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NC Department of Health and Human Services
NC Division of
Medical Assistance
 
 

September 2011 Medicaid Bulletin

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In This Issue . . . .....

All Providers:

Acute Inpatient Hospital Providers:

Behavioral Health Providers:

CAP Providers:

Critical Access Behavioral Health Agencies (CABHA’s):

Dental Providers:

Health Choice Providers:

HIV Case Management Providers:

Nurse Practitioners:

Optical Providers:

Outpatient Behavioral Health Providers:

PASRR Screeners for Instate and Out State:

Physicians:

Physicians and Physician Assistants:


Residential Behavioral Health Providers:

Utilization Review Vendors:

 

Attention: All Providers

Basic Medicaid Seminars

Basic Medicaid seminars are scheduled for the month of October.  These seminars are intended to educate all types of providers on the basics of billing for N.C. Medicaid, recent updates and changes, and the latest budget initiatives.  The focus of the morning session will be the first seven sections of the revised October 2011 Basic Medicaid Billing Guide, which is the primary document that will be referenced during the seminar.  The afternoon sessions will be broken out by claim type:  Professional, Institutional, and Dental /Pharmacy.  The remaining sections of the October 2011 Billing Guide will be reviewed during these breakout sessions with a focus on claims submission, resolving denied claims, and the uses of N.C. Electronic Claims Submission/Recipient Eligibility Verification Web Tool

Providers are encouraged to print the Billing Guide, which will be posted on the DMA website at http://www.ncdhhs.gov/dma/basicmed/ prior to the first scheduled session.  This material will assist providers in following along with the presenters.  If preferred, you may download the Billing Guide to a laptop and bring the laptop to the seminar.  Or, you may access the Billing Guide online using your laptop during the seminar.  However, HP Enterprise Services cannot guarantee a power source or Internet access for your laptop.  Copies of the document will not be provided.

Pre-registration is required for both the morning session and the afternoon session of your choice.  Due to limited seating, registration is limited to two staff members per office.  Unregistered providers are welcome to attend, if space is available.  Please bring your seminar confirmation with you to the morning and afternoon sessions of the seminar. Providers may register for the seminars by completing our online registration.   Providers may attend the morning session only, the afternoon session only, or both morning and afternoon sessions.

The morning session 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; however, there will be a lunch break.  The afternoon sessions will begin at 1:00 p.m. and end at 4:00 p.m.  Providers are encouraged to arrive at 12:45 p.m. to complete registration.  Because meeting room temperatures vary, dressing in layers is advised.

Seminar Dates and Locations

Date Location
October 5, 2011

Asheville
Crowne Plaza Tennis & Gold Resort
One Resort Drive
Asheville, NC 28806
get directions

October 11, 2011

Raleigh
Wake Tech Community College
Student Service Building Conference Center
Second Floor, Rooms 213 & 214
9191 Fayetteville Road
Raleigh, NC 27603
get directions

October 13, 2011

Greensboro
Clarion Hotel Airport
415 Swing Road
Greensboro, NC 27409
get directions

October 20, 2011

Charlotte
Crown Plaza
201 South McDowell Street
Charlotte, NC 28204
Note:  Parking fee of $4.00 per vehicle for parking at this location.
get directions

October 25, 2011

Greenville
Hilton
207 SW Greenville Blvd.
Greenville, NC 27834
get directions


October 27, 2011

Fayetteville
Cumberland County DSS
1225 Ramsey Street
Fayetteville, NC 283001
get directions

 

HP Enterprise Services
1-800-688-6696 or 919-851-8888

 

Attention:  All Providers

Clinical Coverage Policies

The following new or amended clinical coverage policies are now available on DMA’s website at http://www.ncdhhs.gov/dma/mp/:

    • 1A-5, Case Conference for Sexually Abused Children
    • 1B-3, Intravenous Iron Therapy
    • 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics
    • 1S-2, HIV Tropism Assay 
    • 1S-4, Cytogenetic Studies
    • 2A-3, Out-of-State Services
    • 4B, Orthodontics
    • 8A, Enhanced Mental Health and Substance Abuse Services

    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

     

    Attention: All Providers

    Enrolling Medicaid and Health Choice Patients in Community Care of North Carolina (CCNC)/Carolina Access (CA)


    What providers can do to assist with enrollment to CCNC/CA:

    • Check the recipient’s Medicaid card. If the card does not have a primary care physician on it, refer the recipient to the local DSS office to enroll in the CCNC/CA network.
      • The recipient may choose a medical home with a primary doctor. The local County Department of Social Services has a complete list of participating doctors.  A medical home can be chosen for each family member. If recipient does not choose a medical home, one will be automatically assigned. 
    • Give the recipient a Carolina ACCESS member handbook (PDF, 899 KB). This book can be your guide when explaining the benefits and requirements of being a member of CCNC.
      • You can order handbooks by contacting the Division of Medical Assistance, Managed Care Section, at 919-855-4780 or faxing a request to the Managed Care Section at 919-715-0844 or 919-715-5235.
      • It is also located on the DMA website at http://www.ncdhhs.gov/dma/ca/carechandbook.pdf
    • Explain the benefits of being a member of CCNC/CA.
      • A medical home with a primary care provider (PCP). The medical home is a place for well check-ups, sick visits, treatment of special health care needs, etc.
      • Medical advice available 24/7. There is no need to go to the ER unless the problem risks life or health without immediate treatment.
      • Coordinated medical services so that patients receive necessary care either by the PCP or by a referral to a specialist. The PCP will help find the right specialist.
      • Arrangements for hospitalizations when necessary. (Inform patient which hospital PCP admits to.)
      • Care management services available through the CCNC/CA network.
    • Follow up with the local DSS to ensure the recipient has been enrolled in the CCNC/CA network.

    Provider Services
    DMA, 919-855-4780

     

    Attention: All Providers


    False Claims Act Education


    Effective January 1, 2007, Section 6023 of the Deficit Reduction Act (DRA) of 2005 required providers receiving annual Medicaid payments of $5 million or more to educate employees, contractors, and agents about federal and state fraud and false claims laws and the whistleblower protections available under those laws.  The Affordable Care Act (Section 6401) and Session Law 2011-399, modified this requirement.   The federal rule § 455.23 enacted require ALL Medicaid providers, regardless of the amount reimbursed, to attest that they met the minimum business requirements necessary to comply with all federal and state requirements.  

    Previously, the Division of Medical Assistance (DMA) has notified those providers who received a minimum of $5 million in Medicaid payments during the last federal fiscal year (October 1 through September 30) that they must submit a Letter of Attestation to Medicaid in compliance with the DRA.  This minimum amount may have been paid to one N.C. Medicaid provider number or to multiple Medicaid provider numbers associated with the same tax identification number.

    In the October Medicaid Bulletin, all providers will receive further guidance on completing and submitting attestations for Medicaid. Providers should review their corporate compliance programs and be prepared to submit the signed attestations since Medicaid payments will be denied for providers who do not submit a signed Letter of Attestation within thirty days of the date of notification. 

    HP Enterprise Services
    1-800-688-6696 or 919-851-8888


    Attention:  All Providers


    HIPAA 5010 Implementation

    In accordance with 45 CFR Part 162 – Health Insurance Reform; Modifications to the Health Insurance Portability and Accountability Act (HIPAA); Final Rule, HIPAA-covered entities, which include state Medicaid agencies, must adopt modifications to the HIPAA required standard transactions by January 1, 2012.  The modifications are to the HIPAA named transactions to adopt and implement ASC X12 version 5010 and NCPDP Telecommunication version D.0. 

    N.C. Medicaid will implement the HIPAA requirements for the 5010 transactions within the legacy MMIS+ claims processing system. HPES is anticipating beginning Vendor or Trading Partner testing of the 837 transactions in October, 2011.  Providers please contact your vendors/trading partners and inform them to update their Trading Partner Agreement – Appendix in preparation for 5010 testing and implementation. HPES is anticipating publishing the 837 and 835 companion guides in early September 2011. HPES is also anticipating dual processing beginning in November, 2011. In addition, if your Trading Partner Agreement has been updated, you will receive both the ASC X12 versions 4010 and ASC 5010 of the 835 transaction beginning in November.  DMA will notify providers through upcoming Medicaid Bulletins as the HIPAA 5010 implementation efforts progress.

