December 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:

• EDS Announces New Name
• Electronic Claim Submission EOB Code
• Electronic Funds Transfer
• Flu Testing:  CPT Codes 87400 and 87804
• Medicaid Credit Balance Reporting
• Medicaid Recipient Appeal Process/Early and Periodic Screening, Diagnosis, and Treatment
• North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool
• Notice of Legislative Mandate for PASRR
• Paper Claim Submissions
• Payment Error Rate Measurement in North Carolina
• Piedmont Cardinal Health Plan
• Prior Authorization for Non-emergency High-tech Outpatient Radiology and Ultrasound Procedures:  Updates
• Submitting Secondary and Tertiary Claims Electronically/837 Transaction
• Top 10 Reasons a Provider Application is Deemed Incomplete

Adult Care Homes:

• Clarification of the Two-Step Tuberculosis (TB) Test Process and Billing

Adult Day Health Care Centers:

• Clarification of the Two-Step Tuberculosis (TB) Test Process and Billing

CAP/DA Providers:

• Participation in the Community Alternatives Program for Disabled Adults:  Freeze Update

Durable Medical Equipment Providers:

• Prodigy Diabetic Supplies Under the Durable Medical Equipment and Pharmacy Programs:  Update

Enhanced Behavioral Health (Community Intervention) Services Providers:

• Provider Verification and Credentialing Activities

Health Departments:

• Clarification of the Two-Step Tuberculosis (TB) Test Process and Billing
• Lidocaine for Topical Anesthesia and Saline/Water Codes:  Billing Guidelines

Home Health Agencies:

• Using National Drug Codes for the Billing of Diabetic Supplies

Nurse Midwives:

• Lidocaine for Topical Anesthesia and Saline/Water Codes:  Billing Guidelines

Nurse Practitioners:

• Clarification of the Two-Step Tuberculosis (TB) Test Process and Billing
• Golimumab (50 mg per 0.5 ml) for Injection (Simponi, HCPCS Code J3590):  Billing Guidelines
• Lidocaine for Topical Anesthesia and Saline/Water Codes:  Billing Guidelines

Nursing Facilities:

• Clarification of the Two-Step Tuberculosis (TB) Test Process and Billing

Personal Care Services Providers:

• Implementation of PCS PACT Reviews and Independent Assessments

Pharmacists:

• Drug Utilization Review Early Refill Alert
• New Prior Authorization Requirements for Brand Name Fibrates and Lovaza
• Prodigy Diabetic Supplies Under the Durable Medical Equipment and Pharmacy Programs:  Update
• Removal of Cough and Cold Medications from Coverage

Physicians:

• Clarification of the Two-Step Tuberculosis (TB) Test Process and Billing
• Golimumab (50 mg per 0.5 ml) for Injection (Simponi, HCPCS Code J3590):  Billing Guidelines
• Lidocaine for Topical Anesthesia and Saline/Water Codes:  Billing Guidelines

Prescribers:

• New Prior Authorization Requirements for Brand Name Fibrates and Lovaza
• Removal of Cough and Cold Medications from Coverage

Private Duty Nursing Providers:

• Using National Drug Codes for the Billing of Diabetic Supplies

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 for 45 days suspend if an EFT Authorization Agreement has not been submitted to and processed by the N.C. Medicaid Program. After 45 days, the claim will deny with EOB 2901 (Denied due to inactive EFT status).  Providers must complete and submit an EFT Authorization Agreement prior to resubmitting a new claim (not an adjustment).

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

• 919-816-3186
• 919-816-4399

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

Notice of the requirement for electronic payments was first published in the June 2009 Medicaid Bulletin with additional articles published in July, September, October, and November.  The Medicaid Bulletin is available on DMA’s Medicaid Bulletin web page.

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

• Electronic Funds Transfer (EFT) Authorization Agreement for Automatic Deposits
• Electronic Funds Transfer Requirement:
• November 2009
• October 2009
• September 2009
• Electronic Funds Transfers, July 2009
• Electronic Claims Submission and Funds Transfer, June 2009

Attention:  All Providers

Electronic Claim Submission EOB Code

The following article was originally published in the October 2009 and November 2009 Medicaid Bulletin.

