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In This Issue . . .
All Providers:
All Behavioral Health Care Providers:
Adult Care Home Providers:
CAP/C Case Managers:
CAP/MR-DD Service Providers:
Children’s Developmental Services Agencies:
Community Alternatives Program Case Managers:
Enhanced Behavioral Health (Community Intervention) Services Providers:
Health Departments:
HIV Case Management Providers:
Home Health Agencies:
Hospital Outpatient Clinics:
Independent Practitioners:
Local Education Agencies:
Local Management Entities:
Nurse Practitioners:
Outpatient Behavioral Health Providers:
Personal Care Services Providers:
Physicians:
Private Duty Nursing Providers:
Residential Child Care Treatment Facilities:
TCM/DD Case Managers:
DMA shall suspend payment to all N.C. Medicaid providers that currently have outstanding (i.e., thirty days or more past due) balances owed as a result of DMA actions to recoup assessments, overpayments or improper payments until such outstanding balances are either paid in full or the provider enters into an approved payment plan, in accordance with N.C. Session Law 2009-451, Section 10.73A (a) (b) (c), which states:
SECTION 10.73A.(a) The Department of Health and Human Services may suspend payment to any North Carolina Medicaid provider against whom the Division of Medical Assistance has instituted a recoupment action, termination of the N.C. Medicaid Administrative Participation Agreement, or referral to the Medicaid Fraud Investigations Unit of the North Carolina Attorney General's Office. The suspension of payment shall be in the amount under review and shall continue during the pendency of any appeal filed at the Department, the Office of Administrative Hearings, or State or federal courts. If the provider appeals the final agency decision and the decision is in favor of the provider, the Department shall reimburse the provider for payments for all valid claims suspended during the period of appeal.
SECTION 10.73A.(b) Entering into a Medicaid Administrative Participation Agreement with the Department does not give rise to any property or liberty right in continued participation as a provider in the North Carolina Medicaid program.
SECTION 10.73A.(c) The Department shall not make any payment to a provider unless and until all outstanding Medicaid recoupments, assessments, or overpayments have been repaid in full to the Department, together with any applicable penalty and interest charges, or unless and until the provider has entered into an approved payment plan.
For additional information on a repayment plan, please contact DMA Budget Management at 919-855-4140.
Program Integrity
DMA, 919-647-8000
To ensure the privacy and security of protected health information, change your NCECS Web Tool password if your facility has recently terminated an employee. You may contact the ECS Department at 1-800-688-6696, option 1, to obtain a Claims Submission Change Request Form. The ECS Department will fax a Claims Submission Change Request Form to you to be completed and returned via fax (919-859-9703) to facilitate the password change. You may also access the form on DMA’s Provider Forms web page.
HP Enterprise Services
1-800-688-6696 or 919-851-8888
Effective with date of service May 15, 2009, the N.C. Medicaid Program added the following ICD-9-CM diagnosis codes to the coverage of risperdone, long acting, to align with the recent FDA approval for the indication of bipolar disease, type 1. Medicaid already covers Risperdal Consta for the indication of schizophrenia. The diagnoses that were added for coverage of bipolar disease are:
Providers who received denials for J2794 on claims submitted with a diagnosis of bipolar disease, type 1, for dates of service on and after May 15, 2009, may file the denied charges as a new claim. Refer to the March 2009 Special Bulletin, National Drug Code Implementation, Phase III, for additional instructions.
HP Enterprise Services
1-800-688-6696 or 919-851-8888
The list of standard national codes used on the Electronic Remittance Advice (ERA) has been cross-walked to EOB codes as an informational aid to adjudicated claims listed on the Remittance and Status Report (RA). An updated version of the list is available on DMA’s HIPAA web page.
With the implementation of standards for electronic transactions mandated by HIPAA, providers now have the option to receive an ERA in addition to the paper version of the RA.
The EOB codes that providers currently receive on a paper RA are not used on the ERA. Because the EOB codes on the paper RA provide a greater level of detail on claim denials, all providers will continue to receive the paper version of the RA, even if they choose to receive the ERA transaction. The crosswalk is current as of the date of publication. Providers will be notified of changes to the crosswalk through future general Medicaid bulletins.
HP Enterprise Services
1-800-688-6696 or 919-851-8888
The following new or amended clinical coverage policies are now available on DMA’s Clinical Coverage Policies and Provider Manuals web page:
These policies supersede previously published policies and procedures. Providers may contact HP Enterprise Services at 1-800-688-6696 or 919-851-8888 with billing questions.
