November 2000 NC Medicaid Bulletin

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Providers are responsible for informing their billing agency for information in this bulletin.

In this Issue:

All Providers:

Adult Care Home Providers:

Carolina ACCESS Providers:

Durable Medical Equipment Providers:

Independent Practitioner Service Providers:

Nursing Facility Providers:

Optometrists and Opthalmologists:

Outpatient Hospital Providers:




Attention: All Providers
Holiday Observance

The Division of Medical Assistance (DMA) and EDS will be closed on Friday, November 10, in observance of Veteran's Day, and on Thursday, November 23 and Friday, November 24, in observance of Thanksgiving.

EDS, 1-800-688-6696 or 919-851-8888

Attention: All Physicians
Updated Injectable Drug List

The following table is an updated list of FDA approved injectable drugs currently covered by the North Carolina Medicaid program when administered in a physician's office for the FDA approved indications. This list replaces the list published in October, 1999. Newly covered drugs are effective with date of service October 1, 2000. Immunizations that are billed using Current Procedural Terminology (CPT) codes are not included on this list.

Physicians will continue to bill on the HCFA-1500 claim form using the appropriate drug code and indicating the number of units administered. Physicians are to bill their usual and customary charge.

(*) Designates newly covered drugs.
(**) Designates an invoice is required to accompany the HCFA-1500 claim form. Payment is based on the invoice price.
(^^) Designates special pricing.
Procedure Codes Description
  J0130 Abciximab 10 mg
  J1120 Acetazolamide Sodium, up to 500 mg (Diamox) 
  J0150 Adenosine I.V. (Adenocard I.V.) 6 mg.
  J0151 Adenosine (Adenoscan) 90 mg
  J0170 Adrenalin, Epinephrine, up to 1 ml ampule
  Q0156 Albumin Infusion 5%/500ml
  Q0157 Albumin Infusion 25%/50ml
  J0205 Alglucerase, per 10 units (Ceredase)
  J0256 Alpha 1 Proteinase Inhibitor Human A (Prolastin) 10 mg.
  J9015 Aldesleukin (Proleukin, Interleuken II 22 million IU (SDV)
  J2996 Alteplase Recombinant, per 10 mg (Activase)
  J0207 Amifostine 500 mg.
  W5181 Amikacin Sulfate (500 mg)
  J0280 Aminophyllin, up to 250 mg
  J1320 Amitriptyline HCL, up to 20 mg (Elavil, Enovil)
  J0300 Amobarbital, up to 125 mg (Amytal)
  J0285 Amphotericin B (50 mg)
  J0286 Amphotericin B Any Lipid Formulation (50 mg)
  J0295 Ampicillin Sodium/Sulbactam Sodium, per 1.5 gm
  J0290 Ampicillin, up to 500 mg (Omnipen, Polycillin-N, Totacillin-N)
  J0350 Anistreplase, per 30 units (Eminase)
  J7197 Antithrombin II (human) per I.U.
  J0395 Arbutamine HCL (1 mg)
  J9020 Asparaginase, 10,000 units (Elspar)
  J0460 Atropine Sulfate, up to 0.3 mg
  J2910 Aurothioglucose, up to 50 mg (Solganal)
  W5156 Azithromycin, oral suspension 1 unit = 1 gm packet (Zithromax), only oral drug on list
* J0456 Azithromycin, 500 mg. (Zithromax)
  J0475 Baclofen, Kit 1*20 ml. Amp. (10 mg/20ml. 500 meg/ml.)
  W5170 Baclofen, Kit 2*5 ml. Amp. (10 mg./5 ml. 2000 meg./ml.)
  W5169 Baclofen, Kit 4*5 ml. Amp. (10 mg./5ml. 2000 meg./ml.)
  J0476 Baclofen (for intrathecal Trial) 50 mcg
  J9031 BCG (intravesical) per installation (Tice, TheraCys)
  J0510 Benzquinamide HCL, up to 50 mg (Emete-CON)
  J0702 Betamethasone Acetate and Betamethasone Sodium Phosphate, per 3 mg
  J0704 Betamethasone Sodium Phosphate, per 4 mg
  J0520 Bethanechol Chloride up to 5 mg (Urecholine)
** J0190 Biperiden, Akineton 5 mg
  J9040 Bleomycin Sulfate, 15 units (Blenoxane)/2 ml
  J0585 Botulinum toxin type A, per unit
  J0945 Brompheniramine Maleate , 10mg
  J0635 Calcitriol, 1 mcg amp.(Calcijex)
  J0610 Calcium Gluconate, up to 10 ml (Kaleinate)
  J0620 Calcium Glycerophosphate and Calcium Lactate, per 10 ml (Calphosan)
  J9045 Carboplatin, 50 mg (Paraplatin)
  J9050 Carmustine, 100 mg (Bicnu)
  J0690 Cefazolin Sodium, up to 500 mg (Ancef, Kefzol, Zolicef)
  W5185 Cefepime HCL (Maxipime HCL) 500 mg
  J0695 Cefonicid Sodium, 1 gram (Monocid)
  J0698 Cefotaxime Sodium, per gm (Claforan)
  J0694 Cefoxitin Sodium, 1 gm (Mefoxin)
  J0713 Ceftazidime per 500 mg
  J0715 Ceftizoxime Sodium, per 500 mg (Cefizax)
  J0696 Ceftriaxone Sodium, per 250 mg (Rocephin)
  J0697 Cefuroxime Sodium, per 750 mg (Kefurox, Zinacef)
  J1890 Cephalothin Sodium, up to 1 gm (Keflin)
  J0710 Cephapirin Sodium, up to 1 gm (Cefadyl)
  J0720 Chloramphenicol Sodium Succinate, up to 1 gm
  J1990 Chlordiazepoxide HCL, up to 100 mg (Librium)
  J2400 Chlorprocaine HCL 30 ml
  J0390 Chloroquine HCL, up to 250 mg 
  J1205 Chlorothiazide Sodium 500 mg.
  J0730 Chlorpheniramine Maleate, per 10 mg
  J3230 Chlorpromazine HCL, 50 mg (Thorazine, Ormazines)
  J3080 Chlorprothixene, up to 50 mg (Taractan)
  J0725 Chorionic Gonadotropin, per 1,000 usp units
  J0740 Cidofovir 375 mg.
  J0743 Cilastatin Sodium; Imipenem, per 250 mg
  W5176 Cimetadine HCL (Tagamet) (300 mg)
  W5183 Ciprofloxacin (Cipro) 200 mg.
  J9062 Cisplatin, 50 mg (Plantinol, Platinol AQ)
  J9060 Cisplatin, 10 mg (Platinol, Plantinol AQ)
  J9065 Cladribine, per 1 mg (Leustatin)
  J0735 Clonidine Hydrochloride (1 mg)
  J0745 Codeine Phosphate, per 30 mg
  J0760 Colchicine, 1 mg
  J0770 Colistimethate Sodium, up to 150 mg (Coly-Mycin M)
  J0800 Corticotropin, up to 40 units (Acthor, ACTH)
  J0810 Cortisone Acetate, up to 50 mg
  J0835 Cosyntropin, per 0.25 mg (Cortrosyn)
  J3420 Cyanocobalamin, B 12 1000 mcg
  J9096 Cyclophosphamide Lyophilized 1 gm (Cytoxan Lyophilized)
  J9093 Cyclophosphamide Lyophilized, 100 mg (Cytoxan Lyophilized)
  J9091 Cyclophosphamide, 1.0 gm (Cytoxan, Neosar)
  J9070 Cyclophosphamide, 100 mg (Cytoxan, Neosar)
  J9092 Cyclophosphamide, 2.0 gm (Cytoxan, Neosar)
  J9080 Cyclophosphamide, 200 mg (Cytoxan, Neosar)
  J9090 Cyclophosphamide, 500 mg (Cytoxan, Neosar)
  J9094 Cyclophosphamide, Lyophilized, 200 mg (Cytoxan Lyophilized)
  J9095 Cyclophosphamide, Lyophilized, 500 mg (Cytoxan Lyophilized)
  J9097 Cyclophosphamide Lyophilized 2gm
  J9100 Cytarabine 100 mg (Cytosar U)
  J9110 Cytarbine 500 mg
  J9130 Dacarbazine 100 mg 
  J9140 Dacarbazine 200 mg 
  J7513 Daclizumab (Zenapax) 25 mg. 
  J9120 Dactinomycin .5 mg (Cosmegen)
  J1645 Dalteparin (Fragmin) per 2500 I.U./.2 ml. 
  J9150 Daunorubicin HCL, 10 mg (Cerubidine)
  J9151 Daunorubicin Citrate Liposomal 10 mg
  J0895 Deferoxamine, Mesylate 500 mg per 5cc (Deferal)
  W5195 Denileukin Diftitox 9 mcg (Ontak)
