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January 2008
Medicaid Bulletin

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In This Issue.........

NPI Articles:

All Providers:

Adult Care Home:

Ambulatory Surgical Centers:

Case Management Agencies:

Certified Dialysis Providers:

Dental Providers:

Durable Medical Equipment:

Federally Qualified Health Centers:

Health Departments:

Health Department Dental Centers:

Home Health Agencies:

Home Infusion Therapists:

Hospice Providers:

Hospital Outpatient Clinics:

Independent Practitioners:

Local Education Agencies:

Local Health Departments:

Nurse Midwives:

Nurse Facility Providers:

Nurse Practitioners:

Orthotic and Prosthetic Providers:

Personal Care Services, Personal Care Services-Plus:

Pharmacies:

Physicians:

Rural Health Centers:

UB-92 / UB-04 Providers:



NPI Logo 

Attention:  All Providers

National Provider Identifier (NPI) Seminars

N.C. Medicaid will hold National Provider Identifier (NPI) seminars during the month of February 2008.  Seminars are intended for providers that would like more detailed information on how NC Medicaid will be implementing NPI.  New information as well as future changes will be addressed at these seminars.  Providers are encouraged to attend.

The seminars are scheduled at the locations listed below.  Pre-registration is required.  Due to limited seating, registration is limited to two staff members per office.  Unregistered providers are welcome to attend if space is available.

Providers may register for the NPI seminars online.  Sessions will begin at 9:00 a.m. and end at 12:00 p.m.  Providers are encouraged to arrive by 8:45 a.m. to complete registration. 

Please see directions and contact phone numbers for venues.

February 5, 2008
A/B Tech Community College
*Enka Campus*
1459 Sand Hill Rd
Candler, NC

February 6, 2008
Park Inn Gateway Conference Center
909 US Highway 70 SW
Hickory, NC

February 14, 2008
Martin Community College
1161 Kehukee Park Rd
Williamston, NC

February 19, 2008
Holiday Inn Select
5790 University Parkway
Winston-Salem, NC

February 20, 2008
Hilton University Place
8629 J.M. Keynes Drive
Charlotte, NC

February 26, 2008
McKimmon Center
1101 Gorman Street
Raleigh, NC

February 27, 2008
Coastline Convention Center
501 Nutt St
Wilmington, NC

 


Directions to A/B Tech Community College, Enka Campus (828) 254.1921
Take I-40 to Exit 44. At the traffic light at the end of the exit ramp, turn right. Go to the fourth traffic light and turn left on Sand Hill Road. Go to the second entrance on the left and turn onto the campus. The Haynes Conference Center will be on your right and the Incubator will be on your left. You may park on the left or in the lots straight ahead of you. 

Directions to Park Inn Gateway Conference Center, Hickory, NC (828) 328-5101
Exit 123B off of I-40 to 321 North (half a mile) take Exit 44. Park Inn Hickory is on the right hand side. 

Directions to Holiday Inn Select- Winston-Salem (800) 465-4329
From the East or West: Take I-40 to NC Hwy 52 North, travel 8 miles to exit 115B (University Pkwy South).  Hotel is on the right.
From the North:  Take Hwy 52 South, to UNIVERSITY PKWY exit- EXIT 115. Keep RIGHT at the fork to go on UNIVERSITY PKWY.
From the South:  Take Hwy 52 North to exit 115B (University Pkwy South).  Hotel is on the right.

Directions to Hilton University Place, Charlotte NC (704) 547-7444
Exit from I-85 North or South at exit 45A, W.T. Harris Boulevard East. Hilton Charlotte University Place is 1/4 mile on the left in the University Place complex. The hotel is the highrise building in the complex, totally visible from Harris Boulevard. Then left turn at J M Keynes Drive goes directly into the hotel parking lot.

Directions to Martin Community College, Williamston, NC (252) 792-1521
From the West: U.S. Hwy. 64 to Williamston, Exit 512 from Hwy. 64.
Turn right on NC Hwy. 125 (Prison Camp Rd.) and left on Kehukee Park Road. Martin Community College will be on the right. Sign before Exit 512 states Senator Bob Martin Agricultural Center and Martin Community College. If you are coming in on Alternate Hwy. 64 (business), college will be on right.  

From the North: U.S. Highways 13 and 17 run together from Windsor to Williamston.  Both run in to Alternate Hwy. 64 (business) at Holiday Inn. Continue straight on Hwy.  64 West. College will be on left just outside of town.

From the East: From Jamesville/Plymouth on U.S. Hwy. 64 traveling west in

Williamston, turn left at the stoplight at McDonald's. Keep straight at the Holiday Inn Intersection on Hwy. 64 West. College is on the left just outside of Williamston.

From the South: From Washington, take U.S. Hwy. 17 North to Williamston. At the Holiday Inn intersection in Williamston, take a left on Hwy. 64 West. College will be on the left just outside Williamston.

From Greenville, take Hwy. 264 bypass. Exit route Hwy. 11 & 13 North. Turn right on Route 903 through Stokes N.C.; take the first left after going through Stokes (still on Hwy. 903). After entering Martin County, turn right at yellow, blinking light onto Prison Camp Road (also known as State Road #1142). Pass Senator Bob Martin Eastern Agricultural Center, and keep on Prison Camp Rd. Turn left on Kehukee Park Road.  College is on the right.

Directions to Jane S. McKimmon Center - Raleigh (919) 515-2277

Traveling East on I-40:  Take Exit 295 and turn left onto Gorman Street.  Travel approximately 2.5 miles.  The McKimmon Center is located on the right at the corner of Gorman Street and Western Boulevard.

Traveling West on I-40:  Take Exit 295 and turn right onto Gorman Street.  Travel approximately 2.5 miles.  The McKimmon Center is located on the right at the corner of Gorman Street and Western Boulevard.

Directions to Coastline Convention Center - Wilmington (910) 763-6739

From I-40 East / Raleigh Durham Area:  Follow Interstate 40 East to Wilmington. As you approach Wilmington, turn right onto MLK Parkway/74 West/Downtown. Continue on route to downtown and it will become 3rd Street. Follow 3rd Street for five blocks until you reach Red Cross Street. Turn right onto Red Cross Street and follow for two blocks. Turn right onto Nutt Street. Second drive way on left is the entrance to the convention center.

From Hwy 17 S. (Jacksonville area):  Stay on Hwy 17 S. as it turns into Market Street. Follow Market Street until you see the sign for 74 West / Downtown (MLK Parkway).  Take 74 West (MLK Parkway) to downtown (approx 4 miles), turn right on Red Cross Street, come 2 blocks, turn right on Nutt Street. Second drive way on left is the entrance to the convention center.

From Hwy 17 N. or Hwy 74-76 (Myrtle Beach or Fayetteville area):  Come across the Cape Fear Memorial Bridge into Wilmington.  Take a left at the first stoplight onto 3rd Street and come downtown.  Follow 3rd Street to Red Cross Street and turn left at the stoplight.  Go to the bottom of the hill (approximately 3 blocks).  Take a right onto Nutt Street, turn left into the main parking lot of the Coast Line Center.

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



NPI Logo 

Attention:  All Providers

NPI on Paper Remittance and Status Reports

Beginning in January 2008, paper Remittance and Status (RA) Reports will display the billing provider's NPI in addition to the Medicaid Provider Number.  The NPI will appear directly above the Medicaid Provider Number on each page of the RA.  Attending provider NPIs will not be displayed. The NPI shown on the RA will be the NPI reported to N.C. Medicaid for the billing Medicaid Provider Number.   If no NPI appears, N.C. Medicaid does not have your NPI in the provider database and you need to report it as soon as possible.  To report an NPI, visit the DMA NPI and Address Database.

 EDS, 1-800-688-6696 or 919-851-8888 



NPI Logo 

Attention:  All Providers

Include ZIP+4 on Claims

Providers are now required to include the last four digits of their ZIP codes in the billing address and service facility location address fields on all claims.  Once NPI is implemented, the ZIP+4 will be an important component for claims processing. Therefore, it is imperative for providers to begin including this information on claims. Requirements for each claim form regarding ZIP+4 are listed below.

To determine your ZIP+4, visit the U.S. Postal Service Web site, www.usps.com, and use the ZIP Code Lookup function. 

NPI - Get it! Share It! Use It! Getting one is free - Not having one can be costly!

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


NPI Logo 

 Attention:  All Providers

EOB Codes for NPI

This article is for informational purposes only.  N.C. Medicaid is currently not accepting claims containing NPI only. As NPI implementation approaches, providers will begin seeing the following new and modified NPI EOB codes:

NEW EOB CODES FOR NPI:

MODIFIED EOB CODES FOR NPI:

NPI - Get it! Share It! Use It! Getting one is free - Not having one can be costly!