Clinical Policy and Programs
DMA, 919-855-4260
Effective immediately, the following HP Enterprise Services mail box addresses have been changed.
| Old Mail Box Address | Current Mal Box Address | City, State, Zip* |
|---|---|---|
| 300011 | 30968 | Raleigh, NC 27622 |
| 300010 | 30968 | Raleigh, NC 27622 |
| 300001 | 30968 | Raleigh, NC 27622 |
| 300012 | 30968 | Raleigh, NC 27622 |
*Please note the city, state, and zip code have not changed.
When appropriate, providers are instructed to continue to list any departmental information for routing purposes. For example:
HP Enterprise Services
ATTN: UB04 Claims
PO Box 30968
Raleigh, NC 27622
HP Enterprise Services
1-800-688-6696 or 919-851-8888
Federal regulations (42 CFR 433.138 and 139) require Medicaid to be the payer of last resort. For this reason, providers must determine if a recipient has commercial health insurance coverage. If the recipient’s eligibility information indicates a commercial health insurance carrier, the provider must bill the carrier before billing Medicaid.
Occasionally, a carrier has terminated coverage but the recipient’s eligibility information still indicates commercial health insurance. If the insurance information is not updated, a provider’s claim will deny for third party liability when the claim is submitted to Medicaid. To prevent this denial and to allow the claim to be processed, the provider must submit a request for an update to the recipient’s health insurance information. The request must be completed and the eligibility information must be updated before the provider’s claim can be processed.
Medicaid providers now have the option of submitting requests for updates to a recipient’s commercial insurance information electronically via secured Internet connection. The existing paper Health Insurance Information Referral Form (DMA-2057) will continue to be available to providers who choose that process, but electronic submission is preferred by DMA.
The new electronic option expedites the processing of commercial insurance information updates and eliminates the need to attach a paper claim to the referral form. Providers can now submit claims electronically. Because electronic requests are completed within two business days, providers will be able to submit claims immediately upon receipt of the confirmation e-mail from the vendor managing this update process, hms.
To submit a request, follow these easy steps:
The provider will receive an email from hms indicating what action has been taken on the insurance information received.
hms
1-866-263-2227 or 919-424-2800
DMA established a N.C. Medicaid Preferred Drug List (PDL) on March 15, 2010. The N.C. General Assembly [Session Law 2009-451, Sections 10.66(a)-(d)] authorized DMA to establish the PDL in order to obtain better prices for covered outpatient drugs through supplemental rebates. All therapeutic drug classes for which the drug manufacturer provides a supplemental rebate are considered for inclusion on the list with the exception of medications used for the treatment of human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS).
Initially there will not be any changes in the drugs that are currently covered. In the future, selected therapeutic drug classes will be reviewed by DMA and the Pharmacy and Therapeutics Committee of the N.C. Physicians Advisory Group. Specific drug products within the selected therapeutic drug classes will be “preferred” based on therapeutic effectiveness, safety and clinical outcomes. Generally, these drugs will not require prior authorization (PA) unless there are other clinical PA requirements such as step therapy or quantity limits.
“Non-preferred” drugs (drug products not included in the therapeutic drug classes listed on the PDL) will be available if prior authorization criteria are met. The prior authorization process will be the same process as it is today. If a prescriber deems that the patient’s clinical status necessitates therapy with a “non-preferred” drug, the prescriber will be responsible for initiating a prior authorization request.
For therapeutic drug classes that do not appear on the PDL, nothing has changed. Prescribers can prescribe drugs in these classes as in the past, unless existing prior authorization criteria exists.
The PDL is posted on DMA’s Outpatient Pharmacy Program web page.
HP Enterprise Services
1-800-688-6696 or 919-851-8888
The N.C. Medicaid Program is making a targeted effort to enroll recipients who are dually eligible for Medicaid and Medicare into Community Care of North Carolina/Carolina ACCESS (CCNC/CA). Medicaid recipients who are Medicare-eligible are an optional group for enrollment into CCNC/CA and can choose to opt out of enrollment at any time.
During January and February, letters were mailed to all dually eligible recipients seen between January 2009 and December 2009 by a provider who is participating as a CCNC/CA primary care provider. The letter informed these recipients that they were being enrolled as a CCNC/CA member with the last primary care provider that they had seen during this time frame. Recipients were informed to contact their county department of social services if they did not wish to be enrolled with the provider identified in their letter.