    HP Enterprise Services
    1-800-688-6696 or 919-851-8888


    Attention: All Providers


    Guidance for Electronic Signatures

    Electronic Signatures
    Per HIPPAA standards, an electronic signature means the attribute affixed to an electronic document to bind it to a particular party.  An electronic signature secures the user authentication (proof of claimed identity) at the time the signature is generated; creates the logical manifestation of signature (including the possibility for multiple parties to sign a document and have the order of application recognized and proven); supplies additional information such as time stamp and signature purpose specific to that user; and ensures the integrity of the signed document to enable transportability of data, interoperability, independent verifiability, and continuity of signature capability.  Verifying a signature on a document verifies the integrity of the document and associated attributes and verifies the identity of the signer.  If an entity uses electronic signatures, the signature method must assure all of the following features: message integrity (evidence that the document has not been altered); nonrepudiation (strong and substantial evidence that will make it difficult for the signer to claim that the electronic representation is not valid); and user authentication (evidence of the identity of the person signing).  No specific technology is mandated by HIPAA.

    Authenticated/Dated Signatures
    There are some instances where a person’s signature is critical to the authenticity of a document,
    whether it is the signature of the service provider, the individual, the legally responsible person, or other individual.  In situations when a dated signature is required, as in the case of service orders, Person-Centered Plans [PCPs], or service plans, etc., the signature is authenticated when the person enters the date next to his or her signature.  A handwritten signature requires a handwritten date, and an electronic signature shall include a time and date stamp.  In either case, entering the date at the time that the signature is written confirms that the signature was made on that date.  The date entered is always the date that the person signs the document.  The practice of pre- or post-dating signatures in any form or circumstance is prohibited.  As previously discussed in the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services Records Management and Documentation Manual, for late entries, a dated signature is indicated.  When entering corrections in the service record, the staff’s initials and date that the correction was made are required.

    Electronic Signatures of Staff
    For purposes of this policy, the use of the word, “staff” is inclusive of the employees of a governing body, owner(s), individuals under contract with a provider agency, or individual behavioral health practitioners in a private practice.

    When an electronic signature is entered into the electronic record by agency staff [employees or authorized individuals under contract with the agency], the following standards shall be followed:
    1.   When an electronic signature is used, the provider shall be given an opportunity to review the entry for completeness and accuracy prior to electronically signing the entry.
    2.   Once an entry has been signed electronically, the computer system shall prevent the entry from  being deleted or altered.  The entry shall include a time and date stamp.
    3.   If errors are later found in the entry, or if information must be added, this shall be done by means of an addendum to the original entry.  The addendum shall be signed electronically and shall include a time and date stamp.
    4.   Passwords or other personal identifiers shall be controlled to ensure that only the authorized individual can apply a specific electronic signature.  Passwords should be changed at specified intervals.
    5.   Any staff authorized to use electronic signatures shall be required to sign a statement that acknowledges their responsibility and accountability for the use of their electronic signature.  The statement must explicitly state that the provider is the only one who has access to and use of this specific signature code/password.
    6.   An electronic signature shall be under the sole control of the person using it.  A provider shall Not delegate their electronic signature authorization to another person.
    7.   Policies and procedures shall be developed to:
    a.   Safeguard against unauthorized use of electronic signatures.  The policy shall also address sanctions for improper or unauthorized use of electronic signatures.
    b.   Address procedures that staff should follow if the application is unavailable.
    c.   Address procedures when a staff member is not available to electronically sign
         documents.
    8. The governing body shall authorize the use of electronic signatures, and a list of all current staff who are authorized to use electronic signatures shall be maintained and kept on file.

    If an agency has a governing body, authorization and compliance to this policy shall be documented in the governing body minutes, and the governing body chairperson shall sign and date the authorized list, which should be maintained by the executive director [or designee] of the organization and the designated medical records staff person.  In addition, a letter of authorization shall be placed in each staff member’s personnel file.

    If the agency does not have a governing body, then the executive director or designee, along with the medical records staff person or office manager, shall document compliance to this policy and the authorization of staff to use electronic signatures, in an administrative meeting or supervision. In addition, a letter of authorization shall be placed in each staff member’s personnel file. 

    Evidence of compliance with this policy would be supported by a notarized statement of compliance,  maintained by the staff indicated above, as well as filing a letter of authorization in each staff member’s personnel file, with the approval date; agreement for use, and other relevant information.

    Note: The above electronic signature standards are subject to revision based upon State law and/or HIPAA requirements.

    Electronic Signatures of Recipients, Legally Responsible Persons, and Others
    The following protocol is specific to electronic signatures obtained from service recipients, parents, legally responsible persons, representatives from other agencies, and other individuals who are not agency staff.  This guidance applies when an agency is seeking any non-agency signature[s] on documents such as PCPs, service plans, release of information forms, consent forms, etc.

    In all cases, the person whose signature is being sought shall be given ample opportunity to review the document for completeness and accuracy prior to electronically signing the document. 

    When obtaining electronic signatures of individuals receiving services, legally responsible persons, representatives from other agencies, and others, the only acceptable format is a digitized signature - an electronic image of an individual’s handwritten signature reproduced in its identical form using a pen tablet.  The signature(s) must include a time and date stamp, and the signature must be entered on the electronic image of the document that they are signing.   

    Once an entry has been signed electronically, the computer system shall prevent the entry from being deleted or altered.  The entry shall include a time and date stamp.

    If errors are later found in the entry, or if information must be added, this shall be done by means of an addendum to the original entry.  The addendum shall be signed electronically and include a time and date stamp.

    Clinical Policy
    DMA, 919-855-4294

     

    Attention:  All Providers

    Implementation of Additional Correct Coding Edits: Global Surgery and Evaluation and Management Codes

    As previously announced in the May bulletin, DMA began implementing additional correct coding guidelines.  These new correct coding guidelines and edits are nationally sourced by organizations such as the Centers for Medicare and Medicaid Services (CMS) and The American Medical Association (AMA).  These edits identify any inconsistencies with CPT, HCPCS, AMA, CMS and/or DMA policies and will deny the claim line.
    In addition to the May article, in the July 2011 Medicaid bulletin, additional correct coding edits for Global Surgery Package (GSP) and Evaluation and Management (E&M) codes were announced for August 1, 2011 for dates of service on or after August 1, 2011.


    Global Surgery Package (GSP)
    GSP edits are defined by CMS as the specific time periods during which certain services related to a surgical procedure, furnished by the physician who performed the surgery, are to be included in the payment of the surgical procedure code.  The GSP has two main subcategories:


    Evaluation and Management services billed on the same day as the surgical procedure or during the defined global period for the surgical procedure will be denied by the GSP Surgery/E&M editing if not submitted with an appropriate modifier to indicate a separate unrelated service.   The following are examples of Global Surgery E & M Edits:

    Procedure Description Global Analysis
    45385 Colonoscopy with
    polypectomy
    0 Days Deny E&M day of surgery
    36571 Peripheral insertion of central
    VAD with port
    10 Days Deny E&M day of surgery and 10 days after
    44970 Appendectomy 90 Days Deny E&M day before, day of surgery and 90 days after

    The GSP edits also contain logic that detects additional surgeries or procedures billed within the global period of a previously billed surgery.  These edits will deny the subsequent surgery according to DMA Clinical Policy.   The use of an appropriate modifier for a separate unrelated surgical service can be appended to the surgery code and will override a GSP Surgery/Surgery edit when appropriate.  The following are examples of GSP Surgery/Surgery Edits:

      

    Procedure Description Date of Service Analysis
    33510 Coronary artery bypass, vein only, single vessel 01/30/2011 Allow
    (has 90 day global period)
    93510 Left heart catheterization 03/01/2011 Deny
    27275 Manipulation hip joint requiring general anesthesia 02/01/2011 Allow
    (has 10 day global period)
    27025 Fasciotomy, hip or thigh, any type 02/07/2011 Deny

    Evaluation and Management (E&M)
    Evaluation and Management (E&M) codes are used to describe the intensity and work associated with a medical encounter as measured by the risks and complexities associated with the history, physical examination, and medical decision-making.  The more detailed these components are the higher the level of the E&M service.  Correct coding of E&M services stipulates only one E&M code may be reported per day for the same patient/provider. The appropriate use of modifiers complying with DMA policies will allow for appropriate reimbursement.  The E & M edits ensure proper coding of these services.

