March 2008
Medicaid Bulletin

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In This Issue...

NPI Articles:

• Keeping Medicare Crossover Information Current
• National Provider Identifiers for End-dated Providers
• Referring Provider Numbers for Atypical Providers

All Providers:

• Additional CMS Guidance on Tamper-resistant Prescription Pads
• Addition of OTC Cetirizine to the Over-the-Counter Medications Coverage List
• Clinical Coverage Policies
• Legislative Visit Limitation
• Medicaid Credit Balance Reporting
• New Form for Medicaid Provider Refund Requests
• Outdated Enrollment Packets Will No Longer Be Accepted
• Payment Error Rate Measurement in North Carolina
• Program of All-inclusive Care for the Elderly Recipient Eligibility
• Registration for Basic Medicaid Seminars
• Tax Identification Information
• Update to the Implementation of the Web-based Medicaid Uniform Screening Tool
• Update:  PedvaxHIB Recall – Reimbursement for PedvaxHIB and ActHIB Allowed for UCVDP/VFC Program Eligibles

CAP/DA Lead Agencies:

• Automated Quality and Utilization Improvement Program Quarterly Training Seminar

Children’s Developmental Service Agencies:

• Web-based Survey for Outpatient Specialized Therapies Prior Authorization Website

Community Alternatives Program Case Managers:

• Use of the Miscellaneous Medical Supply Code T1999

Dialysis Providers:

• Changes in Drug Rebate Manufacturers

Federally Qualified Health Centers:

• Changes in Drug Rebate Manufacturers

Health Departments:

• Changes in Drug Rebate Manufacturers
• Web-based Survey for Outpatient Specialized Therapies Prior Authorization Website

Home Health Agencies:

• Use of the Miscellaneous Medical Supply Code T1999
• Web-based Survey for Outpatient Specialized Therapies Prior Authorization Website

Independent Laboratories:

• Clinical Laboratory Improvement Amendments Certification-Related Claim Denials

Independent Practitioners:

• Web-based Survey for Outpatient Specialized Therapies Prior Authorization Website

Institutional (UB-92/UB-04) Claim Billers:

• UB-04 Changes to Be Implemented April 25, 2008
• Updated Effective Date for Revised UB Claim Form

Local Management Entities:

• Web-based Survey for Outpatient Specialized Therapies Prior Authorization Website

Nurse Midwives:

• Changes in Drug Rebate Manufacturers

Nurse Practitioners:

• Changes in Drug Rebate Manufacturers

Outpatient Hospital Clinics:

• Web-based Survey for Outpatient Specialized Therapies Prior Authorization Website

Pharmacists:

• Changes in Drug Rebate Manufacturers
• Days Supply for Prescriptions with “Use as Directed” Instructions

Physicians:

• Changes in Drug Rebate Manufacturers
• Clinical Laboratory Improvement Amendments Certification-Related Claim Denials
• Web-based Survey for Outpatient Specialized Therapies Prior Authorization Website

Private Duty Nursing Providers:

• Use of the Miscellaneous Medical Supply Code T1999

Rural Health Clinics:

• Changes in Drug Rebate Manufacturers

Attention:  All Providers

Keeping Medicare Crossover Information Current

To ensure that claims continue to process correctly after the implementation of the National Provider Identifier (NPI), providers should verify that their Medicaid-to-Medicare crosswalk information is accurate.  The NPI associated with the Medicaid and the Medicare number in the crosswalk must be the same.  This can be verified by reviewing the crossover claims section of your Remittance and Status Advice (RA) or by calling EDS Provider Services. 

Submit updates using the Medicare Crossover Reference Request 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

Attention:  All Providers

National Provider Identifiers for End-dated Providers

DMA continues to adjudicate claims for providers who have been end-dated when the claims are for dates of service prior to the provider’s end-date.  To date, over 6,000 providers who were end-dated during the past 12 months have not reported their National Provider Identifier (NPI) to DMA.  After May 23, 2008, claims will be denied for end-dated providers who have not reported their NPI to DMA.

To report your NPI or to verify that your NPI has been received, please access the NPI and Address Information database.

