In This Issue...
NPI Articles:
All Providers:
Adult Care Home Provider:
Area Mental Health Centers:
CAP-MR/DD Targeted Case Managers and CAP-MR/DD Service Providers:
Dental Providers:
Durable Medical Equipment Providers:
Health Department Dental Clinics:
Local Management Entities:
Mental Health Service Providers:
Nurse Practitioners:
Orthotic and Prosthetic Providers:
Pharmacists and Prescribers:
Physicians:
Psychiatric Hospitals:
Psychiatric Residential Treatment Facilities:
Rural Health Centers:
Only 32 percent of providers have reported their National Provider Identifier (NPI) to the Division of Medical Assistance (DMA). You must report an NPI for each of your Medicaid provider numbers to the DMA's Provider Enrollment unit to comply with HIPAA guidelines. (Atypical providers excluded.) At this time, the National Plan and Provider Enumerator are not providing NPI information to health plans.
Instructions and addresses to report the NPI and taxonomy number can be found on DMA's NPI web page. Two options are available for submitting this information: the NPI Collection Spreadsheet (EDI) and the NPI Collection form. Instructions for both are posted on DMA's NPI web page. A copy of the NPI certification (either letter or email) from the National Plan and Provider Enumeration System (NPPES) must be included with each submission to update your DMA provider enrollment file. (If the same NPI represents multiple Medicaid provider numbers, only one NPPES certification is needed.) The NPI reporting process will not be complete without this information. The NPI must be reported and the NPPES certification must be submitted to DMA Provider Enrollment.
NPI Poses No Change in Medicaid Policy or Billing Requirements:
The implementation of NPI requirements does not change Medicaid policy or current billing requirements. Claims processing will not be affected by such NPI changes as taxonomy codes and NPI numbers. Program coverage, reimbursement and Medicaid policy remain the same. Please continue to refer to program enrollment and guidelines to file claims.
EDS, 1-800-688-6696 or 919-851-8888
The NPI electronic mailing list is now complete for providers, software vendors, clearinghouses, and other interested parties. The purpose of the mailing list is for N.C. Medicaid to provide immediate updates regarding NPI. To subscribe to the mailing list, please DMA's NPI web page and select NPI Mailing List. N.C. Medicaid encourages everyone to subscribe to the mailing list in order to stay up to date with the latest NPI information.
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
If a service is rendered at a location other than the billing address on the claim, providers need to complete the service facility location. The service facility location indicates the site where the patient was seen. This information is currently required on the 837 professional and institutional transactions when the location of health care service is different than that carried in the 2010AA (Billing Provider) or 2010AB (Pay-to-Provider) loops. On paper claims, this information is reported in block 32 of the CMS-1500 form. The NCECS Web format currently does not have a field to enter this information, but providers can begin submitting it once NCECSWeb tool is updated on May 18, 2007. This information is required on all claims except in situations where services are rendered in the recipient's home. The service facility location will be an important component for claims processing once NPI is implemented; therefore, it is imperative for providers to include this information on claims.
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
Taxonomy codes will be required on claims upon NPI implementation. The taxonomy codes are mandatory on both electronic and paper claims. For electronic claims, follow the rules of the 837 Implementation Guides to populate the taxonomy for billing and attending provider numbers. For paper claims, the taxonomy must be populated for both billing and attending provider numbers. Claims missing taxonomy codes will deny.
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
(Reprint from March 2007 General Medicaid Bulletin)
Basic Medicaid seminars are being held during the month of April 2007. Seminars are intended to educate providers on the basics of Medicaid billing.
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 Basic Medicaid seminars by completing and submitting the following registration form online.
Sessions will begin at 9 a.m. and end at 12 p.m. Providers are encouraged to arrive by 8:45 to complete registration.
|
Tuesday, April 17, 2007 |
Wednesday, April 18, 2007 |
|
Thursday, April 26, 2007 |
Monday, April 30, 2007 |
Directions to Basic Medicaid Seminars
Holiday Inn Fayetteville-Bordeaux
Traveling east on I-40: Take exit 38- toward Sanford. Turn right onto Martin Luther King Jr / US-421. Continue to follow US-421 S. Turn right onto NC-87 S. Turn right onto Santa Fe Dr. Turn left to take the All American Freeway/ Wilkes Road ramp. All American Freeway becomes Owen Drive.
