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Clinical Coverage Policies and Provider Manuals
Proposed Medicaid Clinical Coverage Policies
DMA will implement a number of changes in response to legislated budget reductions mandated in SL 2009-451. Providers will be notified of operational changes, and coverage and policy changes via the Medicaid Bulletin. These changes will also be listed on this web page.
Public notices of proposed amendments to the State Medicaid Plan and copies of the proposed amendments are available on the State Plan web page.
Session Law 2009-451 mandated DMA to begin collecting a $100 enrollment fee from providers upon initial enrollment with the N.C. Medicaid Program and at 3-year intervals when the provider is re-credentialed.
This process will begin on September 1, 2009, and will apply to applications received on or after that date.
Initial enrollment is defined as an in-state or border-area provider who has never enrolled to participate in the N.C. Medicaid Program. The provider's tax identification number is used to determine if the provider is currently enrolled or was previously enrolled.
Payment is accepted by check or money order made payable to the N.C. Department of Health and Human Services (NC DHHS). Requests for Medicaid enrollment will not be processed unless the payment is received. The enrollment fee is non-refundable.
Additional information is available in the September 2009 Medicaid Bulletin.
Effective October 2, 2009, N.C. Medicaid will require all providers to file claims electronically.
Additional information about this initiative is also available through the Medicaid Bulletin:
Effective with the second checkwrite in September , the N.C. Medicaid Program will no longer issue paper checks for claims payments. All payments will be made electronically by automatic deposit to the account specified in the provider's Electronic Funds Transfer (EFT) Authorization Agreement for Automatic Deposits.
Providers who are currently receiving paper checks for claims payment must complete and submit an EFT Authorization Agreement for Automatic Deposits immediately to ensure that there is no disruption to payments.
Additional information about this requirement is also available through the Medicaid Bulletin:
The N.C. Legislature has mandated the use of the Uniform Screening Program by all providers who are required to conduct a Preadmission Screening and Annual Resident Review (PASARR) for individuals before admission to North Carolina's nursing facilities. All facilities submitting PASARR screenings will need to begin using the NC PASARR Online System.
Information on the NC PASARR Online System application, helpful hints, and tutorials to assist you in registration and getting started using the NC PASARR Online System are available on the NC PASARR Home Page.
Additional information is also available through the Medicaid Bulletin.
The N.C. Medicaid Program will implement reductions/limitations to some services in response to legislated budget reductions.
DMA has been directed by the NC General Assembly to freeze slots in the Community Alternatives Program for Disable Adults (CAP/DA) in order to meet the budget reduction goals for SFY 2010 and 2011.
Additional information is available in the Medicaid Bulletin:
The Community Support Services Steering Committee will will meet on a regular basis to develop a plan in response to the State Legislature's provision to restructure community support services for both Medicaid and State-funded children and adolescents.
More information on Community Support Service Transition.
Note: The Community Support Steering Committee meetings scheduled for September 16 and September 22 have been CANCELLED.
Effective with date of service November 1, 2009, the N.C. Medicaid Dental Program will implement changes outlined in the Conference Committee Money Report attached to the 2009 Budget Bill, which refers to dental policy adjustments resulting in program cost savings of approximately $3.7 million in State appropriations.
The following changes have been proposed:
In addition to the changes listed above, the Medicaid reimbursement for all covered procedure codes will be reduced by 4.52%, effective October 1, 2009. The complete Dental Fee Schedule, located on DMA's Fee Schedule web page, will be updated.
Effective November 15, 2009, Prodigy Diabetes Care, LLC, will be N.C. Medicaid's designated preferred manufacturer for glucose meters, test strips, control solutions, lancets, lancing devices, and syringes. If you have questions or need additional information, please call Prodigy Diabetes Care at 1-866-540-4816 or DMA Clinical Policy at 919-855-4310.
On October 1, 2009, DMA will implement limits on the number of units that may be reimbursed each calendar month per recipient.
Additional information is available in the Medicaid Bulletin:
To address the reduction in funds for Medicaid Case Management services, DMA will work with other DHHS Agencies to identify ways to improve the efficiency and effectiveness of case management services.
More information on Medicaid Case Management Service Initiatives.
The Residential Planning Group will meet on a weekly basis to discuss a comprehensive plan in response to the State Legislature's provision to restructure Residential Services for both Medicaid and State-funded children and adolescents.
More information on MH/SA Residential Service Initiatives.
DMA will implement prior authorization for certain prescription drugs to reduce costs to the the N.C. Medicaid Program. The proposed prior authorization criteria for these drugs can be reviewed on DMA's Proposed Clinical Policies web page.
Effective October 5, 2009, the reimbursement methodology for pharmacy claims will change from AWP-10% to WAC+7%. The drug cost will continue to be calculated based on the lowest cost on the First Data Bank drug file. The following methodologies continue to be used:
Reimbursement for SMAC drugs will also change from 150% of the lowest priced generic to 190% of the lowest priced generic.
Effective December 1, 2009, N.C. Medicaid will stop covering prescription medications used to treat the symptoms of cough and colds. The cough and cold medications that will no longer be covered are those that contain a cough suppressant or a cough expectorant.