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
• Electronic Claim Submission EOB Code:
  • November 2009
  • October 2009
• 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

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 Legislative Mandate for PASRR

As of November 1, 2009, DMA and the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMH) no longer require an Annual Resident Review (ARR) for level II recipients.  Please note that nursing facilities are still responsible for completing a change in condition screen should there be a change in the condition of the admitted recipient.  The change in condition review will determine if serious mental illness (SMI), mental retardation (MR) or a related condition (RC) is evident and, if so, a new level II will be initiated and scheduled.  Also note that the name of this program has changed to Preadmission Screening and Resident Review (PASRR).

Notice of Legislative Mandate for PASRR
The House and Senate voted and approved a $19 billion state budget.  With the budget passed, the N.C. Legislature will mandate the use of electronic transactions by all providers who are required to conduct a PASRR.

Who Will this Affect?
This mandate will affect all providers who are currently submitting PASRR requests and Tracking forms by fax, regular mail or phone.  Beginning on December 1, 2009, all providers will be required to submit PASRR screening or Tracking forms through the State's web-based tool or through a third-party vendor with interface capabilities into the State’s web-based tool.  

When is the Effective Date?
The effective date mandated by the bill is September 1, 2009; however, DMA will continue to accept fax transmissions for up to 90 days as providers transition to the web-based tool.  Effective December 1, 2009, all providers will be required to submit PASRR and Tracking forms through the State's web-based tool or through a third-party vendor with interface capabilities into the State’s web-based tool.

The North Carolina Health Care Facilities and Hospital Associations have worked with HP Enterprise Services (EDS) and DMA to ease the facilitation of compliance with this mandate.  The PASRR form that is available by virtue of DMA's contract with HP Enterprise Services (EDS) has been reduced to required information, is equipped with user-friendly auto population of information, and has easy to use default mechanisms.  The Associations believe that the time required to complete the automated form will be minimal.

Please Note:  Organizations currently submitting PASRR screenings and Tracking forms through Provider Links Online Application can continue to use this method.

For more information, please visit the NC PASRR website or call the NC PASRR team at 1-800-688-6696 or 919-851-8888, option 7.

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

Attention: All Providers

Payment Error Rate Measurement in North Carolina

In compliance with the Improper Payments Information Act of 2002, CMS implemented a national Payment Error Rate Measurement (PERM) Program to measure improper payments in the Medicaid Program and the State Children’s Health Insurance Program (SCHIP).  North Carolina has been selected as one of 17 states required to participate in PERM reviews of Medicaid fee-for-service and Medicaid managed care claims paid in federal fiscal year 2010 (October 1, 2009, through September 30, 2010).  The PERM SCHIP measurement is on hold until publication of the new final rule.

CMS is using two national contractors to measure improper payments.  One of the contractors, Livanta LLC (Livanta), will be communicating directly with providers and requesting medical record documentation associated with the sampled claims.  Providers will be required to furnish the records requested by Livanta, within a timeframe indicated by Livanta.

It is anticipated that Livanta will begin requesting medical records for North Carolina’s sampled claims in January 2010.  Providers are urged to respond to these requests promptly with timely submission of the requested documentation.

Providers are reminded of the requirement in Section 1902(a)(27) of the Social Security Act and federal regulation 42 CFR Part 431.107 to retain any records necessary to disclose the extent of services provided to individuals and, upon request, furnish information regarding any payments claimed by the provider rendering services.

Program Integrity
DMA, 919-647-8002

Attention:  All Providers

Flu Testing: CPT Codes 87400 and 87804

Providers can bill for one unit of flu A and one unit of flu B by using CPT procedure code 87400 (infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; influenza, A or B, each) for a total of two units per day.  Or, providers can bill two units of CPT procedure code 87804 (infectious agent antigen detection by immunoassay with direct optical observation; influenza) with the QW modifier. 

Providers who received a denial with EOB 5201 (Diagnostic procedure allowed once per day unless billed with appropriate modifier) when billing for more that one flu test on the same date of service may correct and resubmit the denied claim for payment if they have filed their claims timely.

HP Enterprise Services
1-800-688-6696 or 919-855-8888

Attention:  All Providers

Submitting Secondary and Tertiary Claims Electronically/837 Transaction

Effective with date of processing October 2, 2009, all providers must file claims electronically.  Only claims that comply with the list of exceptions to the requirement for electronic claim submissions may be submitted on paper.  The list of electronic claims submission (ECS) exceptions can be found on DMA’s ECS Exceptions web page.