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


NPI Logo 

Attention:  All Providers

Recommended Taxonomy Codes for NPI Mapping

N.C. Medicaid has designed a mapping solution to crosswalk the NPI to the Medicaid Provider Number.  Ideally, each NPI will crosswalk to only one Medicaid Provider Number.  If the NPI crosswalks to multiple Medicaid Provider Numbers, the mapping solution will attempt to determine the appropriate Medicaid Provider Number by taking the claim through a series of steps.  The taxonomy will play an important role in determining the appropriate Medicaid Provider Number to use for claim processing.  Therefore, N.C. Medicaid strongly recommends that providers use the table below when choosing an appropriate taxonomy.  This will assist N.C. Medicaid in crosswalking to the correct Medicaid Provider Number in the event the provider chooses not to apply for a unique NPI for each of its Medicaid Provider Numbers.

NOTE:  The taxonomies recommended below are to be used for claims processing only.  Providers are not required to change the taxonomy that was previously reported to NPPES or N.C. Medicaid Provider Enrollment.  Currently, N.C. Medicaid does not compare the taxonomy submitted on claims to what was reported to Provider Enrollment or NPPES. 

Provider Type/Service Provided

Taxonomy Code

Nursing Home - Skilled Nursing Level of Care

314000000X

Nursing Home - Intermediate Care Level of Care

313M00000X

Nursing Home - Vent Level of Care

314000000X

Nursing Home - Head Level of Care

310500000X

Nursing Home - Indian Facility Billing Skilled Nursing Level of Care

314000000X

Nursing Home - Indian Facility Billing Intermediate Nursing Level of Care

313M00000X

Adult Care Home Level of Care

310400000X

Adult Care Home Enhanced Level of Care

310400000X

Adult Care Home Special Care Alzheimer's Level of Care

311500000X

Swing Bed - Any Facility

275N00000X

Personal Care Services

3747P1801X

All Case Management Services (HIV, At Risk, MCC and CSC)

251B00000X

Home Health

251E00000X

Home Infusion Therapy (HIT)

251F00000X

Durable Medical Equipment

332B00000X

Pharmacy Prescription Services

333600000X

Federally Qualified Health Clinic (FQHC) - All services

261QF0400X

Rural Health Clinic (RHC) - All Services

261QR1300X

Physician - Groups

193200000X (Multi-specialty)
193400000X (Single specialty)

Physician - Individuals

Any of the Allopathic and Osteopathic Taxonomies

Private Duty Nurses

215J00000X

Nurse Practitioners - All Services except psychiatric related services

363L00000X

Nurse Practitioners - Mental Health/Psychiatric

363LP0808X

Clinical Nurse Specialist - Mental Health/Psychiatric

364SP0808X

Hospice Services Provided at Any Location

251G00000X

Hospital - Rehabilitation Services ('T' suffix on Medicaid Provider Number)

273Y00000X
276400000X

Hospital - Psychiatric Services ('S' suffix on Medicaid Provider Number)

273R00000X

Hospital - General Services

282N00000X

Hospital - Critical Access

282NC0060X

Area Mental Health (LME)

261QM0801X

Psychiatric Residential Treatment Facility (PRTF)

323P00000X

Residential Child Care

322D00000X

Independent and Outpatient Mental Health Services - Group

Any of the Behavioral Health and Social Service Taxonomies

Community Intervention Services (All Enhanced Benefits

251S00000X

Psychiatric Hospital - Inpatient

283Q00000X

Health Department - All Services

251K00000X

Ambulance

341600000X

Respiratory Therapists Group/Individual

227800000X

Audiologists Group/Individual

231H00000X

Hearing Aid Dealer - Hearing Aid

237700000X

Speech Pathologists Group/Individual

235Z00000X

Physical Therapists Group/Individual

225100000X

Occupational Therapists Group/Individual

225X00000X

Chiropractic Group/Individual

111N00000X

Optometry Group/Individual

152W00000X

Optical Supply Dealer - Eyewear Supplier

332H00000X

Optical Supply  Dealer - Optician

156FX1800X

Podiatry Group/Individual

213E00000X

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


 NPI Logo

Attention:  Nursing Facility Providers

Recommended Taxonomy Codes for NPI Mapping

N.C. Medicaid recommends for NPI mapping that the following taxonomies are submitted on claims when nursing home services are provided.

Provider Type - Service Provided

Taxonomy Code

Nursing Home - Skilled Nursing Level of Care

314000000X

Nursing Home - Intermediate Care Level of Care

313M00000X

Nursing Home - Vent Level of Care

314000000X

Nursing Home - Head Level of Care

310500000X

Nursing Home - Indian Facility Billing Skilled Nursing Level of Care

314000000X

Nursing Home - Indian Facility Billing Intermediate Nursing Level of Care

313M00000X

 EDS, 1-800-688-6696 or 919-851-8888


NPI Logo

Attention:  Case Management Agencies

Recommended Taxonomy Codes for NPI Mapping

N.C. Medicaid recommends for NPI mapping that the following taxonomy is submitted on claims when case management services are provided.

Provider Type/Service Provided

Taxonomy Code

All Case Management Services (HIV, At Risk, MCC and CSC)

251B00000X

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


NPI Logo 

Attention:  Personal Care Services, Personal Care Services-Plus

Recommended Taxonomy Codes for NPI Mapping

N.C. Medicaid recommends for NPI mapping that the following taxonomy is submitted on claims when personal care services are provided.

Provider Type/Service Provided

Taxonomy Code

Personal Care Services

3747P1801X

 EDS, 1-800-688-6696 or 919-851-8888


 NPI Logo

Attention:  Home Health Agencies

Recommended Taxonomy Codes for NPI Mapping

N.C. Medicaid recommends for NPI mapping that the following taxonomy is submitted on claims when home health services are provided.

Provider Type/Service Provided

Taxonomy Code

Home Health

251E00000X

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


NPI Logo 

Attention:  Home Infusion Therapists

Recommended Taxonomy Codes for NPI Mapping

N.C. Medicaid recommends for NPI mapping that the following taxonomy is submitted on claims when home infusion therapy services are provided.

Provider Type/Service Provided

Taxonomy Code

Home Infusion Therapy (HIT)

251F00000X

 EDS, 1-800-688-6696 or 919-851-8888


NPI Logo

Attention:  Durable Medical Equipment Providers

Recommended Taxonomy Codes for NPI Mapping

N.C. Medicaid recommends for NPI mapping that the following taxonomy is submitted on claims when billing for DME supplies.

Provider Type/Service Provided

Taxonomy Code

Durable Medical Equipment

332B00000X

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


NPI Logo 

Attention:  Adult Care Home Providers

Recommended Taxonomy Codes for NPI Mapping

N.C. Medicaid recommends for NPI mapping that the following taxonomies are submitted on claims when adult care home services are provided.

Provider Type/Service Provided

Taxonomy Code

Adult Care Home Level of Care

310400000X

Adult Care Home Enhanced Level of Care

310400000X

Adult Care Home Special Care Alzheimer's Level of Care

311500000X

 EDS, 1-800-688-6696 or 919-851-8888


NPI Logo

Attention:  Health Departments

Recommended Taxonomy Codes for NPI Mapping

N.C. Medicaid recommends for NPI mapping that the following taxonomy is submitted on claims when services are provided at health departments.

Provider Type/Service Provided

Taxonomy Code

Health Department - All Services

251K00000X

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


NPI Logo 

Attention:  Federally Qualified Health Centers, Rural Health Centers

Recommended Taxonomy Codes for NPI Mapping

N.C. Medicaid recommends for NPI mapping that the following taxonomies are submitted on claims when services are provided at FQHC/RHC.  This will ensure accurate mapping for federal funding.

Provider Type/Service Provided

Taxonomy Code

Federally Qualified Health Clinic (FQHC) - All services

261QF0400X

Rural Health Clinic (RHC) - All Services

261QR1300X

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


NPI Logo

Attention:  Hospice Providers

Recommended Taxonomy Codes for NPI Mapping

N.C. Medicaid recommends for NPI mapping that the following taxonomy is submitted on claims when billing for hospice services.

Provider Type/Service Provided

Taxonomy Code

Hospice Services Provided at Any Location

251G00000X

NOTE:  For hospice services being provided in a nursing home facility, N.C. Medicaid recommends for NPI mapping of the attending/rendering provider, the following taxonomies are submitted on the claim at the attending/rendering level.

Provider Type/Service Provided

Taxonomy Code

Nursing Home - Skilled Nursing Level of Care

314000000X

Nursing Home - Intermediate Care Level of Care

313M00000X

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


NPI Logo 

Attention:  All Providers (Except Pharmacy)

New Requirements for NPI, Medicaid Provider Number, and Taxonomy on Claims

Effective January 1, 2008, with the exception of pharmacy, all submitted claims must contain the Medicaid Provider Number, NPI, and Taxonomy.   This data is needed to ensure that providers' claims are mapping and paying to the correct Medicaid Provider Number prior to NPI implementation. 

Beginning in March 2008, claims will deny if one of the above data elements is missing.  For placement of data on the 837 transaction, consult the HIPAA Implementation Guide at www.wpc-edi.com.  The NCECS Webtool now contains fields to report this information.  For UB and ADA paper claims, consult the New Claim Form Instructions Special Bulletin.  

Please note the following change for CMS-1500 paper claim forms:  Report the Billing Taxonomy in Box 19, and the Attending Taxonomy (if applicable) in Box 32b.  Placement of NPI and Medicaid provider number on paper claims remain the same. 