    Procedure Description Date of Service Analysis
    99238 Hospital Discharge Day
    Management
    08/22/2011 Allow
    99233 Subsequent hospital care 08/22/2011 Deny –  99238 includes all
    services by the physician on the
    day of discharge
    99222 Initial hospital care per day 10/05/2011 Allow
    99284 Emergency department visit 10/05/2011 Deny – all E/M  services provided
    on the same date as the
    admission are considered part
    of the initial hospital care

     

    DMA will notify providers through the Medicaid Bulletin as new additional correct coding edits are being implemented.


    HP Enterprise Services
    1-800-688-6696 or 919-851-8888



    Attention:  All Providers


    Revised Timeline for the Implementation of Additional Correct Coding Edits: New Visit and Obstetric Care


    The additional correct coding edits “New Visit” and “Obstetrics Care” will not be implemented on September 1, 2011 for dates of service September 1, 2011 and greater as previously announced in the August 2011 Medicaid Bulletin.  The revised implementation date is October 1, 2011 for dates of service October 1, 2011 and greater.  Providers can view the revised timeline on the Correct Coding – NCCI and Additional Edits DMA webpage at http://www.ncdhhs.gov/dma/provider/ncci.htm.


    New Visit
    New Visit edits are defined by the AMA and CMS.  A new patient is defined as a patient, “who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within 3 years.”  The term “professional services” applies to any face-to-face visit with a provider.  This includes surgical procedures as well as Evaluation and Management (E/M) visits.  An analysis will be performed on a patient’s historical claims data to determine whether a New Visit E/M or another professional service has been paid within a three-year period. 
    Providers are reminded to review the AMA definitions of new and established patients in Evaluation and Management Service section in the CPT Code book.  New patient preventative E&M codes should not be used when the patient has been seen by the provider either inpatient or in the office within the 3 years prior to the current visit.

    Procedure Description Date of Service Analysis
    99205 Office or other outpatient
    visit for the evaluation and management of a new patient
    01/27/2011 Allow
    99345 Home visit for the evaluation
    and management of a new
    patient
    07/11/2011 Deny
    59409 Vaginal delivery only 05/25/2011 Allow
    99385 Initial comprehensive
    preventive medicine
    evaluation and management
    .......... new patient; 18-39 years 
    10/10/2011 Deny
    44950 Appendectomy 04/12/2011 Allow
    99205 Office or other outpatient
    visit for the evaluation and management of a
    new patient
    01/05/2012 Deny

     

    Obstetric Care
    Obstetric Care edits are based on guidance per the AMA.  Per AMA, the total obstetric package includes the provision of antepartum care, delivery, and postpartum care.  The Obstetric Care edits apply acceptable methods of billing obstetric services, and identify duplicate or conflicting methods of billing obstetric services and/or their components, as well as appropriate and/or inappropriate use of modifiers.   The following are examples of Obstetric Care Edits:

    Procedure Description Date of Service Analysis
    59510 Routine global care, including
    antepartum,
    cesarean delivery, and
    postpartum care t
    04/19/2011 Allow
    59425 Antepartum care, 4-6 visits 03/29/2011 Deny (included in
    global care)
    59510 Routine global care,
    including antepartum,
    cesarean and  delivery, and postpartum care
    04/29/2011 Deny (time-window edit)

     

    DMA will notify providers through the Medicaid Bulletin as new additional correct coding edits are being implemented.


    HP Enterprise Services
    1-800-688-6696 or 919-851-8888 


    Attention:  All Providers


    Medicaid Recipient Prior Approval and Appeal Processes (Due Process) and Early and Periodic Screening, Diagnosis and Treatment Seminars 

    Medicaid Recipient Prior Approval and Appeal Processes and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) seminars are scheduled for the month of September and October, 2011.  Seminars are intended to address Medicaid recipient prior approval and appeal processes when a Medicaid service is denied, reduced or terminated. The seminars will also focus on an overview of EPSDT-Medicaid for Children. Billing will not be addressed during the presentation.

    The seminars are scheduled at the location listed below.  This session will begin at 9:00 a.m. and will end at 4:00 p.m.  Providers are encouraged to arrive by 8:45 a.m. to complete registration.  Lunch will not be provided at the seminar.  Because meeting room temperatures vary, dressing in layers is strongly advised.  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 Medicaid Recipient Prior Approval and Appeal Processes and EPSDT seminars online.   Pre-registration is required.  Providers will receive a registration confirmation outlining the training material(s) each provider should bring to the seminar. 

    Date Location
    September 15, 2011 Raleigh
    The Royal Banquet and Conference Center
    Room C
    3801 Hillsborough Street
    Raleigh, NC 27607
    get directions
    October 18, 2011 Raleigh
    The Royal Banquet and Conference Center
    Room C
    3801 Hillsborough Street
    Raleigh, NC 27607
    get directions

     

    HP Enterprise Services
    1-800-688-6696 or 919-851-8888

     

    Attention:  All Providers


    NC Health Choice Claims Processing


    Effective with dates of service on and after October 1, 2011, NC Health Choice (NCHC) medical and pharmacy claims will be processed by DMA’s fiscal agent, HP Enterprise Services instead of BCBS.  For questions regarding claims processing with dates of service of 10/1/2011 and after, providers may contact the HP Provider Services Department at 1-800-688-6696, menu option 3.  There will be a five-month run-out period for providers to file claims for dates of service through September 30, 2011 to BCBS.  The run-out period will begin on October 1, 2011 and end on February 29, 2012.  You must file all claims for dates of service through September 30, 2011 with BCBS by February 29, 2012. 

    Active NC Medicaid providers who want to participate in NCHC will not need to take any action for NCHC enrollment.  However, any provider that is not currently enrolled in the N.C. Medicaid program and wants to provide care to NCHC recipients will need to complete the Medicaid provider enrollment application at www.nctracks.nc.gov.  CSC, DMA’s Enrollment, Verification & Credentialing vendor, is available to assist providers who want to enroll in NC Medicaid.  CSC contact information is provided below.  

     
    EVC Call Center Contact Information

    Enrollment, Verification, and Credentialing Call Center Toll-Free Number 866-844-1113
    EVC Call Center Fax Number 866-844-1382
    EVC Call Center E-Mail Address NCMedicaid@csc.com
    CSC Mailing Address N.C. Medicaid Provider Enrollment
    CSC
    PO Box 300020
    Raleigh NC 27622-8020
    CSC Site Address N.C. Medicaid Provider Enrollment
    CSC
    2610 Wycliff Road, Suite 102
    Raleigh NC 27607-3073
    CSC Website Address http://www.nctracks.nc.gov

    HP Enterprise Services
    1-800-688-6696 or 919-851-8888

     

    Attention: Health Choice Providers


    Upcoming Change to NC Health Choice Recipient Co-Payments

    Effective October 1, 2011, co-payment changes for NC Health Choice recipients will be in effect.  NC Health Choice recipients will receive new ID cards and notification of the co-payment changes in September.  Please see the table below for a detailed listing of all applicable co-payments for NC Health Choice recipients. 

      Income Level Cost-Sharing
    Class A < 150% of FPL
    AND
    Native American OR Alaska Native
    •    No enrollment fee
    •    No co-pays at all
    Class J < 150% of FPL
    • No enrollment fee
    • No provider visit  co-pays
    • Non-emergency ER co-pay $10
    • Generic Prescription co-pay $1
    • Brand Prescription with NO generic available co-pay $1
    • Brand prescription when generic available co-pay $3
    • Over-the-counter medication co-pay $1
    Class K 151% - 200% of FPL
    • $50 enrollment fee, max $100 for 2 or more children
    • Provider visit co-pay $5
    • Non-emergency ER co-pay $25
    • Generic Prescription co-pay $1
    • Brand Prescription with NO generic available co-pay $1
    • Brand prescription when generic available co-pay $10
    • Over-the-counter medication co-pay $1
    Class S 151% - 200% of FPL
    AND
    Native American OR Alaska Native
    • No enrollment fee
    • No co-pays at all
    Class L
    (Optional extended coverage)
    201% - 225% of FPL
    • No enrollment fee
    • Pay monthly premiums
    • Provider visit co-pay $5
    • Non-emergency ER co-pay $25
    • Generic Prescription co-pay $1
    • Brand Prescription with NO generic available co-pay $1
    • Brand prescription when generic available co-pay $10
    • Over-the-counter co-pay $1

     

     

    Clinical Policy
    DMA, 919-855-4100


    Attention: Health Choice Providers


    Clinical Coverage Policy Update

    The NC Physician Advisory Group has recommended that the proposed policies listed below no longer be covered under the N.C. Health Choice Program.

