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May 2007
Medicaid Bulletin

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In This Issue . . .

NPI Articles:

All Providers:

Adult Care Homes:

Aging and Disability Resource Centers:

CAP Case Managers:

Carolina ACCESS Providers:

Community Care Network:

Community Support Providers:

Dental Providers:

Departments of Social Services:

Durable Medical Equipment Providers:

Health Departments Dental Clinics:

Health Departments Dental Clinics:

Home Care Providers:

Home Health:



Maternity Care Coordination Providers:

Mental Health Service Providers:

Nursing Facilities:

Optical Providers:


Personal Care Service (PCS) and Personal Care Service Plus (PCS Plus) Providers:

Pharmacy Providers:


Public Health Departments:

Rural Health Providers:

NPI Logo 

Attention:  All Providers

NPI and New Claim Forms Implementation Changes

DMA will not implement utilization of the National Provider Identifier (NPI) on the originally scheduled implementation date of May 18, 2007.  Claims will continue to be adjudicated after the May 23rd date using the Medicaid Provider Number instead.  The Center for Medicare and Medicaid Services (CMS) is concerned about the health care industry’s state of readiness with regard to successful implementation of the NPI.  CMS will focus on voluntary compliance and is allowing entities covered under the Health Insurance and Portability Act (HIPAA) of 1996 to employ a contingency plan after May 23, 2007.  DMA’s contingency plan is based on continued use of the Medicaid Provider Number.  As a result, the date on which DMA will implement the NPI rule is yet to be determined.

It is important to realize that with the delay in NPI implementation, claims submitted after May 18, 2007 without a Medicaid Provider Number will deny.

Providers should be aware that voluntary compliance does not change the HIPAA requirement that health care providers obtain an NPI by May 23, 2007.  DMA will continue to collect NPI information from providers, and the N. C. Medicaid program strongly encourages providers to immediately begin submitting claims that contain both their Medicaid Provider Number and NPI.

In addition, N.C. Medicaid will no longer accept the old CMS 1500 (12/90) after 06/01/2007.  Any CMS 1500 (12/90) old paper claim version sent after 07/01/2007 will be returned to providers.  N.C. Medicaid requests that providers continue to send only the new paper claim versions of the UB04 and ADA.  Medicaid will publish in up coming bulletin articles the final date that the ADA and UB92 old paper claim versions will be accepted.   

Additional information regarding the new NPI implementation date will be communicated when available.  The quickest and easiest way for providers to obtain updated information regarding the NPI will be via e-mail from the NPI Electronic Mailing List.  If you have not subscribed to the Electronic Mailing List, please do so immediately by visiting the DMA NPI web page .  Click on the NPI Mailing List link highlighted in red at the top of the page to subscribe. In addition, NPI information will be communicated to the provider community via bulletins, RA banner messages, and the DMA website.

NPI - Get It! Share It! Use It! Getting one is free - Not having one can be costly!

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

Attention:  All Providers

2007 Medicare Physician Fee Schedule

Effective with date of service April 1, 2007, do not bill Modifier 51 with CPT codes 17311 or 17313.  The details below reflect an update to the 2007 Medicare Physician Fee Schedule Database from the Centers for Medicare and Medicaid Services (CMS), CMS Change Request 5528.

CPT Code





Mohs micrographic technique, head, neck, hands, feet genitalia; first stage, up to 5 tissue blocks

CMS end-dated the use of modifier 51 with these procedures.

Modifier 51 indicates several procedures were performed on the same day or at the same operative session by the same provider.  These procedures are no longer eligible for billing or pricing with modifier 51.  Claims submitted with this modifier will deny.


Mohs micrographic technique, trunk, arms, legs; first stage, up to 5 tissue blocks

Clinical Policy
DMA, 919 855-4324

Attention:  All Providers

Clinical Coverage Policies

All affected clinical coverage policies have been updated to reflect 1) the acceptance of UB-04 claim forms and 2) clarifications in the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) policy. The revisions are now available on the Division of Medical Assistance’s Clinical Coverage Policies and Provider Manuals web page.

These policies supersede previously published policies and procedures.  Providers may contact EDS at 1-800-688-6696 or 919-851-8888 with billing questions.

