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

December 2013 Medicaid Bulletin

Printer Friendly Version

 

In This Issue . . .

All Providers

Receiving Email Alerts Through NCTracks
NCTracks Common Questions and Issues
NCTracks Tip of the Month: Include Cover Sheet to Submit Additional Information for Prior Approval Requests
Brief Overview of Home and Community Based Medicaid Waivers in North Carolina
N.C. Medicaid Recovery Audit Contract II (RACII)
Clinical Coverage Policies

Ambulance Providers

Billing Ambulance Claims in NCTracks

Enhanced Behavioral Health (Community Intervention Service) Providers

Buprenorphrine in Opioid Treatment Programs

Laboratory Providers

N.C. Medicaid Recovery Audit Contract II (RACII)

Outpatient Behavioral Health Service Providers

Physician Assistants/Associate-Level Licensed Providers: Extension of ‘Incident-to’ Billing

Personal Care Services

Personal Care Services (PCS) Program Highlights

Pharmacists

Procedures for Prior Authorization of Synagis for Respiratory Virus (RSV) Season 2013/2014

Physicians

Procedures for Prior Authorization of Synagis for Respiratory Virus (RSV) Season 2013/2014

Prescribers

Procedures for Prior Authorization of Synagis for Respiratory Virus (RSV) Season 2013/2014

Specialized Therapy Providers

N.C. Medicaid Recovery Audit Contract II (RACII)



Attention: All Providers

Receiving Email Alerts Through NCTracks

Note to Providers: This article was originally published in September 2013.

Providers can subscribe to email alerts through the NCTracks Provider Portal at www.nctracks.nc.gov/. Alerts are sent when there is important information to share between monthly issues of the Medicaid Provider Bulletin. Past email alerts have contained information on these topics:

  • Checkwrite Schedule Updates
  • Overriding Address Validation Error in Manage Change Request
  • How to Update the NCID of an Existing Office Administrator
  • Updates to the SkillPort Learning Management System
  • Medicare Crossover Update
  • Clarification on Roche Rebates for Durable Medical Equipment (DME) Supplies

To receive email alerts and other communications from NCTracks, visit https://www.nctracks.nc.gov/content/public/providers/provider-announcements.htm. Then click on the “Sign up for NCTracks Communications” link under “Quick Links.” Providers who currently receive email alerts will continue to receive them through NCTracks. No other actions are required.

Email addresses will never be shared, sold or used for any purpose other than Medicaid and N.C. Health Choice (NCHC) email alerts and NCTracks communications.

CSC, 1-800-688-6696

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Attention: All Providers

NCTracks Common Questions and Issues

A regularly updated Issues List is available on the NCTracks provider portal at https://www.nctracks.nc.gov/content/public/providers/nctracks-status-page.html, reflecting the most common issues affecting providers. Below are some of the issues which were addressed in the provider portal during the month of November.

Required information when submitting ADA forms for N.C. Health Choice

When mailing or faxing an American Dental Association (ADA) form for N.C. Health Choice (NCHC):

  • Mail all NCHC prior approval requests separately. Do not send them mixed with Medicaid prior approval requests. Please note that the process for submitting NCHC requests differs from that of Medicaid.
  • Write “N.C. Health Choice Dental” or “N.C. Health Choice Orthodontics” in BOX 3 on all mailed or faxed ADA claim forms
  • Write on outside of the mailing envelope - Attn: N.C. Health Choice Dental or Attn: N.C. Health Choice Orthodontics
  • Have a provider signature in BOX 53 on all mailed or faxed requests

Taking these steps will help expedite the processing of ADA forms for NCHC.

Pregnancy Medical Home Issue Resolved

NCTracks was updated on November 3 to allow the submission and payment of Pregnancy Medical Home claims. The system will support all three types of Pregnancy Medical Home claims that receive higher reimbursement, including the pregnancy risk screening, delivery and postpartum plan.

All Pregnancy Medical Home claims billed after November 3 will need to include the modifier “AF” with the procedure code submitted. The “AF” modifier will enable the provider to be paid at the rate previously received in the legacy system.

Providers who have filed Pregnancy Medical Home claims that were denied or pended for Edit 353 (rate not found) will need to submit replacement claims. For claims previously paid at the lower rates, providers can submit claim adjustments.

For more information about Pregnancy Medical Home reimbursement, see the Division of Medical Assistance (DMA) Pregnancy Medical Home Web Page at www.ncdhhs.gov/dma/services/pmh.htm.