    Proposed Policy to no longer be covered by NCHC Date Posted Comment Period End Date
    NCHC Carotic Artery Angioplasty/Stinting August 15, 2011 September 29, 2011
    NCHC Pulmonary Hypertension Drug Management July 28, 2011 September 11, 2011

     

    The NC Physician Advisory Group has recommended that the proposed policies listed below be covered under the N.C. Health Choice Program.

    Proposed Policy to be covered by NCHC

    Date Posted

    Comment Period End Date

    NCHC Bone Mass Measurement

    August 15, 2011

    September 29, 2011

     

    For a complete list of N.C. Health Choice clinical coverage policies, please refer to the N.C. Health Choice Policies web page at http://www.ncdhhs.gov/dma/hcmp/.

    Clinical Policy
    DMA, 919-855-4100

     

    Attention: Health Choice Behavioral Health Providers


    Changes in Behavioral Health Authorizations and Billing for Health Choice

    The Division of Medical Assistance is working to align all Behavioral Health clinical coverage policies and service definitions for Health Choice recipients with Behavioral Health Medicaid policies.  However, the EPSDT Special Provision and the Important Notes on EPDST documented in Medicaid clinical coverage policies do not apply to NC Health Choice.  The target date for this clinical coverage policy transition is October 1, 2011.  All requests for prior authorization submitted to ValueOptions on or after October 1st will therefore use the Medicaid service criteria. 
     
    For outpatient treatment services, the count of unmanaged visits will begin anew on October 1, 2011, under the limitation of 16 visits.  The count of unmanaged visits will then begin anew again on January 1, 2012 and conform to the standard calendar year limitation of 16 visits. These visits are defined by the number of procedure codes paid for services rendered to the recipient and not by the individual units of service provided.  The data system counts each procedure code as one visit with the exception of the following codes for group therapy:  90849, 90853, 90857, H0005, and H004 HQ.  These five codes are counted as ½ visits for the unmanaged unit counts.  When the recipient reaches the maximum number of unmanaged units, any subsequent visits will be denied unless prior approval is obtained.  Once prior approval is on file for a recipient, the system considers the unmanaged count as "used" for that calendar year, regardless of the amount of previous services provided.
     
    Claims adjudication for authorized services rendered prior to October 1, 2011 will occur through Blue Cross Blue Shield (BCBS).  Claims adjudication for authorized services rendered on or after October 1, 2011 will occur through HP Enterprise Services.  It is critical that providers use the October 1st date to separate their claims submissions so that uninterrupted payment may occur.

    Behavioral Health Section
    DMA, 919-855-4290


    Attention:  All Providers


    Procedures for PA Request for Synagis for RSV Season 2011/2012

    The clinical criteria utilized by N.C. Medicaid for the 2011/2012 RSV season are consistent with published guidelines in the Red Book:  2009 Report of the Committee on Infectious Diseases, 28th EditionPrior approval (PA) is required for Medicaid coverage of Synagis during the upcoming RSV season.  The coverage season is November 1, 2011, through March 31, 2012.  An Early and Periodic Screening, Diagnosis and Treatment (EPSDT) medical necessity review will be performed for all Synagis requests.   

    Requesting PA for Synagis for the upcoming season will be an electronic process.  The electronic PA system is designed to capture data succinctly.  Prompts, alerts, dropdown choices, attachment capability as well as free text opportunities will allow the provider to submit a request with all information essential to justify medical necessity.  When the system offers an opportunity to upload supporting documents, a note documenting the patient’s pulmonary or cardiac status should always be submitted as an attachment when available.  The electronic system can automatically approve based on criteria submitted and allows the provider to monitor the status of a pending request.  The auto approval feature will improve the overall timeliness of reviews especially at the beginning of the season when the volume of requests is the highest.       

    The electronic PA method will approve up to five monthly doses of Synagis, but each dose will be individually authorized on a monthly basis.  After the initial approval, providers will submit very limited information such as the most recent weight of the child and date the prior dose was administered for authorization of subsequent doses.  The number of doses requested for authorization by the provider should be adjusted if an infant received the first dose prior to a hospital discharge. 

    It is important for a pharmacy to have a Synagis authorization notification on hand prior to billing a claim to Medicaid.  These notifications must be submitted to the pharmacy by the provider and will include the number of vials approved for the patient.  A claim transmitted at POS will be denied if a prior approval request was not submitted by the provider or if the request was not approved.  It is the responsibility of the provider to ensure that the pharmacy has a prescription for Synagis.

    Maximum of Five Doses
    Up to five doses during the season can be authorized for chronic lung disease (CLD) and hemodynamically significant congenital heart disease (HSCHD) for infants and children less than 24 months of age. 

    CLD
    The diagnosis causing the long-term respiratory problems must be specific.  Treatment, such as supplemental oxygen, bronchodilator, diuretic or chronic corticosteroid therapy, in the six months before the start of the season is required.

    HSCHD
    Infants not at increased risk from RSV who generally should not receive immunoprophylaxis include those with hemodynamically insignificant heart disease, such as secundum atrial septal defect, small ventricular septal defect (VSD), pulmonic stenosis, uncomplicated aortic stenosis, mild coarctation of the aorta, patent ductus arteriosus (PDA), lesions adequately corrected by surgery unless the infant continues on medication for CHF, or mild cardiomyopathy not requiring medication. 

    In addition to the two conditions listed above, a premature infant (prematurity must be counted to the exact day) may qualify for five doses as follows:

    • Born at an EGA of ≤28 weeks 6 days and DOB is on or after November 2, 2010;
    • Born at an EGA of 29 weeks 0 days to 31 weeks 6 days and DOB is on or after May 2, 2011; or
    • Born at an EGA of ≤34 weeks 6 days and DOB is on or after November 2, 2010, and also has severe neuromuscular disease that compromises handling of respiratory secretions; or congenital abnormalities of the airways that compromises handling of respiratory secretions.

    The diagnosis to justify severe neuromuscular disease or congenital airway abnormalities must be specific.  

    Five Dose Authorization Exceptions

    Coverage of Synagis for CLD and HSCHD will terminate when the recipient exceeds 24 months of age AND has received a minimum of three doses during the season.  Coverage of Synagis for congenital abnormalities of the airways and severe neuromuscular disease that compromises handling of respiratory secretions will terminate when the recipient exceeds 12 months of age AND has received a minimum of three doses during the season.  For these occurrences, coverage will continue always to ensure a medication supply for three doses.

    Maximum of Three Doses; Last Dose Administered at Three Months of Age (90 Days of Life)
    Infants meeting clinical criteria as follows may be approved for up to three doses of Synagis during the season: 

    • Born at an EGA of 32 weeks 0 days to 34 weeks 6 days, and DOB is on or after August 2, 2011, and has at least one of the two following defined risk factors:
    • Attends child care [defined as a home or facility where care is provided for any number of infants or young toddlers (toddler age is up to the third birthday)].  The name of the day care facility must be submitted with the request.
    • Has a sibling younger than five years of age in the home.  A twin sibling does not meet this requirement.  

    Generally, the following diagnoses do not singularly justify medical necessity for Synagis prophylaxis:

    • a positive RSV episode during the current season
    • repeated pneumonia
    • sickle cell
    • multiple birth with approved sibling
    • apnea or respiratory failure of newborn 

    Submitting a Request to Exceed Policy
    For doses exceeding policy or for Synagis administration outside the defined coverage period, the provider should use the Non-Covered State Medicaid Plan Services Request Form for Recipients Under 21 Years of Age to request Synagis. The form is available on DMA’s website at http://www.ncdhhs.gov/dma/epsdt/.   A medical necessity review will be done under EPSDT (see http://www.ncdhhs.gov/dma/epsdt/index.htm); if the information provided justifies medical need, the request will be approved. 

    Pharmacy Distributor Information
    Medicaid will allow Synagis claims processing to begin on October 26, 2011, to allow sufficient time for pharmacies to provide Synagis by November 1, 2011.  Payment of Synagis claims prior to October 26, 2011, and after March 31, 2012, will not be allowed.  POS claims should not be submitted by the pharmacy distributor prior to the first billable date of service for the season.  Pharmacy providers should always indicate an accurate days’ supply when submitting claims to N.C. Medicaid.  Claims for Synagis doses that include multiple vial strengths must be submitted as a single compound drug claim.  Synagis doses that require multiple vial strengths that are submitted as individual claims will be subject to recoupment by DMA Program Integrity.  Physicians and pharmacy providers are subject to audits of patient records by DMA Program Integrity.