Clinical Policy and Programs
DMA, 919-855-4260

Attention: All Providers

Correction to Rho (D) Immune Globulins (HCPCS Procedure Codes J2788, J2790 and J2792) Billing Guidelines Article Published in the April 2007 Medicaid General Bulletin

Effective with date of service March 31, 2007, the N.C. Medicaid Physician’s Drug Program end-dated CPT procedure codes 90384, 90385 and 90386.  Effective with date of service April 1, 2007, providers must bill HCPCS procedure codes J2788, J2790 or J2792 for Rho(D) immune globulins.  Claims billed with the end-dated codes for dates of service on and after April 1, 2007 will deny.  Refer to the following table for billing guidelines for the new codes.

End-dated CPT Code



New HCPCS Code



Maximum Reimbursement Rate


Rho(D) immune globulin (RHIG)

300 mcg


Rho D immune globulin, human, full dose

300 mcg



Rho(D) immune globulin (RHIG)

50 mcg


Rho D immune globulin, human, minidose

50 mcg



Rho(D) immune globulin (RHIGIV)

100 IUs


Rho D immune globulin, IV human, solvent detergent

100 IUs


Providers are reminded to bill their usual and customary charge.

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

Attention: Dental Providers and Health Department Dental Centers

Dental Rate Change

Effective with dates of service January 1, 2007, reimbursement rates for the following dental procedures were increased.  The rate changes were entered into the payment system on April 1, 2007; therefore, claims processed after this date will pay with these new rates.  Claims that processed prior to April 1, 2007, will be automatically reprocessed through system adjustments to pay the additional reimbursement.  Providers will be notified through the general Medicaid bulletin and/or a banner message on the remittance advice regarding the scheduled date for system adjustments.  No adjustments will be accepted from providers for these dental rate changes.  Providers are reminded to bill their usual and customary charges rather than the Medicaid rate.

CDT 2007/2008 Code


Reimbursement Rate


Intraoral – occlusal film



Bitewing – single film



Cephalometric film



Diagnostic casts



Prophylaxis – adult



Prophylaxis – child



Resin-based composite crown, anterior



Root canal therapy – anterior (excluding final restoration)



Root canal therapy – bicuspid (excluding final restoration)



Root canal therapy – molar (excluding final restoration)



Periodontal scaling and root planing – four or more teeth per quadrant



Full mouth debridement to enable comprehensive evaluation and diagnosis



Pediatric partial denture, fixed



Extraction, coronal remnants – deciduous tooth



Extraction, erupted tooth or exposed root



Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth



Removal of impacted tooth – soft tissue



Removal of impacted tooth – completely bony



Removal of impacted tooth – completely bony, with unusual surgical complications



Surgical removal of residual tooth roots (cutting procedure)



Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth



Surgical access of an unerupted tooth



Placement of device to facilitate eruption of impacted tooth



Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant



Osteoplasty – for orthognathic deformities



Osteotomy – mandibular rami



Osteotomy – mandibular rami with bone graft; includes obtaining the graft



Osteotomy – segmented or subapical



Osteotomy – body of mandible



LeFort I (maxilla – total)



LeFort I (maxilla – segmented)



LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) – without bone graft



LeFort II or LeFort III – with bone graft



Frenulectomy (frenectomy or frenotomy) – separate procedure



Periodic orthodontic treatment visit (as part of contract)



Deep sedation/general anesthesia – first 30 minutes



Deep sedation/general anesthesia – each additional 15 minutes



Intravenous conscious sedation/analgesia – first 30 minutes



Intravenous conscious sedation/analgesia – each additional 15 minutes


For current pricing on these and all dental codes, refer to DMA’s Fee Schedule web page.  For coverage criteria and additional billing guidelines, please refer to Clinical Coverage Policy 4A, Dental Services, and Clinical Coverage Policy 4B, Orthodontic Services.

Dental Program
DMA, 919-855-4280

 Attention:  Community Support Providers

Community Support Rate Change

The N. C. Department of Health and Human Services ( DHHS) announced a new Medicaid rate to cover the reimbursement of Community Support (CS) services for people with mental health and substance abuse issues.  The rate, $51.28 per hour for children and adult services, $16.48 per hour for group services, is based on a cost analysis of services. This new rate is effective retroactive to April 5, 2007.

The Division of Medical Assistance (DMA) will do an automatic recoup and repay for claims with dates of service on or after April 5, 2007 that have been adjudicated in a previous checkwrite.

The automatic recoup will not occur before June, so if providers want to file an electronic replacement claim before that time please click on the link below for instructions.