Reminder about Internet Explorer 10

Internet Explorer 10 is not currently supported by NCTracks. Supported browsers include Internet Explorer 8 and 9 and Firefox. Check the “System Requirements” link at the bottom of every NCTracks Web Page for a complete description of supported browsers and other software requirements.

Providers will be notified when Internet Explorer 10 has been tested and certified with NCTracks. In the meantime, those using Internet Explorer 10 may find that buttons on some provider portal screens are not visible or do not function properly. Providers can download and install Firefox at www.mozilla.org/firefox to access the full functionality of NCTracks.

For Local Health Departments

The DMA and Division of Public Health (DPH) have jointly developed “Enhanced Roles” for public health nurses starting in the early 1980s. These nurses are not able to directly enroll with Medicaid as providers because they function only within the legal scope of practice for Registered Nurses under the authority of the N.C. Board of Nursing rules in Chapter 36 of Title 21 of the NC Administrative Code and G.S. 90-171.20(7) of the NC Nursing Practice Act. Enhanced Role RNs function under the signed standing orders of a licensed physician in order to perform appropriate lab tests on symptomatic clients and to treat clients based on objective findings (e.g., lab test results). To receive reimbursement, services provided by public health nurses should be billed using the NPI of the Medicaid-enrolled provider who signs those standing orders.

Reminder about Automated Voice Response System

The Automated Voice Response System (AVRS) allows enrolled providers to readily access detailed information on the following N.C. Medicaid, NCHC and DPH topics using a touch-tone telephone:

  • Checkwrite Information
  • Current Claim Status
  • Prior Approval Information for DPH
  • Recipient Eligibility Verification

Providers are granted access by entering either their National Provider Identifier (NPI) or Atypical Provider Number. Provider and Recipient must be in the same health/benefit plan for all inquiries on recipient eligibility.

Providers can access the AVRS by dialing 1-800-723-4337. A Job Aid detailing the AVRS prompts is available on SkillPort.

Update to Frequently Asked Questions (FAQs) – Claim Submission

Q: Should I include the National Drug Code (NDC) on my vaccine claim?

A: No. Providers should omit the NDC when billing vaccine claims. Including the NDC on vaccine claims may cause the claim not to pay.

Q: Are vaccines rebateable?

A: No. Vaccines are not rebateable. Therefore, providers should omit the NDC when billing vaccine claims only.

All FAQs, organized by topic, can be found on the NCTracks Frequently Asked Questions page of the Provider Portal at https://www.nctracks.nc.gov/content/public/providers/faq-main-page.html.

CSC, 1-800-688-6696

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Attention: All Providers

NCTracks Tip of the Month: Include Cover Sheet to Submit Additional Information for Prior Approval Requests

When selecting to mail or fax attachments or supportive documentation for a prior approval request there will be a link to print a cover sheet. It is important to include the provided cover sheet so that the information will be properly attached to the prior approval documentation.

The process works as follows:

  • When creating a prior approval request in the secure provider portal, there will be an opportunity to upload, mail or fax information.
  • When selecting to mail or fax in information there will be a link to print a cover sheet. It is critical to print this cover sheet and mail or fax it with your additional documentation.

The cover sheet is how NCTracks knows which prior approval request to associate with the additional documentation. Attachments submitted without the cover sheet can delay processing of the prior approval request.

It is also important to include the cover sheet when submitting additional information required for pended prior approval requests. The cover sheet is provided with the request for additional information, which is mailed to providers. Failure to do so may result in the creation of a duplicate prior approval request, which can delay processing of the original request.

CSC, 1-800-688-6696

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Attention: All Providers

Brief Overview of Home and Community Based Medicaid Waivers in North Carolina

North Carolina operates several waiver programs which provide home and community based care as a cost-effective alternative to institutionalization. These include the Community Alternatives Program (CAP) for Children (CAP-C), CAP for Disabled Adults (CAP-DA), CAP-Choice, and the North Carolina Innovations Waiver. These programs were approved by the Centers for Medicare & Medicaid Services (CMS) for waiver participants only. This overview provides information on eligibility, population served, services and referral processes for each program.

CAP-C

CAP-C serves medically fragile beneficiaries birth through age 20 who are at-risk for institutionalization in a nursing facility. Services available include:

  • In-Home Nurse
  • Certain Home and Vehicle Modifications
  • Palliative Care
  • Adaptive Tricycles
  • Caregiver Training and Education.

Respite and re-usable diapers are available when case management is received along with one of the above services. To make a referral, contact the case management agency in the county where the beneficiary resides. A list of case management agencies and other information about CAP-C can be found at www.ncdhhs.gov/dma/services/capc.htm.