If all information is correct, no action is necessary.  If the NPI column is blank, your NPI has not been reported.  Print the form and submit your NPI with a copy of the National Plan and Provider Enumeration System (NPPES) certification.

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

Attention:  All Providers

Referring Provider Numbers for Atypical Providers

As defined in the National Provider Identifier (NPI) final rule, an “atypical” provider is an individual or business that does not meet the traditional definition of a health care provider, but is eligible to bill for health-related services covered by some health plans.

Because some types of Medicaid-enrolled providers may be atypical, after the implementation of NPIs, a legacy Medicaid provider number may still be acceptable as the referring provider number entered on a claim.  However, it is the billing provider’s responsibility to verify that the referring provider is atypical and that a legacy Medicaid provider number is acceptable.

The atypical status of a provider may be verified by visiting the NPI and Address Information database.  The database may be searched by the legacy Medicaid provider number.  When a result is returned, the word “atypical” will be displayed under the legacy Medicaid provider number located in the “Provider No.” column if DMA recognizes the provider as atypical.  If the “NPI” column is blank or an NPI is displayed, this means that DMA does not recognize this provider as atypical.  Providers must contact the referring source to obtain the 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

Attention:  All Providers

Additional CMS Guidance on Tamper-resistant Prescription Pads

CMS has reviewed its policy regarding tamper-resistant prescriptions and has provided two updates to that policy.

Provider Additions to Otherwise Non-tamper-resistant Paper
Several states have questioned whether a provider can add a feature to a prescription to make it compliant with the tamper-resistant prescription pad requirements.  States have proposed various features, including particular kinds of ink to write the prescription (gel or indelible); writing out drug quantities rather than just the number ("thirty" vs. "30"); and embossed logos.  The tamper-resistant prescription pad statute states that all written prescriptions must be "executed on a tamper-resistant pad."  As a result, features added to the prescription after the pads are printed do not meet the requirement of the statute.  Features that would make the prescription tamper-resistant include certain types of paper as well as certain items that can be pre-printed on the paper. 

Computer-generated Prescriptions
CMS has further clarified that during the period between April 1, 2008 and October 1, 2008, computer-generated prescriptions printed by a provider on plain paper, including electronic medical record computer-generated prescriptions, may meet CMS guidance by containing one or more industry-recognized features designed either to prevent the erasure or modification of information contained on the prescription, or to prevent the use of counterfeit prescription forms.  However, based on its understanding of current prescription security technology, CMS does not believe that computer-generated prescriptions printed by a prescriber on plain paper will be able to meet the first baseline requirement that prescriptions contain one or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form.  In other words, prescriptions printed on plain paper will not be able to meet all three baseline characteristics outlined by CMS.  Therefore, beginning October 1, 2008, computer-generated prescriptions must be printed on paper that meets that requirement.

Please refer to the DMA guidance document dated September 6, 2007 for a list of acceptable features for N.C. Medicaid prescriptions. 

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

Attention:  All Providers

Addition of OTC Cetirizine to the Over-the-Counter Medications Coverage List

Effective with date of service February 1, 2008, cetirizine is available over-the-counter (OTC) for reimbursement by N.C. Medicaid in conjunction with a prescription by the prescriber.  The following list of OTC cetirizine national drug codes (NDCs) have been added to the list of covered OTC medications:

The list of covered OTC drug codes is available in General Medical Policy #A2, Over-the-Counter Medications. 

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:

1K-1, Breast Imaging Procedures
1R-4, Electrocardiography, Echocardiography, and Intravascular Ultrasound
3B, Program of All-inclusive Care for the Elderly (PACE)

Additionally, the list of drugs in General Medical Policy #A2, Over-the-Counter Medications, has been updated effective February 1, 2008.

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

Medicaid Credit Balance Reporting

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

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

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

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

Submitting the Medicaid Credit Balance Report does not result in the credit balances automatically being reimbursed to the Medicaid program.  A check is the preferred form of satisfying the credit balances; the check must be made payable to EDS and sent to EDS with the Medicaid Provider Refund Request Form attached for a refund.  If an adjustment is to be made to satisfy the credit balance, the Medicaid Claim Adjustment Request Form must be completed and submitted to EDS with all the supporting documentation for processing.