Reminder: on CMS-1500 and UB paper claims, the ZZ qualifier must precede the taxonomy.  Qualifiers are not used on the ADA form.

NPI - Get it! Share It! Use It! Getting one is free - Not having one can be costly!

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


NPI Logo 

Attention:  All Providers

National Provider Identifier and Address Information Database

The Division of Medical Assistance (DMA) has implemented a searchable National Provider Identifier (NPI) and address database. Providers can access the DMA NPI and Address Database by NPI or Medicaid provider number.

Please access the database as soon as possible to verify your NPI, site address, and billing address.

If your NPI is not in the database, previously submitted documentation was either not sufficient to update the database or has not been submitted at all. Providers should print the form and submit your NPI with a copy of your National Plan and Provider Enumeration System (NPPES) certification.

Provider Services
DMA, 919-855-4050


NPI Logo 

Attention: Webtool Users

Updated Fields for National Drug Code (NDC) and NPI

New fields are now available on the NCECS Webtool for submitting NDC and NPI information.  The NDC fields include:  the 11 digit National Drug Code and the NDC units (quantity).   Physicians, nurse practitioners, nurse midwives, Federally Qualified Health Centers, Rural Health Clinics, local health departments, and non-hospital based dialysis centers are required to submit NDCs when billing for rebatable drugs through the Physician's Drug Program (PDP).   For more information regarding NDC, see the October 2007 NDC Special Bulletin

The NPI fields include:  attending provider NPI, referring provider NPI, billing provider taxonomy and attending provider taxonomy.  The existing NPI field now has the ability to save data.  Effective January 1, 2008, NCECSWeb users are required to submit the NPI, Medicaid Provider Number, and taxonomy on all claims.  For more information regarding NPI, see the DMA NPI web page.

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


Attention:  All Providers

Current Procedural Terminology Code Update 2008

Effective with date of service Jan. 1, 2008, the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) have added some new Current Procedural Terminology (CPT) codes, deleted others, and changed the descriptions of some existing codes.  (For complete information regarding all CPT codes and descriptions, refer to the 2008 edition of Current Procedural Terminology, published by the American Medical Association.)  New CPT codes that are covered by the N.C. Medicaid program are effective with date of service Jan. 1, 2008.  Claims submitted with deleted codes will be denied for dates of service on or after Jan .1, 2008.  Previous policy restrictions continue in effect unless otherwise noted.

New Covered CPT Codes (effective 01/01/2008)

99367

99477

01935

01936

20555

21073

22206

22207

22208

24357

24358

24359

27267

27268

27269

27726

27767

27768

27769

29828

29904

29905

29906

29907

32421

32422

32550

32551

32560

33257

33258

33259

33864

34806

35523

36593

41019

49203

49204

49205

49440

49441

49442

49446

49450

49451

49452

49460

49465

50385

50386

51100

51101

51102

52649

55920

57285

57423

58570

58571

58572

58573

60300

67041

67042

67043

67113

67229

68816

75557

75561

80047

82610

83993

84704

86356

86486

87500

87809

90769

90770

90771

96125

             

 

End-Dated CPT Codes (effective 12/31/2007)

 

01905

24350

24351

24352

24354

24356

32000

32002

32005

32019

32020

36540

36550

43750

47719

49200

49201

51000

51005

51010

52510

60001

67038

74350

75552

75553

75554

75555

75556

78615

86586

99361

99362

99371

99372

99373

       

 

New CPT Codes Not Covered Pending Further Review

75559

75563

95980

95982

 

New CPT Codes Not Covered

99366

99368

99406

99407

99408

99409

99441

99442

99443

99444

20985

20986

20987

27416

28446

36591

36592

50593

75558

75560

75562

75564

88381

89322

89331

90284

90661

90662

90663

90776

93982

95981

98966

98967

98968

98969

99174

99605

99606

99607

 

CPT Codes from Previous CPT Updates That Are Now Covered (effective 01/01/2008)

22523

22524

22525

51798

Billing Information

CPT CODE

BILLING INFORMATION

DIAGNOSIS EDITING

PRIOR APPROVAL

68816

This procedure is approved for recipients ages 1 and older.

N/A

N/A

82610

Cystatin C is covered only for the FDA-approved indication, renal function testing.

N/A

N/A

90769 90770 90771

These procedures are not billable when the service is provided in a facility.

N/A

N/A

99367

This procedure is for 30 minutes or more of a physician's time during a medical team conference.

The code will be allowed once per conference per day.

This procedure will be covered only as a replacement for deleted CPT codes 99361 and 99362, and only when it is used as described in Clinical Coverage Policy 1A-5, "Case Conference for Sexually Abused Children."

Allowed diagnoses for this procedure are outlined in the policy.

N/A

Additional information will be published as necessary in future general Medicaid bulletins.

Clinical Policy and Programs
DMA, 919-855-4260


Attention:  Dental Providers and Health Department Dental Centers

Dental Rate Change

Effective with dates of service January 1, 2008, reimbursement rates for the following dental procedures were increased.  No adjustments will be accepted from providers for these dental rate changes.  Providers are reminded to bill their usual and customary charges rather than the Medicaid rate.

CDT
2007/2008
Code

Description

Reimbursement
Rate

D0170

Re-evaluation - limited, problem focused (established patient; not post-operative visit)

24.99

D0240

Intraoral - occlusal film

15.19

D0250

Extraoral - first film

22.54

D0260

Extraoral - each additional film

18.62

D0270

Bitewing - single film

10.78

D0290

Posterior-anterior or lateral skull and facial bone survey film

47.04

D0310

Sialography

100.94

D0320

Temporomandibular joint arthrogram, including injection

205.80

D0340

Cephalometric film

49.98

D0470

Diagnostic casts

40.80

D0473

Accession of tissue, gross and microscopic examination

50.96

D1110

Prophylaxis - adult

35.35

D1120

Prophylaxis - child

25.50

D2161

Amalgam - four or more surfaces, primary or permanent

100.10

D2390

Resin-based composite crown, anterior

163.35

D2931

Prefabricated stainless steel crown - permanent tooth

150.00

D2934

Prefabricated esthetic coated stainless steel crown - primary tooth

181.77

D2940

Sedative filling

41.65

D2950

Core buildup, including any pins

102.90

D2951

Pin retention - per tooth, in addition to restoration

24.99

D2970

Temporary crown (fractured tooth)

132.79

D3310

Root canal therapy - anterior (excluding final restoration)

269.50

D3320

Root canal therapy - bicuspid (excluding final restoration)

318.50

D3330

Root canal therapy - molar (excluding final restoration)

389.55

D3351

Apexification/recalcification - initial visit

131.32

D3352

Apexification/recalcification - interim medication replacement

95.55

D3353

Apexification/recalcification - final visit

191.10

D3410

Apicoectomy/periradicular surgery - anterior

246.96

D4210

Gingivectomy or gingivoplasty - four or more contiguous teeth per quadrant

236.18

D4211

Gingivectomy or gingivoplasty - one to three teeth per quadrant

87.71

D4240

Gingival flap procedure, including root planing - four or more contiguous teeth per quadrant

278.32

D4241

Gingival flap procedure, including root planing - one to three teeth per quadrant

235.20

D4341

Periodontal scaling and root planing - four or more contiguous teeth per quadrant

95.55

D4342

Periodontal scaling and root planing - one to three teeth per quadrant

61.25

D4355

Full mouth debridement to enable comprehensive evaluation and diagnosis

70.56

D4910

Periodontal maintenance

51.94

D5110

Complete denture - maxillary

612.50

D5120

Complete denture - mandibular

612.50

D5130

Immediate denture - maxillary

664.44

D5140

Immediate denture - mandibular

664.44

D5211

Maxillary partial denture - resin base

454.23

D5212

Mandibular partial denture - resin base

454.23

D5213

Maxillary partial denture - cast metal framework with resin denture bases

656.60

D5214

Mandibular partial denture - cast metal framework with resin denture bases

656.60

D5410

Adjust complete denture - maxillary

33.32

D5411

Adjust complete denture - mandibular

33.32

D5421

Adjust partial denture - maxillary

33.32

D5422

Adjust partial denture - mandibular

33.32

D5520

Replace missing or broken teeth - complete denture (each tooth)

68.11

D5620

Repair cast framework

109.76

D5640

Replace broken teeth - per tooth

68.60

D5650

Add tooth to existing partial denture

83.30

D5730

Reline complete maxillary denture (chairside)

142.10

D5731

Reline complete mandibular denture (chairside)

142.10

D5740

Reline maxillary partial denture (chairside)

139.65

D5741

Reline mandibular partial denture (chairside)

139.65

D5750

Reline complete maxillary denture (laboratory)

180.81

D5751

Reline complete mandibular denture (laboratory)

180.81

D5760

Reline maxillary partial denture (laboratory)

176.40

D5761

Reline mandibular partial denture (laboratory)