    Providers will fax the approval notification to the pharmacy distributor of choice.  Single dose vial specific authorizations will be done by DMA up to the maximum number of doses approved for the patient. Please ensure that an authorization notification is received before billing Synagis a claim to Medicaid.  The authorizations should be maintained in accordance with required record keeping time frames. 

    Provider Information
    Please refer to the follow up article coming in the October 2011 Medicaid Bulletin for specific details about the electronic PA process.  The PA website, fax numbers and help numbers will be provided in the article.  Provider registration for the electronic PA process will start in mid to late September.  Providers without internet access should contact Charlene Sampson at (919)855-4300 to facilitate submission of a PA request for Synagis.

    HP Enterprise Services
    1-800-688-6696 or 919-851-8888

    Attention:  All Providers


    Provider Application Fee

    The Section 6401(a) of the Affordable Care Act (ACA), as amended by section 10603 of the ACA, amended section o1866 (j) requires the collection of an application fee to cover costs of screening and to carry out screening and other program integrity efforts. The application fee will be required with the submission of an initial enrollment application, the application to establish a new practice location, or as a part of revalidation. It is essential that the application fee is received with the application. Therefore, application processing for a new or currently enrolled provider or supplier will not begin until the application fee is received.

    All institutional providers of medical or other items or services or suppliers are required to pay the application fee. Institutional providers include, but are not limited to: ambulance service suppliers; ambulatory surgical centers; community mental health centers; comprehensive outpatient rehabilitation facilities; durable medical equipment prosthetics, orthotics, and supplies suppliers; end-stage renal disease facilities; federally qualified health centers; histocompatibility laboratories; home health
    agencies; hospices; hospitals, including but not limited to acute inpatient facilities, inpatient psychiatric facilities, inpatient rehabilitation facilities, and physician-owned specialty hospitals; critical access hospitals; independent clinical laboratories; independent diagnostic testing facilities; mammography centers; mass immunizers (roster billers); organ procurement organizations; outpatient physical therapy/occupational therapy/speech pathology services, portable x-ray suppliers; skilled nursing
    facilities; radiation therapy centers; religious nonmedical health care institutions; and rural health clinics. Institutional providers also include any institutional entity that bills the State Medicaid program or CHIP on a fee-for-service basis, such as: personal care agencies, non-emergency transportation providers, and residential treatment centers, in accordance with the approved Medicaid or CHIP State plan. The ACA exempts physicians and non-physician practitioners from paying the application fee.

    The application fee through December 31, 2011 is $505 as established by Section 1866 (j)(2)C)(i)(I) of the ACA. This amount will be adjusted by the percentage change for the consumer price index for the 12-month period ending June 30 of the prior year.

    Provider Services
    DMA, 919-855-4050

     

     Attention: All Providers


    Reporting Provider Fraud and Abuse

    The N.C. Department of Health and Human Services created a poster http://www.ncdhhs.gov/dma/fraud/FraudPoster.pdf asking citizens to report Medicaid fraud and abuse.  In a memo http://www.ncdhhs.gov/dma/fraud/FraudMemo.pdf dated June 4, 2010, DHHS Secretary Lanier Cansler asked all health care agencies and private health care providers to print and prominently display the poster in their offices.  These efforts continue to be a priority for the Department and the health care industry.  Combating fraud/abuse and over use of services is an effective way to reduce health care costs without compromising recipient care. 

    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.)

    Program Integrity
    DMA, 919-647-8000

    Attention:  All Providers


    Termination of Inactive Medicaid Provider Numbers

    As previously announced in the July 2011 bulletin, DMA has updated its policy for terminating inactive providers to reduce the risk of fraudulent and unscrupulous claims billing practices.  Medicaid provider numbers that do not reflect any billing activity within the previous 12 months will be terminated.  Unless the provider can attest that they have provided services to N.C. Medicaid recipients or Health Choice members in the previous 12 month period, the provider number will be terminated.  A new enrollment application and agreement to re-enroll must be submitted for any provider terminated.  As a result, a lapse in eligibility as a Medicaid provider may occur.

    The termination activity occurs on a quarterly basis with provider notices being mailed April 1, July 1, October 1, and January 1 of each year and the termination dates being effective May 1, August 1, November 1, and February 1. These notices are sent to the current mailing address listed in the provider's file. 

    Note: Providers are reminded to update contact and ownership information timely.

    Provider Services
    DMA, 919-855-4050

    Attention:  All Providers


    Update on the NC Medicaid EHR Incentive Payments

    NC Medicaid has been working with many federal, state, provider, and vendor stakeholders to launch the Electronic Health Record (EHR) Incentive Payments Program this year. 

    NC Medicaid Incentive Payment System (NC MIPS) launched the portal for Eligible Professionals (EP) attestation in March 2011 and for Eligible Hospitals (EH) on September 1, 2011.  Attestation guides have been created and posted on the portal to assist providers in working through their attestations.  The portal is located at https://ncmips.nctracks.nc.gov/.  Assistance is available for the portal from the NC-MIPS CSC EVC Center by phone 866-844-1113 or email NCMIPS@csc.com.

    The first payments in the incentive program have already been made and more are scheduled to go out as EPs and EHs complete the attestation process and those attestations are validated by the State.  As with any new program, there have been a few bumps in the road but we continue to increase the number of payments to providers as we move forward.  We appreciate all of the feedback from participants as we develop new processes and procedures that will ensure a vibrant and solid program in the future.  Please contact NC Medicaid at NCMedicaid.Hit@DHHS.NC.gov with any feedback or specific questions.

    On the horizon, NC Medicaid plans to restart the EHR newsletter, The Provider Insider to provide up to date information about the EHR program.  Our goal is to effectively communicate updates from NC Medicaid, CMS and other HIT/HIE partners.

     NC-MIPS
    CSC, 1-866-844-1113

    Attention:  All Providers


    UPDATE: Prior Authorization for Non-emergency Cardiac Imaging Procedures

    The N.C. Medicaid Program implementation of a prior authorization (PA) program for non-emergency out-patient cardiac imaging procedures for recipients 21 years of age and older is tentatively set for October 1, 2011.  Cardiac catheterization codes have been removed from the list of procedures that will require prior authorizations.  A complete list of codes that require PA is listed at the bottom of this article.

    The proposed policy, 1K-7, Prior Approval for Imaging Services , is posted for comments until September 26, 2011 at http://www.ncdhhs.gov/dma/mpproposed/index.htm .

    As a reminder, imaging procedures performed in the following situations are exempt from the prior approval requirement:
    1. During an inpatient hospitalization
    2. During an observation stay (this includes labor and delivery observation stay)
    3. During an emergency room visit
    4. During an urgent care visit (only for urgent care, not primary care)
    5. As a referral from a hospital emergency department or an urgent care facility
    6. As an emergency procedure

     Note:  Procedures that are exempt from the prior approval requirement must meet current North Carolina Medicaid policies that define medical necessity criteria and unit limitations for claims payment.  Bypassing prior approval by having the procedures performed in the emergency room is not a guarantee of payment.

    Services provided to the following recipients do not require prior approval (these recipients will be identified as “non-delegated” and the option to create an authorization request will be unavailable):

    1. Recipients who are dually eligible (for Medicare and Medicaid)
    2. Recipients who are covered by one of the following third-party insurance:
      • Major Medical Coverage
      • Indemnity Coverage
      • Basic Medicare Supplement
    3. Recipients enrolled in the following Medicaid programs:
      • Program of All-Inclusive Care for the Elderly (PACE)
      • Health Choice
      • Family Planning Waiver
      • Health Insurance Payment Plan (HIPP)
      • Aid to the Aged
      • Special Assistance for the Blind
      • Special Assistance to the Aged
    4. Refugees
    5. Recipients with emergency coverage for approved dates of service
    6. Recipients under 21 years of age for the cardiac imaging procedures

    The ordering physician or non-physician practitioner is responsible for obtaining prior approval.  A rendering facility may request prior approval if the facility has the clinical information necessary to support the requested imaging.