If you are a CCNC/CA provider who is interested in enrolling a dually eligible Medicaid/Medicare patient that you are seeing in your practice, complete the CCNC/CA Enrollment Form for Medicaid Recipients.
When enrolling recipients, you must inform them of their right to opt out or to choose another provider. They must also be informed of their right to disenroll from the program at any time. Disenrolling from the program does not terminate their Medicaid benefits.
Providers who are not currently participating in CCNC/CA as a primary care provider who would like to have more information about becoming a provider with the program may contact the managed care consultant serving their county. The list of consultants can be found on the DMA CCNC/CA web page.
Managed Care
DMA, 919-855-4784
Claims billed with CPT procedure codes 64490 through 64495, in the office setting, for dates of service January 1, 2010, and after, were incorrectly denied. Changes have been applied to the system and providers who received a denial with EOB 36 may now resubmit the denied charges as new claims (not adjustments) for processing.
HP Enterprise Services
1-800-688-6696 or 919-851-8888
On April 20, 2009, CSC took over the provider enrollment, credentialing, and verification functions from DMA’s Provider Services unit. In the past six months, the Provider EVC Center has handled over 12,000 applications from providers who applied for participation in the North Carolina Medicaid Program.
Most applications move quickly through the EVC process but occasionally an application is deemed incomplete and processing is suspended until the issue is resolved with the provider. Our goal is to ensure your application is processed in a timely fashion to allow you to become a participating provider with the N.C. Medicaid Program.
To avoid delays in processing provider applications
To assist providers in preparing their enrollment application, the Provider Qualifications and Requirements Checklist is available on the NC Tracks Provider Enrollment web page.
CSC, 1-866-844-1113
DMA’s Program Integrity (PI) Section is devoted to ensuring compliance, efficiency, and accountability within the N.C. Medicaid Program by detecting and preventing fraud, waste and program abuse, thus ensuring that Medicaid dollars are paid appropriately. You are encouraged to report matters involving Medicaid fraud and abuse. If you want to report fraud or abuse, you can remain anonymous; however, sometimes in order to conduct an effective investigation, staff may need to contact you. Your name will not be shared with anyone investigated. (In rare cases involving legal proceedings, we may have to reveal who you are.)
To report suspected Medicaid fraud, waste or program abuse by a medical provider:
Examples of Medicaid Fraud and Abuse by Medical Providers (list is not all-inclusive)
Program Integrity
DMA, 919-647-8000
The December 2009 Medicaid bulletin article titled Flu Testing: CPT Codes 87400 and 87804 instructed providers to bill two units of CPT code 87804 (infectious agent antigen detection by immunoassay with direct optical observation; influenza) with the QW modifier for flu testing. However, claims have continued to deny. Providers who wish to bill for two influenza tests should now bill CPT code 87804: one unit with the QW modifier and one unit with QW modifier along with 76 modifier.
Providers who have billed more than one flu test on the same day of service and received a denial with EOB 5201 (Diagnostic procedure allowed once per day unless billed with appropriate modifier) or EOB 7701 (Combination of billed modifiers is invalid, please review and resubmit with the correct billing combination) may correct and resubmit the denied claim for payment if they have filed their claims timely.
HP Enterprise Services
1-800-688-6696 or 919-851-8888
The NCECS Web Tool provides recipient eligibility information. A recipient’s Medicare information, including enrollment for Part A, Part B or both, is available. Refer to the illustrations below for examples of the Medicare information.
If the health insurance claim (HIC) number is displayed on the screen without showing Part A and/or Part B coverage, it may mean that the recipient is not eligible for Medicare. In this case, providers should use another method to verify Medicare eligibility.
For additional information on verifying recipient eligibility, refer to the Basic Medicaid Billing Guide and the January 2010 Medicaid Bulletin. For detailed information on the NCECSWeb Tool, refer to the September 2009 Special Bulletin, North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool Instruction Guide.
HP Enterprise Services
1-800-688-6696 or 919-851-8888
Health Check/EPSDT seminars are scheduled for May 2010 at the sites listed below. Information presented at the Health Check/EPSDT seminars is applicable to all providers who provide early and regular medical and dental screenings for Medicaid recipients under the age of 21.
The April 2010 Health Check Billing Guide will be used as the primary training document for the seminar. Please print a copy of the Health Check Billing Guide for review and bring it to the seminar. If preferred, you may download the Health Check Billing Guide to a laptop and bring the laptop to the seminar. Or, you may access the Health Check Billing Guide online using your laptop during the seminar. However, please note that HP Enterprise Services cannot guarantee a power source or Internet access for your laptop.