Traveling West on I-40: Take exit 328A for I-95 S. Merge onto I-95 BR S / US-301 S via EXIT 56. Travel approximately 8.6 miles. Turn right onto Owen Drive.
Jane S. McKimmon Center - Raleigh
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 corner of Gorman Street and Western Boulevard.
Take exit 295 and turn right into Gorman Street. Travel approximately 2.5 miles. The McKimmon Center is located on the right on the corner of Gorman Street and Western Boulevard.
Sheraton Hotel - Greensboro
Traveling East on I-40: Take exit 217 for High Point Road.
Travel .2 mile and cross over High Point Road. The Sheraton will be on your
left.
Take exit 217 for Koury Boulevard. The Sheraton will be on your left.
Crowne Plaza - Asheville
Traveling West on I-40: Take Exit 53 to I-240 West. Pass downtown Asheville. As you cross the French Broad River Bridge, stay in the right lane and take Exit 3B - Westgate and Resort Drive (former Holiday Inn Drive). Pass the Westgate Shopping Center on your right. After passing Mr. Transmission, you will see our entrance sign. Turn right onto Resort Drive and proceed to the main entrance.
Traveling East on I-40: Take Exit 46 (left exit) for I-240 East. Continue on I-240 and stay the left lane. Take Exit 3A. Circle around right and exit onto Patton Avenue. Turn right at the second light into Regent Business Park (between Denny's and Pizza Hut). Turn right; the entrance is on the left around a curve approximately 1000 yards. Follow Resort Drive to the main entrance of the resort on the left.
The following new or amended clinical coverage policies are now available on the Division of Medical Assistance'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
Centers for Medicare and Medicaid Services (CMS) has extended the acceptance period of the CMS 1500 (1290). Electronic Data Systems (EDS) will also extend the April 1st deadline for implementing the revised CMS -1500 to June 1, 2007. Until June 1, 2007 either the CMS 1500 (0805) or the CMS 1500 (12/90) will be accepted.
Source: CMS Web site
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service January 1, 2007, CMS issued HCPCS procedure code Q4081 (injection, epoetin alfa, 100 units; for ESRD on dialysis). This code has been placed in the claims payment system with a payment effective date of April 1, 2007.
Refer to the following information for billing guidelines, paying particular attention to the difference between the units of the J0886 code and the Q4081 code.
Dialysis Facility Providers (837I or UB-92 Claim Form)
Dialysis facilities submitting Epogen claims for dates of service April 1, 2007, or after must bill with code Q4081. Code Q4081 represents 100 units of Epogen. Code Q4081 will not be reimbursed prior to April 1, 2007. Providers should continue to bill with Epogen code J0886 (1,000 units) through March 31, 2007 dates of service. Beginning with April 1, 2007 dates of service, providers will no longer be reimbursed for J0886.
Providers submitting claims for code Q4081 with dates of service prior to April 1, 2007 will receive detail denials for this service. Providers must submit claims with code Q4081 for dates of service prior to April 1, 2007 as adjustments. Please contact EDS Provider Services if you have questions regarding submission of adjustment requests.
Effective with date of service April 1, 2007, the maximum reimbursement rate for HCPCS procedure code Q4081 (100 units = 1 Medicaid unit) is $0.96 per Medicaid unit.
Providers Who Bill on the 837P or CMS 1500 Claim Form
Providers who bill on the 837P or CMS 1500 claim form may continue to bill Epogen code J0886 (1,000 units). On or after April 1, 2007, providers may also bill HCPCS procedure code Q4081 (100 units), for dates of service April 1, 2007, and after.
Effective with date of service April 1, 2007, the maximum reimbursement rate for J0886 (1,000 =1 Medicaid unit) is $9.57 per Medicaid unit.
Effective with date of service April 1, 2007, the maximum reimbursement rate for Q4081 (100 units= 1 Medicaid unit) is $0.96 per Medicaid unit.