    Link to Cardiac Imaging Procedures

     

    Practitioner and Clinic Services
    DMA, 919-855-4320

    Attention:  Acute Inpatient Hospital Services Providers


    Changes to UB-04 Guidelines

    Effective October 1, 2011, changes will be made to the UB-04 guidelines for billing lower level of care services provided in an acute inpatient hospital that does not have swing beds.  A single all inclusive per diem rate will be paid, when it is determined by the Physician or UR Committee that a patient no longer requires care provided at the acute hospital services level of care and appropriate placement can not be located.

    Prior Approval for the appropriate level of care must be obtained from HP by submitting a FL-2 or FL-2E form for billing the appropriate lower level of care.  Forms may be accessed on line @ http://www.providerlink.com.

    • In order to bill for the lower level of care rate, the patient must first be discharged from acute care and then admitted as a lower level of care patient.
    • File an S Claim using Bill Type 11X to discharge the patient from the acute hospital inpatient level of care.
    • You must file a T Claim for billing the lower level of care services
    • Bill Type 66X must be used for billing the Nursing Facility level of care
    • Bill Type 28X must be used for billing the Ventilator level of care
    • The hospital must continue to actively seek appropriate level of care facility placement for individuals in lower level of care beds.  Prepayment and post payment reviews may be performed by DMA or Designated Agents with denial or recoupment of payments when appropriate.

    There will be no changes to Swing Bed or Ventilator Care billing or payment methodology for those that already have this level of care within their facilities.

    Practitioner and Facility Services
    DMA, 919-855-4356

     


    Attention: Behavioral Health Providers


    Electronic Prior Approval Requests

    Mandatory electronic submission of authorization requests
    Effective October 1, 2011, the Appropriations Act of 2011 (House Bill 200) mandates that providers submit authorization requests electronically via the vendor’s website.  For purposes of submitting mental health, substance abuse, and developmental disability requests to the appropriate Utilization Review vendors, please note the following information for submission:

    ValueOptions
    ValueOptions continues to offer live webinar training on ProviderConnect submission. Providers unable to participate in live webinar training can access pre-recorded webinars for self-paced training.  Navigate to the link below and scroll to the Provider Training Opportunities section to view webinar details and access additional ProviderConnect resource documents such as the ProviderConnect User Guide, Quick Reference Guide, and Frequently Asked Questions (FAQ) document:
    http://www.valueoptions.com/providers/Network/North_Carolina_Medicaid.htm

    Eastpointe Human Services Providers
    For purposes of submitting mental health, substance abuse, intellectual and other developmental disability requests to Eastpointe Human Services, providers should utilize the LME ProviderConnect web portal at https://carelink.carenetasp.com/EastpointePC/.

    Eastpointe providers can access pre-recorded webinars for self-paced training.  Navigate to the link below and scroll to the bottom ofthe page and see thesection labeled Webinars.  Providers can also view additional Medicaid utilization review materials from this page.
    http://www.eastpointe.net/providers/MedicaidUR/mur.aspx

    The Durham Center Providers
    For purposes of submitting mental health, substance abuse, IDD and CAP I/DD requests to The Durham Center, providers should utilize the ProviderConnect web portal: https://carelink.carenetasp.com/DurhamPC/

    The Durham Center will be providing several live webinars in the coming months. Please visit the Durham Center’s training/events calendar located on their website or use the following link to get directly to the calendar http://www.alliancebhc.org/providers/training. Providers unable to participate in live webinar training can access pre-recorded webinars for self-paced training. Navigate to the link below and scroll to the ProviderConnect section to access a recorded webinar and to access the Durham Center ProviderConnect User Manual. The webinar and user manual will provide information regarding obtaining a ProviderConnect user name and password.
    http://www.alliancebhc.org.org/

    Pathways LME Providers
    For the Purpose of submitting CAP I/DD requests to Pathways LME, providers should utilize the following link and select “CAP MR/DD Authorization Request”:
    http://www.pathwayslme.org/capur/ 

    The “CAP MR/DD Authorization Request” link is under construction at this time. Please visit Pathways LME website for updates on electronic submissions and trainings they will be providing.  

    Crossroads Behavioral Healthcare Providers
    For the Purpose of submitting CAP I/DD requests to Crossroads Behavioral Healthcare, providers should utilize the following ProviderConnect web portal:
    https://carelink.carenetasp.com/crossroadspc/login.asp

    Crossroads providers can access a ProviderConnect presentation at the link below and select “CAP MR/DD UR” and scroll down to Provider Training Presentations:
    http://crossroadsbhc.org/.  To obtain a login and/or individualized training on Provider Connect, you can contact Pat Draughn at pdraughn@crossroadsbhc.org

    TFC Requests Submitted Online via ValueOptions ProviderConnect
    Therapeutic Foster Care requests can be submitted on ValueOptions ProviderConnect using any Medicaid Provider Number available to the submitting provider. The Medicaid Provider Number included on the submission will be replaced by ValueOptions staff with the appropriate LME Medicaid Provider Number corresponding to the recipient’s county of eligibility at the time of review.

    Therapeutic Foster Care providers that do not have any Medicaid Provider Number should visit the website below to learn how to obtain a “ValueOptions provider number” which will allow for online submission of TFC requests via the ValueOptions ProviderConnect online provider portal.  
    http://www.valueoptions.com/providers/Network/North_Carolina_Medicaid.htm

    Behavioral Health Section
    DMA, 919-855-4290


    Attention: CAP Providers


    CAP I/DD Policy Requirements Extension and Exception Process

    This is A reminder of the Extension/Exception process  for CAP-MR/DD waiver Recipients posted in Implementation Update # 80.
    Implementation Updates # 76 and 80, and Form and Instructions posted on the DMH/DD/SAS website on 10/1/10 and revised 11/1/10 set forth an erroneous Extension/ Exception Request Process for the limit of 129 hours per month of habilitation services for adults.  DMA is RESCINDING the requirement to request an exception because the 129 hour limit does not go into effect until November 1, 2011. For the remainder of this waiver, which is ending October 31, 2011, it is not necessary to submit a request to exceed the 129 hours per month of habilitation.  All Continued Need Reviews that exceed 129 hours a month of habilitation services that meet Medical Necessity will be approved through October 31, 2011, and the new limit for adults will go into effect November 1, 2011.  CNRs which include more than 129 hours will need to be revised effective November 1, 2011 or a request to exceed the limit for children under age 21 must be submitted.  Requests to exceed 129 hours per month for children under 21 years of age after November 1, 2011 will be reviewed under EPSDT and if denied, the recipient will be provided with  appeal rights.

    Effective November 1, 2011, No More Than 129 hours of Habilitation per Month:

    • Effective November 1, 2011, the total habilitation hours received by a participant must not exceed 129 hours of habilitation per month. Please review the CAP MR/DD services that are available. The 129 hours per month limit is inclusive of the habilitation the participant may receive through engagement in Day Supports, Supported Employment, Long Term Vocational Supports and Home and Community Supports.

    NOTE: The combination or distinct utilization of these services is not to exceed 129 hours a month.

    • The 129 hours a month is not viewed as an average yearly amount.  The 129 hour per month limitation does NOT include habilitation hours provided in Residential Supports and/or Home Supports.  (Please see next section for more detail)

    Residential Supports and Home Support services (direct contact hour requirements):

    • Due to the number of individuals who will be affected by the implementation of the Utilization Review Criteria posted in Implementation Update #76 on July 7, 2010, a decision has been made to extend the transition period specific to Residential Supports and Home Support services (direct contact hour requirements) to October 31, 2011.  This extension serves to ensure there is no interruption in services. 

    Utilization Review:

    • All CAP MR/DD service requests as of May 30, 2011 will be reviewed according to the Utilization Review Criteria set forth in Clinical Coverage Policy No. 8M.

    New Waiver effective November 1, 2011

    • The new waiver, effective November 1, 2011, allows for a maximum total of 129 hours of habilitation per month.  This includes Days Supports, Support Employment, Long Term Vocational Support and Home and Community Supports.  This is a firm limit FOR ADULTS over age 21.  Requests to exceed the limit for children under age 21 will be reviewed under EPSDT.
    • All requests authorized prior to October 31, 2011 that exceed the Utilization Criteria for habilitation will need to be in compliance by November 1, 2011. Because of the quantity of Revisions that will be submitted, it is strongly recommended that services are transitioned prior to October, 31 2011or at least 15 business days prior to the effective date of the request to allow the UR Vendors ample time to complete the authorizations.
    • Billing of more than 129 hours a month of habilitation will result in denial of units above the maximum allowable regardless of prior approval, unless more units have been approved for a child under EPSDT. 

