N.C. DMA: February 2003 Medicaid Bulletin

Attention: Independent Practitioners and Local Education Agencies

Correction to December 2002 Special Bulletin VII, HIPAA Code Conversion

The billing instructions for completing the CMS-1500 claim form published in the December 2002 Special Bulletin VII, HIPAA Code Conversion, has been corrected as follows:

Block 24C-Type of Service: enter a 15. Do not enter a 01 or leave this block blank.

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

Attention: All Providers

Medical Coverage Policies

Updated policies for the following programs are now located on the Division of Medical Assistance's website:

1A Physicians

1A-5 Case Conference for Sexually Abused Children
1A-6 Electrical Osteogenic Stimulators
1A-7 Neonatal Intensive Care Services

These policies supersede previously published policies and procedures. Providers may contact EDS at 1-800-688-6696 or 919-851-8888 with billing questions.

Darlene Creech, Medical Policy Section
DMA, 919-857-4020

Attention: All Providers

Update to Regional Managed Care Consultant List

The Regional Managed Care Consultant list has been updated to reflect the new telephone number and fax number for the southeastern regional consultant, Rosemary Long. The new numbers are:

Telephone: 910-738-7399
Fax: 910-738-7349

Regional Managed Care Consultant list

Managed Care Section
DMA, 919-857-4022

Attention: All Providers

Mecklenburg County Managed Care Update

Effective December 1, 2002, United Healthcare of North Carolina, Inc. discontinued participation as a Medicaid health maintenance organization (HMO). SouthCare is now the only Medicaid HMO provider available in Mecklenburg County.

Carolina ACCESS providers, Carolinas Medical Center ACCESS II, and Metrolina Comprehensive (formerly C.W. Williams) are also available to provide services to Mecklenburg County Medicaid recipients in addition to SouthCare.

Darryl Frazier, Managed Care Section
DMA, 919-857-4022

Attention: All Providers

HIPAA Implementation Training Seminars

Seminars on the implementation of the Health Insurance Portability and Accountability Act (HIPAA) transaction sets are scheduled for Spring 2003. Dates and site locations for the seminars will be published in the March general Medicaid bulletin.

EDS, 1-800-588-6696 or 919-851-8888

Attention: All Providers

Revised Health Insurance Information Referral Form (DMA 2057)

The Health Insurance Information Referral form (DMA 2057) has been revised by the Third Party Recovery (TPR) Section. The revised form is effective immediately. This form should be used when insurance information on the TPR database must be updated. A copy of an Explanation of Benefits (EOB) from the insurance carrier or a copy of the insurance card must be attached to the form. Forms indicating only verbal verifications by an insurance carrier will be returned to the provider.

Health Insurance Information Referral Form (DMA 2057)

Third Party Recovery Section
DMA, 919 733 6294

Attention: All Providers

Corrected 1099 Requests - Action Required by March 1, 2003

Providers receiving Medicaid payments of more than $600 annually receive a 1099 MISC tax form from EDS. The 1099 MISC tax form is generated as required by IRS guidelines. It will be mailed to each provider no later than January 31, 2003. The 1099 MISC tax form reflects the tax information on file with Medicaid as of the last Medicaid checkwrite cycle date, December 27, 2002.

If the tax name or tax identification number on the annual 1099 MISC you receive is incorrect, a correction to the 1099 MISC must be requested. This ensures that accurate tax information is on file with Medicaid and sent to the IRS annually. When the IRS receives incorrect information on your 1099 MISC, it may require backup withholding in the amount of 30 percent of future Medicaid payments. The IRS could require EDS to initiate and continue this withholding to obtain correct tax data.

A correction to the original 1099 MISC must be submitted to EDS by March 1, 2003 and must be accompanied by the following documentation:

a copy of the original 1099 MISC
a signed and completed IRS W-9 form clearly indicating the correct tax identification number and tax name. (Additional instructions for completing the W-9 form can be obtained at http://www.irs.gov under the link "Forms and Pubs.")