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 seminars by completing and submitting the online registration form, or providers may register by fax using the Health Check/EPSDT Seminar Registration Form (fax it to the number listed on the form). Please indicate the session you plan to attend on the registration form.
Sessions will begin at 9:00 a.m. and end at 12:00 noon. 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.
| Date | Directions | Location |
|---|---|---|
| May 6, 2010 | Get directions | Asheville Mountain Area Health Education Center (MAHEC) 501 Biltmore Avenue Asheville NC 28801 |
| May 13, 2010 | Get directions | Greensboro Clarion Hotel Airport 415 Swing Road Greensboro NC 27409 |
| May 17, 2010 | Get directions | Raleigh The Royal Banquet and Convention Center 3801 Hillsborough Street Raleigh NC 27607 |
| May 20, 2010 | Get directions | Wilmington Hampton Inn Medical Park 2320 South 17th Street Wilmington NC 28401 |
HP Enterprise Services
1-800-688-6696 or 919-851-8888
The N.C. Medicaid Program is in the process of expanding our North Carolina Electronic Claims Submission/Recipient Eligibility Verification (NCECS) Web Tool for providers to download a PDF version on their paper Remittance and Status Report (RA). Once the expansion is complete, paper RAs will no longer be printed and mailed to providers. Providers will be notified of the expansion via the Medicaid Bulletin.
HP Enterprise Services
1-800-688-6696 or 919-851-8888
DMA has created a new web page with information about prior approval. The page includes contact information, forms, links to best practice guidelines used by DMA and vendor staff, and frequently asked questions as well as general information about the approval process. Providers can access the new page at http://www.ncdhhs.gov/dma/provider/priorapproval.htm.
Provider Services
DMA, 919-855-4050
Attention: HIV Case Management Providers
Effective April 1, 2010, the Division of Public Health will no longer be the operating agency for HIV Case Management services. A new vendor will be announced soon along with appropriate contact numbers. Please be advised that any existing applications or future applications for new HIV case management providers will be reviewed under the new requirements recently approved by CMS. A new HIV Case Management policy will be posted in an upcoming month. Until then, please direct any questions to Victoria Landes, HIV Program Consultant at DMA, 919 855 4389.
Victoria Landes HIV Program
DMA, 919-855-4389
Attention: Behavioral Health Care Providers
Medicaid services are provided to recipients in all 100 North Carolina counties. In accordance with 42 CFR Part 455, which sets forth requirements for a State fraud detection and investigation program, DMA’s Program Integrity Section investigates Medicaid providers when clinically suspect behaviors or administrative billing patterns indicate potentially abusive or fraudulent activity.
The review of providers of community behavioral health services has presented unique challenges. These challenges and the related volume of cases have resulted in a backlog that requires immediate attention. Program Integrity is committed to initiating these reviews and safeguarding against unnecessary or inappropriate use of Medicaid services and against excess payments.
In accordance with 10A NCAC 22F.0202, a Preliminary Investigation shall be conducted on all complaints received or aberrant practices detected, until it is determined that there are sufficient findings to warrant a full investigation; or there is sufficient evidence to warrant referring the case for civil and/or criminal fraud action; or there is insufficient evidence to support the allegation(s) and the case may be closed.
Effective January 28, 2010, Public Consulting Group (PCG), will assist the DMA’s Program Integrity Behavioral Health Review Section in eliminating the backlog of cases and prospectively maintaining a steady state of case reviews, preventing a future backlog of cases from accumulating. For assigned cases, PCG will absorb the full scale of operations, beginning with the receipt of a case file, conducting the clinical review, establishing a statistically valid claim review sample for review, and extrapolating these findings to calculate the recoupment.
PCG will initiate contact with the provider, inform the provider of the post payment review process requirements, and work closely with the provider and DMA. PCG will advise the provider where and how to submit records for the review, and will address provider questions regarding the post-payment review process. If the provider is out of compliance, a recoupment letter shall be forwarded to the provider in the amount of the overpayment. The provider will have reconsideration and appeals rights if the provider does not agree with the findings of the review. Reconsideration and appeal rights instructions will be sent out with the recoupment letter.
If the preliminary investigation supports the conclusion of possible fraud, the case shall be referred to the appropriate law enforcement agency for a full investigation.