  J1000 Depoestradiol Cypionate, up to 5 mg
  J1095 Dexamethasone Acetate 8 mg
  J2597 Desmopression Acetate per 1 mcg
  J1100 Dexamethosone Sodium, up to 4mg/ml
  J1190 Dexrazoxane HCL 250 mg
  J7110 Dextran 75
  J7042 Dextrose/Normal Saline - 5% (500 ml = 1 unit)
  J7070 Dextrose/Water - 5% (1000 cc = 1 unit)
  J7060 Dextrose/Water - 5% (500 ml = 1 unit)
  J3360 Diazepam, up to 5 mg (Valium, Zetran)
  J1730 Diazoxide, up to 300 mg (Hyperstat IV)
  J0500 Dicyclomine HCL up to 20 mg (Bentyl, Dilomine, Antispas)
  J9165 Diethylstilbestrol Diphosphate, 250 mg (Stilphostrol)
  J1160 Digoxin, up to 0.5 mg (Lanoxin)
  J1110 Dihydroergotamine, up to 1 mg
  J0470 Dimecaprol, up to 100 mg
  J1240 Dimenhydrinate, 50 mg
  J1200 Diphenhydramine HCL, up to 50 MG (Benadryl)
  J1245 Dipyridamole, per 10 mg (Persantine IV)
  J1212 DMSO, Dimethyl Sulfoxide, 50%, 50 ml
  J1250 Dobutamine HCL, 250 mg
  J9170 Docetaxel (20 mg)
  J1260 Dolasetron Mesylate (10 mg)
  J9001 Doxil 10 mg/ml
  J9000 Doxorubicin HCL, 10 mg (Adriamycin Rubex)
  J1810 Droperidol and Fentanyl Citrate, up to 2 ml ampule (Innovar)
  J1790 Droperidol, up to 5 mg (Inapsine)
  J1180 Dyphylline, up to 500 mg
  J0600 Edetate Calcium Disodium up to 1000 mg
  J1650 Emoxaparin Sodium (Lovenox) 10 mg
  Q9920 EPO, per 1000 units, Patient HCT 20 or less
  Q9921 EPO, per 1000 units, Patient HCT 21
  Q9922 EPO, per 1000 units, Patient HCT 22
  Q9923 EPO, per 1000 units, Patient HCT 23
  Q9924 EPO, per 1000 units, Patient HCT 24
  Q9925 EPO, per 1000 units, Patient HCT 25
  Q9926 EPO, per 1000 units, Patient HCT 26
  Q9927 EPO, per 1000 units, Patient HCT 27
  Q9928 EPO, per 1000 units, Patient HCT 28
  Q9929 EPO, per 1000 units, Patient HCT 29
  Q9930 EPO, per 1000 units, Patient HCT 30
  Q9931 EPO, per 1000 units, Patient HCT 31
  Q9932 EPO, per 1000 units, Patient HCT 32
  Q9933 EPO, per 1000 units, Patient HCT 33
  Q9934 EPO, per 1000 units, Patient HCT 34
  Q9935 EPO, per 1000 units, Patient HCT 35
  Q9936 EPO, per 1000 units, Patient HCT 36
  Q9937 EPO, per 1000 units, Patient HCT 37
  Q9938 EPO, per 1000 units, Patient HCT 38
  Q9939 EPO, per 1000 units, Patient HCT 39
  Q9940 EPO, per 1000 units, Patient HCT 40
  J1325 Epoprostenol (.5 mg)
  Q0136 Epotin Alpha (for non ESRD use) P/1000 units
  J1330 Ergonovine Maleate, up to 0.2 mg
  J1362 Erythromycin Gluceptate, per 250 mg 
  J1364 Erythromycin Lactobionate, per 500 mg
  J1380 Estradiol Valerate, up to 10 mg
  J1390 Estradiol Valerate, up to 20 mg
  J0970 Estradiol Valerate, up to 40 mg
  J1410 Estrogen Conjugated, per 25 mg (Premarin Intravenuous)
  J1435 Estrone, per 1 mg
  J1436 Etidronate Disodium, per 300 mg (Didronel)
  J9181 Etoposide, 10 mg (Vepesid)
  J9182 Etoposide, 100 mg (Vepesid)
  J3010 Fentanyl Citrate, up to 2 ml (Sublimaze)
  J7190 Factor VIII (anti-hemophilic factor) (human) per IU (Hemofil M) 
  J7191 Factor VIII (anti-hemophilic factor) Porcine per IU
  J7192 Factor VIII (anti-hemophilic factor) Recombinant- per IU
  J7194 Factor IX - (Benefix 1 IU)
  Q0160 Factor IX (Antihemophilic Factor, Purified, non-recombinant) - per I.U.
  Q0161 Factor IX (Antihemophilic Factor, recombinant) - per I.U.
  J1440 Filgrastim , 300 mcg (Neupogen) 
  J1441 Filgrastim , 480 mcg (Neupogen)
  J9200 Floxuridine, 500 mg (FUDR)
  J9185 Fludarabine Phosphate, 50 mg (Fludara)
  J9190 Fluorouracil, 500 mg (Adrucil)
  J2680 Fluphenazine Decanoate, up to 25 mg (Prolixin Decanoate)
  J1455 Foscarnet Sodium, per 1000 mg
  J1940 Furosemide, up to 20 mg (Lasix, Furomide M.D.)
  J1460 Gamma Globulin, Intramuscular, 1 cc
  J1470 Gamma Globulin, Intramuscular, 2 cc
  J1480 Gamma Globulin, Intramuscular, 3 cc
  J1490 Gamma Globulin, Intramuscular, 4 cc
  J1500 Gamma Globulin, Intramuscular, 5 cc
  J1510 Gamma Globulin, Intramuscular, 6 cc
  J1520 Gamma Globulin, Intramuscular, 7 cc
  J1530 Gamma Globulin, Intramuscular, 8 cc
  J1540 Gamma Globulin, Intramuscular, 9 cc
  J1550 Gamma Globulin Intramuscular 10 cc
^^ J1560 Gamma Globulin, Intramuscular, over 10 cc (use correct combinations of services)
  J1570 Ganciclovir Sodium, 500 mg (Cytovene)
  J7310 Ganciclovir, Long-acting Implant (4.5 mg)
  J9201 Gemcitabine HCl. 200 mg
  J1580 Gentamicin (Garamycin Sulfate) 80 mg 
  J1610 Glucagon Hydrochloride, per 1 mg
  J1600 Gold Sodium Thiomaleate, up to 50 mg
  J1620 Gonadorelin Hydrochloride, per 100 mcg
  J9202 Goserelin Acetate Implant, per 3.6 mg (Zoladex)
  J1626 Granisetron Hydrochloride (100 mcg)
  J1631 Haloperidol Decanoate, per 50 mg (Haldol Decanoate - 50 or 100)
  J1630 Haloperidol, up to 5 mg (Haldol)
  J1642 Heparin Sodium, (Heparin Lock Flush), per 10 units
  J1644 Heparin Sodium, per 1000 units
  J9355 Herceptin (Trastuzumab) 10 mg
  J7315 Hyalgan (Sodium Hyaluronate) 20 mg. (Series of 5 weekly injections)
  J3470 Hyaluronidase, up to 150 units (Wydase)
  J0360 Hydralazine HCL, up to 20 mg (Apresoline)
  J2480 Hydrochlorides of Opium Alkaloids, up to 20 mg (Pantopon)
  J1700 Hydrocortisone Acetate, up to 25 mg
  J1710 Hydrocortisone Sodium Phosphate, up to 50 mg
  J1720 Hydrocortisone Sodium Succinate, up to 100 mg
  J1170 Hydromorphone, up to 4 mg (Dilaudid)
  J1739 Hydroxyprogesterone Caproate 125 mg/ml 
  J1741 Hydroxyprogesterone Caproate, 250 mg/ml
  J3410 Hydroxyzine HCL, up to 25 mg (Vistaril, Vistaject-25, Hyzine-50)
  J7320 Hylan G-F 20 (Synvisc) 16 mg/ 2 ml Series of 3 weekly injections
  J1980 Hyoscyamine Sulfate, up to 0.25 mg (Levsin)
  J7130 Hypertonic Saline Solution (50 or 100 meq, 20 cc vial)
  J1742 Ibutilide Fumarate (1 mg.)
  J9211 Idarubicin Hydrochloride, 5 mg
  J9208 Ifosfamide, 1 gm
  J1785 Imiglucerase, per unit (Cerezyme)
** J3270 Imipramine HCL, up to 25 mg (Tofranil)
  J1561 Immune Globulin, Intravenous, per 500 mg (Gammar IV)
  J1745 Infliximab 5 mg (Remicade)
  J1820 Insulin, up to 100 units (Pork Regular)
  J9213 Interferon, Alfa-2A, recombinant, 3 million units (Roferon)
  J9214 Interferon, Alfa-2B, Recombinant, 1 million units (Intron A)
  J9215 Interferon, Alfa-N3, 250,000 IU
  J9212 Interferon, Alfacon-1, Recombinant, 1 mcg
  J9216 Interferon, Gamma 1-B, 3 million units (Actimmune)
  J9206 Irinotecan (20 mg)
  J1750 Iron Dextran, Infed 50 mg
  J1840 Kanamycin Sulfate, 500 mg (Kantrex, Klebcil)
  J1850 Kanamycin Sulfate, 75 mg (Kantrex, Klebcil)
  J1885 Ketorolac Tromethamine, per 15 mg (Toradol)
  J1910 Kutapressin, up to 2 ml
  J0640 Leucovorin Calcium, per 50 mg
  J9217 Leuprolide Acetate (for depot suspension), 7.5 mg (Lupron)