CAP-DA

CAP-DA serves beneficiaries 18 years of age and older who have physical disabilities and qualify for nursing facility care. Services available include:

  • Personal Care
  • Medical Equipment and Supplies
  • Adult Day Health
  • Nutritional Supplements
  • Respite

Referrals can be made by contacting the local lead in agency in the beneficiary’s county of residence. A listing of lead agencies can be found at www.ncdhhs.gov/dma/cap/CAPContactList.pdf.

More information about CAP-DA can be found at www.ncdhhs.gov/dma/services/capda.htm.

CAP-Choice

CAP-Choice is a program under CAP-DA which serves the same beneficiaries and offers the same services. However, CAP-Choice allows beneficiaries to have more control over the personal care and respite services they receive. CAP-Choice beneficiaries can select their individual workers, more fully direct their care and have more flexibility in tailoring plans of care to their home care requirements.

Referrals can be made by contacting the local lead in agency in the beneficiary’s county of residence. A listing of lead agencies can be found at www.ncdhhs.gov/dma/cap/CAPContactList.pdf.

More information about CAP-Choice can be found at www.ncdhhs.gov/dma/services/capchoice.htm.

The North Carolina Innovations Waiver

The N.C. Innovations Waiver serves beneficiaries who meet the criteria for Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF IID) level of care. Services funded through the N.C. Innovations Waiver include:

  • In-Home Skill Building
  • In-Home Intensive Supports
  • Respite
  • Residential Support
  • Day Support
  • Crisis Services
  • Supported Employment
  • Natural Supports Education
  • Specialized Consultative Supports
  • Assistive Technology-Equipment And Supplies
  • Community Guides
  • Vehicle Adaptations
  • Home Modifications
  • Financial Supports
  • Individual Good and Services

Individuals who are not currently enrolled as Medicaid beneficiaries can contact their Local Management Entity/Managed Care Organization (LME-MCO) to see if they qualify for services under the N.C. Innovations Waiver. A list of LME/MCOs can be found at www.ncdhhs.gov/dma/lme/LME-Contact-Info.html. More information about the N.C. Innovations Waiver can be found at www.ncdhhs.gov/dma/lme/Innovations.html.

Overview of Medicaid Waiver Programs


Program

Population

Eligibility

Services

Referral Process

Community Alternatives Program for Children
(CAP-C)

Medically fragile beneficiaries ages birth through 20

At-risk for institutionalization in a nursing home

In-home nursing care; certain home and vehicle modifications; palliative care; adaptive tricycles; caregiver training and education.

Respite and re-usable diapers are available when case management is received along with one of the above services.

Contact a case management agency in the county where the child resides. www.ncdhhs.gov/dma/services/capc.htm.

Community Alternatives Program for Disabled Adults (CAP-DA)

______

Community
Alternatives
Programs –
Choice
(CAP-Choice)

 

Disabled beneficiaries 18 years and older

Qualify for nursing facility care

Personal care, medical equipment and supplies, adult day health, nutritional supplements and respite care.

________________

Under CAP-Choice Beneficiaries can self direct personal care and respite services.

Contact the lead agency in the beneficiary’s county of residence.
www.ncdhhs.gov/dma/cap/CAPContactList_012913.pdf

N.C. Innovations Waiver

Beneficiaries with  Intellectual/
Developmental Disabilities

Meets ICF IID level of care requirements

In-home skill building, in-home intensive supports, respite, residential support, day support, crisis services, supported employment, natural supports education, specialized consultative supports, assistive technology equipment and supplies, community guides, vehicle adaptations, home modifications, financial supports and individual good and services.

Contact the LME/MCO in the county in the county of residence, or, if receiving Medicaid funding, the county in which Medicaid has been established.

List of LME/MCOs:
www.ncdhhs.gov/dma/lme/LME-Contact-Info.html.

More information: www.ncdhhs.gov/dma/lme/Innovations.html.


CAP-C: 919-855-4340
CA-DA and CAP-Choice: 919-855-4380
N.C. Innovations: 919-855-4290

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Attention: All Providers, Lab Providers and Specialized Therapy Providers

N.C. Medicaid Recovery Audit Contract II (RACII)

As described in the October 2012 Medicaid Bulletin, HMS has contracted with the N.C. Division of Medical Assistance (DMA) to become North Carolina’s second Recovery Audit Contract (RAC) vendor. HMS has initiated RAC activities by performing post-pay audits on inpatient and outpatient hospital claims. It is now auditing claims of laboratory, specialized outpatient therapy, x-ray and long-term care claims reviews.