Program Integrity Behavioral Health Review Section
DMA, 919-647-8000
Attention: Nurse Practitioners
Effective with date of service March 1, 2010, nurse practitioners can bill and receive reimbursement for CPT procedure codes 57452, 57454, and 57505. To qualify for reimbursement, the nurse practitioner must have formal education and training in the procedure, be validated as competent in performing the procedure, and the procedure must be included in the Collaborative Practice Agreement signed by the nurse practitioner and the primary supervising physician.
HP Enterprise Services
1-800-688-6696 or 919-851-8888
Attention: Nurse Practitioners and Physicians
Billing guidelines for the injectable drug C1 esterase inhibitor were published in the February 2010 Medicaid Bulletin and indicated that billing with HCPCS code J0598 applied to both Cinryze and Berinert. The article is being republished to document that the use of HCPCS code J3590 for C1 esterase inhibitor must be used to bill for Berinert. Refer to the article on Cinryze for guidelines on billing for Cinryze.
Effective with date of service January 1, 2010, the N.C. Medicaid Program covers C1 esterase inhibitor (human) injectable (Berinert) for use in the Physician’s Drug Program when billed with HCPCS code J3590 (unclassified biologics). Berinert is available as single-use vials for reconstitution containing 500 units of lyophilized concentrate with 10 ml of diluent per vial.
Berinert is a plasma-derived C1 esterase inhibitor (human) indicated for the treatment of acute abdominal or facial attacks of hereditary angioedema (HAE) in adult and adolescent patients.
Treatment with Berinert should be through intravenous injections of 20 units per kg of body weight at a rate of 4 ml per minute.
For Medicaid Billing
The new fee schedule for the Physician’s Drug Program is available on DMA’s Fee Schedule web page.
HP Enterprise Services
1-800-688-6696 or 919-851-8888
Attention: Nurse Practitioners and Physicians
Billing guidelines for the injectable drug C1 esterase inhibitor were published in the February 2010 Medicaid Bulletin and indicated that billing with HCPCS code J0598 applied to both Cinryze and Berinert. The article is being republished to document that the use of HCPCS code J0598 for C1 esterase inhibitor applies only to Cinryze. Refer to the article on Berinert for guidelines on billing for Berinert.
Effective with date of service January 1, 2010, the N.C. Medicaid Program covers C1 esterase inhibitor (human) (Cinryze), for use in the Physician’s Drug Program when billed with HCPCS code J0598. Cinryze is available as 8-ml single-use vials with approximately 500 units of lyophilized powder per vial.
Cinryze is indicated for routine prophylaxis against angioedema attacks in adolescent and adult patients with hereditary angioedema (HAE). Cinryze is a replacement product, working on one’s own natural C1 inhibitor to regulate clotting and inflammatory reaction that, when impaired, can lead to tissue swelling.
The recommended dosage of Cinryze is 1,000 units (2 vials) of Cinryze administered intravenously every
3 or 4 days. Cinryze is administered at an injection rate of 1 ml per minute.
For Medicaid Billing
The new fee schedule for the Physician’s Drug Program is available on DMA’s Fee Schedule web page.
HP Enterprise Services
1-800-688-6696 or 919-851-8888
Attention: Community Alternatives Case Managers, Home Health Agencies, and Private Duty Nursing Providers
Effective with date of service November 1, 2009, the following codes were added to the Home Health Medical Supply Fee Schedule. Included on the list of codes are the monthly maximum limits for private duty nursing (PDN) providers. The limits apply to only recipients 21 years of age or older regardless of whether they are approved for PDN services or not.
Providers should be cautioned that there is no entitlement to the recipient for receiving the maximum quantity available. The quantity of medical supplies provided should be based solely on medical necessity for the individual recipient. Please refer to the Home Health Fee Schedule on DMA’s Fee Schedule web page for maximum reimbursement rates.