Secondary and tertiary claims may be required to be submitted electronically depending on the status of the primary claim(s).  Refer to the following instructions to ensure claims are submitted correctly.

When the Primary Payer Makes a Payment
For all claim types including professional, institutional and dental, the claims should be submitted to Medicaid electronically.  Providers have various options when submitting electronic claims via the 837 transaction.  The North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool (NCECSWeb) is the State-supplied web-based option for submitting claims electronically free of charge.  Providers may also contract with a vendor or clearinghouse or they may also have in-house software.  If there are questions regarding placement of information on contracted software, providers are advised to consult with their vendor/clearinghouse or the ECS department at HP Enterprise Services.  To contact HP Enterprise Services, providers should call 1-800-688-6696, option 1.  Online assistance is also available in the HIPAA companion guides on DMA’s HIPAA Companion Guides web page.

When a payment is not made on the primary claim, the secondary claim should be submitted to Medicaid in accordance with the claim type. 

If it is on a professional claim or a dental claim, it should be submitted on paper using the Medicaid Resolution Inquiry Form.  All documents supporting the override request should be included with the form.  However on a professional claim, if there is a Medicare Part B primary claim that applies 100% of the payment to the deductible, it should be submitted electronically.  Medicaid will recognize the deductible amount and pay the appropriate percent based on the provider type and specialty.

If it is on an institutional claim, the secondary claim should be submitted electronically using occurrence and/or condition codes to override third-party insurance and/or Medicare Part A or B. 

Note:  Providers can override Medicare electronically.  When billing on the professional or the institutional claim form, please refer to the August 2009 bulletin article titled Electronic Medicare Overrides for specific instructions.

Institutional Billing for Medicare Primary Claims Reporting a Zero or Negative Medicare Payment
To submit claims when Medicare Part A or B has paid zero (i.e., 0.00), which results in the Medicare payment completely applied to the deductible and coinsurance, the claim must be submitted on paper with a Resolution Inquiry form and a copy of the Medicare EOB.  In the remarks field please note “Medicare zero paid claim – submit as a special batch.”

To submit claims when Medicare's EOB describe a negative payment, submit the claim on paper with a Resolution Inquiry form and a copy of the Medicare EOB.  In the remarks field please note “Medicare negative paid claim – submit as a special batch.”

For claim specific questions, providers can call Provider Services for assistance at 1-800-688-6696, option 3.

Please refer to Section 5 of the Basic Medicaid Billing Guide for information regarding the submission of Medicare HMO secondary claims.

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

• Basic Medicaid Billing Guide
• Electronic Medicare Overrides, August 2009
• HIPAA Companion Guides Web Page
• Medicaid Resolution Inquiry Form
• North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool

Attention:  All Providers

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

Prior authorization (PA) is required for non-emergency, high-tech outpatient radiology and ultrasound procedures.  The ordering physician should obtain the PA; however, rendering facilities and reading radiologists can obtain the PA.  Please use the ordering physician’s individual NPI number.  Do not use a group NPI number.  Only an individual provider can request the PA.  The PA should be obtained before the testing is scheduled.  The PA number should be provided to the facility performing the test.  The PA is good for 30 days following its issuance.

Prior authorization is not required for recipients in the benefit categories listed below.  MedSolutions refers to these recipients as non-delegated.

• Recipients that 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
• Recipients with emergency coverage for approved dates of services
• Undocumented or documented aliens
• Refugees
• Recipients incarcerated or confined in a mental institutions
• Recipients enrolled in Aid to the Aged, Special Assistance to the Blind, and Special Assistance to the Aged

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.

Providers submitting claims in an institutional format:

Providers submitting claims in a professional format:

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

The following procedure codes require prior approval.  Note:  CPT codes 70482, 70486, 70487, 70488, and 70490 were inadvertently omitted from previous articles.

Positron Emission Tomography (PET) Scans

Computed Tomography Angiography (CTA)

Computed Tomography (CT) Scans

Note:  CPT codes 70482, 70486, 70487, 70488, and 70490 were inadvertently omitted from previous articles.