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service February 1, 2007, a human papilloma virus (HPV) vaccine, Gardasil, was added to the list of vaccines covered through the Universal Childhood Vaccine Distribution Program (UCVDP)/Vaccines for Children (VFC) Program. These programs provide all vaccines required by the Advisory Committee of Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). UCVDP/VFC HPV vaccine is available to VFC-eligible children through 18 years of age.
The North Carolina Immunization Branch distributes childhood vaccines to local health departments, hospitals, and private providers under guidelines of the North Carolina UCVDP/VFC programs. Only VFC-eligible females through age 18 may receive state-supplied HPV vaccine.
According to ACIP, the final recommendation for routine administration of HPV vaccine is for adolescent females 11-12 years of age, although the vaccination series can be started in girls as young as 9 years of age. Catch-up vaccination is recommended for young women 13-26 years of age who have not been previously vaccinated, or who have not completed the full vaccine series. The vaccine should be administered as a three-dose series, with the second dose administered two months after the first, and the last dose given four months later (0, 2 months, 6 months). For maximum benefit, the vaccine should be administered before the onset of sexual activity; however females who are already sexually active can also benefit from being vaccinated. The complete ACIP final recommendations for HPV vaccine are online at http://www.cdc.gov/mmwr/pdf/rr/rr5602.pdf.
Billing Reminders:
EDS, 1-800-688-6696 or 919 688-6696
Beginning April 1, 2007 both Automated Voice Response System (AVRS) and Electronic Data Interchange (EDI) (vendor responses 270/271 electronic transmittals) will be updated to review the first four characters of a recipient's eligibility. This change will ensure providers have access to all recipient coverage including Medicaid restrictive coverage. The AVRS and EDI enable providers to access information regarding recipient eligibility.
Providers that access eligibility through the AVRS system will continue to get eligibility as they did in the past. However, this update will advise providers if a recipient has restricted coverage. For example if a recipient is only eligible for pregnancy related services, the voice response will now indicate, "This is a restrictive coverage category. Recipient is eligible for pregnancy related services only on date of service."
Providers that access eligibility through EDI (vendor responses 270/271 electronic transmittals) will now receive four characters, instead of three. The characters include the aid program category and class. In addition, to the four characters providers will continue to get a "yes" or "no" that indicates a recipient's eligibility. Providers are responsible to determine if the recipient has full Medicaid coverage or restricted coverage using the eligibility and class categories listed below:
Eligibility and Class Categories
N.C. Medicaid recipients receive benefits in the following assistance categories:
|
Medicaid Program Name |
Abbreviation |
Fourth Character Class Identifier |
Medicaid Eligibility |
|
|---|---|---|---|---|
|
Work First Family Assistance |
AAF |
C |
Recipient is eligible for Medicaid |
|
|
Aid to the Aged |
MAA |
C, G, or N |
Recipient is eligible for Medicaid |
|
|
B or Q |
Recipient is eligible for Medicaid and payment of Medicare Part B premiums |
|||
|
M or P |
After meeting a deductible recipient is eligible for Medicaid (for EDI users a yes will indicate eligible and a no will indicate not eligible) |
|||
|
F, H, O, or R |
This is a restrictive coverage category. Recipient is eligible for emergency services only. |
|||
|
Aid to the Blind |
MAB |
C, G, or N |
Recipient is eligible for Medicaid |
|
|
B or Q |
Recipient is eligible for Medicaid and payment of Medicare Part B premium |
|||
|
M or P |
After meeting a deductible recipient is eligible for Medicaid (for EDI users a yes will indicate eligible and a no will indicate not eligible) |
|||
|
F, H, O, or R |
This is a restrictive coverage category. Recipient is eligible for emergency services only. |
|||
Aid to the Disabled |
MAD |
C, G, or N |
Recipient is eligible for Medicaid |
|
|
B or Q |
Recipient is eligible for Medicaid and payment of Medicare Part B premium |
|||
|
M or P |
After meeting a deductible recipient is eligible for Medicaid (for EDI users a yes will indicate eligible and a no will indicate not eligible) |