Submit only the completed Medicaid Credit Balance Report to DMA.  Do not send refund checks or adjustment forms to DMA.  Do not send the Credit Balance Report to EDS.  Failure to submit a Medicaid Credit Balance Report will result in the withholding of Medicaid payment until the report is received.

• Medicaid Credit Balance Report Form
• Medicaid Provider Refund Form
• Medicaid Provider Refund Form Instructions
• Medicaid Claim Adjustment Request Form

Third Party Recovery Section
DMA, 919-647-8100

Attention:  All Providers

Outdated Enrollment Packets Will No Longer Be Accepted

The N.C. Medicaid Program’s provider enrollment packets have been updated to include a Letter of Attestation as required by Section 6023 of the Deficit Reduction Act (DRA) of 2005.  Effective May 1, 2008, outdated enrollment packets will no longer be accepted.  Providers who are enrolling or re-enrolling must complete and submit the most recent version (December 2007 and after) of the provider enrollment packets, including the signed Letter of Attestation.  Providers will be notified by e-mail, telephone, or written correspondence if a new provider enrollment packet must be submitted.

To ensure that there is no delay in processing an enrollment application, providers should obtain the current version of the Provider Enrollment Packets from DMA’s website.

Provider Services
DMA, 919-855-4050

Attention:  All Providers

New Form for Medicaid Provider Refund Requests

The process for submitting refunds to the N.C. Medicaid program has changed.  Previously, the process stated that the provider should highlight the appropriate recipient information, claim information, and dollar amount of the refund on a copy of the Remittance Advice and Status Advice (RA) submitted with the refund check.

EDS recognizes that due to increasing number of providers receiving an electronic RA (835) or the potential for an RA to be used by more than one provider, the provider requesting a refund may not have an RA available to submit with a refund request.  EDS has therefore developed the Medicaid Provider Refund Request form to replace the previous process for submitting refunds to Medicaid.  The form, which can be completed and printed in Microsoft Excel, does not require a copy of the RA, claim forms, or other documentation to be submitted in order for EDS to process the refund. 

• Medicaid Provider Refund Form
• Medicaid Provider Refund Form Instructions

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, 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 through 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 to 1200 claims for North Carolina).  Providers are required to furnish the records requested by Livanta within a timeframe indicated by Livanta. 

Livanta began requesting medical records for the sampled claims in North Carolina on November 20, 2007.  Providers are urged to respond to these requests promptly.  Records must 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 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 the N.C. Medicaid program.

Program Integrity
DMA, 919-647-8000

Attention:  All Providers

Legislative Visit Limitation

When first published, the October 2007 general Medicaid Bulletin included an article stating that recipients are allowed 30 visits per year, instead of the existing 24 visits.  This article has since been revised.  Session Law 2007-323 modified the law concerning Medicaid visit limitations.  DMA is in the process of implementing these changes and a detailed bulletin article will be published as we get closer to completion of the project.

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

Attention:  All Providers

Program of All-inclusive Care for the Elderly Recipient Eligibility

The Program of All-inclusive Care for the Elderly (PACE) is a managed care program that enables elderly individuals who are certified to need nursing facility care to live as independently as possible.  The PACE provider receives monthly Medicare and/or Medicaid capitation payments for each eligible enrollee.  The PACE provider assumes full financial risk for participants’ care without limits on amount, duration or scope of services.  Medicaid will not reimburse non-PACE providers for services provided to PACE participants.

Effective February 1, 2008, to enroll in this program, an individual must be Medicaid-eligible and

• be 55 years of age or older;
• meet the State’s Medicaid criteria for nursing facility level of care;
• able to live safely in the community at the time of enrollment; and
• reside in the service area of the PACE organization.

Note:  Currently, PACE is available only in New Hanover and Brunswick counties through the Elderhaus, Inc. PACE organization.  Additional PACE sites are being developed in Fayetteville and Burlington.