Magnetic Resonance Angiography (MRA)

Magnetic Resonance Imaging (MRI)

Ultrasound

Other

Revenue Codes

For assistance with requesting prior approval, refer to the following table:

Practitioner and Clinic Services
DMA, 910-355-1883

• Accuracy Management Website
• CSC NC Tracks Provider Services Web Pag for Reporting a Change in Provider Status
• DMA Address and NPI Database

Attention:  All Providers

Piedmont Cardinal Health Plan

DMA, in collaboration with the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, is in the process of requesting approval from CMS for a mental health, developmental disabilities, substance abuse (MH/DD/SA) services waiver program.  The model will be based upon the waiver that has been operating in Cabarrus, Davidson, Rowan, Stanly, and Union counties since April 2005.  The existing waiver is currently administered by the State through Piedmont Behavioral HealthCare (PBH), a local management entity (LME) for the delivery of publicly funded MH/DD/SA services.

The expansion will allow other LMEs to apply to the State to operate in the same capacity as PBH as a prepaid health plan for the delivery of MH/DD/SA services.  All Medicaid recipients residing in the selected LME catchment areas who are approved for participation will be required to obtain MH/DD/SA services through their respective LMEs.

The State plans to release a request for applications in the spring of 2010.  The State will initially select one or two waiver entities to begin operation in July of 2010 or at a date approved by CMS.  The request for applications will provide details on requirements for participation.  Additional information will be provided through the Medicaid Bulletin as it becomes available. 

Waiver Development and Demonstrations Unit
DMA, 919-855-4260

Attention:  All Providers

Medicaid Credit Balance Reporting

All providers participating in the Medicaid Program are required to submit a quarterly Credit Balance Report to the DMA Third-Party Recovery Section identifying balances due to Medicaid.  Providers must report any outstanding credits owed to Medicaid that have not been reported previously on a Medicaid Credit Balance Report.  However, hospital and nursing facility providers are required to submit a report every calendar quarter even if there are no credit balances.  The report must be submitted no later than 30 days following the end of the calendar quarter (March 31, June 30, September 30, and December 31).

The Medicaid Credit Balance Report is used to monitor and recover “credit balances” owed to the Medicaid Program.  A credit balance results from an improper or excess payment made to a provider.  For example, refunds must be made to Medicaid if a provider is paid twice for the same service (e.g., by Medicaid and a medical insurance policy, by Medicare and Medicaid, by Medicaid and a liability insurance policy) or if the patient liability was not reported in the billing process or if computer or billing errors occur.

For the purpose of completing the report, a Medicaid Credit Balance is the amount determined to be refundable to the Medicaid Program.  When a provider receives an improper or excess payment for a claim, it is reflected in the provider's accounting records (patient accounts receivable) as a “credit.”  However, credit balances include money due to Medicaid regardless of its classification in a provider's accounting records.  If a provider maintains a credit balance account for a stipulated period (e.g., 90 days) and then transfers the account or writes it off to a holding account, this does not relieve the provider of liability to the Medicaid Program.  The provider is responsible for identifying and repaying all monies owed the Medicaid Program.

The Medicaid Credit Balance Report requires specific information for each credit balance on a claim-by-claim basis.  The reporting form provides space for 15 claims but may be reproduced as many times as necessary to accommodate all the credit balances being reported.  Specific instructions for completing the report are on the reverse side of the reporting form.

Submitting the Medicaid Credit Balance Report does not result in the credit balances automatically being reimbursed to the Medicaid Program.  Electronic adjustments are the preferred method of satisfying the credit balances and can be performed through the North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool.  Refer to the September 2009 Special Bulletin, North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool Instruction Guide, for specific filing instructions.

In the event, a billing error caused an individual provider to be paid for a service in which a provider group should have been paid, a refund check will need to be sent to HP Enterprise Services (EDS) to correct the error as it is unlikely the individual provider will have future claims to adjust.  In these circumstances only, a check must be made payable to HP Enterprise Services (EDS) and sent to HP Enterprise Services (EDS) using the Medicaid Provider Refund Form.  The information on the form must be complete and accurate in order to process the provider refund check.  

Submit only the completed Medicaid Credit Balance Report to DMA.  Failure to submit a Medicaid Credit Balance Report to DMA will result in the withholding of Medicaid payment until the report is received.