| HCPCS Code | Description | Maximum Monthly Limitations PDN Providers |
|---|---|---|
| Ostomy Supplies | ||
| A4361 | Ostomy faceplate | 3/6 mo |
| A4368 | Ostomy filter | 60/mo |
| A4376 | Ostomy pouch, drainable, with faceplate attached, rubber, each. | 3/mo |
| A4378 | Ostomy pouch, drainable, for use on faceplate, rubber, each. | 3/mo |
| A4380 | Ostomy pouch, urinary, with faceplate attached, rubber, each. | 3/mo |
| A4382 | Ostomy pouch, urinary, for use on faceplate, heavy plastic, each | 3/mo |
| A4383 | Ostomy pouch, urinary, for use on faceplate, rubber, each | 3/mo |
| A4384 | Ostomy faceplate equivalent, silicone ring, each. | 3/6 months |
| A4389 | Ostomy pouch, drainable, with barrier attached, with convexity (one-piece), each. | 20/month |
| A4390 | Ostomy pouch, drainable, with extended barrier attached, with convexity (one-piece) | 60/month |
| A4391 | Ostomy pouch, urinary, with extended wear barrier attached, (one-piece), each | 20/month |
| A4392 | Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity, (one-piece), each | 20/month |
| A4393 | Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, (one-piece), each | 20/month |
| A4395 | Ostomy deodorant for use in ostomy pouch, solid, per tablet | 100/month |
| A4396 | Ostomy belt with peri-stomal hernia support | 1/6 month |
| A4402 | Lubricant, per oz | 4/month |
| A4412 | Ostomy pouch, drainable, high output, for use on a barrier with flange (two-piece system), without filter | 20/month |
| A4413 | Ostomy pouch, drainable, high output, for use on a barrier with flange (two-piece system) | 20/month |
| A4422 | Ostomy absorbent material (sheet, pad, crystal packet) for use in ostomy pouch to thicken liquid stomal output, each | 100 per mo |
| A5093 | Ostomy Accessory; convex insert | 10/mo |
| A5102 | Bedside drainage bottle with or without tubing, rigid or expandable, each. | 1/month |
| A5131 | cleaner, incontinence and ostomy appliances, per 16 oz | 1/month |
| Dressing Supplies | ||
| A6010 | Collagen based wound filler, dry form, sterile, per gram of collagen | n/a |
| A6011 | Collagen based wound filler, gel/paste, sterile, per gram of collagen | n/a |
| A6021 | Collagen dressing, sterile, pad size 16 sq. in. or less, each | n/a |
| A6022 | Collagen dressing, sterile, pad size more than 16 sq. in. but less than or equal to 48 in | n/a |
| A6240 | Hydrocolloid dressing, wound filler, paste, sterile, per ounce | n/a |
| A6241 | Hydrocolloid dressing, wound filler, dry form, sterile, per gram | n/a |
| A6254 | Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing | n/a |
| A6255 | Specialty absorptive dressing, wound cover, sterile, pad size more than 16 in but less than or equal to 48 sq. in., with any size adhesive border, each dressing | n/a |
| A6441 | Padding bandage, non-elastic, non-woven/non-knitted, width greater than or equal to three inches and less than five inches, per yard | n/a |
| A6442 | Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than three inches, per yard | n/a |
| A6448 | Light compression bandage, elastic, knitted/woven, width less than three inches, per yard | n/a |
HP Enterprise Services
1-800-688-6696 or 919-851-8888
Attention: CAP/C Case Managers, Home Health Agencies, and Private Duty Nursing Providers
Home health skilled nursing services are not covered on the same day as private duty nursing (PDN) services. The PDN nurse must provide all of the nursing care needed in the home for the PDN recipient. The PDN provider assumes the responsibility for providing medical supplies and billing Medicaid for the supplies as part of the PDN service. This guideline also applies to CAP/C Nursing (HCPCS code T1000) under the CAP/C program.
Specialized therapies may be provided during the same time period that a PDN recipient is receiving PDN services.
Refer to Section 7.3.1 of Clinical Coverage Policy 3A, Home Health Services.
HP Enterprise Services
1-800-688-6696 or 919-851-8888
Attention: Private Duty Nursing Providers
Effective September 1, 2009, private duty nursing (PDN) providers can provide incontinent, ostomy, and urological (IOU) medical supplies to any eligible Medicaid recipient regardless of whether the recipient has been approved for PDN services. Providers were notified of this provision in an article published in the September 2009 Medicaid Bulletin. This article provides additional information and further clarification of the criteria for providing this service.
The provision of medical supplies to Medicaid recipients without PDN coverage is limited to IOU supplies. Providers must adhere to the criteria outlined in the September 2009 bulletin article. Clarification to the criteria for this provision is as follows.
Providers are reminded that under EPSDT, the policy limits do not apply to recipients under 21 years of age. Services can be provided to these recipients to the extent of medical necessity, or to correct or ameliorate the recipient’s condition as long as all of the EPSDT criteria are met. A request for coverage under EPSDT to exceed the policy limits is required prior to exceeding the limits. The request is submitted to DMA using the Non-Covered State Medicaid Plan Services Request Form for Recipients under 21 Years of Age or a letter of medical necessity from the provider that addresses all of the EPSDT criteria. The EPSDT coverage criteria can be found on the DMA EPSDT web page.