Services provided directly by the PACE provider include, but are not limited to

• interdisciplinary team case management
• adult day health program
• skilled nursing care
• primary care physician services
• specialized therapies
• personal care services
• nutrition counseling
• meals
• transportation
• prescriptions

EDS, 1-800-668-6696 or 919-851-8888

Attention:  All Providers

Registration for Basic Medicaid Seminars

Basic Medicaid seminars will be held in April 2008.  Registration information, a list of dates, and site locations for the seminars are listed below.

Seminars will begin at 9:00 a.m. and will end at 12:00 p.m.  Providers are encouraged to arrive by 8:45 a.m. to complete registration.  Lunch will not be provided at the seminars.  Because meeting room temperatures vary, dressing in layers is strongly advised.

Due to limited seating, registration is limited to two staff members per office.  Preregistration is required.  Unregistered providers are welcome to attend if space is available.  Providers may register for the seminars by completing and submitting the Online Registration Form.  Providers may also complete the paper version of the Seminar Registration Form and fax it to the number listed on the form.  Please indicate on the registration form the session you plan to attend.

The Basic Medicaid Billing Guide will be used as the primary training document for the seminar.  Please review and print the April 2008 version and bring it to the seminar.  The April 2008 Basic Medicaid Billing Guide will be available the first week of March 2008.

Directions to the Basic Medicaid Seminars:

Western Piedmont Community College – Morganton, NC
Traveling West on I-40
From Hickory, take Exit #103 and turn right onto Burkemont Avenue.  Travel one block.  Western Piedmont Community College is on the right, one block from I-40.

Traveling East on I-40
From Asheville, take Exit #103 and turn left onto Burkemont Avenue. Cross the bridge over I-40.  Western Piedmont Community College is on the right, one block from I-40.

Traveling on NC 18 from Lenoir
Turn left onto South Sterling Street.  Turn right at Burger King onto W. Fleming Drive.  At the N.C. School for the Deaf, turn left onto Burkemont Avenue.  Western Piedmont Community College is on the left at the second traffic light.

Traveling on NC 64 from Rutherfordton
Driving into Morganton, cross over I-40.  Western Piedmont Community College is on the right, one block beyond I-40.

Holiday Inn Select – Winston-Salem, NC
Traveling East or West on I-40
Take I-40 to the NC 52 North exit.  Travel eight miles to exit 115B (University Pkwy South).  The Holiday Inn Select is located on the right.

Traveling North on NC 52
Take NC 52 South to University Parkway, exit 115.  Keep right at the fork to go on University Parkway.

Traveling South on NC 52
Take NC 52 North to University Parkway South, exit 115B.  The Holiday Inn Select is located on the right.

Coastline Convention Center – Wilmington, NC
Traveling East on I-40
Take I-40 East towards Wilmington.  As you approach Wilmington, turn right onto MLK Parkway/NC 74 West/Downtown.  Continue on this route towards downtown Wilmington.  The road becomes Third Street.  Follow Third Street for five blocks until you reach Red Cross Street.  Turn right onto Red Cross Street and continue for two blocks.  Turn right onto Nutt Street.  The entrance to the Coastline Convention Center is the second drive way on the left.

Traveling South on US 17
As you approach Wilmington, US 17 becomes Market Street.  Continue on Market Street until you see the sign for MLK Parkway/NC 74 West/Downtown.  Take NC 74 West (MLK Parkway) towards downtown Wilmington (approximately four miles).  Turn right onto Red Cross Street and continue for two blocks.  Turn right onto Nutt Street.  The entrance to the Coastline Convention Center is the second driveway on the left.

Traveling North on US 17 or NC 74/76
After crossing the Cape Fear Memorial Bridge into Wilmington, turn left at the first stoplight onto Third Street.  Turn left onto Red Cross Street.  At the bottom of the hill (approximately three blocks), turn right onto Nutt Street.  The entrance to the Coastline Convention Center is the second driveway on the left.