Send to DMA:

• The original completed Medicaid Credit Balance Report.
• Please circle “Adjustment” at bottom of original credit balance report to indicate an electronic adjustment has been performed.  (Note:  You may circle “Refund” in the event a check must be sent due to the reason stated above).

Send to EDS Refunds Department:

• Always send live credit balance refund check(s) to the HP Enterprise Services (EDS) refunds address listed in this bulletin.
• Enclose a copy of the Medicaid Credit Balance Report associated with the refund.
• Include a completed Medicaid Provider Refund Form to ensure that HP Enterprise Services (EDS) can appropriately document individual refund amounts.
• Please circle “Refund” at the bottom of the copy of the Medicaid Credit Balance Report.

Debbie Odette, Third Party Recovery Section
DMA, 919-647-8100

• Medicaid Credit Balance Report
• Medicaid Provider Refund Form
• North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool Instruction Guide, September 2009 Special Bulletin

Attention:  CAP/DA Case Managers and CAP/DA Service Providers

Participation in the Community Alternatives Program for Disabled Adults:  Freeze Update

In response to the Joint Conference Committee Report on the Continuation, Expansion, and Capital Budgets, Section G, Item 170 of the 2009 Appropriation Act (SL 2009-451), each county, as of October 2009, was assigned a new slot allocation.  This new slot allocation allows compliance with the proposed freeze as well as allowing lead agencies to continue to serve citizens in their catchment area.  Please direct questions about the new slot allocation to the CAP/DA Unit in the Facility and Community Care Section by calling 919-855-4340 or faxing 919-715-2372.

Facility and Community Care Section
DMA, 919-855-4340

Attention:  Enhanced Behavioral Health (Community Intervention) Services Providers

Provider Verification and Credentialing Activities

Community Intervention Services (CIS) agencies have now received the re-verification packets that must be completed and returned to CSC immediately to ensure uninterrupted enrollment as a CIS provider. 
For detailed information, please review Implementation Update #63, the November 2009 Medicaid Bulletin or contact the CSC EVC Call Center at 1-866-844-1113.

Behavioral Health Section
DMA, 919-855-4290

Attention:  Pharmacists

Drug Utilization Review Early Refill Alert

DMA is continuing to see a large number of claims that are denied with the early refill alert and are subsequently being rebilled by overriding the denial at the point of sale.  In accordance with Clinical Coverage Policy 9, Outpatient Pharmacy Program, pharmacy providers are reminded that there is no provision for payment by N.C. Medicaid for early refills on controlled substances except in the event that a recipient’s therapy has changed.  Providers are cautioned to carefully consider the appropriateness of overriding the Drug Utilization Review (DUR) early refill alert.  When using 05 to designate a therapy change, the provider should verify that indeed a therapy change did occur. 

Program Integrity will monitor the use of the early refill override codes.  Claims billed with the incorrect override code, overridden for an invalid reason, or otherwise not in compliance with policy will be subject to recoupment.

Pharmacy Review Unit
DMA, 919-647-8000

Attention:  Pharmacists and Prescribers

New Prior Authorization Requirements for Brand Name Fibrates and Lovaza

Effective with date of service of November 17, 2009, the N.C. Outpatient Pharmacy Program will begin requiring prior authorization (PA) for brand-name fibrates and Lovaza.  Prescribers can request prior authorization by contacting ACS at 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 Antara, Fenoglide, Lipofen, Lofibra, Lopid, Tricor, Triglide, Trilipix, and Lovaza.

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

Attention:  Personal Care Services Providers

Implementation of PCS PACT Reviews and Independent Assessments

In response to Session Law 2009-451 (Senate Bill 202), Section 10.68A.(a)(3), DMA is implementing changes in the Medicaid In-Home Personal Care Services (PCS) Program.  The required changes are being implemented in two stages.

Stage I PCS PACT Reviews were implemented November 3, 2009, with a notice to all active enrolled PCS providers.  The postmark deadline for all materials requested in the notice was November 23, 2009.  If you did not receive the notice and submit the required materials, refer to the PACT Review website for instructions and forms, and submit the required materials immediately.  Questions may be directed to the PACT Help Line at 1-800-228-3365 or by e-mail to PACTreview@thecarolinascenter.org.