|||
|
F, H, O, or R |
This is a restrictive coverage category. Recipient is eligible for emergency services only. |
|||
|
Families and Children |
MAF |
C, G, N, T, or W |
Recipient is eligible for Medicaid |
|
|
M or P |
After meeting a deductible recipient is eligible for Medicaid (for EDI users a yes will indicate eligible and a no will indicate not eligible) |
|||
|
F, H, O, R, U, or V |
This is a restrictive coverage category. Recipient is eligible for emergency services only. |
|||
|
Families and Children, Family Planning Waiver |
MAF-D |
D |
This is a restrictive coverage category. Recipient is limited to Family Planning Services only, under the Family Planning Waiver. |
|
|
Infants and Children |
MIC |
1, G, or N |
Recipient is eligible for Medicaid |
|
|
F or H |
This is a restrictive coverage category. Recipient is eligible for emergency services only. |
|||
|
North Carolina Health Choice |
MIC |
A, J, K, L, or S |
Recipient is covered by North Carolina Health Choice (NCHC). Request NCHC ID card or contact Blue Cross Blue Shield for verification. |
|
|
Pregnant Women |
MPW |
I or N |
This is a restrictive coverage category. Recipient is eligible for pregnancy-related services only. |
|
|
F or H |
This is a restrictive coverage category. Recipient is eligible for emergency services only, including labor and delivery. |
|||
|
Special Assistance to the Blind |
MSB |
C |
Recipient is eligible for Medicaid |
|
|
B or Q |
Recipient is eligible for Medicaid and payment of Medicare Part B premium |
|||
|
Foster Care; Adoption Subsidy |
HSF; IAS |
C, G, or N |
Recipient is eligible for Medicaid |
|
|
M or P |
After meeting a deductible recipient is eligible for Medicaid (for EDI users a yes will indicate eligible and a no will indicate not eligible) |
|||
|
F, H, O, or R |
This is a restrictive coverage category. Recipient is eligible for emergency services only. |
|||
|
Medicaid Program Name |
Abbreviation |
Fourth Character Class Identifier |
Medicaid Eligibility |
|---|---|---|---|
|
Special Assistance - Aid to the Aged |
SAA |
C |
Recipient is eligible for Medicaid |
|
Q or B |
Recipient is eligible for Medicaid and payment of Medicare Part B premium |
||
|
Special Assistance - Aid to the Disabled |
SAD |
C |
Recipient is eligible for Medicaid |
|
Q or B |
Recipient is eligible for Medicaid and payment of Medicare Part B premium |
||
|
Medicare-Qualified Beneficiaries |
MQB |
Q |
This is a restrictive coverage category. Medicaid pays the Medicare premium and cost sharing charges only. |
|
B or E |
No Medicaid coverage. Recipient is eligible for payment of the Part B premium only. |
||
|
Refugees |
MRF |
N |
Recipient is eligible for Medicaid |
|
M |
After meeting a deductible recipient is eligible for Medicaid (for EDI users a yes will indicate eligible and a no will indicate not eligible) |
||
|
Refugee Assistance |
RRF |
C |
Recipient is eligible for Medicaid |
Providers who have general eligibility questions should contact their local Department of Social Services office. A list of all the local offices is available online at http://www.ncdhhs.gov/dss/local/.
EDS, 1-800-688-6696 or 919-851-8888
The N.C. Identity Theft Protection Act mandates that Social Security Numbers (SSNs) cannot be embedded in any kind of number issued for recipients to receive benefits. The Eligibility Information System has over 500,000 SSN-based IDs that must be reassigned by July 1, 2007, to be in compliance with this mandate. Beginning in March 2007, the affected ID numbers will be changed and cross-referenced with new assigned numbers. As a result, it is possible that the ID number on a Medicaid card presented to you may not be the same ID number you have in your records. You do not need to do anything except be aware of this change. This will not affect claims processing. Providers that bill under an old ID number will still receive payment, as the new ID number will cross reference with the old ID number.
(Reprint from February 2007 General Medicaid Bulletin)
In compliance with the Improper Payments Information Act of 2002, the Centers for Medicare and Medicaid Services (CMS) implemented a national Payment Error Rate Measurement (PERM) program to measure improper payments in the Medicaid program and the State Children's Health Insurance Program (SCHIP). This is to inform you that North Carolina has been selected as one of 17 states required to participate in PERM reviews for 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.