The first laboratory review is an automated review which targets excessive drug screening. Automated reviews are used in cases where improper payments can be easily identified through claims analysis. When HMS identifies overpayments, the provider will receive a Tentative Notice of Overpayment (TNO) letter specifying each claim overpayment and a description of the findings. The findings for the first group of automated lab reviews were released in early November. Additional lab reviews are expected to be completed and findings released by late December 2013.

It is anticipated that specialized therapy services will be the next provider type to be reviewed. HMS is finalizing review guidelines with DMA and plans to initiate reviews of specialized therapy claims by the end of the first quarter of 2014.

Those with questions should contact:

DMA: Linda Marsh: linda.marsh@dhhs.nc.gov; DMA Phone: 919-814-0000

HMS: Email: NCRACII@HMS.com; Toll-Free Phone Number: 1-855-438-6415); Provider Website: www.medicaid-rac.com/ncproviders/

Program Integrity
919-814-0000

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Attention: All Providers

Clinical Coverage Policies

The following new or amended combined N.C. Medicaid and N.C. Health Choice clinical coverage policies are available on the Division of Medical Assistance (DMA) Website at www.ncdhhs.gov/dma/mp/:

  • 1H, Telemedicine and Telepsychiatry (11/15/13)
  • 9D, Off Label Antipsychotic Safety Monitoring in Beneficiaries Through Age 17 (11/1/13)
  • 9E, Off Label Antipsychotic Safety Monitoring in Beneficiaries 18 and Older (11/1/13)

These policies supersede previously published policies and procedures.

Clinical Policy and Programs
DMA, 919-855-4260

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Attention:  Ambulance Providers

Billing Ambulance Claims in NCTracks

All ambulance providers billing straight Medicaid claims or claims requiring a Medicare override are to continue billing with an institutional claim (UB-04/837I transaction) in NCTracks until further notice. Ambulance providers billing with Medicare payments are to continue to bill on professional claims.

Billing will be updated with a new ambulance policy, but until that time ambulance providers billing straight Medicaid claims or claims requiring a Medicare override with a professional claim (CMS-1500/837P transaction) will receive a denial and be instructed to rebill on an institutional claim.

Clinical Policy
DMA, 919-855-4100

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Attention: Enhanced Behavioral Health (Community Intervention Service) Providers

Buprenorphrine in Opioid Treatment Programs

N.C. Division of Medical Assistance (DMA) reimburses licensed Opioid Treatment Programs (OTPs) to dose medication to treat opioid dependence. Historically, outpatient OTPs have used methadone to treat opioid dependence in those aged 18 and over. Clinical Coverage Policy 8A (www.ncdhhs.gov/dma/mp/8A.pdf) states that OTPs can use methadone or other drug approved by the Food and Drug Administration (FDA) for the treatment of opiate addiction, in conjunction with the provision of rehabilitation and medical services. Later in this same policy, DMA specifically notes that buprenorphrine can be used. However, under the “Service Type” section, it states “Methadone maintenance is the only opioid treatment for opiate addiction disorders that is Medicaid or N.C. Health Choice (NCHC) billable.”

This article clarifies that the DMA Outpatient Opioid Treatment policy allows OTPs to bill for Medicaid reimbursement for dispensing methadone, buprenorphrine (e.g., Suboxone or Subutex), or any medication approved by the FDA for the treatment of opiate addiction using the H0020 code.

Note: Medicaid and NCHC reimbursement has always been for the dosing event and not for the medication.

Behavioral Health Policy Section
DMA, 919-855-4290

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Attention: Outpatient Behavioral Health Service Providers

Physician Assistants/Associate-Level Licensed Providers: Extension of ‘Incident-to’ Billing

Physician Assistants may choose to directly enroll as Medicaid providers. (See the August 2013 Medicaid Bulletin titled “Physician Assistants/Associate-Level Licensed Providers: Taxonomy Codes.”)

Physician Assistants may also continue billing “incident-to” a physician until July 1, 2014 (See the October 2008 Medicaid Bulletin article titled “Modification in Supervision When Practicing ‘Incident-to’ a Physician.”)

Associate-Level licensed providers delivering outpatient behavioral health services under Medicaid and State Funds can continue bill through their Local Management Entity/Managed Care Organization (LME/MCO) until July 1, 2014.

