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

Electronic Claim Exceptions

The following list outlines some of the situations in which a claim must be billed on paper. Only claims that comply with the exceptions listed below may be submitted on paper. All other claims are required to be submitted electronically. Providers will be notified of updates to the list through the Medicaid Bulletin.

List of Claims that May Be Filed on Paper (revised July 27, 2009)

  • Medicare HMO (Part C) primary claims
  • Medicare Part A inpatient claims submitted directly to Medicaid
  • Nursing home crossovers submitted directly to Medicaid
  • Services that require an invoice to be submitted with the claim including, but not limited to
    • Hearing aids and related items
    • Some visual aids
    • Unclassified and unlisted procedures
    • Undelivered dentures
    • Radiopharmaceuticals
    • Compounded injectable drugs billed with an unclassified HCPCS procedure code (for example, J3490)
      Note: 17-P compounds do not require invoices and should be billed electronically when this provision becomes effective.
    • Some services and procedures covered through the Money Follows the Person Waiver Program
  • Claims submitted with a Medicaid Resolution Inquiry Form for
    • Time limit override
    • Medicare override
    • Third-party override
    • Recipient eligibility review
  • Pharmacy claims for
    • Charges over $9,999
    • Compound drugs, when the compound comprises both legend and non-legend drugs
    • Compound drugs, when the compound contains an over-the-counter drug
    • Non-covered over-the-counter drugs prior approved through EPSDT
    • Retroactive charges that exceed the time limit for filing
    • DMA-approved quantity overrides
    • Medicare deductibles
    • Synagis that does not meet the established guidelines for coverage
    • Depo-Provera that does not meet the established guidelines for coverage
  • Any professional claim billed with one of the following CPT procedure codes:
    • 99082 (if more than 180 units per day)
    • 59200
    • 59830
    • 59840
    • 59841
    • 59850
    • 59851
    • 59852
    • 59855
    • 59856
    • 59867
    • 01966
  • Any institutional claim billed with one of the following ICD-9-CM procedure codes:
    • 69.01
    • 69.51
    • 74.91
    • 75.0
    • 96.49
  • Any professional or instituitional claim billed with one of the following ICD-9-CM diagnosis codes:
    • 635.00 through 635.99
    • 638.00 through 638.99
  • Any dental claim billed with one of the following ADA procedure codes:
    • D0340
    • D0470
    • D8680
  • Dental claims for special consideration tooth number reviews
  • Dental assistant surgeon claims with records
  • Dental ambulatory surgical claims denoting total surgical time in field 24
  • Visual field exams requiring medical justification billed with CPT procedure code 92081, 92082, or 92083 without one of the dignosis codes listed in the table below:
Diagnosis Code
List #1
Diagnosis Code
List #2
094.84
191.2
191.6
191.9
192.1
239.6
250
250.00
250.01
250.02
250.03
250.50
250.51
250.52
250.53
323.9
340
343
343.0
348.2
360
360.00
360.24
360.4
360.40
360.41
361
361.00
361.9
362.01
362.02
362.11
362.12
362.21
362.3
362.30
362.31
362.33
362.4
362.40
362.5
362.50
362.51
362.52
362.53
362.54
362.55
362.56
362.57
362.6
362.60
362.63
362.64
362.65
362.66
362.7
362.70
362.74
362.75
362.81
362.83
363.11
363.2
363.20
363.30
364.1
364.10
364.11
364.21
364.22
364.23
364.3
364.42
364.51
364.52
364.53
364.54
364.55
364.56
364.57
364.59
364.60
364.61
364.62
364.63
364.64
364.70
364.71
364.72
364.73
364.74
364.75
364.76
364.77
364.8
364.81
364.89
364.9
365
365.00
365.01
365.02
365.03
365.04
365.5
365.51
365.52
365.59
365.6
365.60
365.61
365.62
365.63
365.64
365.65
365.81
365.82
365.89
365.9
366.11
366.14
366.16
368.41
368.43
368.44
368.46
368.47
369
369.00
369.01
369.2
369.20
369.3
370
370.00
371.00
371.60
377
377.00
377.1
377.10
377.14
377.21
377.24
377.3
377.30
377.32
377.39
377.41
377.52
377.62
377.75
377.9
379.21
379.24
379.5
379.50
434.91
435.9
695.4
710
710.0
743.2
743.20
921.3
921.9
948.4
950
950.0
996.69
225.1
227.3
307.81
346.90
349.9
352.9
364.00
364.01
364.02
364.03
364.04
364.05
364.24
364.41
367.0
367.1
367.2
367.4
367.9
368.12
368.4
370.20
372.0
372.01
372.02
372.03
372.04
372.05
372.3
372.31
372.33
372.39
372.73
373.9
374.11
375.15
376.1
376.30
378.00
378.1
378.11
378.12
378.13
378.14
378.15
378.16
378.17
378.18
378.4
378.41
378.42
378.43
378.44
378.45
378.53
379.3
379.32
379.33
379.34
379.39
379.41
379.53
379.91
381.4
386.01
386.10
462
465.9
473.9
716.90
743.9
747.8
784.0
791.0
850.9
921
921.1
921.2
931
V20.2
V67.51
V72.0
V80.0
V80.1

 

 

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