The limitations on the IOU supplies listed below have been increased to allow more flexibility in meeting the medical needs of the recipient. These limits apply to only the recipients 21 years of age and older regardless of whether they are PDN-approved or non-PDN-approved recipients.
Providers should be cautioned that there is no entitlement for the recipient to receive the maximum quantity available. The quantity of medical supplies provided should be based solely on medical necessity for each individual recipient.
| HCPCS Code | PDN-Provided Medical Supplies Description |
Unit | Monthly Maximum Limits |
|---|---|---|---|
| A4554 | Disposable underpads, all sizes (e.g. Chux's) | each | 200 |
| T4521 | Adult sized disposable incontinence product, brief/diaper, small | each | 225 |
| T4522 | Adult sized disposable incontinence product, brief/diaper, medium | each | 225 |
| T4523 | Adult sized disposable incontinence product, brief/diaper, large | each | 225 |
| T4524 | Adult sized disposable incontinence product, brief/diaper, extra large | each | 225 |
| T4529 | Pediatric sized disposable incontinence product, brief/diaper, small/medium size | each | 225 |
| T4530 | Pediatric sized disposable incontinence product, brief/diaper, large size | each | 225 |
| T4533 | Youth-sized disposable incontinence product, brief/diaper | each | 225 |
| A4927 | Non-sterile exam gloves | 100/box | 2 |
| A4321 | Therapeutic agent for urinary catheter irrigation (acetic acid - 250 to 1,000 cc) | 1 bottle | 3 |
| A6216 | Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border | each | 400 |
HP Enterprise Services
1-800-688-6696 or 919-851-8888
Attention: Children’s Developmental Service Agencies, Health Departments, Home Health Providers, Hospital Outpatient Clinics, Independent Practitioners, Local Education Agencies, Local Management Entities, and Physicians
Beginning April 2010, The Carolinas Center for Medical Excellence (CCME) will implement post-payment validation on paid therapy claims. Validation will initially occur for service dates July 1, 2009, through November 30, 2009. Providers will be notified of recipients selected in the sample and documentation for those recipients, such as the therapy order, evaluation, and progress notes, will be requested. This documentation will be reviewed for compliance with policy requirements. If documentation for service dates is found to be non-compliant with policy requirements, recoupment of monies paid will be determined and providers will be notified of overpayment.
An informational power point presentation and additional details about the post-payment validation process are posted on CCME’s prior authorization website, http://www.medicaidprograms.org/nc/therapyservices. Providers who billed for therapy services between July and November 2009 are encouraged to register for secure web access on CCME’s prior authorization website (http://www.medicaidprograms.org/nc/therapyservices) to view information about the post-payment validation process.
CCME, 1-800-228-3365
Attention: TCM/DD Case Managers
Effective May 1, 2010, all requests for non-waiver targeted case management services for developmental disabilities will be authorized on an annual schedule rather than the current process of quarterly authorizations. The annual schedule is based on the recipient’s birth month. The effective date of the annual authorization period will be the first day of the month following the recipient’s birth month and the end of the authorization period will be the last day of the recipient’s birth month.
Example 1
If the recipient’s birthday is in June, the annual authorization period will be July 1, 2010, through June 30, 2011.
Any request submitted to ValueOptions on, or after, May 1, 2010, will be authorized through the last day of the recipient’s birth month.
Example 2
A request with a start date of May 1, 2010, with the recipient’s birth month of November, will have an authorization period of May 1 through November 30, 2010.
Requests received by ValueOptions prior to May 1, 2010, will be authorized for 90 days. Prior to the end of the 90-day period, the case manager is to submit a request with an end date of the last day of the recipient’s birth month.
Example 3
A request with a start date of April 1, 2010, with the recipient’s birth month of November will have an authorization period of April 1, 2010, through June 30, 2010. The case manager will then submit a request, prior to June 30, 2010, with a start date of July 1, 2010, and an end date of November 30, 2010.
Behavioral Health Section
DMA, 919-855-4290
Attention: Local Management Entities, Outpatient Behavioral Health Providers, and Provisionally Licensed Providers
The March 2010 Medicaid Bulletin and Implementation Update #70 (on the DMH Enhanced Services Implementation Updates web page) reported on the extension of coverage of provisionally licensed providers delivering outpatient behavioral health services as a reimbursable service under Medicaid and state funds and billed through the Local Management Entity (LME) to June 30, 2011. This bulletin article listed the HCPCS procedure codes that could be utilized to bill for services delivered by the provisionally licensed individuals. These codes were codes H0001, H0004, and H0005. HCPCS procedure code H0031 was inadvertently omitted and should be added to the above list of procedure codes.