After you have responded to the initial PACT Review notice, continue to conduct new referral assessments, annual reassessments, and change of status reviews until you are notified that Stage II Independent Assessments have been implemented.  Until you receive further notice, also complete and submit weekly assessment and discharge updates using the Weekly Summary Form.

Implementation of Stage II Independent Assessments will occur as early as possible in calendar year 2010.  Watch the PACT Review website and future bulletin articles for important announcements and updates.

Facility and Community Care Section
DMA, 919-855-4340

• PACT Review Website
• Session Law 2009-451
• Weekly Summary Form

Attention:  Health Departments, Nurse Midwives, Nurse Practitioners, and Physicians

Lidocaine for Topical Anesthesia and Saline/Water Codes:  Billing Guidelines

Effective with date of service November 1, 2009, the N.C. Medicaid Program covers lidocaine anesthetic agent (including formulations) when it is used to block pain sensation during outpatient procedures and it is billed using HCPCS code J3490.  National Drug Codes (NDCs) are required on the claim.

Note:  The HCPCS code appropriate for billing lidocaine administered intravenously is J2001.  For providers billing on professional claims, the maximum reimbursement rate for lidocaine will depend on the NDC that is billed.  

Effective with date of service November 1, 2009, codes for sterile water/saline and/or dextrose (diluent flush),
10 ml (HCPCS code A4216), and for sterile water/saline, 500 ml (HCPCS code A4217), are also covered when used as flushes and irrigations or to dilute medications prior to administration.  For providers billing on professional claims, the maximum reimbursement rate for A4216 is $0.42 and the maximum reimbursement rate for A4217 is $2.64.  For multi-dose vials, only the amount administered to the recipient may be billed.  When single-dose vials are used, the entire vial may be billed. 

HCPCS codes A4216 and A4217 do NOT require NDCs to be reported.  Refer to the March 2009 Special Bulletin, National Drug Code Implementation, Phase III, and to general Medicaid bulletin articles for additional instructions regarding the NDC requirements.

The Physicians Drug Program fee schedule (HCPCS code J3490) and the Physician Services fee schedule (HCPCS codes A4216 and A4217) on DMA’s Fee Schedule web page.

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

• Fee Schedule Web Page
• National Drug Code Implementation, Phase III, March 2009 Special Bulletin

Attention:  All Providers

Medicaid Recipient Appeal Process/Early and Periodic Screening, Diagnosis, and Treatment

Medicaid Recipient Appeal Process/Early and Periodic Screening, Diagnosis and Treatment (EPSDT) seminars are scheduled for the month of February 2010.  Seminars are intended to address Medicaid recipient appeal process when a Medicaid service is denied, reduced or terminated.  The seminar will also focus on an overview of EPDST – Medicaid for Children.

The seminar sites and dates will be announced in the January 2010 Medicaid Bulletin.  Pre-registration will be required.  Due to limited seating, registration will be limited to two staff members per office.  Unregistered providers are welcome to attend if space is available.

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

Attention:  Nurse Practitioners and Physicians

Golimumab (50 mg per 0.5 ml) for Injection (Simponi, HCPCS Code J3590):  Billing Guidelines

The following article from the July 2009 Medicaid bulletin is being republished to correct the maximum allowable reimbursement rate.  Systematic adjustments will be made to previously paid claims for dates of service on or after July 1, 2009.

Effective with date of service July 1, 2009, the N.C. Medicaid Program covers golimumab injectable (Simponi) for use in the Physician’s Drug Program when billed with HCPCS code J3590 (unclassified biologics).  Simponi is available as either single-dose, 50 mg per 0.5 ml pre-filled syringes or single-dose, 50 mg per 0.5 ml pre-filled SmartJect autoinjectors.

Simponi is a human monoclonal antibody that is indicated for the treatment of adults with active moderate to severe rheumatoid arthritis (RA), active psoriatic arthritis (PsA), and active ankylosing spondylitis (AS).

Simponi is administered as a subcutaneous (SC) injection once a month.  The recommended dose for Simponi is 50 mg.

