded Drug Classes under Medicare Part D

Beginning January 1, 2006, Medicaid recipients with Medicare will start receiving their drugs through a Prescription Drug Plan (PDP). The PDPs will have formularies of drugs that are covered and noncovered. If a client is prescribed a noncovered drug, Medicaid will not pay for the drug. The client will have to work with their PDP to get the drug covered or switch to another drug on the PDP’s formulary.

There are classes of drugs that federal regulations do not require PDP formularies to cover. These classes of drugs are referred to as excluded drugs. Medicaid currently covers a subset of these excluded drugs and will continue to cover them for all Medicaid clients after January 2006.

The following criteria will be used in determining the drugs that will be covered by Medicaid once Medicare Part D is implemented on January 1, 2006:
There will be no coverage for the following excluded drug classes:

1. Agents Used for Anorexia, Weight Loss, Weight Gain
2. Agents Used to Promote Fertility
3. Agents Used for Cosmetic Purposes or Hair Growth
4. Covered Outpatient Drugs which the Manufacturer Seeks to Require as a Condition of Sale that Associated Tests or Monitoring Services be Purchased Exclusively from the Manufacturer or its Designee

There will be coverage for the following excluded drug classes if the manufacturer has a rebate agreement with the Centers for Medicare and Medicaid Services and if the drug is a legend drug:

1. Agents Used for the Symptomatic Relief of Cough and Colds
2. Prescription Vitamins and Mineral Products, Except Prenatal Vitamins and Fluoride
3. Barbiturates
4. Benzodiazepines
5. Nonprescription drugs covered by NC Medicaid as documented in General Clinical Policy A2 on DMA’s website at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm.

All claims should be submitted to the PDP first to ensure that they are not covering these products. If denied, the claim can then be submitted to Medicaid through POS with a “03” (other coverage exits-this claim not covered) in the other coverage code field.

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

Attention: All Providers

Meningococcal Conjugate Vaccine, MCV4 (CPT® code 90734), Menactra™ Coverage in the UCVDP/VFC Program and Billing Guidelines

Effective with date of service October 1, 2005, the N.C. Medicaid program recognized Menactra™ as a vaccine covered through the Universal Childhood Vaccine Distribution Program (UCVDP)/Vaccines for Children (VFC) program. These programs provide all vaccines required by the Advisory Committee of Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). UCVDP/VFC covered vaccines are available to children birth through 18 years of age. To review the complete MCV4 recommendations of the Advisory Committee on Immunization Practices (ACIP), refer to http://www.cdc.gov/mmwr/PDF/rr/rr5407.pdf.

Generally, UCVDP/VFC covered vaccines are available to all children birth though 18 years of age. However, because of restricted federal funding, state supplied MCV4 will only be available to children who are both:

1. Eligible for the VFC program, and

2. Are included in one of the ACIP recommended coverage groups below.

Children eligible for the VFC program must meet at least one of the VFC criteria below:

· Medicaid eligible,

· Uninsured,

· American Indian or Alaskan Native, or

· Underinsured children whose health insurance benefit plan does not cover the full cost of vaccinations and they receive immunizations at a Federally Qualified Health Center (FQHC) or a Rural Health Clinic (RHC).

Children eligible for UCVDP state supplied MCV4 must meet one of the ACIP recommended coverage groups below:

Adolescents aged 11-12 years old,

Adolescents at high school entry who were not vaccinated at the preadolescent visit,

College freshmen, through 18 years of age, who live in dormitories,

Children > 11 years of age who are at increased risk for meningococcal disease. (See ACIP guidelines on children who are at increased risk.)

The manufacturer of Menactra recommends that it be used for persons aged 11 - 55 years. To view the complete MCV4 recommendations from ACIP, go to http://www.cdc.gov/mmwr/PDF/rr/rr5407.pdf .