The Royal Banquet Center – Raleigh, NC
Traveling West on I-40
Take I-40 West towards Raleigh.  Take the Wade Avenue exit.  Merge onto I-440 S/US 1 South toward I-40 East/Hillsborough Street/Sanford.  Take Exit 3 for NC 54/Hillsborough Street.  Turn left onto Hillsborough Street/NC 54.  Turn right at the 3^rd traffic light at Meredith College and Playmakers (the turn is located in front of Quizno's and Ben & Jerry's).  Go to the end of the parking lot and turn left to park BEHIND the building or in the covered parking area.

Traveling East on I-40
Take I-40 East into Raleigh.  Take Exit 293 for I-440/US 1/US 64/Raleigh/Wake Forest.  The exit will split into two lanes.  Stay in the right-hand lane to merge onto I-440/Inner Beltline/Raleigh.  Take Exit 3 for NC 54/Hillsborough Street.  Turn left at the bottom of the exit ramp.  Turn right at the 3^rd traffic light at Meredith College and Playmakers (the turn is located in front of Quizno's and Ben & Jerry's).  Go to the end of the parking lot and turn left to park BEHIND the building or in the covered parking area.

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

Attention:  All Providers

Tax Identification Information

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

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

How to Correct Tax Information
All providers are required to complete a W-9 form for each provider for whom incorrect information is on file.  Please go to the following website to obtain a copy of a W-9 form.  Correct information must be received by November 1, 2008. 

All providers who identify incorrect tax information must submit a completed and signed W-9 form along with a completed and signed Medicaid Provider Change form to the address listed below:

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

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

Attention:  All Providers

Update:  PedvaxHIB Recall – Reimbursement for PedvaxHIB and ActHIB Allowed for UCVDP/VFC Program Eligibles

Effective with date of service December 13, 2007, and until further notice, N.C. Medicaid will reimburse for purchased PedvaxHIB (CPT procedure code 90467) or ActHIB (CPT procedure code 90468), when administered to recipients through 18 years of age because of a recent vaccine recall and a resulting shortage.

On December 13, 2007, Merck and Company announced a voluntary recall of certain lots of PedvaxHIB vaccine due to manufacturing issues.  Subsequently, the Universal Childhood Vaccine Distribution Program/Vaccines for Children Program notified participants that there is currently a shortage of Haemophilus influenzae Type b (Hib) products.  Additionally, the requirement to administer a booster dose of Hib vaccine on or after the age of 12 months has been temporarily suspended.  As the recommendations state, the suspension affects the routine booster.  Children who are in specified high-risk groups should receive the booster dose.  The recommendations for the Hib vaccines are available from the Centers for Disease Control and Prevention (MMWR Weekly, Dec. 21, 2007/56(50);1318-1320).

The decision about whether the child should receive a two- or three-dose series depends on the vaccine product used.  Please refer to the following table for guidelines.

The SC modifier must be appended to the procedure code to indicate that purchased vaccine was administered. 

Medicaid continues to reimburse for the Hib vaccine for high-risk recipients according to the existing recommendations of the Advisory Committee on Immunization Practices.  Other billing requirements regarding vaccines also remain in effect.

EPSDT allows a recipient less than 21 years of age to receive services in excess of the limitations or restrictions indicated above and without meeting the specific criteria in this section when such services are medically necessary health care services to correct or ameliorate a defect, physical or mental illness, or a condition (health problem); that is, documentation shows how the service, product, or procedure will correct or 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.

EPSDT DOES NOT ELIMINATE THE REQUIREMENT FOR PRIOR APPROVAL IF PRIOR APPROVAL IS REQUIRED.  Additional information on EPSDT guidelines may be accessed on the EPSDT webpage for providers.