176.40

D6985

Pediatric partial denture, fixed

359.17

D7111

Extraction, coronal remnants - deciduous tooth

49.00

D7140

Extraction, erupted tooth or exposed root

60.50

D7210

Surgical removal of erupted tooth

104.00

D7220

Removal of impacted tooth - soft tissue

118.09

D7230

Removal of impacted tooth - partially bony

158.60

D7240

Removal of impacted tooth - completely bony

183.75

D7241

Removal of impacted tooth - completely bony, with unusual surgical complications

220.50

D7250

Surgical removal of residual tooth roots (cutting procedure)

113.19

D7270

Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth

200.90

D7280

Surgical access of an unerupted tooth

180.81

D7283

Placement of device to facilitate eruption of impacted tooth

203.35

D7285

Biopsy of oral tissue - hard (bone, tooth)

143.08

D7310

Alveoloplasty in conjunction with extractions - four or more tooth spaces, per quadrant

107.80

D7311

Alveoloplasty in conjunction with extractions - one to three tooth spaces, per quadrant

100.80

D7320

Alveoloplasty not in conjunction with extractions - four or more tooth spaces, per quadrant

157.29

D7321

Alveoloplasty not in conjunction with extractions - one to three tooth spaces, per quadrant

141.12

D7411

Excision of benign lesion greater than 1.25 cm

221.48

D7412

Excision of benign lesion, complicated

292.04

D7413

Excision of malignant lesion up to 1.25 cm

243.04

D7414

Excision of malignant lesion greater than 1.25 cm

355.74

D7415

Excision of malignant lesion, complicated

426.30

D7440

Excision of malignant tumor - lesion diameter up to 1.25 cm

196.00

D7450

Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm

186.20

D7451

Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm

238.63

D7465

Destruction of lesion(s) by physical or chemical method, by report

146.51

D7472

Removal of torus palatinus

274.40

D7473

Removal of torus mandibularis

272.93

D7485

Surgical reduction of osseous tuberosity

245.98

D7490

Radical resection of mandible with bone graft

3,109.05

D7530

Removal of foreign body from mucosa, skin or subcutaneous alveolar tissue

132.30

D7540

Removal of reaction producing foreign bodies, musculoskeletal system

245.00

D7560

Maxillary sinusotomy for removal of tooth fragment or foreign body

400.82

D7610

Maxilla - open reduction (teeth immobilized, if present)

1,604.75

D7620

Maxilla - closed reduction (teeth immobilized, if present)

1,260.77

D7630

Mandible - open reduction (teeth immobilized, if present)

1,581.23

D7640

Mandible - closed reduction (teeth immobilized, if present)

1,242.15

D7650

Malar and/or zygomatic arch - open reduction

1,434.72

D7660

Malar and/or zygomatic arch - closed reduction

1,219.12

D7670

Alveolus - closed reduction, may include stabilization of teeth

498.82

D7680

Facial bones - complicated reduction with fixation and multiple surgical approaches

2,408.35

D7710

Maxilla - open reduction

1,690.50

D7720

Maxilla - closed reduction

1,230.88

D7730

Mandible - open reduction

1,715.00

D7740

Mandible - closed reduction

1,327.90

D7750

Malar and/or zygomatic arch - open reduction

1,512.14

D7760

Malar and/or zygomatic arch - closed reduction

1,673.84

D7770

Alveolus - open reduction stabilization of teeth

980.00

D7780

Facial bones - complicated reduction with fixation and multiple surgical approaches

2,884.14

D7810

Open reduction of dislocation

1,565.55

D7820

Closed reduction of dislocation

191.10

D7830

Manipulation under anesthesia

250.88

D7840

Condylectomy

2,025.17

D7850

Surgical discectomy, with/without implant

2,041.34

D7870

Arthrocentesis

129.85

D7920

Skin graft

895.23

D7940

Osteoplasty - for orthognathic deformities

1,321.53

D7941

Osteotomy - mandibular rami

3,454.01

D7943

Osteotomy - mandibular rami with bone graft; includes obtaining the graft

3,181.08

D7944

Osteotomy - segmented or subapical

2,642.08

D7945

Osteotomy - body of mandible

2,744.00

D7946

LeFort I (maxilla - total)

3,218.32

D7947

LeFort I (maxilla - segmented)

3,253.11

D7950

Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla

1,006.95

D7960

Frenulectomy (frenectomy or frenotomy) - separate procedure

168.07

D7972

Surgical reduction of fibrous tuberosity

269.50

D7982

Sialodochoplasty

611.03

D7983

Closure of salivary fistula

401.80

D7990

Emergency tracheotomy

453.25

D7991

Coronoidectomy

1,440.60

D8670

Periodic orthodontic treatment visit (as part of contract)

92.40

D9110

Palliative (emergency) treatment of dental pain - minor procedure

44.59

D9220

Deep sedation/general anesthesia - first 30 minutes

141.61

D9221

Deep sedation/general anesthesia - each additional 15 minutes

60.27

D9242

Intravenous conscious sedation/analgesia - each additional 15 minutes

56.35

D9410

House/extended care facility call

78.40

D9440

Office visit - after regularly scheduled hours

61.25

D9610

Therapeutic parenteral drug, single administration

36.75

For current pricing on these and all dental codes, please refer to the fee schedule on the Division of Medical Assistance (DMA) Fee Schedule web page.  For coverage criteria and additional billing guidelines, please refer to Clinical Coverage Policy 4A, Dental Services, and Clinical Coverage Policy 4B, Orthodontic Services, on DMA's Web site.

Dental Program
DMA, 919-855-4280


Attention:  Local Education Agencies and Independent Practitioners

Code Addition

Effective with date of service Jan. 1, 2008, the following new CPT code has been added to the list of appropriate codes that independent practitioner and Local Education Agency speech language pathologists and occupational therapists may bill.

New CPT Code

Description

96125

Standardized cognitive performance testing (e.g., Ross Information Processing Assessment) per hour of a qualified health care professional's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.   (1 unit = 1 hour)

Clinical Coverage Policies 10B, Independent Practitioners, and 10C, Local Education Agencies, have been updated to reflect this code addition and are available on the Division of Medical Assistance Web site.

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


Attention: Orthotic and Prosthetic Providers

2008 HCPCS Code Changes for Orthotics and Prosthetics

Effective with date of service Dec. 31, 2007, the following codes were end dated and removed from the Orthotics and Prosthetics (O&P) fee schedule.

L0960

L1855

L1858

L1870

L1880

L3800

L3805

L3810

L3815

L3820

L3825

L3830

L3835

L3840

L3845

L3850

L3855

L3860

L3907

L3910

L3916

L3918

L3920

L3922

L3924

L3926

L3928

L3930

L3932

L3934

L3936

L3938

L3940

L3942

L3944

L3946

L3948

L3950

L3952

L3954

L3985

L3986

     

Effective with date of service Jan. 1, 2008 the following code description change was made:  

Code

New Description

L3806*

Wrist hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment. 

Effective with date of service Jan. 1, 2008 the following codes were added to the O&P fee schedule:  

New Code

Description

Modifier

Lifetime Expectancy/QuantityLimitations

L3925*

Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), nontorsion joint/spring, extension/flexion, may include soft interface material, prefabricated, includes fitting and adjustment. 

New
Left
Right

6 months:  ages 00-20; 1 year  ages 21 and older

L3927*

Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), without joint/spring, extension/flexion, (e.g. static or ring type), may include soft interface material, prefabricated, includes fitting and adjustment. 

New
Left
Right

6 months:  ages 00-20; 1 year  ages 21 and older

L3929*

Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment. 

New
Left
Right

6 months:  ages 00-20; 1 year  ages 21 and older

L3931*

Wrist hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment. 

New
Left
Right

6 months:  ages 00-20; 1 year  ages 21 and older

L7611*

Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric

New
Left
Right

1 year:  ages 00-20

L7612*

Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric

New
Left
Right

1 year:  ages 00-20

L7613*

Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric

New
Left
Right

1 year:  ages 00-20

L7614*

Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric

New
Left
Right

1 year:  ages 00-20

L7621*

Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined

New
Left
Right

1 year:  ages 00-20; 3 years ages 21 and older

L7622*

Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined

New
Left
Right

1 year:  ages 00-20; 3 years ages 21 and older

Please refer to the O&P Fee Schedule on the DMA Fee Schedule web page.

Note:  In the tables above, HCPCS codes with an asterisk (*) require prior approval and bold type indicates the item is covered by Medicare.  A Certificate of Medical Necessity and Prior Approval (CMNPA) must be completed for all items, regardless of the requirement for prior approval.  The coverage criteria for these items have not changed.  Refer to the Clinical Coverage Policy 5B, Orthotics and Prosthetics, for detailed coverage information.