Billing Guidelines:

• The procedure code for billing Menactra™ is CPT® 90734.
• Medicaid does not reimburse for meningococcal vaccine supplied through the UCVDP/VFC program for recipients through 18 years of age.
• For dates of service March 1, 2005 through September 30, 2005, bill 90734 with the SC modifier for vaccine that was purchased and administered to a Medicaid recipient 11 through 55 years of age. Bill the usual and customary charge. Refer to the table below.
• Beginning with date of service October 1, 2005, bill 90734 without the SC modifier for vaccine that is state supplied. Because this vaccine is available to recipients through 18 years of age through the UCVDP/VFC program, Medicaid does not reimburse for the cost of the vaccine; however, an administration fee may be billed to Medicaid, if appropriate. Refer to the table below.
• Beginning with date of service October 1, 2005, bill 90734 with the SC modifier for vaccine that was purchased and administered to those recipients 19 through 55 years of age. Bill the usual and customary charge. Refer to the table below.
• Diagnosis code V01.84 or V03.89 must be used when billing for Menactra™, if applicable.

Dates Of Service	Vaccine Used	HCPCS Code and Modifier
March 1, 2005 – September 30, 2005	Purchased MCV4 vaccine for any Medicaid recipient 11 through 55 years of age.	Bill CPT® 90734 with SC modifier. Bill for vaccine administration fee.
October 1, 2005 forward	Vaccine For Children supplied MCV4 vaccine for recipients through 18 years of age.	Bill CPT® 90734 without SC modifier at a charge of $0.00 Bill for vaccine administration fee.
October 1, 2005 forward	Purchased MCV4 vaccine for recipients 19 through 55 years of age.	Bill CPT® 90734 with SC modifier at the usual and customary charge Bill for vaccine administration fee.

In accordance with ACIP recommendations, Medicaid will reimburse for meningococcal vaccine for recipients 19 through 55 years of age. To view the complete MCV4 recommendations from ACIP, go to http://www.cdc.gov/mmwr/PDF/rr/rr5407.pdf.

The maximum reimbursement rate for purchased Menactra™ per unit (0.5 ml) is $88.56. Add this vaccine to the list published in the November 2004 general Medicaid bulletin.

For additional information on billing Medicaid for immunizations, providers should refer to the April 2005 Special Bulletin III, Health Check Billing Guide 2005, and to the article titled CPT® Code 90645 and 90666 – New Immunization Administration Codes for Recipients Under Eight Years of Age, published in the July 2005 general Medicaid bulletin.

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 that 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 NCHC will be moved to the Medicaid program effective January 1, 2006. The NCHC 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 have NCHC cards with expiration dates after January 1, 2006. These cards are not valid after December 31, 2005. A blue Medicaid card for the children will be issued early January 2006. Providers will be reimbursed Medicaid rates for children birth through age five that are moved from NCHC to Medicaid.

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

Medicaid Eligibility Unit

DMA, 919-855-4000

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: All Providers

Place of Service Codes

Effective with date of service December 1, 2005, providers must enter one of the two-digit place of service (POS) codes listed in the table below in block 24B of the CMS-1500 claim forms.

Services rendered in schools must now be billed to Medicaid with POS 03 in lieu of the unassigned code 99.

Place of Service Code	Definition
00 – 02	Unassigned
03	School
04	Homeless Shelter
05	Indian Health Service Free-Standing Facility
06	Indian Health Service Provider-Based Facility
07	Tribal 638 Free-Standing Facility
08	Tribal 638 Provider-Based Facility
09 – 10	Unassigned
11	Office
12	Home
13	Assisted Living Facility
14	Group Home
15	Mobile Unit
16 – 19	Unassigned
20	Urgent Care Facility
21	Inpatient Hospital
22	Outpatient Hospital
23	Emergency Room Hospital
24	Ambulatory Surgical Center
25	Birthing Center
26	Military Treatment Facility
27 – 30	Unassigned
31	Skilled Nursing Facility
32	Nursing Facility
33	Custodial Care Facility
34	Hospice
35 - 40	Unassigned
41	Ambulance – Land
42	Ambulance – Air or Water
43 – 48	Unassigned
49	Independent Clinic
50	Federally Qualified Health Center
51	Inpatient Psychiatric Facility
52	Psychiatric Facility Partial Hospitalization
53	Community Mental Health Center
54	Intermediate Care Facility for the Mentally Retarded
55	Residential Substance Abuse Treatment Facility
56	Psychiatric Residential Treatment
57	Non-residential Substance Abuse Treatment Facility
58 – 59	Unassigned
60	Mass Immunization Center
61	Comprehensive Inpatient Rehabilitation Center
62	Comprehensive Outpatient Rehabilitation Center
63 – 64	Unassigned
65	End-Stage Renal Disease Treatment Facility
66 – 70	Unassigned
71	State or Local Health Clinic
72	Rural Health Clinic
73 – 80	Unassigned
81	Independent Laboratory
82 - 98	Unassigned
99	Other Place of Service