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

Attention:  All Providers

Update to the Implementation of the Web-based Medicaid Uniform Screening Tool

The web-based Medicaid Uniform Screening Tool (MUST) will soon replace the FL2, the FL2e, the Pre-Admission Screening and Annual Resident Review Level I screen, telephone prior approvals for nursing facility level of care, the Community Alternatives Program for Children (CAP/C) Referral form, the Nursing Facility Tracking form, and the Ventilator Addendum form used to screen applicants and to document their medical, functional, and behavioral health status.  Initially, the MUST will be used prior to entry into the following Medicaid covered services/facilities:

• nursing facilities
• adult care homes (basic, enhanced personal care services, and special care/Alzheimer’s units)
• personal care services (PCS)
• PCS–Plus
• Community Alternatives Program for Disabled Adults (CAP/DA)
• Community Alternatives Program-Choice (CAP/Choice Independence Plus Waiver)
• Community Alternatives Program for Medically Fragile Children (CAP/C)
• private duty nursing (PDN)

Authorized and trained screeners (local professionals) will enter the medical, functional and behavioral health information into the automated web-based tool.  The data will be processed through a rules engine that contains the clinical coverage criteria as documented in the Medicaid program’s clinical coverage policies.

A “best fit” service will be presented to the screener, along with other service options for which the recipient may apply.  The screener and the applicant will jointly determine which service option to select and the screener can then make a referral to the service provider.

Eligible screeners include

1. Clinical professionals utilizing MUST to make a referral to Medicaid for long-term-care services and supports (covered under the Uniform Screening Program and expanding over time), including

a. physicians

b. physician assistants, family nurse practitioners, and other mid-level practitioners

c. registered nurses and licensed practical nurses

d. medical/clinical social workers, qualified professionals, and psychologists

2. Hospital discharge planners and case managers who make referrals to long-term-care services and supports

3. Case managers from regional, local, and community organizations who make referrals to long-term-care services and supports.

4. Staff of Aging Disability Resource Centers; local departments of social services; and other providers, agencies, and networks whose entity administrator determines the potential screener has the experience and informal training with which to complete the screenings.

All MUST screeners will be qualified to be screeners by participating in MUST training and by demonstrating competency in the use of the tool as evidenced by passing the MUST test. Ongoing authorization will be monitored through several DMA quality assurance initiatives.  DMA reserves the right to revoke the screener’s access to the web-based MUST.

MUST is currently being field tested by a cross section of all provider groups mentioned above.  This process consists of two testing periods:  February 11 through March 14 for round No. 1 and March 31 through April 25 for round No. 2.  Following each testing period, the current Uniform Screening Program contractor, EDS, will refine the tool.  Regional training classes will be held across the state once field testing is completed.

MUST regional training is scheduled to begin May 26, 2008.  Training dates and site locations, along with registration information, will be published in the April general Medicaid Bulletin and on April 1, 2008, on the MUST website.

Once a screener attends the training and passes the test, he/she may begin using the MUST to replace the FL2 in the work flow.  No FL2 or FL2e will be accepted after September 12, 2008.

Julie Budzinski, Facility and Community Care
DMA, 919-855-4360

Attention:  Children’s Developmental Service Agencies, Health Departments, Home Health Agencies, Independent Practitioners, Local Management Entities, Outpatient Hospital Clinics, and Physicians

Web-based Survey for Outpatient Specialized Therapies Prior Authorization Website

The Carolinas Center for Medical Excellence (CCME) website for Prior Authorization (PA) of Outpatient Specialized Therapies marked its first anniversary on February 5, 2008.  We would like to take this opportunity to solicit your feedback regarding the current PA process including the new fax forms and the option for electronic submission for PA as well as the overall convenience of the website. 

The survey will be available March 1 through 16, 2008, via a link on the CCME website for Prior Authorization.  Please share your opinions with CCME by completing this brief survey.  Your feedback and comments are greatly appreciated.

CCME, 1-800-228-3365

Attention:  CAP/DA Lead Agencies

Automated Quality and Utilization Improvement Program Quarterly Training Seminar

The Carolinas Center for Medical Excellence (CCME) announces continued quarterly training for new users of the Automated Quality and Utilization Improvement Program (AQUIP) in CAP/DA lead agencies.

The first quarterly training session this year will be held on March 18, 2008, at the Hilton Charlotte University Place in Charlotte.  Attendance at this meeting is of the utmost importance for new AQUIP users.  CAP/DA lead agency contacts have been informed via e-mail of any identified new users in their counties who should attend this session.  We recommend that all attendees read and become familiar with the AQUIP User Manual, which can be accessed by going to the AQUIP website and clicking on Downloads, prior to the training session.  Current users who would like to attend the session may do so if space permits.  However, the information presented will be designed for new users.