Effective with date of service December 1, 2009, prior authorization (PA) for outpatient specialized therapies (occupational therapy, physical therapy, speech therapy, respiratory therapy, and audiology services) will once again be required for recipients under 21 years of age.
Effective with date of service January 1, 2010, PA for outpatient specialized therapies will also be required for recipients 21 years of age and older.
Prior authorization will be required for all therapy treatments regardless of the setting.
The Carolinas Center for Medical Excellence (CCME) will perform the authorizations. All authorizations must be submitted via CCME's new Prior Authorization Website.
| Date | Procedure | Instructions to Providers |
|---|---|---|
| 10/26/09 | Launch of New Prior Authorization Website | Providers can access general information about the PA process and instructions on how to register for access for submitting requests electronically. CCME will begin processing registrations upon receipt from the provider. |
| 11/16/09 | CCME Will Begin Accepting PA Submissions for Recipients Under 21 via the New Prior Authorization Website | Provider notification of review outcomes will not begin until 12/1/09. PA requests received prior to 12/1/09 will be processed as if the received date is 12/1/09 and will be reviewed within five business days (12/8/09). (Note: 12/5/09 is a Saturday and 12/6/09 is a Sunday.) Technical assistance will be available beginning 11/16/09. |
| 12/15/09 | CCME will Begin Accepting PA Submissions for Recipients 21 and Older via the New Prior Authorization Website | All PAs received prior to 1/4/10 will be processed as if the received date is 1/4/10 and will be reviewed within five business days (1/11/10) (Note: 1/1/10 is a holiday, 1/2/10 is a Saturday, and 1/3/10 is a Sunday.) |
A provider training webinar is scheduled for November 12, 2009. Please check CCME's Prior Authorization Website for detatiled information, including the time of the webinar session, and instructions on how to register for the webinar. Providers will receive an e-mail confirmation of their successful registration to participate in the webinar.
Additional information is available in the Medicaid Bulletin.
DMA has been directed by the N.C. General Assembly to implement changes in the Medicaid In-home Personal Care Services (PCS) Program. These changes include a refined method for determining the number of hours of PCS to be approved for qualifying program participnts and the requirement that all PCS assessments be conducted by an independent entity that does not provide PCS.
DMA is implementing the PCS statutory mandate in two stages. A notice to all active PCS providers was mailed on November 3, 2009, with instructions on how to comply with the first stage if implementation. Materials requested in the notice should be postmarked no later than November 23, 2009.
The notice to PCS aproviders, required forms, and additional information are available on the PCS PACT review website. Questions may be directed to the PACT Help Line at 1-800-228-3365 or by e-mail to PACTreview@thecarolinascenter.org.
In response to legislated budget reductions, N.C. Medicaid will implement a prior authorization process for certain radiology procedures including CT, MR, PET scans, and ultrasounds.
Dates related to the implementation of prior authorization of high-tech radiology and ultrasound procedures are as follows:
| Date | Procedures | Instructions to Providers |
|---|---|---|
| 10/7/09 10/8/09 10/13/09 10/14/09 10/15/09 10/16/09 10/20/09 10/29/09 11/4/09 |
Online Training Session | Online provider training sessions will be provided at 9:00 a.m. and 1:00 p.m. on each day. Refer to MedSolutions Orientation Session Invitation for information on how to register for the online training sessions. An overview of the Radiology Management Program is available in the Radiology Orientation Presentation. |
| 10/30/09 | Online Training Session | Online provider training sessions will be provided on this day at 10:00 a.m. and 2:00 p.m. |
| 10/19/09 | CT, CTA, MR, MRA, PET | All ordering providers will begin requesting PA for tests scheduled November 1, 2009, and after. |
| 11/01/09 | CT, CTA, MR, MRA, PET | Institutional and Professional claims submitted to EDS for testing performed on November 1, 2009, and after will require PA on file. Outpatient claims will require Revenue Codes and CPT codes on the UB-04 detail. |
| 12/15/09 | Ultrasounds | All ordering providers will begin requesting PA for tests scheduled January 1, 2010, and after. |
| 1/1/10 | Ultrasounds | Institutional and Professional claims submitted to EDS for testing performed on January 1, 2010, and after will require PA on file. Outpatient claims will require Revenue Codes and CPT codes on the UB-04 detail. |
Additional information is available through the MedSolutions website, the Radiology Services web page, and the Medicaid Bulletin.
Beginning September 8, 2009, the N.C. Medicaid Program will begin issuance of one Medicaid identification (MID) card per year to each recipient. The annual cards will be printed on gray card stock.
Because the new gray-colored card will not be issued prior to September 8, 2009, current recipients will be issued an old version (blue, pink, green, or buff-colored) of the monthly card for September. Individuals approved for Medicaid prior to September 8, 2009, will also be issued an old version of the monthly cards. Therefore, during the month of September, providers will continue to see the blue, pink, green, and buff-colored cards and may also begin to see the new gray-colored card. Old monthly cards with September or earlier eligiblity dates will continue to serve as proof of eligibility for the months shown on the card.
Additional information is available through the Medicaid Bulletin:
For information on verifying a recipient's eligibility, refer to the Recipient Eligibility Verification web page.