Fax both documents to 919-816-4399, Attention: Corrected 1099 Request - Financial

Mail both documents to:

EDS
4905 Waters Edge Drive
Raleigh, NC 27606
Attention: Corrected 1099 Request - Financial

A copy of the corrected 1099 MISC will be mailed to you for your records. All corrected 1099 MISC requests are reported to the IRS. In some cases, additional information may be required to ensure that the tax information on file with Medicaid is accurate. Providers will be notified by mail of any additional action that may be required to complete the correction to their tax information.

IRS W-9 form

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

Attention: All Providers

Third Party Health Insurance and Medicaid Eligibility Policy Clarification

It has come to our attention that there may be some confusion regarding the relation of third party health insurance to Medicaid eligibility. Individuals with third party health insurance coverage may be eligible to receive Medicaid benefits. However, applicants with third party health insurance coverage are not eligible for benefits through the North Carolina Health Choice (NCHC) program. (Note: NCHC is available only to persons under the age of 19.)

Because Medicaid is always the payer of last resort, providers must file claims with the recipient's private health insurance before submitting claims to Medicaid. Individuals with questions about Medicaid eligibility should be referred to their local county department of social services.

Medicaid Eligibility Unit
DMA, 919-857-4019

Attention: All Providers

Proposed Medical Coverage Policies

In accordance with Session Law 2001-424, Senate Bill 1005, proposed new or amended Medicaid medical coverage policies are available for review and comment on DMA's website. To submit a comment related to a policy, refer to the instructions on the website. Providers without internet access can submit written comments to the address listed below.

Darlene Creech
Medical Policy Section
Division of Medical Assistance
2511 Mail Service Center
Raleigh, NC 27699-2511

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.

Proposed Medical Coverage Policies

Darlene Creech, Medical Policy Section
DMA, 919-857-4020

Attention: Hospitals, Anesthesiologists, and Certified Registered Nurse Anesthetists

Billing for Certified Registered Nurse Anesthetist Services

The February 1, 2003 date of service to implement the use of modifiers when billing for Certified Registered Nurse Anesthetist (CRNA) services announced in the December 2002 general Medicaid bulletin article entitled Billing for Certified Registered Nurse Anesthetist Services has been delayed. Providers will be notified through the general Medicaid bulletin of the new date to implement the revised billing guidelines.

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

Attention: Durable Medical Equipment Providers

HCPCS Code Changes

Effective with date of service February 1, 2003, the following codes will be end-dated and replaced with new codes.

End-Dated Code(s)	New Code	Description	Maximum Reimbursement Rate
W4669	K0409	Sterile water, 1000 ml	$ 3.27
W4671	A4323	Sterile saline, 1000 ml	2.42
W4675 W4676 W4677	A4250	Urine test or reagent strips or tablets (100 tablets or strips)	25.00
W4201 W4202	A4927	Gloves, non-sterile, per 100	10.92
W4203 W4204	A4930	Gloves, sterile, per pair	.85

These codes do not require prior approval. However, as with all durable medical equipment (DME), a Certificate of Medical Necessity and Prior Approval form must be completed.

Melody B. Yeargan, P.T., Medical Policy Section
DMA, 919-857-4020

Attention: Durable Medical Equipment Providers, Home Health Agencies, and Home Infusion Therapy Providers

Fee Schedules Available on the Internet

The following fee schedules are now available on DMA's website:

Durable Medical Equipment
Orthotics and Prosthetics
Home Health Services and Supplies
Home Infusion Therapy

These rates, effective with dates of service January 1, 2003, represent the maximum reimbursement rate allowed by Medicaid.

Providers must bill their usual and customary charges.

Debbie Barnes, Financial Operations
DMA, 919-857-4015

Attention: Physicians, Health Departments, and Nurse Practitioners

Pegfilgrastim, 6 mg (Neulasta, S0135) - Billing Guidelines

Effective with date of service January 1, 2003, the N.C. Medicaid program covers pegfilgrastim (Neulasta) for use in the Physician's Drug Program. Neulasta is indicated to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia. One of the following ICD-9-CM diagnoses must be listed on the CMS-1500 claim form:

205.00

205.01

205.10

205.11

238.7

288.0

288.9

V42.9

V58.1

V59.3

V59.8

V66.2

V66.5

Providers must bill S0135, indicating the number of units given in block 24G on the claim. For Medicaid billing, one unit of coverage is 6 mg. The maximum reimbursement rate per unit is $2,655.00. Providers must bill their usual and customary charge.