To use this option, the LME/MCO must be willing to allow the Associate-Level licensed provider to use the LME/MCO’s National Provider Identifier (NPI) number to process these claims. Associate-Level licensed providers may also continue to bill “Incident to” a supervising physician until July 1, 2014, as stated in Clinical Coverage Policy 8C.

Division of Medical Assistance (DMA) and Division of Mental Health/Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) are working collaboratively on policies and procedures to support direct enrollment of Associate-Level licensed professionals and will publish guidance when this process is completed. DMA is also working to ensure that all Physician Assistants will be able to directly enroll and bill for services.

Behavioral Health Policy Section
DMA, 919-855-4290

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Attention: Personal Care Services Providers

Personal Care Services (PCS) Program Highlights

Note: This article does not apply to providers billing for Personal Care Services (PCS) under the Community Alternatives Program (CAP) program.

Screening for Serious Mental Illness (SMI) in Adult Care Homes

Effective January 1, 2013, all Medicaid beneficiaries referred to or seeking admission to Adult Care Homes licensed under G.S. 131D-2.4 must be screened through the Preadmission Screening and Resident Review (PASRR). Adult Care Home providers licensed under G.S. 131D-2.4 will not receive prior approval to bill PCS without verification of PASRR numbers.

Stakeholder Meetings

PCS Stakeholder meetings are held the third Thursday of each month from 1:00 p.m. to 2:30 p.m. (there is no online option). The goals of the meetings are to provide improved coordination of information and networking options for stakeholders.

Meeting agendas (which will indicate meeting locations), handouts, and minutes are available for download on the PCS Web page at www.ncdhhs.gov/dma/pcs/pas.html. Stakeholders should continue to submit questions through the PCS mailbox at PCS_Program_Questions@dhhs.nc.gov. Questions and concerns providers would like addressed during the stakeholder meetings should be emailed at least three days before the scheduled stakeholder meeting with “FOR STAKEHOLDER MEETING” in the subject line.

QiRePort Provider Interface

The PCS QiRePort Provider Interface is a Web-based information system to support PCS Independent Assessments. The interface collects, stores and communicates beneficiary information such as decision notices, independent assessments – which are required to develop beneficiary plans of care, change of status assessment request and discharge reporting.

The PCS Program encourages providers to register as users of the QiReport Provider Interface. To register, providers must complete the QiReport Registration form, which is available on the PCS Website at www.ncdhhs.gov/dma/pcs/pas.html under “Forms.”  Once the registration form is complete, it should be sent to VieBridge, Inc. at:

     QiRePort Support Fax: 919-301-0765

     Mail: VieBridge, Inc. QiReport Team, 8130 Boone Boulevard, Suite 350, Vienna, VA 22182

As of September 3, 2013, all QiReport users must have a North Carolina Identification Management Service (NCID) username and password to obtain access to qireport.net. For questions, contact the QiReport Support Team at 1-888-705-0970 option 3, or email support@qireport.net.

Upcoming Training

Visit the PCS Web page at www.ncdhhs.gov/dma/pcs/pas.html and click on “Trainings” to view posted trainings on the DMA 3051 PCS Request for Services Form, as well as QiReport Registration and Utilization. Additional plans for provider trainings and Webinars will be announced on the PCS Web page.

Personal Care Services (PCS) Program Contacts

Those with questions regarding trainings or other issues can contact the PCS program by phone at 919-855-4340 or via email at PCS_Program_Questions@dhhs.nc.gov.

Home and Community Care
DMA, 919-855-4340

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Attention: Pharmacists, Prescribers and Physicians

Procedures for Prior Authorization of Synagis for Respiratory Syncytial Virus (RSV) Season 2013/2014

The clinical criteria used by N.C. Medicaid for the 2013/2014 Respiratory Syncytial Virus (RSV) season are consistent with published guidelines in the Red Book: 2012 Report of the Committee on Infectious Diseases, 29th Edition. Prior authorization (PA) is required for Medicaid coverage of Synagis during the upcoming RSV season. The coverage season is November 1, 2013 through March 31, 2014. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) criteria are considered for Synagis requests.

Submit all PA requests for coverage of Synagis for the upcoming season electronically at www.documentforsafety.org. The online Synagis Program will accept requests starting on October 15, 2013. This Web-based tool is designed to capture all information for a PA request. When the system offers an opportunity to upload supporting documents, the most recent progress note documenting the patient’s pulmonary or cardiac status is required when a specialist is involved in the care. The electronic system can automatically approve a request based on the criteria submitted and allows a provider to self-monitor the status of a request pending medical review.