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


Attention: Durable Medical Equipment Providers

2008 HCPCS Code Changes for Discontinued, Description Changes and Code Additions for Durable Medical Equipment

Effective with date of service December 31, 2007, in order to comply with the Centers for Medicare and Medicaid Services (CMS) HCPCS coding changes, the following codes were end dated and removed from the DME fee schedule:

W4210

B4086

E2618

Effective with date of service January 1, 2008 the following code description changes were made:

Code

New Description

B4034

Enteral Feeding Supply Kit; Syringe Fed, Per Day

E0630

Patient Lift, Hydraulic or Mechanical, Includes Any Seat, Sling, Strap(s) Or Pad(s)

E2205

Manual Wheelchair Accessory, Handrim Without Projections (Includes Ergonomic or Contoured), Any Type, Replacement Only, Each

E2373

Power Wheelchair Accessory, Hand Or Chin Control Interface, Compact Remote Joystick, Proportional, Including Fixed Mounting Hardware

Effective with date of service January 1, 2008 the following codes were added to the DME fee schedule:

New Code

Description

Modifier

Lifetime Expectancy/QuantityLimitations

A7027

Combination, oral/nasal mask used with CPAP device, each

New

2/year

A7028

Oral cushion for combination oral/nasal mask, replacement only, each

New

2/year

A7029

Nasal pillows for combination oral/nasal mask, replacement only, pair

New

2/year

B4087

Gastrostomy/Jejunostomy tube, standard, any material, any type, each

New

2/month

B4088

Gastrostomy/Jejunostomy tube, low-profile, any material, any type, each

New

2/month

E2227

Manual Wheelchair accessory, gear reduction drive wheel, each

New
Used
Rental

1 year

E2228

Manual wheelchair accessory, wheel braking system and lock, complete, each

New
Used
Rental

1 year

E2312*

Power wheelchair accessory, hand or chin control interface, mini-proportional remove joystick, proportional, including fixed mounting hardware, each

New
Used
Rental

4 yrs/ 2yrs 00-20

E2313*

Power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each

New
Used
Rental

4 yrs/ 2yrs 00-20

Note: For these and all maximum allowable rates, please refer to the DMA Fee Schedule web page.

In the tables above, HCPCS codes with an asterisk (*) require prior approval and bold type indicates the item is covered by Medicare.  A Certificate of Medical Necessity and Prior Approval form must be completed for all items regardless of the requirement for prior approval.  The coverage criteria for these items have not been changed.  Refer to the Clinical Coverage Policy 5A, Durable Medical Equipment on DMA's website for detailed coverage information.   Also for these and all maximum allowable rates, please refer to the DME fee schedule found on DMA's Fee Schedule web page.

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


Attention:  All Providers

HCPCS Procedure Code Changes for the Physician's Drug Program

The following HCPCS procedure code changes have been made to comply with the Centers for Medicare and Medicaid Services (CMS) HCPCS procedure code changes.

End-Dated Codes with No Replacement Codes

Effective with date of service Dec. 31, 2007, HCPCS procedure code A9527 (iodine I-125 sodium iodide solution, therapeutic, per millicurie) was end-dated. Claims submitted for dates of service on or after Jan. 1, 2008, using the end-dated code will be denied. This therapeutic radiopharmaceutical agent is used for research purposes only.

New HCPCS Procedure Codes

The following HCPCS procedure codes were added to the list of covered codes for the Physician's Drug Program effective with date of service Jan. 1, 2008.

New HCPCS Code

Description Unit

J1573

Hepatitis B immune globulin, (Hepagam B), IV

0.5 ml

A9564

Radiopharmaceutical: Chromic phosphate P-32 suspension, therapeutic

Per mCi

A9600

Radiopharmaceutical: Strontium Sr-89 chloride, therapeutic

Per mCi

A9605

Radiopharmaceutical: Samarium Sm-153 lexidronamm, therapeutic

Per 50 mCi

End-Dated Codes with Replacement Codes

The following HCPCS procedure codes were end-dated with date of service Dec. 31, 2007, and replaced with new codes effective with date of service Jan. 1, 2008. Claims submitted for dates of service on or after Jan. 1, 2008, using the end-dated codes will be denied.


End-Dated HCPCS Code

Description

Unit

New HCPCS Code

Description

Unit

Q4079

Natalizumab (Tysabri)

1 mg

J2323

Natalizumab (Tysabri)

1 mg

Q4083

Hyalgan or Supartz, for intra-articular injection

 

J7321

Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection

Per dose

Q4084

Synvisc, for intra-articular injection

 

J7322

Hyaluronan or derivative, Synvisc, for intra-articular injection

Per dose

Q4085

Euflexxa, for intra-articular injection

 

J7323

Hyaluronan or derivative, Euflexxa, for intra-articular injection

Per dose

Q4086

Orthovisc, for intra-articular injection

 

J7324

Hyaluronan or derivative, Orthovisc, for intra-articular injection

Per dose

Q4087

Immune globulin, Octagam, IV non-lyophilized

500 mg

J1568

Immune globulin, Octagam, IV non-lyophilized (e.g. liquid)

500 mg

Q4088

Immune globulin, Gammagard liquid, IV, non-lyophilized

500 mg

J1569

Immune globulin, (Gammagard liquid), IV, non-lyophilized (e.g. liquid)

500 mg

Q4089

Rho(D) immune globulin, (Rhophylac), IM or IV, non-lyophilized

100 IU

J2791

Rho(D) immune globulin, (Human) Rhophylac, IM or IV, non-lyophilized

100 IU

Q4090

Hepatitis B immune globulin, (Hepagam B), IM,

0.5 ml

J1571

Hepatitis B immune globulin, (Hepagam B), IM

0.5 ml

Q4091

Immune globulin (Flebogamma), IV, non-lyophilized (e.g. liquid)

500 mg

J1572

Immune globulin (Flebogamma), IV, non-lyophilized (e.g. liquid)

500 mg

Q4092

Immune globulin (Gamunex) IV, non-lyophilized (e.g. liquid)

500 mg

J1561

Immune globulin (Gamunex) IV, non-lyophilized (e.g. liquid)

500 mg

Q4095

Zoledronic acid (Reclast)

1 mg

J3488**

Zoledronic acid (Reclast)

1 mg

S0180

Etonogestrel contraceptive implant system, including implants and supplies

 

J7307*

Etonogestrel contraceptive implant system, including implants and supplies

 

Note:*Implanon must be billed with the family planning (FP) modifier and with the appropriate CPT administration code, also billed with FP.

**Zoledronic acid (Reclast) has been included in the PDP since July 1, 2007, for Paget's disease of the bone (N.C. general Medicaid bulletin, July 2007). The FDA has recently approved its use for post-menopausal osteoporosis as well and Medicaid has added it to the PDP for this purpose, effective with date of service Sept. 1, 2007.

The ICD-9-CM diagnosis codes required for billing Reclast are 731.0 [Osteitis deformans without mention of bone tumor (Paget's disease of bone)] OR 733.01 (Post-menopausal osteoporosis).

New Codes That Were Previously Billed with the Miscellaneous Drug Codes
J3490, J3590, and J9999

Effective with date of service Jan. 1, 2008, the N.C. Medicaid program covers the individual HCPCS procedure codes for the drugs listed in the following table.  Claims submitted for dates of service on or after Jan. 1, 2008, using the unlisted drug codes J3490, J3590, or J9999 for these drugs will be denied.  An invoice is not required.

Old HCPCS Code

Description

Old Unit

New HCPCS Code

New Unit

J3590

Eculizumab (Soliris)

300 mg

J1300

10 mg

J3490

Idursulfase (Elaprase)

1 mg

J1743

1 mg

J3590

Protein C Concentrate, human (Ceprotin)

1 IU

J2724

1 IU

J3590

Ranibizumab (Lucentis)

0.5

J2778

0.1 mg

J9999

Panitumumab (Vectibix)

100 mg/ml

J9303

10 mg

J3490

Histrelin implant (Supprelin LA)

50 mg

J9226

50 mg

J3590

Pegylated interferon alfa-2b (Peg-Intron)

10 mcg

S0146

10 mcg per 0.5 ml

Refer to the fee schedule for the Physician's Drug Program on DMA's Fee Schedule web page. for the latest available fees.

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


Attention: All Providers

2008 ICD-9-CM Procedure and Diagnosis Codes

The following new 2008 ICD-9-CM procedure codes have been implemented effective with date of service October 1, 2007. 

00.94

01.10

01.16

01.17

07.83

07.84

07.95

07.98

32.20

32.30

32.39

32.41

32.49

32.50

32.59

33.20

34.06

34.20

34.52

50.13

50.14

70.53

70.54

70.55

70.63

70.64

70.78

70.93

70.94

70.95

88.59

92.41

 

The following new 2008 ICD-9-CM diagnosis codes have been implemented effective with date of service October 1, 2007. 

