December 2005 Medicaid Bulletin


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In This Issue...

All Providers:

Adult Care Homes:

All Outpatient UB-92 Billers:

Automated Quality and Utilization Improvement Program (AQUIP) Users:

CAP/DA Lead Agencies:

Durable Medical Equipment Providers:

Health Choice Providers:

Intermediate Care Facilities for Individuals with Intellectual and Developmental Disabilities:

Nursing Facilities:

Orthotic and Prosthetic Providers:

Personal Care Services Providers:

Pharmacists and Prescribers:

Providers of Enhanced Mental Health Services:




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.

The clinical coverage policies are available on DMA’s website.

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:

  1. 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.
  2. 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 Administration 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:

    1. Medicaid does not cover influenza vaccine that is supplied through  

          UCVDP/VFC for recipients through 18 years of age. 

    1. 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.

    1. 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/vaccines/recs/acip/default.htm
    1. 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.  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.

    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)

    1. 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.
    1. 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.

    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/.

    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:

    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® Codes 90465 and 90466. 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:

    1. The provider’s Medicaid provider number.
    2. 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.
    1. 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:

    1. Help maintain commercial insurance for Medicaid recipients.
    2. 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 Ľ 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 ˝ 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, 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 Individuals with Intellectual and Developmental Disabilities, 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:

    January

    5, 12 , 16,  and 23

    July

    6 and 13

    February

    2, 9, 16, and 23

    August

    3 and 17

    March

    2 and16

    September

    7 and 21

    April

    6 and 13

    October

    5 and 19

    May

    4 and 18

    November

    2 and 16

    June

    1 and 15

    December

    7 and 21

    The training sessions begin at 9:00 a.m. and end at 1:30 p.m.  Lunch will not be provided. Attendance is limited to 15 RN’s per session on a first-come, first-served basis.

    Pre-registration is required.  To register, please complete the Class Registration Form and fax it to (919) 715-2628 or return it by mail to the address listed on the form.  Registration by phone is not permitted.  Providers will receive registration confirmation via fax with the date of the training session and directions to the DMA office.

    Facility and Community Care
    DMA, 919-855-4360



    Attention: Providers of Enhanced Mental Health Services

    Enhanced Mental Health Services Seminar Schedule

    Enhanced Mental Health Services seminars have been scheduled for January 2006.  Seminars are intended for providers who meet the approval and endorsement criteria to bill for Enhanced Mental Health Services on or after the implementation date.  Topics to be discussed will include, but are not limited to, provider enrollment requirements, eligibility issues, billing instructions, and clinical coverage policies.  Those who will be billing for these services to N.C. Medicaid are encouraged to attend. 

    The seminars are scheduled at the locations listed below.  Preregistration is required.  It is recommended that the office manager, a clinical professional, and a billing person from each office attend these seminars.  Due to limited seating, registration is limited to three staff members per office.  Unregistered providers are welcome to attend if space is available.

    Providers may register for the Enhanced Mental Health Services seminars by completing and submitting the registration form available on the next page or by registering online.  The seminars will begin at 9:00 a.m. and will end at 1:00 p.m.  Providers are encouraged to arrive by 8:45 a.m. to complete registration.  Refreshments will not be provided during the seminar.

    Providers must print the PDF version of the January 2006 Special Bulletin, Providers of Enhanced Mental Health Services and bring it to the seminar. The January 2006 Special Bulletin will be available January 1, 2006.  General information about billing Medicaid will also be discussed during the seminar.  Providers may wish to print the August 2005 Basic Medicaid Billing Guide and bring it to the seminar, but they are not required to do so. 

    Monday, January 9, 2006

    Crowne Plaza Resort
    (formerly Holiday Inn Sunspree)
    One Holiday Inn Drive
    Asheville, N.C.

    Wednesday, January 11, 2006

    Holiday Inn Statesville
    1215 Garner Bagnal Blvd.
    Statesville, N.C.

    Tuesday, January 17, 2006

    Greenville Hilton
    207 SW Greenville Boulevard
    Greenville, N.C.

    Thursday, January 19, 2006

    Jane S. McKimmon Center
    1101 Gorman Street
    Raleigh, N.C.

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



    Directions to the Enhanced Mental Health Services Seminars

    Crowne Plaza Resort (formerly Holiday Inn Sunspree)– Asheville, North Carolina
    Traveling West on I-40
    Take I-40 W to Exit 53B.  Take I-240 W to Exit 3B – Westgate and Holiday Inn Drive.

    Traveling East on I-40
    Take I-40 E to Exit 46, which is I-240 E.  Go to Exit 3A and exit onto Patton Avenue.  Take a right at the second light onto Regents Business Park.  Entrance sign is on the immediate left.

    Holiday Inn - Statesville, North Carolina
    Traveling West on I-40
    Merge onto I-77 S at Exit 152A toward Charlotte.  Take Exit 49A toward Garner Bagnal Blvd.

    Traveling East on I-40
    Merge onto I-77 S at Exit 152A toward Charlotte.  Take Exit 49A toward Garner Bagnal Blvd.

    Greenville Hilton – Greenville, North Carolina
    Take US 64 east to US 264 east.  Follow 264 east to Greenville.  Once you enter Greenville, turn right on Allen Road.  After traveling approximately 2 miles, Allen Road becomes Greenville Boulevard/Alternate 264.  Follow Greenville Boulevard for approximately 2˝ miles.  The Hilton Greenville is located on the right.

    Jane S. McKimmon Center – Raleigh, North Carolina
    Traveling East on I-40
    Take exit 295 and turn left onto Gorman Street.  Travel approximately one mile.  The McKimmon Center is located on the right at the corner of Gorman Street and Western Boulevard.

    Traveling East on I-40
    Take exit 295 and turn right onto Gorman Street.  Travel approximately one mile.  The McKimmon Center is located on the right at the corner of Gorman Street and Western Boulevard.


    NCLeads Update

    Information related to the implementation of the new Medicaid Management Information System, NCLeads, can be found online.  Please refer to the NCLeads website for information, updates, and contact information related to the NCLeads system.

    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 website.  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.


    Holiday Closing

    The Division of Medical Assistance (DMA) and EDS will be closed on Friday, December 23 and Monday, December 26, in observance of the Christmas Holidays. 

     

    2005-2006Checkwrite Schedule

    Month

    Electronic Cut-Off Date

    Checkwrite Date

    December

    12/02/2005

    12/06/2005

     

    12/09/2005

    12/13/2005

     

    12/16/2005

    12/22/2005

    January

    12/30/2005

    01/06/2006

     

    01/06/2006

    01/10/2006

     

    01/13/2006

    01/18/2006

     

    01/20/2006

    01/26/2006

    February

    02/03/2006

    02/07/2006

     

    02/10/2006

    02/14/2006

     

    02/17/2006

    02/23/2006

          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.


     2005 Checkwrite Schedule


    _____________________   _____________________
    Mark T. Benton, Senior Deputy Director and
    Chief Operating Officer
      Cheryll Collier
    Division of Medical Assistance   Executive Director
    Department of Health and Human Services   EDS

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