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

Attention: Physicians, Health Departments, and Nurse Practitioners

Fulvestrant, 250 mg/5 ml (Faslodex, J9999) - Billing Guidelines

Effective with date of service May 1, 2002, the N.C. Medicaid program covers fulvestrant (Faslodex) for use in the Physician's Drug Program. Faslodex is an injectable estrogen receptor antagonist for the treatment of hormone receptor positive metastatic breast cancer in postmenopausal women with disease progression following antiestrogen therapy. Medicaid policy states that if a drug is available in both oral and injectable forms, the oral form should be used unless there is medical justification for using the injectable form. The medical record should reflect why oral anastrozole was not used. ICD-9-CM diagnoses appropriate to bill with Faslodex are 174.0 through 174.9.

Providers must bill J9999, the unclassified drug code for antineoplastic agents, with an invoice attached to the CMS-1500 claim form. An invoice must be submitted with each claim. The paper invoice must indicate the name of the recipient, the recipient's MID number, the name of the medication, the dosage given, the National Drug Code (NDC) number from the vial(s) used, the number of vials used, and the cost per dose. Providers must indicate the number of units given in block 24G on the claim form. For Medicaid billing, one unit of coverage is 250 mg/5 ml. The maximum reimbursement rate per unit is $832.00. Providers must bill their usual and customary charge. Previously denied claims for dates of service beginning May 1, 2002 may be resubmitted.

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

Attention: Physicians, Health Departments, and Nurse Practitioners

Leuprolide Acetate Implant, 65 mg (Viadur, J9219) - Billing Guidelines

Effective with date of service January 1, 2003, the N.C. Medicaid program covers the leuprolide acetate (Viadur) implant for use in the Physician's Drug Program. Providers must bill J9219 for the implant on the CMS-1500 claim form. ICD-9-CM diagnosis 185, malignant neoplasm of prostate, must be listed on the claim. For Medicaid billing, one unit of coverage is one 65 mg implant. The maximum reimbursement rate per implant is $5,129.81. One implant is allowed per year. The year begins with the insertion date. CPT codes 11981, 11982, and 11983 are covered for the insertion, removal, and removal and reinsertion of the implant. Providers are expected to bill their usual and customary charge.

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

Attention: Physicians, Health Departments, and Nurse Practitioners

Factor VIIa (Coagulation Factor, Recombinant) per 1.2 mg (Novoseven, Q0187) - Billing Guidelines

Effective with date of service February 1, 2003, the N.C. Medicaid program covers factor VIIa (NovoSeven) for use in the Physician's Drug Program. Providers must bill Q0187, indicating the number of units given in block 24G on the CMS-1500 claim form. One of the following ICD-9-CM diagnoses must be listed on the claim:

286.0

286.1

286.3

286.5

286.7

287.1

For Medicaid billing, one unit of coverage is 1.2 mg. The maximum reimbursement rate per unit is $1,516.20. Providers are expected to bill their usual and customary charge.

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

Attention: Prescribers and Pharmacists

"Medically Necessary" Replaces "Dispense as Written"

Effective January 1, 2003, the words "medically necessary" handwritten on a prescription by the prescriber is required to dispense a trade or brand name drug. "Dispense as written" is no longer valid. Senate Bill 1115, Section 21.19(h) Dispensing of Generic Drugs mandates this change.