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
Paper adjustment processing procedures require that providers attach a copy of all paper Medicaid Remittance Advice (RA) page(s) related to the referenced claim, a copy of the corrected claim, and any other documentation, such as medical records, necessary to process the adjustment.
Since the implementation of electronic HIPAA transactions, EDS has been receiving paper adjustment requests with RA pages generated from the provider's Electronic Medicaid Media Remittance. This provider-generated RA is not an acceptable substitute for the paper copy mailed to providers by EDS. These generated RAs have varied formats and do not include all information necessary for manual adjustment processing.
Paper adjustments that do not include the required RA will continue to be denied with EOB 812, "Adjustment denied. Please refile with all related RA's, including original processing." Providers receiving this denial should resubmit a copy of their adjustment with the requested RA.
Providers who do not have a copy of the paper RA may contact EDS Provider Services to request a replacement. There is a $0.35 per page charge for RA requests that are older than 10 checkwrites before the date requested. RA reprints for the last 10 checkwrites are provided at no charge.
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service March 31, 2007, the N.C. Medicaid Physician's Drug Program end-dated CPT procedure codes 90384, 90385, and 90386. Effective with date of service April 1, 2007, providers must bill HCPCS procedure codes J2788, J2790, or J2792 for Rho(D) immune globulins. Claims billed with the end-dated codes for dates of service April 1, 2007, and after will be denied. Refer to the following table for billing guidelines for the new codes.
|
End-dated CPT Code |
Description |
Unit |
New HCPCS Code |
Description |
Unit |
Maximum Reimbursement Rate |
|---|---|---|---|---|---|---|
|
90384 |
Rho(D) immune globulin (RHIG) |
300 mcg |
J2790 |
Rho D immune globulin, human, full dose |
300 mcg |
$26.17 |
|
90385 |
Rho(D) immune globulin (RHIG) |
50 mcg |
J2788 |
Rho D immune globulin, human, minidose |
50 mcg |
$81.59 |
|
90386 |
Rho(D) immune globulin (RHIGIV) |
100 IUs |
J2792 |
Rho D immune globulin, IV human, solvent detergent |
100 IUs |
$16.52 |
Note: Providers are reminded to bill their usual and customary charge.
EDS, 1-800-688-6696 or 919-851-8888
Please Note: Instructions here replace any previous instructions.
Effective with the date of service October 1, 2006, the N.C. Medicaid Program implemented a special care rate for ACH providers operating Special Care Units for Persons with Alzheimer's and Related Disorders.
The SCU-A Rate is $46.79 per day for those qualifying homes of 30 beds or less and $51.25 per day for those qualifying homes of 31 or more beds.
Medicaid reimburses providers according to the following procedure:
Division of Medical Assistance
Facility and Community Care Section
ACH Unit
1985 Umstead Drive
2501 Mail Service Center
Raleigh, NC 27699-2501Only requested follow-up and or discharge information may be faxed to DMA Attention: SCU-A Approval @ 919-715-2372.
Charles Jackson @ 919-855-4346 or Charles.Jackson@ncmail.net or
Julie Budzinski @ 919-855-4368 or Julie.Budzinski@ncmail.net
CAP/Targeted Case Management (CTCM) Request for Authorization forms submitted to ValueOptions to request discrete services for individuals receiving services under North Carolina's 1915 (c) waiver for Individuals with Mental Retardation/Developmental Disabilities (CAP-MR/DD) must clearly identify the provider's correct provider number. Failure to provide the correct provider number for the provider listed for each service requested may cause delayed or incorrect authorization.
In the future, CTCM forms that request authorization for CAP-MR/DD discrete services but do not identify the providing agency by Medicaid provider number will be returned to the TCM agency as incomplete.
NOTE: Each provider agency must be identified by complete name of agency and provider number to ensure accurate prior approval of services.
Behavioral Health
DMA, 919-855-4290
Upcoming June Seminars
Seminars on Dental Medicaid billing guidelines are scheduled
for June 2007. Registration information, a list of dates, and site locations
for the seminars will be published in the May 2007 General Medicaid bulletin.