(22.5 mg allowed for DX 185 only)

  J1950 Leuprolide Acetate (for depot suspension), per 3.75 mg (Lupron)
Leuprolide Acetate (for depot suspension), per 11.25 mg(Lupron) (3 months)
  J9218 Leuprolide Acetate, per 1 mg (Lupron)
  J1955 Levocarnitine per 1 gm
  J1956 Levofloxacin (250 mg)
  J1960 Levorphanol tartrate, up to 2 mg
  J2000 Lidocaine HCL, 50 cc
  J2010 Lincomycin HCL, up to 300 mg (Lincocin)
  J2060 Lorazepam, 2 mg (Ativan) 
  W5128 Lupron Depot Pediatric 11.25 mg
  W5129 Lupron Depot Pediatric 15 mg
  W5127 Lupron Depot Pediatric 7.5 mg
  J3475 Magnesium Sulfate, 500 mg, injection
  J2150 Mannitol, 25% in 50 ml
  J9230 Mechlorethamine Hydrochloride (Nitrogen Mustard), 10 mg
  J1055 Medroxyprogesterone Acetate for Contraceptive Use, 150 mg (Depo-Provera)
  J1050 Medroxyprogesterone Acetate, 100 mg (Depo-Provera)
  J9245 Melphalan Hydrochloride 50 mg (Alkeran)
  J2180 Meperidine and Promethazine HCL, up to 50 mg (Mepergan Injection)
  J2175 Meperidine Hydrochloride, per 100 mg (Demerol HCL)
  J3450 Mephentermine, up to 30 mg
  J0670 Mepivacaine (Carbocaine) 10 ml
  J9209 Mesna, 200 mg (Mesnex)
  J0380 Metaraminol Bitartrate 10 mg (Aramine)
  J1230 Methadone HCL, up to 10 mg
  J2970 Methicillin Sodium, up to 1 gm (Staphcillin)
  J2800 Methocarbamol, up to 10 ml (Robaxin)
  J9250 Methotrexate Sodium, 5 mg
  J9260 Methotrexate Sodium, 50 mg
  J1970 Methotrimeprazine, up to 20 mg
  J3390 Methoxamine, up to 20 mg (Vasoxyl)
  J0210 Methyldopate HCL, up to 250 mg (Aldomet)
  J2210 Methylergonovine Maleate, up to 0.2 mg (Methergine)
  J1020 Methylprednisolone Acetate, 20 mg (Depo Medrol)
  J1030 Methylprednisolone Acetate, 40 mg
  J1040 Methylprednisolone Acetate, 80 mg
  J2930 Methylprednisolone Sodium Succinate, up to 125 mg (SoluMedrol, Anetha Pred)
  J2920 Methylprednisolone Sodium Succinate, up to 40 mg (Solu Medrol, Anetha Pred)
  J2765 Metoclopramide HCL, up to 10 mg (Reglan)
  J2250 Midozolem HCL (Versed) per 1 mg
  J2260 Milrinone Lactate, per 5 ml (Primacor)
  J9290 Mitomycin, 20 mg (Mutamycin)
  J9291 Mitomycin, 40 mg (Mutamycin)
  J9280 Mitomycin, 5 mg (Mutamycin)
  J9293 Mitoxantrone Hydrochloride, per 5 mg (Novantrone)
  J2275 Morphine Sulfate (preservative-free sterile solution), per 10 mg
  J2270 Morphine Sulfate, up to 10 mg
  J2271 Morphine Sulfate (100 mg)
  J2310 Nalaxone Hydrochloride (Narcan) per 1 mg
  J2300 Nalbuphine Hydrochloride, 10 mg
  J2321 Nandrolone Decanoate, up to 100 mg
  J2322 Nandrolone Decanoate, up to 200 mg
  J2320 Nandrolone Decanoate, up to 50 mg
  J0340 Nandrolone Phenpropionate, up to 50 mg (Duradolin)
  J9390 Navelbine 10 mg
  J2710 Neostigmine Methylsulfate, up to 0.5 mg (Prostigmine)
  J7030 Normal Saline Solution, 1000 cc, infusion
  J7050 Normal Saline Solution, 250 cc, infusion
  J7040 Normal Saline Solution, Sterile (500 ml=1 unit), infusion
  J2405 Ondansetron Hydrochloride, per 1 mg (Zofran)
  J2355 Oprelvekin (Newmega) 5 mg
  J2360 Orphenadrine Citrate, up to 60 mg
  J2700 Oxacillin Sodium, up to 250 mg (Bactocile, Prostaphlin)
  J2410 Oxymorphone HCL, up to 1 mg
  J2460 Oxytetracycline HCL, up to 50 mg (Terramycin IM)
  J2590 Oxytocin, 10 units/1ml (Pitocin, Syntocinon)
  J9265 Paclitaxel, 30 mg (Taxol) 
  J2430 Pamidronate Disodium, per 30 mg (Aredia)
  J2440 Papaverine HCL, up to 60 mg
  J9266 Pegaspargase (Onscospar) Single Dose vial (5 ml/ SDV)
  J0540 Penicillin G Benzathine and Penicillin G Procaine, up to 1,200,000 units
  J0550 Penicillin G Benzathine and Penicillin G Procaine, up to 2,400,000 units
  J0530 Penicillin G Benzathine and Penicillin G procaine, up to 600,000 units
  J0570 Penicillin G Benzathine, up to 1,200,000 units (Bicillin L-A, Permapen)
  J0580 Penicillin G Benzathine, up to 2,400,000 units (Bicillin L-A, Permapen)
  J0560 Penicillin G Benzathine, up to 600,000 units (Bicillin L-A, Permapen)
  J2540 Penicillin G Potassium, up to 600,000 units
  J2510 Penicillin G Procaine, Aqueous, up to 600,000 units
** J2512 Pentagastrin, per 2 ml (Peptavlon)
  J2545 Pentamidine (Pentam 300)