040.41

040.42

058.10

058.11

058.12

058.21

058.29

058.81

058.82

058.89

079.83

200.30

200.31

200.32

200.33

200.34

200.35

200.36

200.37

200.38

200.40

200.41

200.42

200.43

200.44

200.45

200.46

200.47

200.48

200.50

200.51

200.52

200.53

200.54

200.55

200.56

200.57

200.58

200.60

200.61

200.62

200.63

200.64

200.65

200.66

200.67

200.68

200.70

200.71

200.72

200.73

200.74

200.75

200.76

200.77

200.78

202.70

202.71

202.72

202.73

202.74

202.75

202.76

202.77

202.78

233.30

233.31

233.32

233.39

255.41

255.42

258.01

258.02

258.03

284.81

284.89

288.66

315.34

331.5

359.21

359.22

359.23

359.24

359.29

364.81

364.89

388.45

389.05

389.06

389.13

389.17

389.20

389.21

389.22

414.2

415.12

423.3

440.4

449

488

569.43

624.01

624.02

624.09

664.60

664.61

664.64

733.45

787.20

787.21

787.22

787.23

787.24

787.29

789.51

789.59

999.31

999.39

V12.53

V12.54

V13.22

V16.52

V25.04

V49.85

V72.12

V73.81

 

The following new 2008 ICD-9-CM procedure codes are not covered effective with date of service October 1, 2007: 

00.19

84.80

84.81

84.82

84.83

84.84

84.85

The following new 2008 ICD-9-CM diagnosis codes are not covered effective with date of service October 1, 2007. 

525.71

525.72

525.73

525.79

V17.41

V17.49

V18.11

V18.19

V26.41

V26.49

V26.81

V26.89

V68.01

V68.09

V84.81

V84.89

 

Providers must use current national codes from the 2008 ICD-9-CM manual when submitting claims to N.C. Medicaid.

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


Attention:  All Providers

Revised Procedures for Prescribing Synagis to Include EPSDT Information

Procedures for prescribing Synagis for the 2007-2008 Respiratory Syncytial Virus season have been revised to include Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) information. See the September 2007 North Carolina General Medicaid Bulletin and October 2007 North Carolina Pharmacy Newsletter for the original procedure. Synagis is administered under Medicaid's Outpatient Pharmacy Program (Clinical Coverage Policy 9, available on the Web Therefore, all administrative policy requirements, including EPSDT, found in that policy apply to Synagis administration.

The Synagis procedure is consistent with currently published American Academy of Pediatrics RedBook guidelines (on the Web at http://aapredbook.aappublications.org/cgi/content/full/2006/1/3.107, subscription required, or in RedBook: 2006 Report of the Committee on Infectious Diseases-27th edition).  It is important to note the following:

  1. The decision to approve or deny a request for Synagis that exceeds the guidelines specified in the above publications will be based on the recipient's medical need to correct or ameliorate a defect, physical [or] mental illness, or condition [health problem].  "Ameliorate" means to improve or maintain the recipient's health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.
  2. The specific coverage criteria (e.g., particular diagnoses, signs, or symptoms) specified in the above publications do not have to be met for recipients under 21 years of age if Synagis is medically necessary to correct or ameliorate a defect, physical or mental illness, or condition [health problems].  For these recipients, the Request for Medical Review for Synagis Outside of Criteria form is used to request Synagis.
  3. The specific numerical limits (number of hours, number of visits, or other limitations on scope, amount or frequency, age of the recipient) specified in the above publications do not apply to recipients under 21 years of age if Synagis is medically necessary to correct or ameliorate a defect, physical or mental illness, or condition [health problem].  Under EPSDT, Synagis (like any other Medicaid service) may be prescribed as often as needed for any Medicaid recipient under age 21 if it is medically necessary to correct or ameliorate the recipient's health problem. 
  4. Other restrictions specified in the publications above may be waived under EPSDT as long as exceeding those restrictions is medically necessary to correct or ameliorate a defect, physical or mental illness, or condition [health problem].

For further information about EPSDT, see the August 2007 EPSDT Policy Instructions Update.

Submitting the Request for Medical Review Form

When a recipient does not meet the guidelines published in the Synagis procedure but the provider still wishes to prescribe Synagis, submit the Request for Medical Review for Synagis Outside of Criteria Form by doing the following:

Justification documentation must clearly address how exceeding policy limits is medically necessary as described in the EPSDT Policy Instructions Update [will correct or ameliorate (improve or maintain the recipient's health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems)].  Should additional information be required, the provider will be contacted.

Note: Processing delays can occur if the recipient does not have a Medicaid identification number or the form is not complete.

Pharmacy and Ancillary Services
DMA, 919-855-4300


Attention:  Physicians, Nurse Practitioners and Pharmacies

Additions to Over-the-Counter Medications Coverage List

Effective with date of service Nov. 10, 2007, numerous additional over-the-counter (OTC) drug codes are eligible for reimbursement by N.C. Medicaid if the drugs are purchased in conjunction with a prescription order by a physician.  The updated list is available on the N.C. Division of Medical Assistance Web site in General Clinical Coverage Policy A-2.

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


Attention:  Pharmacies

Change in the Determination of the Prescription Count for Global Limits, the FORM and Recipient Opt-In Programs

Effective Jan. 1, 2008, the Division of Medical Assistance (DMA) will count only unique, unduplicated prescriptions when counting prescriptions for global limits and for the FORM and Recipient Opt-In programs.  Duplicate prescriptions filled during the month, for example early refills, will no longer be included in the monthly prescription counts.  Duplicate prescriptions are defined as prescriptions that have the same GCN sequence number (same drug, strength and dosage form) as a prescription previously filled within the same calendar month.

DMA will continue to systematically review recipients who have opted into a pharmacy under the FORM and Recipient Opt-In programs and will automatically remove them from both programs when fewer than 12 prescriptions have been dispensed in two out of the last three months or when fewer than 12 prescriptions have been dispensed in the sixth month.  With this change, some recipients who have qualified for the FORM and Recipient Opt-In programs in the past may no longer qualify for either of these programs.

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


Attention:  All Providers

Tamper-Resistant Prescription Pads for Medicaid Outpatient Prescriptions

Important legislation was passed by Congress in May 2007 requiring prescriptions for all Medicaid outpatient drugs to be written on tamper-resistant prescription pads by October 1, 2007.  On September 29, 2007, President George W. Bush signed the Extenders Law, delaying this implementation date to April 1, 2008.

On September 6, 2007, the NC Division of Medical Assistance (DMA) published guidance regarding the use of tamper-resistant prescription pads for prescriptions written for NC Medicaid recipients.  This previously issued guidance will become effective as of April 1, 2008. 

This guidance is available on DMA's Tamper Resistent Prescription Pad information web page.  More detailed information regarding this new requirement can also be found in the January 1, 2008 Special Bulletin.

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


Attention:  All Providers

Clinical Coverage Policies

The following new or amended clinical coverage policies are now available on 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

Update: FluMist Availability in the UCVDP/VFC Program

Effective immediately, the Universal Childhood Vaccine Distribution Program/Vaccines for Children Program (UCVDP/VFC) has expanded its coverage criteria to include children 2 to 5 years of age. Therefore, the N.C. Medicaid program will now reimburse for the administration of FluMist for VFC children from 2 through 18 years of age. Refer to "Influenza Vaccine and Reimbursement Guidelines for 2007-2008," on p. 9 of the October general Medicaid bulletin, for billing guidelines and other information regarding Medicaid coverage of the influenza vaccines.

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


Attention:  Ambulatory Surgical Centers

Ambulatory Surgical Centers Revised Payment System

The Centers for Medicare and Medicaid Services (CMS) has revised the ambulatory surgical center (ASC) payment system.  The final CMS rule establishes the ambulatory surgery center list of covered surgical procedures, identifies covered ancillary services and sets forth the amounts and factors that will be used to determine the payment rates for calendar year 2008 under the revised payment system.

The Division of Medical Assistance is reviewing the list of codes added for 2008 and the revised payment methodology.  The Current Procedural Terminology codes added to the ASC list effective January 1, 2008 will not be covered by NC Medicaid when provided in an ASC on or after January 1, 2008 pending further review by the Division.  Providers will be informed of coverage decisions in a future Medicaid bulletin when this process and review are completed.

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


Attention:  Physicians, Nurse Practitioners and Local Health Departments

Drugs Added to the Physician's Drug Program - Billing Guidelines

Effective with date of service Jan. 1, 2008, the N.C. Medicaid program covers the following drugs for use in the Physicians Drug Program when the requirements specified below are met: aglucosidase (Myozyme); aripiprazole (Abilify); decitabline (Dacogen); naltrexone (Vivitrol); and nelarabine (Arranon).  Effective with date of service Jan. 1, 2005, histrelin implant (Vantas) is covered.

Reminders That Apply to All Drugs in This Article

Aglucosidase Alfa (Myozyme)-HCPCS procedure code J0220

Myozyme is indicated for the treatment of Pompe's disease, and is usually given every 2 weeks as an intravenous infusion.  The infusion dosage is calculated on 20 mg/kg of body weight, and should be administered over approximately 4 hours.

The ICD-9-CM diagnosis code required for billing Myozyme is 271.0 (Pompe's disease). One unit of coverage is 10 mg. Physicians and nurse practitioners may bill for this drug.

Aripiprazole (Abilify)-HCPCS procedure code J0400

Abilify injection is indicated for the treatment of 1) agitation associated with schizophrenia or bipolar disorder, manic or mixed; and 2) depression. Abilify is an atypical antipsychotic.

The recommended dose of Abilify injection is 9.75 mg/1.3 ml via intramuscular injection, administered once per day. If agitation warranting a second dose persists following the initial injection, cumulative doses up to a total of 30 mg/day may be given. If ongoing Abilify therapy is clinically indicated, oral Abilify in a range of 10 mg to 30 mg per day should replace Abilify injection as soon as possible.