EDS, 1-800-688-6696 or 919-851-8888
Clinical policy for the Farrell valve enteral gastric pressure relief system went into effect April 1, 2007. Please refer to Clinical Coverage Policy #5A, Durable Medical Equipment, for coverage details. Section 9.0 of that policy lists the changes that were made by effective date.
Clinical Policy and Programs
DMA, 919-855-4310
Clinical policy for the cough-stimulating device (Cough Assist) went into effect March 1, 2007. Please refer to Clinical Coverage Policy #5A, Durable Medical Equipment, for coverage details. Section 9.0 of that policy lists the changes that were made by effective date.
Clinical Policy and Programs
DMA, 919 855-4310
Medicaid providers enrolled to offer the waiver service of Day Supports Individual (T2021) and Day Supports Group (T2021HQ), please note the following rate changes, which reflect the increased cost of transportation:
|
Service Code |
Old Rate |
New Rate |
|---|---|---|
|
T2021 Individual |
$5.94/unit |
$6.47/unit |
|
T2021HQ Group |
$3.31/unit |
$3.84/unit |
Providers of the waiver service day supports are required to transport the recipient to and from his place of residence to the licensed facility and from the licensed facility to activities that originate from the facility.
This rate is effective as of January 1, 2007. Providers are not required to resubmit their claims. An automatic recoupment and repayment will be done by EDS.
Rate Setting
DMA, 919-855-4200
As described in the July 2006 Medicaid Special Bulletin, Authorization and Utilization Review for Behavioral Health Services, Federal regulations require a Certificate of Need form (CON) and prior approval for an inpatient admission to a psychiatric hospital or a psychiatric residential treatment facility for Medicaid recipients under the age of 21. These detailed regulations can be found at 42CFR441.152, 441.153, and 441.156.
To expedite prior approval, the CON is often faxed to ValueOptions (919-461-0599). This is still acceptable, and ValueOptions will no longer withhold prior approval pending receipt of the original. The original must remain in the patient's medical record. All other regulations remain in effect.
Behavioral Health
DMA, 919-855-4290
Revised clinical coverage policy for cast boots, post-operative sandals or shoes, and healing shoes went into effect April 1, 2007. There are several significant changes from the previous policy. Please refer to Clinical Coverage Policy #5B, Orthotics and Prosthetics, for coverage details. Section 9.0 of that policy lists the changes that were made by effective date.
Clinical Policy and Programs
DMA, 919-855-4310
Coverage policy for cranial orthosis for plagiocephaly went into effect April 1, 2007. Please refer to Clinical Coverage Policy #5B, Orthotics and Prosthetics, for coverage details. Section 9.0 of that policy has the changes that were made by effective date.
Clinical Policy and Programs
DMA, 919-855-4310
Effective immediately, the billing restriction has been removed for Botox in the pharmacy point-of-sale system. All claims for Botox can now process online up to the billed amount of $9,999.99.
EDS, 1-800-688-6696 or 919-851-8888
The prior authorization criteria have been revised for the following medications in the Medicaid outpatient pharmacy prior authorization program:
The revised criteria are available on the N.C. Medicaid Enhanced Pharmacy Program Web site (http://www.ncmedicaidpbm.com; click on PA List & Criteria, then on individual drugs).
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service February 14, 2007, Neupogen no longer requires prior authorization from the Medicaid outpatient pharmacy program.
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service April 1, 2007, the N.C. Medicaid Physician's Drug Program covers weekly 17 alpha hydroxyprogesterone caproate (17P) intramuscular injections for use in pregnant women with a history of a preterm delivery before 37 weeks gestation but no preterm labor in the current pregnancy. 17P for intramuscular injection is not commercially available, but can be compounded by a pharmacy provider, and must be billed with HCPCS procedure code J3490 (unclassified drugs) and a copy of the invoice.
Progesterone therapy as a technique to prevent preterm labor is considered investigational/not medically necessary for pregnant women who do not meet the above criteria, or for those with other risk factors for preterm delivery, including but not limited to multiple gestations, short cervical length, or positive tests for cervicovaginal fetal fibronectin.