Prior to initiating Simponi and periodically during therapy, patients should be evaluated for active tuberculosis and tested for latent infection.  For patients with RA, Simponi should be given in combination with methotrexate and for patients with PsA or AS, Simponi may be given with or without methotrexate or other non-biologic disease-modifying antirheumatic drugs (DMARDs).  For patients with RA, PsA, or AS, corticosteroids, non-biologic DMARDs, and/or non-steroidal anti-inflammatory drugs (NSAIDs) may be continued during treatment with Simponi.

For Medicaid Billing

• The ICD-9-CM diagnosis codes required for billing Simponi are:
  • 714.0 through 714.9 (rheumatoid arthritis)
    OR

• 696.0 (psoriatic arthritis [severe])
  OR

• 720.0 (ankylosing spondylitis)

• Providers should bill Simponi with HCPCS code J3590 (unclassified biologics).
• One Medicaid unit of coverage is 50 mg.  The maximum reimbursement rate, per unit (50 mg), is $1,701.00.
• Providers must indicate the number of HCPCS units used.
• Providers must bill with National Drug Codes (NDCs).  The NDC units should be reported as “ML.”  For example, each 50 mg administered (0.5 ml from either the disposable pen or the disposable syringe), the NDC units should be reported as “ML0.5.” 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 on DMA's Fee Schedule web page.

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

• Fee Schedule Web Page
• National Drug Code Implementation, Phase III, March 2009 Special Bulletin

Attention:  Adult Care Homes, Adult Day Health Care Centers, Health Departments, Nurse Practitioners, Nursing Facilities, and Physicians

Clarification of the Two-Step Tuberculosis (TB) Test Process and Billing

There has been much confusion regarding the two-step tuberculosis (TB) test – what is it and how can a physician’s office get paid for administering both parts of the test?

Two-step testing reduces the likelihood of interpreting a "boosted" reaction as a true conversion or a new infection; it is recommended in situations where there will be repeat testing on a regular basis.

Two-step testing is required for residents of long-term care facilities upon admission.  If the resident has had a documented TB skin test (TST) within the last 12 months, that TST can be counted as the first step in two-step testing.

1. If the reaction to the first test is positive, consider the individual infected.
2. If the reaction to the first test is negative, a second test should be given 1 to 3 weeks later.
   1. If the second test is positive, consider the individual infected.
   2. If the second test is negative, consider the individual not infected, record reactions, and document dates of reading and signature(s) of person(s) reading the tests.

Source:  NCTB Control Program Policy Manual (Rev 01/09 11-11)

Physicians should bill Medicaid for the two-step TB test as follows:

1. Bill the first part of the test using CPT procedure code 86580.  This code can be billed only one time per day.
2. For the second part of the test that is administered 1 to 3 weeks after the first test, bill using the same CPT procedure code, 86580.  No modifier is required.

Two-step testing is required for staff in long-term care facilities, as well as for staff in adult day health care centers who provide care for HIV/AIDS clients (see Chapter XI, 10A NCAC 41A.0205 (b) 4 and 5).  TB skin testing is not covered by Medicaid for job requirements.  Another payment source will need to be identified when the test is administered to staff to meet these requirements.

Julie Budzinski, MA
Clinical Policy and Programs
DMA, 919-855-4368

Margaret Comin, RN, BSN, MPA
Clinical Policy and Programs
DMA, 919-855-4355

Attention:  Pharmacists and Prescribers

Removal of Cough and Cold Medications from Coverage

Effective December 1, 2009, N.C. Medicaid will stop covering prescription medications used to treat the symptoms of cough and colds.  The cough and cold medications that will no longer be covered are those that contain a cough suppressant or a cough expectorant.  Products that do not have a cough suppressant or an expectorant will continue to be covered.

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

Attention:  Home Health Agencies and Private Duty Nursing Providers

Using National Drug Codes for the Billing of Diabetic Supplies

Effective November 15, 2009, Prodigy Diabetes Care, LLC, became N.C. Medicaid's designated preferred manufacturer for glucose meters, diabetic test strips, control solutions, lancets, lancing devices, and syringes. This change to a preferred manufacturer means that only Prodigy test strips, control solutions, lancets, lancing devices, and syringes will be covered by N.C. Medicaid. 

Effective with date of service February 1, 2010, home health agencies and private duty nursing (PDN) providers who provide diabetic supplies must also comply with this requirement.  Beginning February 1, 2010, only Prodigy test strips, lancets, lancing devices, and syringes will be covered by N.C. Medicaid.  Diabetic supplies billed for Medicaid reimbursement must be obtained from Prodigy Diabetes Care, LLC.