Section 21.19(h) Dispensing of Generic Drugs. - Notwithstanding G.S. 90-85.27 through G.S. 90-85.31, or any other law to the contrary, under the Medical Assistance Program (Title XIX of the SSA), and except as otherwise provided in this subsection for atypical antipsychotic drugs and drugs listed in the narrow therapeutic index, a prescription order for a drug designated by a trade or brand name shall be considered to be an order for the drug by its established or generic name, except when the prescriber has determined, at the time the drug is prescribed, that the brand name drug is medically necessary and has written on the prescription order the phrase "medically necessary." An initial prescription order for an atypical antipsychotic drug or a drug listed in the narrow therapeutic drug index that does not contain the phrase "medically necessary" shall be considered an order for the drug by its established or generic name, except that a pharmacy shall not substitute a generic or established name prescription drug for subsequent brand or trade name prescription orders of the same prescription drug without explicit oral or written approval of the prescriber given at the time the order is filled. Generic drugs shall be dispensed at a lower cost to the Medical Assistance Program rather than trade or brand name drugs. As used in this subsection, "brand name" means the proprietary name the manufacturer places upon a drug product or on its container, label, or wrapping at the time of packaging; and "established name" has the same meaning as in section 502(e) (3) of the Federal Food, Drug, and Cosmetic Act as amended, 21 U.S.C. § 352 (e) (3).

Melissa Weeks, Medical Policy Section
DMA, 919-857-4020

Attention: Personal Care Services (in Private Residences) Providers, Home Health Agencies, Durable Medical Equipment Providers, Home Infusion Therapy Providers, Private Duty Nursing Providers, and Adult Care Home Providers

Amended Implementation of Transfer of Assets Policy for Specified Home Care Services

Effective with date of service February 1, 2003, payments for specified home care services may be affected by a new transfer of assets policy that applies to certain Medicaid recipients. The implementation of the policy was announced in the January 2003 general Medicaid bulletin in an article entitled, Implementation of Transfer of Assets Policy for Specified Home Care Services. The amended implementation removes the provision to suspend claims while awaiting a transfer of assets determination. It also eliminates the possibility of a retroactive sanction period for an individual who is a Medicaid recipient at the time of the review. This article updates the information in the January 2003 article and should be read in its entirety.

Transfer of Assets Determinations and Sanctions
If an applicant/recipient has transferred assets in a manner contrary to the policy, he will not qualify for payment for any of the specified services provided during the sanction period. Sanction periods are by calendar month.

Medicaid Applicants: The county department of social services (DSS) makes a transfer of assets determination as part of the Medicaid eligibility process. A sanction period may be in a period of retroactive Medicaid eligibility as well as extend through the current time period. Providers should be alert that individuals with a pending Medicaid application on the date of service may not be eligible for Medicaid payment for the service if a sanction is imposed. (Refer to Retroactive Eligibility on page 2 of the What is Medicaid section of Basic Medicaid Handout - April 2002 for information about accepting retroactive eligibility.
Medicaid Recipients: The county DSS will review transfer of assets at each eligibility review. It also will review transfer of assets when it becomes aware of the receipt of one of the specified home care services. In either instance, a sanction period will not begin until after the recipient's right to an advance notice and the related appeal rights have been met. Sanction periods will not be retroactive.

The determination and any resulting sanction will apply to all of the services. A separate determination for each service is not required. This policy does not apply to transfers prior to February 1, 2003; therefore, there will be no sanction periods that begin before that date.

Services Included in the Policy
The Medicaid services included in the policy are:

Personal Care Services (PCS) in private residences
Home Health Services, including the supplies provided by home health agencies
Durable Medical Equipment (DME), including the supplies provided by DME providers
Home Infusion Therapy
The supplies on the Home Health fee schedule provided by Private Duty Nursing (PDN) providers to PDN patients (the nursing care is not included in the policy)

Medicaid Recipients Subject to the Policy
The policy applies to individuals in the following Medicaid eligibility categories:

Medical Assistance for the Aged (MAA)
Medical Assistance for the Disabled (MAD)
Medical Assistance for the Blind (MAB)
Medicare Aid (MQB-Q)

Adult care home providers should note that this policy does not apply to their residents receiving State/County Special Assistance. It does apply to a private pay adult care home resident if the individual is in one of the four eligibility categories (MAA, MAD, MAB, and MQB-Q).

MAA, MAD, and MAB recipients have a blue Medicaid identification (MID) card with the abbreviation listed under "Program" on the card. MQB-Q recipients have a buff card labeled as a "MEDICARE-AID ID CARD."