The recommended dose of 17P is a 250-mg weekly intramuscular injection administered from gestational weeks 16 through 36.
For Medicaid Billing:
EDS, 1-800-688-6696 or 919-851-8888
In addition to previously published covered diagnoses, the N.C. Medicaid program covers bevacizumab (Avastin) for use in the Physician's Drug Program for wet age-related macular degeneration for patients who have not responded to therapy with ocular photodynamic therapy with verteporfin or to therapy with intravitreal pegaptanib. Coverage should be limited to patients who are deemed by their treating physician to have failed FDA-approved therapies, or who, in the judgment of their treating physician, based on his/her experience, are likely to have greater benefit from the use of intravitreal bevacizumab. Medical record documentation should validate the use of bevacizumab for the appropriate diagnosis.
Diagnoses previously covered for Avastin include malignant neoplasm of the colon, rectum, recto-sigmoid junction, and anus when used in combination with intravenous 5-fluorouracil based chemotherapy; and unresectable, locally advanced, recurrent or metastatic non-squamous, non-small cell lung carcinoma.
The following ICD-9-CM diagnosis codes are required when billing for Avastin:
And
1. 153.0 through 154.8
2. 162.2 through 162.9
3. 362.52
EDS, 1-800-688-6696 or 919-851-8888
Previously, freestanding rural health clinics submitted their Medicaid cost reports to Riverbend Government Benefits Administrator. However, effective immediately, all rural health clinics are to submit their Medicaid cost reports directly to the Division of Medical Assistance.
The following information must be submitted along with the original Medicaid FQHC/RHC cost report:
Please submit the cost report and information by one of the following means:
|
US Mail |
Express Mail/Shipping |
|---|---|
|
Division of Medical Assistance |
Division of Medical Assistance |
|
Audit Section |
Audit Section |
|
Attn: Jason Hockaday |
Attn: Jason Hockaday |
|
2501 Mail Service Center |
421 Fayetteville St. |
|
Raleigh NC 27699-2501 |
Raleigh NC 27601 |
Audit
DMA, 919-647-8060
In accordance with Session Law 2005-276, proposed new or amended Medicaid clinical coverage policies are available for review and comment on DMA's website. To submit a comment related to a policy, refer to the instructions on the website. Providers without Internet access can submit written comments to the address listed below.
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.
|
Month |
Electronic Cut-Off Date |
Checkwrite Date |
|
April |
04/05/07 |
04/10/07 |
|
04/12/07 |
04/17/07 |
|
|
04/19/07 |
04/26/07 |
|
|
May |
05/03/07 |
05/08/07 |
|
05/10/07 |
05/15/07 |
|
|
05/17/07 |
05/22/07 |
|
|
05/24/07 |
05/31/07 |
|
|
05/31/07 |
06/05/07 |
|
|
June |
06/07/07 |
06/12/07 |
|
06/14/07 |
06/21/07 |
|
|
06/28/07 |
07/03/07 |
|
|
July |
07/05/07 |
07/10/07 |
|
07/12/07 |
07/17/07 |
|
|
07/19/07 |
07/26/07 |
|
|
August |
08/02/07 |
08/07/07 |
|
08/09/07 |
08/14/07 |
|
|
08/16/07 |
08/23/07 |
|
|
08/30/07 |
09/05/07 |
|
|
September |
09/06/07 |
09/11/07 |
|
09/13/07 |
09/18/07 |
|
|
09/20/07 |
09/27/07 |
|
|
October |
10/04/07 |
10/09/07 |
|
10/11/07 |
10/16/07 |
|
|
10/18/07 |
10/23/07 |
|
|
10/25/07 |
10/31/07 |
|
|
November |
11/01/07 |
11/06/07 |
|
11/08/07 |
11/14/07 |
|
|
11/15/07 |
11/21/07 |
|
|
11/29/07 |
12/04/07 |
|
|
December |
12/06/07 |
12/11/07 |
|
12/13/07 |
12/20/07 |
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.
| Mark T. Benton, Senior Deputy Director and Chief Operating Officer | Cheryll Collier | |
| Division of Medical Assistance | Executive Director | |
| Department of Health and Human Services | EDS |