The seminar is scheduled to begin at 9:00 a.m. and end at 3:00 p.m.  The session will focus on Resource Utilization Group (RUG) scores, accurately completing the three parts of the AQUIP tool (client information sheet, data set assessment, and plan of care), and resolving common data entry errors.  The session will end with an overview of Health Check/Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) for Medicaid-eligible recipients under the age of 21.

Preregistration is required.  Contact your CAP/DA lead agency to verify if your name is on the required attendance list.  You may register for the seminar online, beginning March 3, 2008, by going to the AQUIP website and clicking on Training Sessions.  You will receive a computer-generated confirmation number, which you should bring to the seminar.  Check-in will be from 8:30 a.m. until 9:00 a.m. on the day of the seminar; lunch will be on your own.

• AQUIP website
• CCME home page

CCME, 1-800-682-2650

Attention:  Community Alternatives Program Case Managers, Home Health Agencies, and Private Duty Nursing Providers

Use of the Miscellaneous Medical Supply Code T1999

The use of miscellaneous code T1999 is permitted only in instances where a medical supply item is needed and is medically necessary for the recipient’s treatment or illness, but no code describing the item is listed on the Home Health Fee schedule.  The need for this code will continue with the ongoing updates and advances in medical treatment and the continual development of new and more effectual products.  The use of this code is a provision made to allow billing and reimbursement for these supplies on a temporary basis. 

A recent review of home health supply billing revealed that some providers are not adhering to coding guidelines regarding the use of the miscellaneous medical supply code T1999.  Providers should refer to Section 3.6 of Clinical Coverage Policy #3A, Home Health Services, for complete instructions on billing supplies and the use of the miscellaneous medical supply code. 

The Home Health Fee Schedule lists the Medicaid-covered home health medical supplies that can be reimbursed when billed by home health agencies, Community Alternatives Program (CAP) case managers, and private duty nursing providers.  The Home Health Fee Schedule includes the applicable national HCPCS code for each covered supply code as mandated under HIPAA.

Periodic updates are made to the fee schedule to accommodate coding changes made by CMS and as needed to include the items that are medically necessary and reasonable to treat the illnesses, diseases, or injuries common to the Medicaid home care population.  The codes generically describe the supply item and list the unit quantity measurement.  Providers must use the national HCPCS code that fits the item description and bill the units accordingly.  Misuse of code T1999 may result in the recoupment of any payment made for the medical supply item billed.

• Clinical Coverage Policy #3A, Home Health Services
• Home Health Fee Schedule
  • Adobe Acrobat Format
  • Microsoft Excel Format

Clinical Policy and Programs
DMA, 919-855-4380

Attention:  Independent Laboratories and Physicians

Clinical Laboratory Improvement Amendments Certification-related Claim Denials

It has come to DMA’s attention that some providers continue to receive claim denials when billing certain laboratory procedure codes with modifier QW.  In order to ensure that claims are coded appropriately when submitted, providers should refer to the CMS website at http://www.cms.hhs.gov/CLIA/10_Categorization_of_Tests.asp for the current lists as follows:

• waived tests
• tests categorized as provider-performed microscopy procedures (PPMP)
• tests (CPT-4 codes) subject to CLIA edits, including non-waived and non-PPMP tests
• tests (CPT-4 codes) excluded from CLIA edits

The lists may be printed and retained for future reference; however, this information is periodically updated and new tests are added as they are approved.

Billing Reminders
If a CPT code is listed with the QW modifier on the list of waived tests, the modifier must be appended to the CPT code for reimbursement.  Failure to append the QW modifier will result in claims being denied for EOB 0936, “Certification not valid for DOS/Level.”  Claims submitted with the QW modifier appended to a CPT code that is not indicated on the list of waived tests will also deny for EOB 0936.