  W5192 Pentamidine Isethionate, 300 mg
  J3070 Pentazocine HCL, up to 30 mg (Talwin)
  J2515 Pentobarbital Sodium (Nembutal Sodium Solution) 50 mg
  J9268 Pentostatin, 10 mg
  J2543 Piperacillin Sodium 4 gm (Pipracil)
  J3310 Perphenazine, up to 5 mg (Trilafon)
  J2560 Phenobarbital Sodium, up to 120 mg
  J2760 Phentolamine Mesylate, up to 5 mg (Regitine)
  J2370 Phenylephrine HCL, up to 1 ml (NeoSynephrine)
  J1165 Phenytoin Sodium (Dilantin)
  J9270 Plicamycin, (Mithracin) 2.5 mg
  J9600 Porfimer Sodium (75 mg)
  J3480 Potassium Chloride 2 meq. 
  J2730 Pralidoxime Chloride, up to 1 gm (Protopam Chloride)
  J2650 Prednisolone Acetate, up to 1 ml
  J2640 Prednisolone Sodium Phosphate, to 20 mg
  J1690 Prednisolone Tebutate, up to 20 mg
  J2690 Procainamide HCL, up to 1 gm (Pronestyl)
  J0780 Prochlorperazine Edisylate 10 mg Compazine, Cotranzine, Compa-Z, Ultrazine-10
  J2675 Progesterone, per 50 mg
  J2950 Promazine HCL, up to 25 mg (Sparine, Prozine-50)
  J2550 Promethazine HCL, up to 50 mg (Phenergan, Phenazine)
  J1930 Propiomazine HCL, up to 20 mg
  J1800 Propranolol HCL, up to 1 mg (Inderal)
  J2720 Protamine Sulfate, per 10 mg
  J2725 Protirelin, per 250 mg
  J2780 Rantidine (Zantac) 25 mg.
  J2994 Reteplase (37.6 mg/ 2 SDV)
  J7120 Ringers Lactate Infusion, up to 1000 cc
  J9310 Rituximab (Rituxan) 100 mg./ 10ml.
  W5198 Sandostatin (Octreotide Acetate) 50 mcg
* J2352 Sandostatin (Octreotide Acetate) LAR Depot 1 mg (10 or 20 mg) (30 mg. ^^)
  J2820 Sargramostim (GM-CSF), (Leukine, Prokine) 50 mcg
  J2860 Secobarbital Sodium, up to 250 mg (Seconal)
  Y1856 Sodium Bicarbonate 7.5% up to 50 ml
  J2912 Sodium Chloride 9% per ml
  J3320 Spectinomycin-Dihydrochloride, up to 2 gm (Trobicin)
  X1270 Stadol
  J7051 Sterile Saline or Water (up to 5cc)
  J2995 Streptokinase, per 250,000 IU
  J3000 Streptomycin 1 gm
  J9320 Streptozocin, 1 gm (Zanosar)
  J0330 Succinycholine Chloride, up to 20 mg (Anectine, Quelicin, Surostrin)
  J9170 Taxotere 20 mg
  J3105 Terbutaline Sulfate, up to 1 mg (Brethine)
  J1060 Testosterone Estradiol Cypionate, 50 mg
  J1080 Testosterone Estradiol Cypionate, 200 mg
  J1090 Testosterone Cypionate, 50 mg
  J1070 Testosterone Estradiol Cypionate, 100 mg
  J0900 Testosterone Enanthate and Estradiol Valerate 1 cc
  J3120 Testosterone Enanthate, 100 mg
  J3130 Testosterone Enanthate, 200 mg
  J3150 Testosterone Propionate, 100 mg
  J3140 Testosterone Suspension, 50 mg
** J0120 Tetracycline, up to 250 mg (Achromycin)
  J3280 Thiethylperazine Maleate, 10 mg (Norzine, Torecan)
  J9340 Thiotepa Triethylenthiophosphoromide, 15 mg
  J2330 Thiothixene, up to 4 mg (Navane)
  J3240 Thyrotropin Alfa (Thyrogen) 0.9 mg
  J3260 Tobramycin Sulfate, up to 80 mg (Nebcin)
  J9350 Topatecan (4 mg.)
  J3265 Torsemide 10 mg/ml
  J2670 Tolazoline HCL, up to 25 mg (Priscoline HCL)
  J3301 Triamcinolone Acetonide, per 10 mg
  J3302 Triamcinolone Diacetate, per 5 mg
  J3303 Triamcinolone Hexacetonide, per 5 mg
  J3400 Triflupromazine HCL, up to 20 mg
  J0400 Trimethapan Camsylate up to 500 mg 
  J3250 Trimethobenzamide HCL, up to 200 mg (Tigan)
  J3305 Trimetrexate Glucoronate 25 mg
  J3350 Urea, up to 40 gm
  J3365 Urokinase, 250,000 i.u. vial 
  J3364 Urokinase, 5000 iu vial 
  J9357 Valstar (Valvubicin) 200 mg
  J3370 Vancomycin HCL, up to 500 mg
  J9360 Vinblastine Sulfate, 1 mg
  J9370 Vincristine Sulfate, 1 mg (Oncovin, Vincasar PFS)
  J9375 Vincristine Sulfate, 2 mg 
  J9380 Vincristine Sulfate, 5 mg (Oncovin, Vincasar PFS)
  J3430 Vitamin K, Phytonadione 1 mg/0.5ml
  J2500 Zemplar (Paricalcitol) 5 mcg

EDS, 1-800-688-6696 or 919-851-8888

Attention: All Providers
Facsimiles and Electronic Signatures

Facsimiles (FAXes) and electronic signatures that meet the Division of Medical Assistance (DMA) requirements listed below are acceptable for supporting Medicaid claims. This policy does not exempt a provider from meeting licensure, certification, enrollment, and accreditation requirements, or other legal and regulatory requirements.