One unit of coverage is 0.25 mg. Physicians, nurse practitioners and local health departments may bill for this drug.

Decitabine (Dacogen)-HCPCS procedure code J0894

Decitabine, an antineoplastic agent indicated for the treatment of patients with myelodysplastic syndromes (MDS), is administered as an intravenous infusion. The recommended dosage is 15 mg/m2 over 3 hours, every 8 hours, on three consecutive days every six weeks. Treatment may be continued as long as the patient continues to benefit.

The ICD-9-CM diagnosis codes required for billing decitabine are V58.11 (admission or encounter for chemotherapy) AND EITHER 238.7 through 238.79 (myelodysplastic syndrome) OR 205.10 (chronic myelomonocytic leukemia). One unit of coverage is 1 mg. Physicians and nurse practitioners may bill for this drug.

Histrelin Acetate (Vantas)

Coverage effective Jan. 1, 2005: Vantas is indicated for the palliative treatment of prostate cancer. Each kit contains one implant, which releases about 50 to 60 mcg of histrelin acetate per day over 12 months, and an insertion tool. Vantas is administered as one 50-mg subcutaneous implant every 12 months, with removal of the implant no later than 12 months after implantation.

For dates of service Jan. 1, 2005, through Dec. 31, 2005, use HCPCS procedure code J3490.

The original invoice or copy of the invoice must be submitted with the claim. For dates of service on and after Jan. 1, 2006, use HCPCS procedure code J9225. An invoice should not be submitted. The ICD-9-CM diagnosis code required for billing Vantas is 185 (malignant neoplasm of prostate). One unit of coverage is one 50-mg implant kit. Providers must not bill for Vantas more than once every 12 months for each recipient. Physicians and nurse practitioners may bill for this implant.

Naltrexone (Vivtrol)-HCPCS procedure code J0894

Naltrexone, which is indicated for the treatment of patients with alcohol dependence, is an opiate antagonist that is administered as an intramuscular injection. The recommended dosage is 380 mg per treatment day once a month or every four weeks.

The ICD-9-CM diagnosis code required for billing Naltrexone is 303.9 (other or unspecified alcohol dependence). One unit of coverage is 1 mg. Physicians, nurse practitioners and local health departments may bill for this drug.

Nelarabine (Arranon)-HCPCS procedure code J9261

Nelarabine is indicated for the treatment of patients with T-cell acute lymphoblastic leukemia (T-ALL) and T-cell lymphoblastic lymphoma (T-TBL) whose disease has not responded to or has relapsed following treatment with at least two chemotherapy regimens. Nelarabine is administered as an intravenous infusion. The recommended adult dosage is 1,500 mg/m2 administered over 2 hours on days 1, 3 and 5 and repeated every 21 days. The recommended pediatric dosage is 650 mg/m2 over 1 hour daily for 5 consecutive days and repeated every 21 days.

The ICD-9-CM diagnosis codes required for billing nelarabine are V58.11 (chemotherapy admission or encounter) AND 204.00 through 204.09 (lymphoblastic leukemia) OR 200.10 through 200.19, 200.20 through 200.29 or 202.80 through 202.89 (lymphoblastic lymphoma). One unit of coverage is 50 mg. Physicians and nurse practitioners may bill for this drug.

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


Attention: All Providers

Updated EOB Code Crosswalk to HIPAA Standard Codes

The list of standard national codes used on the Electronic Remittance Advice (ERA) has been cross-walked to EOB codes as an informational aid to adjudicated claims listed on the Remittance and Status Report (RA). An updated version of the list is available on the Division of Medical Assistance HIPAA web page.

With the implementation of standards for electronic transactions mandated by the Health Insurance Portability and Accountability Act (HIPAA), providers now have the option to receive an ERA in addition to the paper version of the RA.

The EOB codes that providers currently receive on a paper RA are not used on the ERA. Because the EOB codes on the paper RA provide a greater level of detail on claim denials, all providers will continue to receive the paper version of the RA, even if they choose to receive the ERA transaction. The crosswalk is current as of the date of publication. Providers will be notified of changes to the crosswalk through the general Medicaid bulletin.

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


Attention: Adult Care Homes

Update:  Prior Approval Process for Medicaid's Enhanced Rate for the Special Care Unit for Alzheimer's and Related Disorders

Please Note:  Instructions here replace any previous instructions.

Effective October 1, 2006, the N.C. Medicaid Program (DMA) implemented a prior approval process for adult care home (ACH) providers to receive an enhanced Medicaid reimbursement rate for operating special care units for persons with Alzheimer's and related disorders (SCU-As).  This enhanced rate does not include any provisions for special care units for recipients with mental health and related disorders noted in the Adult Care Home Rules 10NCAC 13F.1400.

The enhanced rate is based on submitted documentation. ACH providers must obtain prior approval for the enhanced rate for the care of eligible recipients if the potential resident has a primary diagnosis of Alzheimer's or related disorders, is not currently receiving hospice care, and meets the prior approval criteria documented below.

  1. a.   A documented primary diagnosis of Alzheimer's or related disorders.  The related disorder diagnoses are limited to those supported by the National Alzheimer's Association. Therefore, we will no longer accept a general diagnosis of "dementia."  Only the following primary diagnoses are acceptable for purposes of the enhanced rate:

    Diagnosis

    ICD-9-CM Code

    Alzheimer’s Disease

    331.0

    Multi-Infarct Dementia

    290.4

    Creutzfeldt-Jakob Disease

    294.10

    Pick’s Disease

    331.11

    Lewy Body Dementia

    331.82

    Parkinson’s Disease

    332

    Huntington’s Disease

    333.4


    b.If the resident also has a major psychiatric diagnosis, then the physician must provide additional information indicating that the resident's psychiatric disorder is not active, that the resident is not a threat to other residents and is appropriate for a unit such as that described in 10NCAC13F.1300.

  2. ACH providers who have a current ACH license in good standing with a SCU-A designation may apply for prior approval from Medicaid for care of recipients with the above‑approved diagnoses.
  3. Providers must obtain prior approval from DMA before admitting a current resident of the ACH to a SCU-A bed.
  4. Providers must obtain prior approval from DMA within 7 days of admitting a resident who is new to the home into the home's SCU‑A in order to receive the Medicaid SCU‑A rate from the date of admission to that unit.  Otherwise, if approved, prior approval will be effective the date the request was received by DMA.
  5. If information is not complete, DMA will request additional information, and the approval date may be delayed.  If the information is not received within 14 calendar days of the request for additional information, the resident's prior approval will be denied.
    NOTE: Effective with date of service Febuary. 1, 2008, the Division of Aging and Adult Services (DAAS) will be notified monthly of any prior approval denials.
  6. Providers must send the following information to obtain this prior approval by Medicaid and avoid delays.  All information must be clear and legible:

    a. Completed DMA SCU-A Prior Approval Request Form, showing the accurate ACH provider number and the recipient's Medicaid ID number, date of birth and date of admission to the facility

    b.Current FL-2 signed by a physician, with a primary diagnosis of Alzheimer's or one of the above‑specified related disorders

    c.Copy of the completed Pre-Admission Screening that the home uses to evaluate the appropriateness of an individual's placement in the SCU-A as required by current Rule (10A NCAC 13F.1302)

    d.Copy of the current individualized care plan that states how the home will strive for the maintenance of the resident's abilities and promote the highest level of physical and mental functioning; manage behavior in ways that preserve the recipient's dignity; and deliver programming that involves environmental, social and health care strategies to help the resident attain or maintain the maximum level of functioning possible and compensate for lost abilities as required by Rule (10 NCAC 13 F. 1307)

    e.Copy of the provider's current ACH license with SCU-A designation

    f. Copy of the provider's current ACH SCU-A disclosure statement

  7. Upon approval of the resident‑specific information, DMA will communicate to the fiscal agent the specific SCU‑A effective date and end date. The end date is one year from the date of the care plan that is submitted with the recipient's prior approval packet of information.
  8. DMA will send an approval notification to the home indicating that the resident was approved and specifying the effective date and the end date of the approval.
    If prior approval is denied, notification will come from the fiscal agent.
  9. In the event that the resident is discharged from the home due to death, level of care change, or any other reason, then the home must notify DMA by telephone and follow up by faxing the following information within two business days: the recipient's name, MID number, discharge date and discharge destination. DMA will then notify the fiscal agent as appropriate.
  10. The end date of the prior approval is one year from the date of the last submitted care plan.  Recertification is required yearly.  If the recertification/continued need review is not received by the end date, payment will stop.
  11. Yearly recertification requirements include submission of the following documents to DMA:  a current signed and dated FL-2, a new care plan, and a copy of the ACH's current license.  Mail to DMA (see specific instructions in #12 and #15 below) within seven days of the end date to ensure continuous payment.
  12. Providers send the requested information via U.S. Mail to
    Division of Medical Assistance
    Facility and Community Care Section, ACH Unit
    1985 Umstead Drive
    2501 Mail Service Center
    Raleigh NC  27699-2501
  13. Only requested follow-up and/or discharge information may be faxed to DMA (Attention: SCU‑A Approval) at 919-715-2372.
  14. The newly revised DMA SCU-A form and instructions are on the DMA Provider Forms web page.
  15. This is a HIPAA requirement: The completed form and information must be sealed in an envelope on which "CONFIDENTIAL" is written in red, then placed in another envelope and addressed as in #12 above.  Do not fax the actual original recipient prior approval request information.
  16. The following are contacts for the ACH unit.  We do not have secured e-mail.
    Do not send recipient-specific information by e-mail.