If a test is not included on the QW list, providers should contact CLIA at the Licensure and Certification Section of the N.C. Division of Health Service Regulation at 919-855-4620 to discuss their certificate type and the tests that can be performed based on the certificate type.

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

Attention:  Institutional (UB-92/UB-04) Claim Billers

UB-04 Changes to Be Implemented April 25, 2008

This article, originally published in the February 2008 general Medicaid Bulletin, includes information on additional bill type changes.

The National Uniform Billing Committee (NUBC) previously released the UB-04 paper claim and manual for billing.  DMA will implement claim processing modifications on April 25, 2008 based on the UB-04 manual.  These changes apply to the UB-04 paper claim form, 837 Institutional transactions, and UB claims submitted through the NCECSWeb claim submission tool.  Providers will receive a claim denial if they bill using any UB code that has been labeled by the NUBC in the UB-04 manual as “Reserved for assignment by the NUBC.”  The impacted form locators and data elements are:

Bill Type Changes
Due to a definition change in the UB-04 Manual, the following Bill Types are required for claims received on or after April 25, 2008.  Claims received on or after that date without the required Bill Types will be denied.

• All hospitals should use Bill Type 11X for admissions and discharges.
• Psychiatric hospital lower level of care beds should use Bill Type 66X for services previously billed under bill type 17X.
• Head level of care nursing home bed services should use Bill Type 65X for services previously billed under bill type 28X.
• Criterion #5 should use Bill Type 65X with Revenue Code 902.  Previously, Criterion #5 used Bill Type 14X.
• Residential levels of care I through IV should use Bill Type 86X.  Previously, residential levels of care I through IV used Bill Type 84X.
• Skilled nursing facility and intermediate care facility nursing home beds should use Bill Type 21X or 22X for services previously billed under Bill Type 28X and 67X.
• Skilled nursing facility swing beds and intermediate care facility swing beds should use Bill Type 18X.  Previously SNF/ICF swing beds used Bill Types 15X, 16X, 18X and 88X.
• Ventilator nursing facility bed services will continue to use Bill Type 28X.

Revenue Code Changes
Due to a definition change in the UB-04 Manual claims received on or after April 25, 2008 for Adult Care Home services must use Revenue Code 679 in place of 599.  Revenue Code 599 has been discontinued.  Claims submitted with Revenue Code 599 will be denied.

Priority (Type) of Visit Changes
DMA will allow code 5 defined as Trauma in FL 14 for claims received on or after April 25, 2008.

Patient Discharge Status Changes
DMA will allow code 70 defined as Discharged/Transferred to another Type of Health Care Institution not Defined Elsewhere in this code list in FL 17 for claims received on or after April 25, 2008.

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

Attention:  Institutional (UB-92/UB-04) Claim Billers

Updated Effective Date for Revised UB Claim Form

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

All institutional paper claims received on or after April 25, 2008 must be filed on the UB-04 claim form regardless of the date of service.

Providers who submit the UB-92 claim form for processing on or after April 25, 2008 will receive denial EOB 9960, “Resubmit on the new UB04 Claim Form” on their remittance advice. 

Refer to the June 2007 Special Bulletin, New Claim Form Instructions, and the NUBC website for specific billing guidelines.

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

Attention:  Pharmacists

Days Supply for Prescriptions with “Use as Directed” Instructions

Submitting an accurate days supply is important.  Daily supply should be determined from the directions for use and the quantity written on a prescription.  For a prescription with instructions “use as directed,” the pharmacist should estimate the days supply based on professional judgment and/or contact with the prescriber.  The maximum days supply for drugs is 34 days unless the drug meets the criteria to obtain a 90 days supply. 

Please refer to the Clinical Coverage Policy #9, Outpatient Pharmacy Program, for additional information on days supply. 

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

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

Changes in Drug Rebate Manufacturers

The following changes are being made for manufacturers with drug rebate agreements.  The changes are listed by manufacturer code, which are the first five digits of the National Drug Code.

Additions
The following labelers have entered into drug rebate agreements and have joined the rebate program effective on the dates indicated below:

Voluntarily Terminated Labeler
The following labeler has requested voluntary termination effective on the date below:

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

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.

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