This list has been expanded to include all of the POS codes approved by the Centers for Medicaid and Medicare Services and replaces the list of POS codes previously published in the Basic Medicaid Billing Guide.

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

Attention: All Providers

Reinstating Providers Suspended for Outstanding Repayments

Providers who have been suspended from the Medicaid program due to an unresolved repayment may request reinstatement by submitting a request in writing to:

DHHS

Mail Service Center 2022

Attn: John Moody

Raleigh, NC 27699

The request must include the following:

The provider’s Medicaid provider number.
A copy of the Remittance and Status Report showing the amount of the repayment that is due to Medicaid.
Note: The amount of the repayment that is due to Medicaid can also be confirmed by calling the EDS Finance Department.

A check for the outstanding amount made payable to the Division of Medical Assistance.

Once the outstanding repayment is received and the request has been processed, the provider will be reinstated.

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

Attention: All Providers

Update to Family Planning Waiver August 2005 Special Bulletin

The revised Special Bulletin, Family Planning Waiver “Be Smart,” will update information that was published in the August 2005 Special Bulletin about the Medicaid Family Planning Waiver. The updated information is effective with date of implementation October 1, 2005.

The revised Family Planning Waiver Special Bulletin supersedes the previously published special bulletin which will be available in the near future. For your convenience, shading will indicate new information.

Providers may contact EDS with billing questions.

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

Attention: All Providers

The HIPP Program

The HIPP (Health Insurance Premium Payment) program is designed to:

Help maintain commercial insurance for Medicaid recipients.
Save taxpayer dollars.

If you have patients who have a catastrophic medical condition or patients who have numerous conditions or several family members covered on a commercial insurance policy, please inform them of this program. Normally a patient who is on the transplant list, has had a transplant, is currently undergoing cancer treatment, or is HIV positive will automatically qualify.

The patient must be Medicaid eligible at all times for DMA to pay the health insurance premium. We do not cover the cost of Medicare supplements that have prescription coverage due to Part D.

To join this program patients must complete a DMA-2069 and submit it with either a three-month itemization of all claims submitted to the insurance company or the three months of Explanations of Benefits from the commercial insurance company.

For more information, please contact the HIPP Program Coordinator in the Third Party Recovery Section at 919-647-8100.

HIPP Coordinator, Third Party Recovery

DMA, 919-647-8100

Attention: All Providers

Tax Identification Information

Alert – Tax Update Requested
The N.C. Medicaid program must have the correct tax information on file for all providers. This ensures that 1099 MISC forms are issued correctly each year and that correct tax information is provided to the IRS. Incorrect information on file with Medicaid will result in the IRS withholding 28 percent of a provider’s Medicaid payments. The individual responsible for maintenance of tax information must receive the information contained in this article.

How to Verify Tax Information
The last page of the Medicaid Remittance and Status Report (RA) indicates the tax name and number on file with Medicaid for the provider number listed. Review the Medicaid RA throughout the year to ensure that the correct tax information is on file for each provider number. If you do not have access to a Medicaid RA, call EDS Provider Services at 919-851-8888 or 1-800-688-6696 to verify the tax information on file for each provider.

How to Correct Tax Information
All providers are required to complete a W-9 form for each provider for which incorrect information is not file. Correct information must be received by December 7, 2005. The procedure for submitting corrected tax information to the Medicaid program is outlined below:

· All providers, including Managed Care providers, must submit completed and signed W-9 forms along with a completed and signed Notification of Change in Provider Status form to the address listed below:

Division of Medical Assistance
Provider Services
2501 Mail Service Center
Raleigh, NC 27699-2501

Refer to the following instructions for completing the W-9. Additional instructions can be found on the IRS website at www.irs.gov under the link "Forms and Pubs."