Fax Copies

Providers may furnish FAX copies of physicians' orders and certifications for Medicaid services, provided prior arrangements for sending FAX information have been made. (Unsolicited items faxed to EDS may not reach the appropriate destination.) Although providers are not required to have original physician signatures on file, it is the provider's responsibility to produce the document with the original signature in the event that additional information is needed during a review of documentation related to the Medicaid claim.

Electronic Signatures

Providers that maintain patient records by computer rather than hard copy may use electronic signatures on valid supporting documentation for Medicaid claims if such entries are appropriately authenticated and dated. The following requirements apply:

EDS, 1-800-688-6696 or 919-851-8888

Attention: All Providers
Coverage of Atrial Septectomy or Septostomy

Effective with dates of service April 1, 2000, North Carolina Medicaid began covering CPT codes 92992, atrial septectomy or septostomy, transvenous method; and 92993, atrial septectomy or septostomy, blade method.

Providers who have received denial code 009 on procedure code 92992 or 92993 for dates of service April 1, 2000 to present may request an adjustment through the adjustment section at EDS.

EDS, 1-800-688-6696 or 919-851-8888

Attention: Nursing Facility Providers
Preadmission Screening and Annual Resident Review (PASARR)

Effective January 1, 2001, all nursing facility residents must have a First Health Services (formerly First Mental Health) PASARR number. Residents who were "grandfathered" in with PASARR forms used prior to February 1994, must be screened and receive a PASARR number from First Health Services (FHS) by the effective date.

Tracking forms must be sent to FHS for all new admissions in order for the receiving facility to obtain a copy of the Level I and, if appropriate, the Level II results. Level I and Level II documentation must be kept in the resident's medical record.

FHS authorization numbers end with an "alpha" character. The following is an explanation of the alpha characters:

A     Nursing facility placement appropriate, does not meet target population for mental illness (MI), mental retardation (MR), or related condition (RC).

B     Nursing facility placement appropriate, no specialized services required. An annual resident review is required.

C     Nursing facility placement appropriate, specialized services required. An annual resident review is required.

D     Represents 7-day time-limited approvals.

E     Represents 30-day time-limited approvals.

F     Represents 60-day time-limited approvals.

J     Residents approved for admission only to state psychiatric hospitals.

Z     Denial for placement in a nursing facility.

NOTE: The D, E, and F alphas indicate time-limited stays and the EDS prior approval number (PA) for level of care is also time-limited. Payment will be denied when the PA number is end-dated. Residents who have PASARR numbers with these alpha characters must be closely monitored. If a resident needs to remain in the facility beyond the specified time limit, a Level II screening must be initiated through FHS. Payment will be denied for each day past the time-limited stay. For time-limited stays E and F, a new FL2 must be submitted to EDS as soon as the facility receives the new PASARR number.

Margaret O. Langston, RN, Institutional Services, Medical Policy Section
DMA, 919-857-4020

Attention: All Providers
Electronic Funds Transfer

EDS currently offers Electronic Funds Transfer (EFT) as an alternative to paper check issuance. EFT enables the receipt of Medicaid payments through automatic deposit at a bank while the provider continues to receive the Remittance and Status Report (RA) at the current mailing address. This process guarantees payment in a timely manner and prevents checks from being lost or stolen.

Frequently Asked Questions about Automatic Deposit:

Q.    What is the automatic deposit process?
A.     EDS generates a list of deposits on an electronic wire, which represents payments to providers who have chosen automatic deposit. This electronic wire is sent to the Federal Reserve Bank, which makes the transactions to the providers' bank. Simultaneously, the EDS account is debited for the funds.

Q.     What are the advantages to automatic deposit?
A.     The major advantage is that automatic deposit eliminates needless worry about check delays and checks lost in the mail. It generally takes 2 to 3 weeks to reissue a lost check.

Q.     How do I enroll for EFT?
A.     Providers must complete an EFT Agreement form. A copy of the form follows this article or can be obtained by calling EDS at 1-800-688-6696 (select option "1"). The form is also available online at A separate form must be completed for each provider number your organization plans to enroll. A deposit slip or voided check for each bank account must be attached to verify the account number and bank transit number.

Q.     Where do I send my completed forms?
A.     Mail completed form along with a deposit slip or voided check for each bank account to:

EDS, 4905 Waters Edge Dr., Raleigh, NC 27606, ATT: Finance-EFT
Or fax to: EDS, ATT: Finance-EFT, 919-859-9703

Q.     How will I know when my form has been processed and direct deposit begins?
A.     The last page of the RA indicates the method of payment for that checkwrite. A "check number" or an "EFT number" is indicated in the top left corner beneath the provider number.

Q.     When will funds be deposited into my account?
A.     Funds are automatically deposited within four days of the checkwrite date. Refer to the back of the Medicaid Bulletin for each month's checkwrite dates.

Q.     How can I be sure my bank received the money?
A.     Once EDS initiates the transfer, it is each individual bank's responsibility to receive the funds and post them to your account. Transfers can be confirmed by calling your bank's automatic clearinghouse department. The bank will need your account number, the checkwrite date, and the amount of money EDS paid on the checkwrite date. The transfer amount can be obtained by calling the Automated Voice Response System at 1-800-723-4337.

Q.     How do I report changes in my banking service?
A.     Providers must complete and submit a new EFT agreement with the new information. Providers receive paper checks during the interim period of two checkwrites before automatic deposit begins to the new account.

Q.     Will recoupments ever be withdrawn from my bank account?
A.     No. EFT cannot withdraw money from your account. It can only make deposits to your account.

Q.     What if I have a question or concern regarding my automatic deposit?
A.     EDS will be glad to address any questions or concerns regarding automatic deposit. You may contact Provider Services by calling 1-800-688-6696.

EDS, 1-800-688-6696 or 919-851-8888

Electronic Funds Transfer (EFT) Form

Attention: Nursing Facility Providers
Utilization Review

Effective January 1, 2001, all Utilization Review (UR) FL2 forms must have a First Health Services (formerly First Mental Health) Preadmission Screening and Annual Resident Review (PASARR) number documented in block 10. Recommended level of care (LOC) changes will not be processed and approved if the PASARR number is not on the FL2.

All UR FL2s and their transmittal sheets (FL12s) must be mailed to the Division of Medical Assistance (DMA). Note below the appropriate DMA mailing addresses for UR FL2 and FL12 forms:
Division of Medical Assistance
Medical Policy 
2511 Mail Service Center
Raleigh, NC 27699-2511
ATTN: Utilization Review
Division of Medical Assistance
Medical Policy 
1985 Umstead Drive
Raleigh, NC 27603
ATTN: Utilization Review

The correct prior approval (PA) number and current LOC must be documented on the UR FL2. (If you are unsure of the correct number, check with your nursing facility billing office or call the resident's county of eligibility.)

If you have a UR LOC change request already in the UR process, do not call EDS for an LOC change and new PA number. This will result in denial of payment if the incorrect PA number is used on the claim.

The correct and complete responsible party's name and address and the correct and complete attending physician's name and address must be noted on the UR FL2. When this information is incomplete, staff at DMA and Medical Review of North Carolina must contact the nursing facility to obtain the correct information, causing a delay in the facility receiving approval for LOC recommendations as well as a delay in appropriate payment. In addition, if the LOC change letter is sent to the incorrect responsible party or address, letters may be received late, interfering with the resident's right to appeal.