  • For approved requests, each Synagis dose will be individually authorized to promote efficient product distribution.
  • After the initial approval, providers must submit a “next dose request” to obtain an authorization for each subsequent dose up to the approved number of doses.
  • If an infant received one or more Synagis doses prior to hospital discharge, the provider should indicate as part of the request the most recent date a dose was administered and the number of doses administered by the provider should be adjusted accordingly.
  • Providers should ensure the previously obtained supply of Synagis is administered before submitting a next dose request.

It is important for a Synagis distributor to have the appropriate single dose authorization on hand and a paid claim prior to shipping Synagis. An individual dose authorization is required for each paid Synagis claim. The claim should not exceed the quantity indicated on the authorization. A Synagis claim will deny if a dose request was not done by the provider.

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.

Chronic Lung Disease (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.

Hemodynamically Significant Congenital Heart Disease (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.

Congenital Abnormalities of the Airway or Neuromuscular Disease

Infants born on or after November 2, 2012, with compromised handling of respiratory secretions secondary to congenital abnormalities of the airway or neuromuscular disease may be eligible for prophylaxis during the first year of life. The diagnosis to justify severe neuromuscular disease or congenital airway abnormalities must be specific.

Prematurity

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

  • Born at an Estimated Gestational Age (EGA) of ≤28 weeks 6 days and Date of Birth (DOB) is on or after November 2, 2012
  • Born at an EGA of 29 weeks 0 days to 31 weeks 6 days and DOB is on or after May 2, 2013

Five Dose Exceptions

Coverage of Synagis for CLD and HSCHD will terminate when the beneficiary exceeds 24 months of age AND has received a minimum of three doses during the season.

Coverage of Synagis for congenital abnormalities of the airway and severe neuromuscular disease that compromises handling of respiratory secretions will terminate when the beneficiary exceeds 12 months of age AND has received a minimum of three doses during the season.

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, 2013, 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 living permanently in the same household. Multiple births do not qualify as fulfilling this risk factor.

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 www.ncdhhs.gov/dma/epsdt/. A medical necessity review will be done under EPSDT (see www.ncdhhs.gov/dma/epsdt/ ). If the information provided justifies medical need, the request will be approved.

Pharmacy Distributor Information

Synagis claims processing began on October 29, 2013, to allow sufficient time for pharmacies to provide Synagis by November 1, 2013. Payment of Synagis claims with date of service prior to October 29, 2013, and after March 31, 2014, will not be allowed. Point of sale 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 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 beneficiary records by DMA Program Integrity. Providers will fax each single dose authorization to the pharmacy distributor of choice. Single dose vial specific authorizations, up to the maximum number of doses approved for the beneficiary, will be issued by Medicaid.

Ensure the appropriate authorization is received before submitting a claim to Medicaid. The authorizations should be maintained in accordance with required record keeping time frames.

Provider Information

Providers without internet access should contact the Medicaid Outpatient Pharmacy Program at (919)855-4300 to facilitate submission of a PA request for Synagis. More information about the Synagis program is available at www.documentforsafety.org.

Technical Support

Technical support is available from 8 a.m. to 5 p.m. by calling 1-855-272-6576 (local: 919-657-8843). Technical support can assist with provider registration, user name and password issues, beneficiary searches, and other registry functions.

Outpatient Pharmacy
DMA, 919-855-4300

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Employment Opportunities with the N.C. Division of Medical Assistance (DMA)

Employment opportunities with DMA are advertised on the Office of State Personnel’s website at  www.osp.state.nc.us/jobs/. 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 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 at www.ncdhhs.gov/dma/mpproposed/. Providers without Internet access can submit written comments to:

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. If the adoption of a new or amended medical coverage policy is necessitated by an act of the General Assembly or a change in federal law, then the 45 and 15-day time periods shall instead be 30 and 10-day time periods.

Checkwrite Schedule

Month
Checkwrite Cycle Cutoff Date Checkwrite Date EFT Effective Date
December, 2013
12/06/13 12/10/13 12/11/13
12/13/13 12/27/13 12/18/13
12/27/13 12/31/13 01/02/14
January, 2014 01/02/14 01/07/14 01/08/14
01/09/14 01/14/14 01/15/14
01/16/14 01/22/14 01/23/14
01/23/14 01/18/14 01/29/14

Electronic claims must be transmitted and completed by 5:00 p.m. on the cut-off date to be included in the next checkwrite.  Any claims transmitted after 5:00 p.m. will be processed on the second checkwrite following the transmission date.

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