Community Alternatives Program (CAP) participants are not subject to a transfer of assets determination for the specified services. Providers may identify a CAP participant by the entry in the "CAP" block of the MID card.

How the Policy Affects Payment
Payment for a date of service on and after February 1, 2003, depends on the information that is in the claims processing system.

If a date of service is in a sanction period, payment for the date of service will be denied. (Refer to Billing the Recipient.)
If the date of service is not in a sanction period, the claim will continue to process for payment.

Nothing in this policy involves recouping a payment from a provider agency because of a transfer of assets by a recipient.

Transfer of Asset Information
Providers may access the Automated Voice Response (AVR) system to get a recipient's transfer of assets status as of a specified date. The AVR response provides information that is in the claims processing system at the time of the inquiry. AVR information is not a guarantee of payment.

To access transfer of assets information, the provider selects option 6 at the main menu for information about recipient eligibility. The call flow to get to transfer of assets information is as follows:

Provider Number Verification - When the provider selects option 6 from the main menu, AVR prompts the provider to enter their N.C. Medicaid provider number for verification. After the provider number is verified, the prompt will allow a caller to go in either of two directions: Recipient Eligibility and Coordination of Benefits or Hospice Eligibility. Choose selection 1.

Recipient Access Method Prompt - To obtain recipient eligibility information, the provider must enter a valid recipient MID number OR a combination of the recipient's date of birth and social security number, and a "FROM" date of service. AVR prompts the provider to select a method for accessing the recipient data.

"Please select one of the following recipient identification options. To enter a recipient identification number, press 1. To enter a recipient date of birth and social security number, press 2."

Date of Service Prompt - The provider must enter either a pound sign (#) only (for the current date) or a "FROM" date of service in a MMDDCCYY format.

Host Response - After receiving a valid provider number and recipient MID number, and "FROM" date of service, AVR determines whether or not the provider is authorized to access recipient eligibility information from the eligibility file.

Eligibility/Enrollment Prompt - The AVR will give the following response asking the provider to choose one of these two options:

"For eligibility information, press 1. For enrollment information, press 2."

Choose selection 1 for eligibility information. Transfer of assets information will be the last information given. The provider will be told one of the following:

"There is no information in the system about a transfer of assets determination for the recipient related to personal care services in a private residence, home health services, durable medical equipment, home infusion therapy, and supplies furnished by a private duty nursing agency. If you are a provider of one of these services, ask the recipient to contact the county DSS to begin a transfer of assets assessment."

"For the given date of service, the recipient is not eligible for the payment of personal care services in a private residence, home health services, durable medical equipment, home infusion therapy, and supplies furnished by a private duty nursing agency. The given date is within a transfer of assets sanction period."

"At this time, the given date of service is not in a transfer of assets sanction period for the payment of personal care services in a private residence, home health services, durable medical equipment, home infusion therapy, or supplies furnished by a private duty nursing agency. This information is subject to change."

Providers also may verify the recipient's transfer of assets status by seeing the recipient's notice about the results of a transfer of assets determination. The county DSS will provide the recipient a notice indicating that transfer of assets has been reviewed and any penalty period assessed.

Billing the Recipient
A provider may bill the recipient if Medicaid payment is denied due to a transfer of assets sanction and the provider has advised the recipient of his responsibility for payment before the services are rendered. The provider should maintain documentation that the recipient was notified of and accepted the responsibility.

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

Checkwrite Schedule

February 11, 2003	March 4, 2003	April 8, 2003
February 18, 2003	March 11, 2003	April 15, 2003
February 27, 2003	March 18, 2003	April 22, 2003
	March 27, 2003

Electronic Cut-Off Schedule

February 7, 2003	March 7, 2003	April 4, 2003
February 14, 2003	March 14, 2003	April 11, 2003
February 21, 2003	March 21, 2003	April 17, 2003
February 28, 2003

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.

_____________________		_____________________
Nina M. Yeager, Director		Ricky Pope
Division of Medical Assitance		Executive Director
Department of Health and Human Services		EDS

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