When a resident or responsible party appeals a LOC change, the resident must remain at the LOC until the hearing is held and a decision is made by the hearing officer. Do not submit a LOC change through EDS PA or DMA UR for a resident who has requested an appeal. If there is a major change in the resident's condition, the resident is hospitalized or the resident expires, you must notify the DMA Hearing Office at 919-857-4016.

Utilization Review, Medical Policy Section
DMA, 919-857-4020

Attention: All Providers
Mail Service Center Addresses

Effective January 2, 2001, all mail to the Division of Medical Assistance (DMA) must be addressed to the appropriate Mail Service Center address. Mail sent to any address other than the Mail Service Center addresses will not be forwarded and will be returned to the sender. Refer to the table below for DMA's Mail Service Center addresses.

UPS, FEDEX, Airborne, and other freight companies will continue to deliver to DMA's physical address, 1985 Umstead Drive, Raleigh NC, 27626. Include the DMA employee's name and section with the address to ensure that the delivery is routed correctly.

If you are using forms that have not been updated with DMA's Mail Service Center addresses, refer to the table below for the correct Mail Service Center address.
Administration and Regulatory Affairs
Division of Medical Assistance
2504 Mail Service Center
Raleigh, NC 27699-2504
Division of Medical Assistance
2507 Mail Service Center
Raleigh, NC 27699-2507
Carolina ACCESS; Managed Care
Division of Medical Assistance
2516 Mail Service Center
Raleigh, NC 27699-2516
Claims Analysis and Medicare Buy-In
Division of Medical Assistance
2519 Mail Service Center
Raleigh, NC 27699-2519
Community Care
Division of Medical Assistance
2502 Mail Service Center
Raleigh, NC 27699-2502
DHHS Accounts Receivable
Division of Medical Assistance
2022 Mail Service Center
Raleigh, NC 27699-2022
Director or Deputy Director
Division of Medical Assistance
2517 Mail Service Center
Raleigh, NC 27699-2517
Eligibility Unit
Division of Medical Assistance
2512 Mail Service Center
Raleigh, NC 27699-2512
Financial Operations
Division of Medical Assistance
2509 Mail Service Center
Raleigh, NC 27699-2509
Hearing Office
Division of Medical Assistance
2505 Mail Service Center
Raleigh, NC 27699-2505
Information Services
Division of Medical Assistance
2514 Mail Service Center
Raleigh, NC 27699-2514
Mail Management
Division of Medical Assistance
2513 Mail Service Center
Raleigh, NC 27699-2513
Medicaid Mgt. Info. System (MMIS)
Division of Medical Assistance
2510 Mail Service Center
Raleigh, NC 27699-2510
Medical Policy/Utilization Control
Division of Medical Assistance
2511 Mail Service Center
Raleigh, NC 27699-2511
Program Integrity
Division of Medical Assistance
2515 Mail Service Center
Raleigh, NC 27699-2515
Provider Services
Division of Medical Assistance
2506 Mail Service Center
Raleigh, NC 27699-2506
Quality Control
Division of Medical Assistance
2518 Mail Service Center
Raleigh, NC 27699-2518
Third Party Recovery or Health Insurance Premium Payment Program (HIPP)
Division of Medical Assistance
2508 Mail Service Center
Raleigh, NC 27699-2508

If you do not know which DMA section or unit's address to use, send your correspondence to the following general address:

(Name of DMA employee)
Division of Medical Assistance
2501 Mail Service Center
Raleigh, NC 27699-2501
Clarence Rogers, Financial Operations
DMA, 919-857-4015

Attention: Carolina ACCESS Providers
Office Wait Times for Carolina ACCESS Primary Care Providers

Effective November 1, 2000, all Carolina ACCESS primary care providers (PCPs) must adhere to the following office-wait time limits:

  1. Walk-in Appointment - within two (2) hours

  2. (The walk-in patient should be triaged and treated according to practice protocol and severity of condition. If the condition warrants a visit with the medical provider that day, the wait should not exceed two (2) hours).
  3. Scheduled Appointment - within one (1) hour
  4. Life-threatening Emergencies - must be managed immediately
Carolina ACCESS PCPs should keep their enrollees apprised of their office policies and standards. PCPs may advise enrollees of their obligations to be punctual and to keep scheduled appointments.

Program Operations, Managed Care Section
DMA, 919-857-4022

Attention: All Providers
Renovation of the MMIS System - Identification Tracking Measurement Enhancement (ITME) Project

The Division of Medical Assistance (DMA) is upgrading and enhancing the Medicaid Management Information System (MMIS). The goals of the renovation, as noted in the April, 2000 Bulletin, are:

The enhancements will include minimal changes to the Remittance and Status Advice (RA), submission of adjustment requests, prior approval, and voice response and eligibility verification systems.

Changes to the following parts are detailed in the Provider Impact section of this article.

Part I - Remittance and Status Advice
Part II - Adjustment Requests - NEW FORM
Part III - Prior Approval (PA)
Part IV - Automated Voice Response (AVR) System and Eligibility Verification System (EVS)

Implementation Schedule

Updated Implementation Date: The implementation of system changes for the ITME project has been extended to February 9, 2001. The revised date of February 9, 2001 supercedes the original implementation date reflected in the September and October, 2000 ITME bulletin articles. Please note that all references to effective dates in the remainder of this article have been revised to reflect the extended date of February 9, 2001.

The RA will reflect the changes noted in Part I beginning February 9, 2001. Part II reflects the new N.C. Medicaid adjustment form. Use of this form is required as of February 9, 2001. Part III provides new instructions for submitting services that have been prior approved. Part IV addresses changes to the AVR System and EVS resulting from this enhancement.
Provider Impact
Part I: Remittance and Status Advice (RA) - See Example 1

RA modifications/format changes will be kept to only those that are necessary in conjunction with the ITME project. Overall, the RA will look very similar to the current format. Please note the format changes on the RA sample following this article (Example 1).

Addition of Financial Payer Code

A financial payer code follows the claim internal control number (ICN) in the first line of the claim data reflected on the RA. This financial payer code denotes the entity responsible for payment of the claims listed on the RA. Upon implementation, N.C. Medicaid will be the only financially responsible payer; therefore, the N.C. Medicaid payer code of NCXIX (five characters) will be reflected.

Addition of Population Group Payer Code

The RA reflects the population payer code for each claim detail. The population payer code is printed at the beginning of each claim detail line on the RA. The population payer code denotes the special program/population group from which a recipient is receiving Medicaid benefits. Examples of population payer codes are as follows:
Code Name Description
CA-I Carolina ACCESS All recipients enrolled in Medicaid's Carolina ACCESS program
CA-II ACCESS II All recipients enrolled in Medicaid's ACCESS II program
CAB ACCESS III - Cabarrus County All recipients enrolled in Medicaid's ACCESS III program for Cabarrus County
PITT ACCESS III - Pitt County All recipients enrolled in Medicaid's ACCESS III program for Pitt County
HMOM Health Management Organization (HMO) All recipients enrolled in Medicaid's HMO program
NCXIX Medicaid All recipients not enrolled in any of the above noted population payer programs. Any recipient not identified with Carolina ACCESS, ACCESS II, ACCESS III, or HMO will be assigned the NCXIX population payer code to identify them with the Medicaid fee-for-service program.