    Due Process

    • As of November 1, 2011the 129 hours a month of habilitation will be a limitation for adults and therefore it cannot be appealed for recipients 21 and over. Requests submitted for recipients under the age of 21 will be reviewed under EPSDT and if denied, the recipient will be provided with an adverse decision notice that includes an appeal form and a description of how to appeal to the Office of Administrative Hearings.

    Reminder:

    • As stated in Implementation Update # 78, when submitting CAP MR/DD revision or provider change requests for CNRs that have been approved by ValueOptions (VO), the Targeted Case Managers are required to submit the following documents:

    1. A complete revision request including CTCM forms, cost summary, and signature page, as well as any other documentation required per service definitions.
    2. A complete copy of the last CNR packet including cost summary, signature page, and MR2.
    3. Copies of any revisions that were approved by VO after the last CNR and prior to the revision being requested.

    If the Targeted Case Manager has not needed to submit a revision or provider change to the new UR Vendor, please include the last approved CNR packet and copies of any revisions that were approved by VO when the annual CNR is submitted to the appropriate UR Vendor.

    Clinical Policy
    DMA, 919-855-4372

     

    Attention: Critical Access Behavioral Health Agencies and Utilization Review Vendors


    Implementation of Independent Assessments for Community Support Team (CST)

    The final revised policy for Community Support Team (CST) was posted in early August 2011.  Although the policy stated that there was a 6-month per year hard limit for CST, the policy revision allows for exceptions to this limit when medical necessity is shown.  The revision states:  

    Any request for an exception to this six month limit must be accompanied by a comprehensive clinical assessment completed by an independent licensed professional and an updated PCP with new service order signed by an MD, Licensed Psychologist, NP or PA.  The Clinical Assessment must meet the requirements as specified in IU #36  and clearly document medical necessity as defined in the continued stay criteria in this policy. The independent licensed mental health professional must meet the criteria included in 10A NCAC 27G .0104 and must not be employed by the agency providing the Community Support Team service or have any financial or other interest in the agency providing the Community Support Team service.

    Beginning on and after October 1, 2011, all requests for concurrent authorizations that extend the authorization beyond a 6 month period for that consumer per that year, must be accompanied by an independent assessment indicating that CST continues to be medically necessary as well as an updated PCP as noted above and in the policy.  The independent assessment must have been completed within 60 days of the new authorization request.  The 6 months per calendar year are cumulative and include any time over that calendar year when the consumer received CST services.  If there has been a gap in services, and an initial authorization is requested that would lead to an individual receiving 6 or more months of CST that year, those initial requests must be accompanied by an independent assessment and PCP as noted above.  Requests that do not include this documentation will be sent back as incomplete.

    Behavioral Health Section
    DMA, 919-855-4294

     

     Attention:  Dental Providers


    Dental Seminars


    Dental seminars are scheduled for the month of September, 2011.  Information presented at these seminars will include a review of clinical coverage guidelines including prior approval and billing procedures, uses of the N.C. Electronic Claims Submission/Recipient Eligibility Verification Tool, and a review of common problems from provider enrollment to unintended billing errors to fraud, waste, and abuse.  The seminars are scheduled at the locations listed below.  Clinical Coverage Policy 4A, Dental Services, (January 1, 2011 revision) will be used as the primary training document for the seminar.  Please review and print the Policy (on DMA’s Clinical Coverage Policy and Provider Manuals web page) and bring it to the seminar. If preferred, you may download the Clinical Coverage Policy to a laptop and bring the laptop to the seminar or you may access the Clinical Coverage Policy 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.

     

    Date Location
    September 8, 2011 New Bern
    New Bern Convention Center
    Ballroom C
    203 South Front Street
    New Bern  NC  28563
    get directions
    September 13, 2011 Asheville
    Crowne Plaza Tennis & Gold Resort
    One Resort Drive
    Asheville  NC  28806
    get directions
    September 14, 2011 Charlotte
    Crowne Plaza
    201 South McDowell Street
    Charlotte  NC  28204
    Note:  Parking fee of $6.00 per vehicle for parking at this location.
    get directions
    September 21, 2011 Raleigh
    Wake Tech Community College
    Student Service Building Conference Center
    Second Floor, Rooms 212-215
    9191 Fayetteville Road
    Raleigh  NC  27603
    get directions

    September 27, 2011 Greensboro
    Clarion Hotel Airport
    415 Swing Road
    Greensboro  NC  27409
    get directions

     

     September 2011 Seminar Registration Form

     

    HP Enterprise Services
    1-800-688-6696 or 919-851-8888


    Attention: HIV Case Management Providers


    Application Deadline

    The Division of Medical Assistance announced in the September 10, 2010 Medicaid Bulletin that there would be a restructuring of the certification process.  The article went on to state that “All providers who are currently certified to provide HIV Case Management and enrolled with DMA will be required to complete a new application and undergo the certification process.”  The deadline for submission of the application to The Carolinas Center for Medical Excellence is December 31, 2011.  Any agency that has not submitted an application by cob on December 31, 2011 will have their certification terminated and Provider Enrollment will be notified to terminate their provider number.

    Training:
    The Carolinas Center for Medical Excellence (CCME) and The Division of Medical Assistance are pleased to announce that in September 2011 we are offering HIV Basic Training for case managers and supervisors.   This is mandatory training for those individuals who were hired after May 1, 2011 and have not attended Basic Training.  It is also mandatory for those individuals who were hired prior to May 1, 2011 and did not attend one of the two day trainings on Clinical Coverage Policy 12B.  See below for details.

    Registration is now open for the following training: HIV Case Management Basic Training.
    The location of this training is to be announced. Information for the September 2011 training including location is available on CCMEs’ HIV Case Management web page.

     

    Date Session Topic Required Attendees
    September 12-15, 2011 HIV Case Management Basic Training HIV Case Managers and HIV Case Manager Program Supervisors who were hired on or after May 1, 2011.  In addition those case managers and supervisors who were hired as of April 1, 2010 and did not attend any of the sessions on Clinical Coverage Policy 12 B offered in 2010 and 2011.

    The Carolinas Center for Medical Excellence in collaboration with the Division of Medical Assistance began in August 2011 the first round of site visits to certify agencies under Clinical Coverage Policy12 B.  As part of this endeavor portions of new audit tool used for measuring compliance with Quality Assurance requirements were posted on CCME’s web site.  Those providers who are registered with CCME can access this tool by going to their web site (http://www.thecarolinascenter.org/HIVCM).

    HIV Case Management Program
    DMA, 919-855-4389

     

    Attention: Nurse Practitioners and Physicians


    Injection, Factor XIII Concentrate, 1 IU (Corifact®, HCPCS code J7199): Billing Guidelines

    Effective with date of service April 4, 2011, the NC Medicaid Program covers factor XIII concentrate (human) (Corifact) for use in the Physician’s Drug Program when billed with HCPCS code J7199 (hemophilia clotting factor, not otherwise classified). Corifact is available in single-unit kit of 1000-1600 units of Factor XIII (FXIII). 

    Corifact is indicated for routine prophylactic treatment of congenital Factor XIII (FXIII) deficiency.
    Corifact should be administered as 40 units/kg infused intravenously at a rate not exceeding 4 ml/minute, as an initial dose. A dose should be administered every 28 days and be adjusted +/- 5 units/kg based on trough levels from the Berichrom Activity Assay.

    For Medicaid Billing

    • Providers must bill Corifact with HCPCS code J7199 (hemophilia clotting factor, not otherwise classified).
    • Providers must indicate the number of HCPCS units. Providers may bill for a whole single-dose kit.
    • ICD-9-CM diagnosis code 286.3 (congenital deficiency of other clotting factors) must be billed with Corifact.
    •  One Medicaid unit of coverage is 1 IU. The maximum reimbursement rate per unit is $8.12.
    • Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units on rebatable NDCs. The NDC units for Corifact should be reported in international units as “F2.” To bill for the whole single-dose kit of Corifact, report the NDC units as the total number of IUs in the kit. For example, if the kit contains 1000 IUs, report the NDC units as “F21000.”If the drug was purchased under the 340-B drug pricing program, place a “UD” modifier in the modifier field for that drug detail.
    • Refer to the March 2009 Special Bulletin, National Drug Code Implementation, Phase III, on DMA’s website (http://www.ncdhhs.gov/dma/bulletin/) for additional instructions.
    • Providers must bill their usual and customary charge. The new fee schedule for the Physician’s Drug Program is available on DMA’s website at: http://www.ncdhhs.gov/dma/fee/.