Tamara Derieux

919-855-4364

Tamara.Derieux@dhhs.nc.gov

Linda Perry

919-855-4363

 

Instructions for Completing the Adult Care Home SCU-A Prior Approval Form

  1. This form, which is available on DMA's Provider Forms web page, is to be used only by Adult Care Homes with Special Care Unit designations. Print this form in landscape orientation.
  2. Print clearly.
  3. All copies of items submitted must be legible.
  4. The complete facility information is due only once per year according to the date on the care plan, or upon facility status change, or as otherwise needed.
  5. THIS IS A HIPAA REQUIREMENT:  The completed form and information must be sent in a sealed envelope with "confidential" written in red and then placed in another envelope and addressed as in #6 below. DMA will not accept faxed records.
  6. Send the completed form via U.S. Mail to the following address: N.C. Division of Medical Assistance, ACH Unit-Facility and Community Care, 1985 Umstead Drive, 2501 Mail Service Center, Raleigh, NC 27699-2501
  7. Direct questions to:
    Linda R. Perry, RN(1-919-855-4363) or
    Tamara Derieux (1-919-855-4364)    Tamara.Derieux@dhhs.nc.gov.

Facility and Community Care
DMA, 919-855-4363


Attention: All Providers

Accepting a Medicaid Recipient

According to 10A NCAC 22J.0106 a provider has a choice whether or not to accept or refuse a patient as Medicaid patient.  However, providers may not discriminate against Medicaid recipients based on the recipient's race, religion, national origin, color, or handicap.

Providers are reminded of the following:

A provider may bill a Medicaid recipient if the recipient, rather than the provider, receives payments from either the commercial insurance or Medicare; if the recipient fails to provide proof of eligibility by presenting a current Medicaid card; if the recipient loses eligibility for Medicaid as defined in 10A NCAC 21B; or if the recipient owes an allowable Medicaid deductible or co-payment.  The following services may also be billed to the recipient:

For recipients under the age of 21 and EPSDT requirements see Section 2 and 6 of the Basic Medicaid Billing Guide, available at www.ncdhhs.gov/dma/basicmed/index.htm. 

Providers are encouraged to make use of the resources available to assist in filing claims 

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


Attention: Durable Medical Equipment Providers

Revised Oxygen, Oxygen Supplies and Equipment Clinical Coverage Policy

Beginning with date of service Jan. 1, 2008, newly revised clinical coverage policies for oxygen and oxygen supplies and equipment will be in effect.  There are several significant changes from the old policy.  Please see Clinical Coverage Policy #5A, Durable Medical Equipment, on DMA's Web site for more coverage details.

EDS, 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, the Centers for Medicare and Medicaid Services (CMS) implemented a 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 claims paid in Federal fiscal year 2007 (October 1, 2006-September 30, 2007).

CMS is using three 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 (approximately 800-1200 claims for North Carolina).  Providers will be required to furnish the records requested by Livanta, within a timeframe indicated by Livanta. 

Livanta began requesting medical records for the NC sampled claims on November 20, 2007.  Providers are urged to respond to these requests promptly.  Records are required to be submitted by providers no later than 60 days after issuance of the contractor's letter requesting such records (PERM Final Rule, Federal Register/Vol. 72, No. 169/Friday, August 31, 2007/Rules & Regulations, pg. 50496).

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 for rendering services.

Provider cooperation to furnish requested records is critical in this CMS project.  No response to requests and/or insufficient documentation will be considered a payment error.  This can result in a payback by the provider and a monetary penalty for North Carolina Medicaid.

Program Integrity
DMA, 919-647-8000


Attention: Physicians, Nurse Practitioners, Nurse Midwives, Federally Qualified Health Centers, Rural Health Centers, Local Health Departments and Certified Dialysis Providers

Changes in Drug Rebate Manufacturers

The following changes are being made in manufacturers with Drug Rebate Agreements.  They are listed by manufacturer code, which are the first five digits of the NDC.

Additions - The following labelers have entered into Drug Rebate Agreements and have joined the rebate program effective on the dates indicated below:

Code

Manufacturer

Date

25010

Aton Pharma. Inc.

10/22/2007

31722

Camber Pharmaceuticals, Inc

10/03/2007

Voluntarily Terminated Labelers - The following labelers requested voluntary termination effective October 1, 2007:

Laser Pharmaceuticals, LLC.

(Labeler 64860)

PediaMed Pharmaceuticals, Inc

(Labeler 96346)

The following labelers have requested voluntary termination effective January 1, 2008:

Elan Pharmaceuticals, LLC.

(Labeler 00086)

Stada Pharmaceuticals, Inc.

(Labeler 55370)

Stada Pharmaceuticals, Inc.

(Labeler 64860)

For a complete list of Manufacturers participating in the Drug Rebate Program, visit the Outpatient Pharmacy Services web page.

Active Drug Rebate Labeler List

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


Attention:  Hospital Outpatient Clinics, Physicians, Health Departments, Federally Qualified Health Centers, and Rural Health Clinics

Dietary Evaluation and Counseling

Effective with date of service April 1, 2007, Clinical Coverage Policy 1I, Dietary Evaluation and Counseling, hospital outpatient clinics and physicians were added as providers who may receive reimbursement for dietary evaluation and counseling (also referred to as Medical Nutrition Therapy) when the service is performed by a registered dietitian or licensed nutritionist.  Local health departments, federally qualified health centers and rural health clinics will continue to receive coverage for the services described in the policy.  Children ages zero through twenty and pregnant women until the end of the month in which the sixtieth day postpartum falls are eligible for this service.  Refer to the Dietary Evaluation and Counseling policy on the the DMA web site.

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


Attention: UB - 92 / UB - 04 Providers

Updated Effective Date for Revised UB Claim Form

The National Uniform Billing Committee (NUBC) has issued the revised institutional paper claim format.

All UB paper claims received on or after February 29, 2008 must be filed on the UB-04 claim format regardless of the date of service.

Providers who submit the UB-92 claim form for processing on or after February 29, 2008 will receive denial EOB 9960 on their remittance advice. EOB 9960 states, "Resubmit on the new UB04 Claim Form." Refer to New Claim Form Instructions Special Bulletin June 2007 and the National Uniform Billing Committee (NUBC) website at www.nubc.org for specific billing guidelines.

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


Attention:  All Providers

Community Care of North Carolina/Carolina ACCESS (CCNC/CA) Override Policy

Currently, 74% of North Carolina's Medicaid population is enrolled in CCNC/CA. For these recipients, their medical home becomes the primary place where well care and routine sick care are provided.  PCPs coordinate care for members by providing and arranging for the recipient's health care needs.  It is at the discretion of the primary care provider to refer or authorize payment for services performed by another provider.  If a service is provided and the PCP refuses to authorize the service, a request for an override may be submitted to EDS via fax at 919-816-4420.  Only requests made on the Carolina ACCESS Override Request form will be considered.  If a patient is in the requesting provider's office, the provider may contact EDS by telephone at 919-816-4321.  The division provides the following guidelines:

  1. Overrides will be granted only when extenuating circumstances beyond the control of the PCP or the patient affect access to care. Examples: patient is incorrectly enrolled; system problem that impacts the ability to determine enrollment or current PCP.
  2. Overrides for past, current, or future dates of service will not be considered unless the current PC, as identified on the patient's Medicaid care, has been contacted and has refused authorization of payment for services.
  3. The override request form must be completed in its entirety or it will be returned to the provider requesting the override.  The provider may resubmit the request when all information is provided.
  4. PCPs are required to see patients based on the standards of appointment availability or authorize another provider to see the patient as stated in the Carolina ACCESS agreement.
  5. If requesting an override, it must be made within six (6) months of the date the service was provided.

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


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.

Loretta Bohn
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.



2008 Checkwrite Schedule

Month

Electronic Cut-Off Date

Checkwrite Date

January 2008

01/03/08

01/08/08

 

01/10/08

01/15/08

 

01/17/08

01/24/08

February 2008

01/31/08

02/05/08

 

02/07/08

02/12/08

 

02/14/08

02/19/08

 

02/21/08

02/28/08

March 2008

2/28/08

3/04/08

 

3/06/08

03/11/08

 

03/13/08

03/18/08

 

3/20/08

3/27/08

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.

EDS, 1-800-688-6696 or 919-851-8888 

William W. Lawrence, Jr. M.D.
Acting Director
Division of Medical Assistance
Department of Health and Human Services
Cheryll Collier
Executive Director
EDS

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