· List the N.C. Medicaid provider number in the block titled "List account number(s) here."

· List the N.C. Medicaid provider name in the block titled "Business Name." It should appear exactly as the IRS has on file.

· Indicate the appropriate type of business.

· Fill in either a social security number or a tax identification number. Indicate the number exactly as the IRS has on file for the provider’s business. Do not insert a social security number unless the business is a sole proprietorship or individually owned and operated.

· An authorized person must sign and date this form or it will be returned as incomplete and the tax information on file with Medicaid will not be updated.

Change of Ownership
· All providers, including Managed Care providers, must report changes to DMA Provider Services using the Notification of Change in Provider Status form.
· Carolina ACCESS providers must also report changes to DMA Provider Services using the Carolina ACCESS Provider Information Change form.

· DMA Provider Services will assign a new Medicaid provider number if appropriate and will ensure the correct tax information is on file for Medicaid payments.

If DMA is not contacted and the incorrect tax identification 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.

W-9 form

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

Attention: All Outpatient UB-92 Billers

ICD-9 CM Procedure Codes on Outpatient UB-92 Claims

In the January 2004 General Medicaid Bulletin providers were advised that under HIPAA rules, ICD-9 CM procedure codes were no longer acceptable on the outpatient UB-92 claim. The Division of Medical Assistance (DMA) has been unable to fully implement this change.

As an interim measure, the Division is working under a HIPAA contingency plan which allows for the continued billing of the ICD-9 procedure codes on the outpatient UB claims.

Note: Use of ICD-9 CM procedure codes on sterilization, abortion, hysterectomy and transplant claims will eliminate the majority of the EOB 082 denials you may have been receiving since billing without the ICD-9 procedure codes.

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

Attention: CAP/DA Lead Agencies and Automated Quality and Utilization Improvement Program (AQUIP) Users

New AQUIP System Training Seminars

Seminars on the new AQUIP system for all AQUIP users are scheduled for December 2005. Attendance at these sessions is of the utmost importance. The seminar will focus on using the new AQUIP system, RUGs, quality measures, and changes to the AQUIP User/System Manual.

Preregistration is required. Due to limited space, only 125 attendees can register for each session. Registration is on a first-come first served basis. Early registration is encouraged in order to get your first preference. CAP/DA lead agencies and AQUIP users may register online by going to the AQUIP website at https://www2.mrnc.org/aquip and clicking on registration. Select the session you plan to attend and complete the registration information. A computer-generated confirmation number will confirm your registration.

Note: Registration forms will be mailed to those counties that do not have computer access. The completed form may be faxed to (919) 380-9457 or mailed to The Carolinas Center for Medical Excellence (CCME), formerly Medical Review of North Carolina, Inc. Once the information is received, you will be sent a confirmation number.

The AQUIP training sessions are scheduled to begin at 9:30 a.m. and end at 3:30 p.m. Lunch will not be provided. Registration will be from 8:30 a.m.

to 9:30 a.m.

The schedule for the AQUIP System Seminars is as follows:

Tuesday, December 6, 2005

Holiday Inn Crowne Plaza

One Holiday Inn Drive

Asheville, N.C.

Wednesday, December 7, 2005

Park Inn Hickory

909 Hwy 70 SW

Hickory, N.C.

Thursday, December 8, 2005

Holiday Inn Select

5790 University Parkway

Winston Salem, N.C.

Tuesday, December 13, 2005

Hilton Charlotte University Place

8629 J.M. Keynes Drive

Charlotte, N.C.

Wednesday, December 14, 2005

Holiday Inn

650 US Hwy 1

Southern Pines, N.C.

Thursday, December 15, 2005

Sheraton Imperial

4700 Emperor Blvd

Durham, N.C.

Monday, December 19, 2005

Hilton Greenville

207 SW Greenville Blvd

Greenville, N.C.

Tuesday, December 20, 2005

Ramada Inn Conference Center

5001 Market Street

Wilmington, N.C.

Driving Directions to the AQUIP Training Sites

Holiday Inn Crowne Plaza & Resort - Asheville

I-40 West

Exit 53B, I-240 W. take exit 3B, turn right. Follow signs to Holiday Inn. I-40 East, exit 46, I-240E. Take exit 3B and follow signs to Holiday Inn.