    HP Enterprise Services
    1-800-688-6696 or 1-919-851-8888


    Attention: Nurse Practitioners


    Nurse Practitioner Enrollment and Billing Instruction

    All Nurse Practitioners must be enrolled with North Carolina Medicaid and all services provided by Nurse Practitioners must be filed to Medicaid with their NPI as the rendering (or attending) provider by October 1, 2011.  Nurse Practitioners will not be allowed to bill “incident to” the physician after November 30, 2011.

    Applicants must meet all program requirements and qualifications for enrollment before they can be enrolled as a Medicaid provider.  Nurse Practitioners may enroll by completing the Medicaid provider enrollment application on www.nctracks.nc.gov.  CSC, DMA’s Enrollment, Verification and Credentialing vendor, is available to assist providers who want to enroll in NC Medicaid at 866-844-1113 or NCMedicaid@csc.com.   

    Clinical Policy
    DMA, 919-855-4331

     

    Attention:  Optical Providers


    Elimination of Adult Routine Eye Exams, Refractions, and Visual Aids Services and Related Prior Approval and Billing Issues

    In accordance with House Bill 200, Section 10.37.(a), effective with date of service October 1, 2011, all routine eye exams, refractions, and visual aids for adult Medicaid recipients 21 years of age and older will no longer be covered.

    In preparation for this policy revision, providers may view the proposed Routine Eye Exam and Visual Aids for Recipients under Age 21 Policy at  http://www.ncdhhs.gov/dma/mpproposed/index.htm

    Regarding prior approval for visual aids:

    Visual aids may be approved for adult Medicaid recipients when the initial fitting date (date prior approval request is completed by the provider) is on or before September 30, 2011.

    Regarding billing for visual aids:

    For prior approved visual aids with an initial fitting date on or before September 30, 2011 and a dispensing date on or after October 1, 2011, the provider must bill the refraction date.  Otherwise, the claim will deny.

    Effective October 1, 2011, providers must bill S0620 (routine ophthalmological examination including refraction, new patient) or S0621 (routine ophthalmological examination including refraction, established patient) for routine eye exams.

    Optical Program
    DMA, 919-855-4310


    Attention:  Outpatient Behavioral Health Services Providers


    Outpatient Behavioral Health Services Seminars

    Outpatient Behavioral Health Services Provider seminars have been scheduled for November 2011. Information presented will include a review of Clinical Coverage Policy 8C -- Outpatient Behavioral Health services provided by Direct-Enrolled Providers and policy updates, billing procedures including billing “incident to” a physician, prior approval, National Correct Coding Initiative, Carolina Access for recipients under age 21, and Health Choice.

    The seminar sites and dates will be announced in the October 2011 Medicaid Bulletin, which will be posted to http://www.ncdhhs.gov/dma/bulletin/index.htm.  Pre-registration will be required.  Due to limited seating, registration is limited to two staff members per office. Unregistered providers are welcome to attend if space is available.

    Behavioral Health Section
    DMA, 919-855-4290

      

    Attention: PASRR Screeners for Instate and Out of State


    N.C. Preadmission Screening and Resident Review 

    North Carolina and Out of State PASRR Screeners are required to accurately complete and attest to the accuracy of the screening information prior to admission to a NC Nursing Facility. The screen information must be accurate in order to comply with Subpart C CFR 483.100 and 483.126.  Placement of an individual with mental illness (MI) or mental retardation (MR) in a nursing facility (NF) may be considered appropriate only when the individual’s needs are such that he or she meets the minimum standards for admission and the individual’s needs for treatment do not exceed the level of services which can be delivered in the NF to which the individual is admitted either through NF services alone or, where necessary, through NF services supplemented by specialized services arranged for by the State Mental Health Authority.  The accuracy of the PASRR information is required for appropriate NF placement for individuals with MI or MR.

    Note:  The NC PASRR contractor (HP Enterprise Services) will review all PASRR documentation PRIOR TO ADMISSION to ensure nursing facility placement is appropriate. 

    HP Enterprise Services
    1-800-688-6696 or 919-851-8888

     

    Attention: Physicians and Physician Assistants


    Physician Assistant Enrollment

    Physician Assistants will be required to enroll with North Carolina Medicaid effective November 1, 2011. All services rendered by Physician Assistants must be filed to Medicaid with their NPI as the rendering (or attending) provider.  Physician Assistants will not be allowed to bill “incident to” the physician after December 31, 2011.

    Applicants must meet all program requirements and qualifications for enrollment before they can be enrolled as a Medicaid provider.  Physician Assistants may enroll by completing the Medicaid provider enrollment application on www.nctracks.nc.gov.  CSC, DMA’s Enrollment, Verification and Credentialing vendor, is available to assist providers who want to enroll in NC Medicaid at 866-844-1113 or NCMedicaid@csc.com.   

    Clinical Policy
    DMA, 919-855-4331

     

    Attention: Residential Behavioral Health Providers


    New Utilization Review Guidelines for Residential Behavioral Health Providers

    As per legislation, Session Law, House Bill 200 on page 126 –127:

    • Effective November 1, 2011, a comprehensive clinical assessment (CCA) completed and signed by a licensed mental health professional within 30 days of the requested admission date must be submitted with the ITR for initial reviews to assure the appropriateness of placement.  Requests for transfer from one Level III or Level IV facility to another do not require a new CCA completed if the transfer is for the same level of care.  Please see Implementation Update #36 for more information regarding comprehensive clinical assessments.
    • Effective November 1, 2011, a psychiatric or psychological assessment is required for authorization requests past the 180 day mark, to be completed by a psychiatrist (MD/DO) or psychologist (PhD) within 60 days of the requested start date of the requested re-authorization period. This psychiatric or psychological assessment must be completed by an independent practitioner who is not associated with the residential services provider if the provider is not a Critical Access Behavioral Health Agency (CABHA)..  If the residential services provider is a certified CABHA the assessment may be completed by a professional associated with the CABHA.. The UR vendor will require a statement from the independent evaluator who completes the CCA for the non-CABHA attesting that he or she is independent from, and not employed by or under contract with, the residential provider seeking prior authorization for services. When prior authorization is being requested a CABHA, the UR Vendor will require a statement signed by the CABHA Clinical Director that the person completing the assessment is employed by or under contract with the CABHA. 

    Documentation in the request for an extensive past the 180 day mark must support that a Child and Family Team has  reviewed goals and treatment progress and that the child or adolescent’s family or discharge setting is involvement in treatment planning and engaged in the treatment interventions. 

    Independent assessments for extensions on Level III and Level IV past the 120 day mark are no longer required for requests for prior authorization.

    Providers will continue to submit an updated discharge summary but it will no longer need to be signed by the System of Care coordinator at the time of submission. 

    Clinical Policy
    DMA, 919-855-4289


     

     

    Employment Opportunities with the N.C. Division of Medical Assistance

    Employment opportunities with DMA are advertised on the Office of State Personnel’s website at  http://agency.governmentjobs.com/northcarolina/default.cfm.  To view the vacancy postings for DMA, click on “Agency,” then click on “Department of Health and Human Services”.  If you identify a position for which you are both interested and qualified, complete a state application form online and submit it to the contact person listed for the vacancy.  If you need additional information regarding a posted vacancy, call the contact person at the telephone number given in the vacancy posting.  General information about employment with North Carolina State Government is also available online at http://www.osp.state.nc.us/jobs/general.htm.

    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.

    Richard K. Davis
    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.

     

    Checkwrite Schedule

    Month

    Checkwrite Cycle Cutoff Date

    Checkwrite Date

    EFT Effective Date

    September

    9/1/11

    9/7/11

    9/8/11

    9/8/11

    9/13/11

    9/14/11

    9/15/11

    9/22/11

    9/23/11

    9/29/11

    10/4/11

    10/5/11

    October

    10/6/11

    10/12/11

    10/13/11

    10/13/11

    10/18/11

    10/19/11

    10/20/11

    10/27/11

    10/28/11

    10/27/11

    11/1/11

    11/2/11

    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

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