Billing Instructions for Submitting Claims for Medicaid Reimbursement of Diabetic Supplies

Claims for diabetic test strips, lancets, lancing devices, and insulin syringes must be billed using the National Drug Code (NDC) for the product.  The following table lists the HCPCS codes affected by this requirement along with the corresponding NDC.  The codes listed below are the only diabetic supply codes affected.

Home health agencies must complete the following fields on the UB-04 claim form when billing for these supplies.  Providers using the 837I transaction or other electronic claims submission should enter the information in the comparable blocks.

The following fields are required when reporting NDCs with the UB-04:

• FL42:  Revenue code
• FL43:  Enter the NDC qualifier of N4, followed by the 11-digit NDC number
  • Do not enter spaces between the NDC data elements.
  • Do not enter hyphens within the NDC number.
  • Enter UN immediately following the NDC.
• FL44: Enter the appropriate HCPCS procedure code.

PDN providers using the CMS-1500 claim form or electronic equivalent are also required to use the NDC in addition to the HCPCS code to bill the codes listed above.  Enter the information as follows.

• Field 24 A:
  • Begin by left justifying the N4 qualifier.  Immediately follow it with the 11-digit NDC.
  • Insert three (3) spaces
  • Enter the code UN (describes the unit of measure)
• Field 24 B:  Enter the quantity

For information on billing with the NDC, please refer to the March 2009 Special Bulletin, National Drug Code Implementation, Phase III. 

For additional information, providers may call Prodigy Diabetic Care, LLC, at 1-866-540-4816.

Clinical Policies and Programs
DMA, 919-855-4380

Attention:  Durable Medical Equipment Providers and Pharmacy Providers

Prodigy Diabetic Supplies Under the Durable Medical Equipment and Pharmacy Programs:  Update

Effective November 15, 2009, Prodigy Diabetes Care, LLC, was designated as N.C. Medicaid's 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 applies 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 (see page 28). 

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 were 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. 

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 were end-dated.

For patients on insulin pumps incompatible with Prodigy products, there will be an override process available for patients who cannot use Prodigy products for clinical reasons.  In these instances, the provider must be a DME provider.  The following protocol, documented in Section 5.5 of Clinical Coverage Policy 5A, Durable Medical Equipment, needs to be followed for overrides.  Submit the denial to DMA at the designated diabetic supply override fax line, 919-715-3166, along with the required medical necessity forms.  Consideration will be given to the request and a written decision will be returned to the provider.

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

• Clinical Coverage Policy 5A, Durable Medical Equipment
• National Drug Code Implementation, Phase III, March 2009 Special Bulletin

Attention: All Providers

Top 10 Reasons a Provider Application is Deemed Incomplete

On April 20, 2009, CSC took over the provider enrollment, credentialing, and verification functions from DMA's Provider Services unit. In just six months, the CSC EVC Call Center has handled almost 10,000 applications from providers who want to participate in North Carolina's Medicaid Program

Most applications move smoothly through the EVC process but occasionally an application is deemed incomplete and processing is suspended until the provider submits the necessary information.

The top 10 reasons an application may be deemed incomplete are:

1. The W-9 form is not filled out correctly.
2. Section 18 A and B of the ownership and managing employees form are not provided.
3. The indicator boxes are not marked.
4. Titles are not provided.
5. Required documents are not provided.
6. Documents that have been returned are incorrect.
7. A DMA Provider Sservices Business Rule requirement is not met.
8. An administrative review is needed.
9. The provider has not responded to e-mails and return letters.
10. The signer is not an authorized agent for the provider.

In even rarer instances, a provider's application is rejected. The top three reasons an application may be rejected are:

1. The wrong type of application is submitted.
2. The wrong version of an application is used.
3. An enrolled provider has submitted a new application instead of a change form.

We appreciate your willingness to provider services to some of our State's most vulnerable citizens. Our goal is to ensure your application is processed in a timely fashion so that you can participate in the N.C. Medicaid Program. We hope that these lists will help you avoid some common mistakes as you complete your application packet. We look forward to helping you become part of North Carolina's Medicaid community

CSC, 1-866-844-1113

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

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