Park Inn Hickory – Hickory, North Carolina

I-40 East

Take Interstate 40, exit at 123b to 321 Business and Highway 70 exit 44 – Hotel is on the right.

I-40 West

Take Interstate 40 west to exit 123b to exit 44 – The Hotel is located on the right off of the exit.

Holiday Inn Select - Winston –Salem, North Carolina

Take Interstate 40 to Hwy 52 North, 8 miles to exit 115B, University Pkwy South, Hotel is on the right.

Hilton Charlotte University Place – Charlotte, North Carolina

Exit from I-85 North or South at exit 45A, W.T. Harris Boulevard East. Hilton Charlotte University Place is ¼ mile on the left in University Place Complex. The hotel is the high-rise building in the complex, totally visible from Harris Boulevard. The left turn at J.M. Keynes Drive goes directly into the hotel parking lot.

Holiday Inn - Southern Pines, North Carolina

Take US-1 south to Southern Pines, take the Service Rd. exit just before the Morganton Rd. Exit, turn right into the hotel from the service road. Hotel will be visible from US-1.

Sheraton Imperial – Durham, North Carolina

From Interstate 40 West

Take exit # 282, Page Road. At the yield sign at the bottom of the exit ramp, turn right. Get into the far left lane and turn left at the first light. The hotel is one block up on the left.

From Interstate 40 East

Take exit # 282, Page Road. Stay in the center lane and at the stoplight; proceed straight across Page Road into the Imperial Center. The hotel is one block up on the left.

Hilton Greenville – Greenville, North Carolina

From Raleigh/Durham

Take 64 East to 264 East. Follow 264 East to Greenville. Turn right on Allen Rd. once you enter Greenville. Go approximately 2 miles and Allen Rd. turns into Greenville Blvd/Alternate 264. Follow Greenville Blvd. for 2 ½ miles, the Hilton Greenville is located on the right.

Attention: Durable Medical Equipment and Orthotic and Prosthetic Providers

Place of Service for Durable Medical Equipment and Orthotic and Prosthetic Devices

Durable medical equipment (DME) and orthotic and prosthetic device providers are reminded that they may only bill for DME and orthotic and prosthetic devices, and related supplies when the patient resides in a private residence or an adult care home. Therefore, DME providers may not bill N.C. Medicaid for DME, orthotic or prosthetic devices or related supplies when the patient resides in a nursing facility or intermediate care facility. Remember that your designation of place of service “12” in block 24B on the CMS-1500 claim form indicates that you are have verified the patient’s place of residence as the recipient’s home or an adult care home. Refer to Clinical Coverage Policies #5A, Durable Medical Equipment, and #5B, Orthotics and Prosthetics, on DMA’s website at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm for detailed coverage and billing information.

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

Attention: Prescribers, Nursing Facilities, Adult Care Homes, Intermediate Care Facilities for the Mentally Retarded, and Pharmacists

Discontinuation of the 34-Day Grace Period for Prescription Drug Prior Authorization for Long-Term Care Facilities

Effective November 8, 2005, the 34-day grace period for obtaining prescription drug prior authorization for Medicaid recipients in nursing facilities, adult care homes, and intermediate care facilities for the mentally retarded was discontinued.

Prescribers should refer to the N.C. Pharmacy Program website at http://www.ncmedicaidpbm.com for the prior authorization drug list, criteria, forms, and additional information.

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

Attention: Personal Care Service Providers

PCS/PCS-Plus Training

The Division of Medical Assistance (DMA) has scheduled combined Personal Care Services (PCS) and PCS-Plus training sessions beginning in January 2006. The sessions will be held in the DMA office in Raleigh. The purpose of this training is to provide a policy orientation for new registered nurses (RNs) who conduct PCS and/or PCS-Plus assessments for Medicaid recipients. The training will include a review of the new policy guidelines for both the PCS and PCS-Plus programs. Attendees will learn the correct way to conduct and document a PCS assessment and how to develop a PCS plan of care. There will also be time for attendees to ask questions related to the program. The

training's are scheduled as follows:

In this issue................................

Attention: All Providers