Catharine Goldsmith, Behavioral Health Section
DMA, 919-855-4290
Attention: Adult Care Home Providers, CAP/MR-DD Service Providers, Enhanced Behavioral Health (Community Intervention) Services Providers, Personal Care Services Providers, and Residential Child Care Treatment Facilities
Effective January 1, 2010, mandatory Medicaid cost reports for the above mentioned providers are suspended until rescinded by the Secretary of the N.C. Department of Health and Human Services (DHHS). The official DHHS notification can be found on DMA’s Cost Report web page. Specific questions may be addressed to the contacts identified in the notification.
It is important to note that any outstanding cost reports due prior to December 31, 2009, are due and must be filed with the appropriate DHHS Division. This suspension is for cost reports only; cost settlements will continue on the filed cost reports for those providers that are part of the cost settlement process.
Frequently Asked Questions
Finance Management
DMA, 919-855-4180
Attention: Personal Care Services Providers
Independent assessment of personal care services (PCS) recipients is being implemented in response to Session Law 2009-451 (Senate Bill 202), Section 10.68A.(a)(3). The Carolinas Center for Medical Excellence (CCME)was awarded the contract to conduct PCS independent assessments.
All PACT forms received by CCME on or before March 19, 2010 have been reviewed. Denial of service notifications will be mailed by April 9, 2010, to recipients and providers regarding recipients who do not meet program qualifying criteria. Requests for additional information will be mailed to providers regarding recipients whose PACT forms lack critical information or documentation. The timeline for mailing requests for additional information will be announced on the Independent Assessment website. Payments for prior services not provided in compliance with program policy are subject to recoupment.
Independent assessment, prior authorization, and the new clinical coverage policy for PCS and PCS-Plus will be implemented April 1, 2010. Effective April 1, 2010, the following changes will occur:
Refer to the Independent Assessment website and future bulletin articles for additional information and updates. Questions also may be directed to the CCME Independent Assessment Help Line at 1-800-228-3365 and by e-mail to PCSAssessment@thecarolinascenter.org.
CCME, 1-800-228-3365
Service limitations on scope, amount, duration, frequency, location of service, and other specific criteria stated in this publication may be exceeded or may not apply to recipients under 21 years of age if the provider's documentation shows that
This applies to both proposed and current limitations. Providers should review any information in this publication that contains limitations in the context of EPSDT and apply that information to their service requests for recipients under 21 years of age. A brief summary of EPSDT follows.
EPSDT is a federal Medicaid requirement (42 U.S.C. § 1396d(r) of the Social Security Act) that requires the coverage of services, products, or procedures for Medicaid recipients under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination (including any evaluation by a physician or other licensed clinician).
This means that EPSDT covers most of the medical or remedial care a child needs to
Medically necessary services will be provided in the most economic mode possible, as long as the treatment made available is similarly efficacious to the service requested by the recipient's physician, therapist, or other licensed practitioner; the determination process does not delay the delivery of the needed service; and the determination does not limit the recipient's right to a free choice of providers.
EPSDT does not require the state Medicaid agency to provide any service, product, or procedure that is unsafe, ineffective, experimental, or investigational; that is not medical in nature; or that is not generally recognized as an accepted method of medical practice or treatment.
If the service, product, or procedure requires prior approval, the fact that the recipient is under 21 years of age does not eliminate the requirement for prior approval.
For important additional information about EPSDT, please visit the following websites:
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.
Richard K. Davis
Division of Medical Assistance
Clinical Policy Section
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 | 4/1/10 | 4/6/10 |
| 4/8/10 | 4/13/10 | |
| 4/15/10 | 4/22/10 | |
| May | 4/29/10 | 5/4/10 |
| 5/6/10 | 5/11/10 | |
| 5/13/10 | 5/18/10 | |
| 5/20/10 | 5/27/10 |
Electronic claims must be transmitted and completed by 5:00 p.m. on the cut-off date to be included in the next checkwrite. Any claims transmitted after 5:00 p.m. will be processed on the second checkwrite following the transmission date.
| Craigan L. Gray, MD, MBA, JD Director Division of Medical Assistance Department of Health and Human Services |
Melissa Robinson Executive Director HP Enterprise Services |