Other population payers may be designated by DMA in the future.

Addition of new totals following the current claim total line
An additional line is added following each claim total line of the paid and denied claim sections of the RA for the following claim types: Medical (J), Dental (K), Home Health, Hospice and Personal Care (Q), Medical Vendor (P), Outpatient (M), and Professional Crossover (O). This additional line reflects original claim billed amount, original claim detail count, and total number of financial payers. Upon implementation February, 2001, N.C. Medicaid will be the only financial payer; these new totals will reflect the submitted claim totals.

These additional totals do not appear for claim types Drug (D), Inpatient (S), Nursing Home (T), and Medicare Crossover (W) since they are not processed at the claim detail level and will not have multiple financial payers assigned, based on current N.C. Medicaid billing policy.

Addition of a new summary page at end of RA
For each Medicaid population payer identified on the paper RA, a new summary page showing total payments by population payer is provided at the end of the RA. This provides population payer detail information for tracking and informational purposes.

New specifications for Tape RA
Updated specifications have been mailed to all Tape RA Providers. If you are currently receiving a Tape RA and have not received the updated specifications, or have questions regarding the changes, please contact Glenda Raynor, Manager of EDS Electronic Commerce Services, at 919-851-8888 extension 5-3099.

Part II: Adjustment Requests - NEW FORM (Example 2)

The N.C. Medicaid program will begin using a new RA format in February, 2001. This new format affects the way adjustment request forms are completed by the provider and processed by EDS. The appropriate "financial payer" information found on the new RA will be required on all adjustment request forms after February 9, 2001. DMA and EDS have implemented a new adjustment request form to help with these changes. One of the predominant changes is in the "claim number" field. This area is now identified with twenty boxes, each box for one number of the referenced claim number. Until February 9, 2001, there will be five empty boxes at the end of the claim number. After the February 9, 2001 implementation of the MMIS enhancements, these spaces will be used for the financial payer code information. Providers may begin using this new adjustment request form now if it facilitates implementing these changes. (Refer to example of claim field below.) Please contact EDS Provider Services with questions about the new format and processing of an adjustment request.

Claim # field on Adjustment form from RA prior to February 9, 2001:
Claim #:
# # # # # # # # # # # # # # #
Claim # field on Adjustment form from RA after February 9, 2001:
Claim #:
# # # # # # # # # # # # # # # N C X I X
Part III: Prior Approval (PA)

Effective February 9, 2001, entering the prior approval number on the claim form by the provider to receive payment for services rendered will no longer be required. This holds true for all prior approved Medicaid services, regardless of the entity giving the prior approval.

Prior approval requirements and the criteria for approval of services have not changed. Those services that previously required prior approval before the implementation of the enhanced MMIS will continue to require prior approval. If a service was approved prior to February 9, 2001 but was not provided or billed until after February 9, 2001, the original prior approval is still valid. The MMIS will verify that prior approval was obtained before claims payment can occur. If the services being submitted on the claim form require prior approval, and approval has not been obtained, that claim will be denied. The only change is that the input of the prior approval number is no longer required on the claim form by the provider as of February 9, 2001.

Part IV: Automated Voice Response (AVR) System and Eligibility Verification System (EVS)

These systems will be enhanced with new messages that will explain under which special Medicaid program or programs a recipient is enrolled as a participant. Additional information regarding these system enhancements will be provided in subsequent bulletin articles.

EDS, 1-800-688-6696 or 919-851-8888

Remittance and Status Advice Samples

Medicaid Claim Adjustment Request Form

Attention: Outpatient Hospital Providers
Billing Outpatient Diabetes Self-Management Training

Outpatient hospital providers who meet the requirements for "Certificate of Recognition" from the American Diabetes Association may bill for Outpatient Diabetes Self-management Training. Refer to the November 1999 North Carolina Medicaid Bulletin for additional information. Revenue code (RC) 942 and the appropriate CPT code 99404, individual counseling, or 99412, group counseling, must be used to bill the service. North Carolina Medicaid covers RC 942 only for Diabetes Self-management Training.

If you received claim denials for dates of service on or after November 1, 1999 that stated the service is noncovered, refile the claim using the appropriate RC and CPT code combination.

EDS, 1-800-688-6696 or 919-851-8888


Attention: All Providers
Tax Identification Information

Alert - Tax Update Requested

North Carolina Medicaid must have the proper tax information for all providers. This ensures correct issuance of 1099 MISC forms each year and that the correct tax information is provided to the IRS. Inappropriate information on file can result in the IRS withholding 31% of a provider's Medicaid payments. Be sure the individual responsible for maintenance of tax information receives the following information.

How to Verify Tax Information

The last page of the Medicaid Remittance and Status Advice (RA) indicates the provider tax name and number that Medicaid has on file. Refer to the Medicaid RA throughout the year for each provider number to ensure Medicaid has the correct tax information on file. The tax information needed for a group practice is as follows: (1) Group tax name and group tax number (2) Attending Medicaid provider numbers in the group. If a Medicaid RA is needed, call EDS Provider Services 919-851-8888 or 1-800-688-6696 to verify the tax information on file for each provider number.

Providers should complete a Special W-9  for all provider numbers with incorrect information on file. Instructions for completing the Special W-9 are listed below.

Send Completed and Signed Forms by December 8, 2000 to:

4905 Waters Edge Drive
Raleigh, NC 27606
Attention: Provider Services

FAX to 919-851-4014
Attention: Provider Services

Change of Ownership
Contact DMA Provider Services at 919-857-4017 to report all changes in business ownership. If necessary, a new Medicaid provider number will be assigned and Provider Services will ensure the correct tax information is on file for Medicaid payments.

If DMA is not contacted and the incorrect provider number is used, that provider will be liable for taxes on income not necessarily received by the provider's business. DMA will assume no responsibility for penalties assessed by the IRS or for misrouted payments prior to written receipt of notification of ownership changes.

Group Practice Changes
When a physician leaves or a physician is added to a group practice, contact DMA Provider Services to update Medicaid enrollment and tax information.

Remember, without notifying DMA Provider Services, the incorrect tax information could remain on file and your business could become liable for taxes on Medicaid payments you did not receive.

EDS, 1-800-688-6696 or 919-851-8888

Special W-9 Form

Attention: All Providers
PCG Medicare Recoupment Mailouts

During the month of October, Public Consulting Group, Inc. (PCG) and the Division of Medical Assistance, Third Party Recovery Section forwarded to hospitals a list of Medicare claims with a December 31, 2000 filing deadline date. A separate mailing will be issued for Medicare claims with a December 31, 2001 filing deadline date.

Please direct all questions to Jennifer Malchak with PCG.

Jennifer Malchak
PCG, 1-800-372-0878


Attention: Nursing Facility Providers
Level of Care Monitoring

Each month a sample of the Utilization Review (UR) FL2s received at the Division of Medical Assistance (DMA) is sent to Medical Review of North Carolina (MRNC), the contractor for level of care (LOC) monitoring. DMA has recently increased the sample number. Therefore, nursing facilities can expect the UR FL2s to be reviewed several times a year.

MRNC nurses review the sample FL2s to determine if the LOC recommended by the UR Committee is appropriate to meet the resident's needs. (This process is outlined in Chapter Seven of the June 2000 Nursing Facility provider manual.) When the documentation on the FL2 is not consistent with the LOC, MRNC will request medical records for the most recent thirty (30) days. If MRNC changes the LOC, written notification will be forwarded to the nursing facility. The new prior approval number will appear in the upper right corner of the notification letter. A copy of the FL2 will not be mailed with the notification letter.

Utilization Review, Medical Policy Section
DMA, 919-857-4020


Attention: Nursing Facility Providers
Discharge of a Nursing Facility Resident

When a nursing facility resident requires hospitalization, the nursing facility provider must indicate a Discharge Status in form locator 22 and a Discharge Bill Type in form locator 4 on the UB-92 claim form. (Bill Types and Discharge Status Codes are noted in Chapter Eight of the June 2000 Nursing Facility provider manual.)

Payments made to nursing facilities for claims billed with the incorrect bill type will be recouped.

EDS, 1-800-688-6696 or 919-851-8888

Attention: All Prescribers
Conversion from UPIN Numbers to DEA Numbers on Pharmacy Prescriptions and Claims

The Division of Medical Assistance (DMA) is now requiring DEA numbers on all recipient pharmacy claims instead of UPIN numbers. Providers must have their DEA registration number on file. Failure to do so may result in denied claims. If a prescriber does not have a DEA number and needs to issue prescriptions to recipients served by the Medicaid program, the prescriber should contact the DUR Section at 919-733-3590.

An identification number (ID) will be issued in lieu of the DEA number. The ID number, following the same format as the DEA number, will always begin with a Z (for example, ZF1234567). Prescribers will need to enter this number on their Medicaid prescriptions. This number is referred to as a MEDICAID IDENTIFICATION NUMBER only and should not be referred to as a DEA number.

If EDS Provider Enrollment does not have your updated information, please copy, complete, and return the DEA Number form for each prescriber in your practice. Please send the information to the following address:

EDS Provider Enrollment Unit
P.O. Box 300009
Raleigh, North Carolina 27622
FAX, 919-851-4014

EDS, 1-800-688-6696 or 919-851-8888

DEA Number form:

Sharman Leinwand, DUR Coordinator, Program Integrity Section
DMA, 919-733-3590 ext. 229

Attention: Carolina ACCESS Providers
Changes Made within Your Practice

Carolina ACCESS (CA) primary care providers (PCPs) must communicate all pertinent changes made within the practice to the local Managed Care Representative. Changes may involve hospital admitting privileges, the CA contact person for the office, new office hours, new providers added to the practice, etc. The Managed Care Representative will notify the Division of Medical Assistance (DMA) Managed Care Section, and the change will be made to the CA application and agreement on file. If information is needed regarding the best way to contact your Managed Care Representative, please call the DMA Managed Care Section at 919-857-4022.

Kirby Ferguson, Managed Care Section
DMA, 919-857-4022

Attention: Carolina ACCESS Primary Care Providers
Mandatory Participation in Medicare and Medicaid for Carolina ACCESS Primary Care Providers (PCPs)

Carolina ACCESS (CA) welcomes and encourages Medicaid recipients who are also receiving Medicare benefits (Dually Eligible) to enroll in the CA program. If a Dually Eligible recipient chooses to participate in CA, they must select a CA PCP who participates in both Medicare and Medicaid.

CA PCPs electing to care for CA Dually Eligible recipients must participate in both the Medicare and Medicaid programs. In addition, PCPs must report to the Division of Medical Assistance if their participation with Medicare or Medicaid is voluntarily or involuntarily terminated.

Program Operations, Managed Care Section
DMA, 919-857-4022


Attention: Independent Practitioner Service Providers
Health-Related Services for Recipients Provided By Independent Practitioner (IP) Providers

Effective with date of service October 1, 2000, the October 1999 workshop handout published by EDS will be used as the updated version of DMA's medical policy for IPs until further notice. Updated handouts were provided at the EDS workshops in 1999 and mailed to all enrolled providers.

Please review the October 1999 EDS handout for updates, deletions, and other changes to the medical policy for IP providers. A copy of the handout may be obtained by calling EDS Provider Services at 1-800-688-6696 or 919-851-8888.

EDS, 1-800-688-6696 or 919-851-8888

Attention: Optometrists and Ophthalmololgists
Reminder: Eye Refractions and Office Visits for Diabetic Patients

Diabetic recipients do not generally require more frequent eye refractions or eyeglass lens changes than other recipients. However, retinal disease (diabetic retinopathy, diabetic macular edema, etc.) is the leading cause of blindness in diabetic patients. Therefore, it is important that diabetic recipients are seen annually to evaluate the health of the eye.

For diabetic recipients with no complications, providers should bill for an office visit a minimum of one year from the previous eye exam date. Based on the findings, more frequent evaluation may be indicated. Providers should bill one of the following CPT codes and follow CPT guidelines:

OfficeVisit - New Patient
(No Prior Authorization Required)


Office Visit - Established Patient
(No Prior Authorization Required)


When a diabetic patient is evaluated for retinopathy, documentation of the evaluation should be forwarded to the primary care physician or referring physician.

When a significant change in visual acuity is detected during an office visit, the recipient should be referred back to the medical physician for evaluation of the diabetic condition (stable or unstable). The medical physician should write a referral to the ophthalmologist or optometrist stating the diabetic condition and requesting a new eye refraction. The ophthalmologist or optometrist may request a refraction only by submitting a general Request for Prior Approval form (371-118) and the referring medical physician's letter to the EDS address listed on the top of the form. The optometrist or ophthalmologist should document medical justification for an early refraction in block 7 of the Request for Prior Approval form (i.e., visual acuity with current glasses, pressure changes, current medications, etc.). A minimal change of one diopter in power is required for approval of a new lens(es). Each request for an early refraction will be reviewed on a case-by-case basis.

EDS, 1-800-688-6696 or 919-851-8888

Attention: Adult Care Home Providers
Policy for Correcting the DMA-3050

The Division of Medical Assistance (DMA) has implemented a policy to allow Adult Care Home (ACH) providers to make limited corrections to the ACH assessment and care plan form (DMA-3050).

Acceptable Format

Corrections to the DMA-3050 are acceptable when the incorrect information is lined through once with the new information noted, initialed, and dated by the assessor. Example: supervise toileting, bh 11/1/00 assist on and off toilet.


Bill Hottel, Adult Care Home Services Unit, Medical Policy Section
DMA, 919-857-4020

Attention: Durable Medical Equipment Providers
Rate Decrease

Effective with date of service December 1, 2000, the following codes have a maximum reimbursement rate reduction. Please make these changes on the Durable Medical Equipment Fee schedule dated August 1, 2000. Providers are expected to bill their usual and customary rate
A4627 Spacer, Bag or Reservoir, w/ or w/o mask, for use w/ metered dose inhaler $ 35.37, new
A4614 Peak Expiratory Flow Rate Meter, hand held $ 25.60, new
W4721 Group 27 Gel Cell Battery, each $203.00, new
W4721 Group 27 Gel Cell Battery, each $152.25, used
W4721 Group 27 Gel Cell Battery, each $ 20.30, rented


EDS, 1-800-688-6696 or 919-851-8888

Checkwrite Schedule
November 7, 2000 December 5, 2000 January 9, 2001
November 14, 2000 December 12, 2000 January 17, 2001
November 21, 2000 December 21, 2000 January 25, 2001
November 30, 2000

Electronic Cut-Off Schedule
November 3, 2000 December 1, 2000 January 5, 2001
November 10, 2000 December 8, 2000 January 12, 2001
November 17, 2000 December 15, 2000 January 19, 2001
November 22, 2000    

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.


Paul R. Perruzzi, Director John W. Tsikerdanos
Division of Medical Assistance Executive Director
Department of Health and Human Services EDS

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