Electronic Adjustments

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

Attention: Dental Providers and Health Department Dental Clinics

Dental Seminars

Dental seminars will be held in June 2007 to educate providers on the basics of dental billing.  The seminar will focus on recent changes to the clinical coverage policy for dental services, CDT-2007/2008 ADA code updates, completion of the 2006 ADA claim form, addition of the National Provider Identifier, most common denials for dental claims, and other general Medicaid issues.  Medicaid billing personnel, supervisors, and office managers are encouraged to attend.

Seminars will begin at 9:30 a.m. and end at 1 p.m. Providers are encouraged to arrive by 9:15 to complete registration.  Lunch will not be provided at the seminars.  Due to limited seating, registration is limited to two staff members per office.  Pre-registration is required to reserve a space. Unregistered providers are welcome to attend if space is available.

Providers may register for the dental seminars by completing and submitting the following registration form on the next or online.  Please indicate on the registration form the session you plan to attend.

Dental Services Clinical Coverage Policy 4A will be used as the primary training document for the seminar. The current policy manual is available on DMA's website. Please print the current manual and bring it to the seminar.

Because the seminar also will briefly address the general Medicaid billing guidelines, providers may wish to bring a copy of the Basic Medicaid Billing Guide.

Tuesday, June 12, 2007
Crowne Plaza
One Resort Plaza
Asheville, NC

Wednesday, June 13, 2007
Omni Hotel
132 East Trade Street
Charlotte, NC

Wednesday, June 27, 2007
Jane S. McKimmon Center
1101 Gorman Street
      Raleigh, NC

Tuesday, June 19, 2007
Hilton Hotel
207 Greenville Blvd
Greenville, NC

Wednesday, June 20, 2007
Coastline Convention Center
503 Nutt Street
Wilmington, NC


Directions to Dental Seminars

Crowne Plaza – Asheville
Traveling East on I-40: Take Exit 46 (left exit) for I-240 East. Continue on I-240 and stay the left lane. Take Exit 3A. Circle around right and exit onto Patton Avenue. Turn right at the second light into Regent Business Park (between Denny’s and Pizza Hut). Turn right; the entrance is on the left around a curve approximately 1000 yards. Follow Resort Drive to the main entrance of the resort on the left.

Traveling West on I-40: Take Exit 53 to I-240 West. Pass downtown Asheville. As you cross the French Broad River Bridge, stay in the right lane and take Exit 3B - Westgate and Resort Drive (former Holiday Inn Drive). Pass the Westgate Shopping Center on your right. After passing Mr. Transmission, you will see our entrance sign. Turn right onto Resort Drive and proceed to the main entrance.

Omni Hotel - Charlotte
Traveling East: Take Hwy. 74 to I-277. Take the College Street exit. Proceed toward Uptown and make a left onto Trade Street. The motor lobby entrance of the hotel is on the left.

Traveling South: Take I-77 South to Exit 10B (Trade Street). Go east on Trade Street toward Uptown for approximately one mile, crossing the Square at Tryon Street. Hotel is located on the corner. The motor lobby entrance of the hotel is located half a block past Tryon Street on the right.

Traveling North: Take I-77 North to Exit 10 Trade Street. Go east on Trade Street toward Uptown for approximately one mile, crossing the Square at Trade & Tryon Street. After going through the intersection, the entrance to the motor lobby of the hotel is the second driveway on the right.

Traveling West: Take I-85 North to Exit 36, NC-16/Brookshire Boulevard exit, toward US-74 East/Downtown. Merge onto NC-16 South toward Charlotte/Bank of America Stadium. Merge onto I-77 South. Take I-77 South to exit 10B Trade Street. Go East on Trade Street toward Uptown for approximately one mile, crossing the Square at Tryon Street. The Hotel is on the corner. The motor lobby entrance of the hotel is one half block past Tryon Street on the right.

Hilton – Greenville
Traveling East:- take 64 east to 264 east. Follow 264 east to Greenville. Turn right on Allen Rd. once you enter Greenville. Go approx. 2 miles and Allen Rd. turns into Greenville Blvd/Alternate 264. Follow Greenville Blvd. for 2 1/2 miles, the Hilton Greenville is located on the right.

Traveling South:  Take 64 to US-13 S/NC-11 S. Continue to follow NC-11 S. Turn left onto US-Greenville Blvd.  The hotel is on the left.

Traveling North: Take NC Highway 11 North to Greenville. Turn right onto Greenville Blvd. Hotel is approximately one mile ahead on the right.

Coastline Convention Center – Wilmington
From I-40 East / Raleigh Durham Area:  Follow Interstate 40 East to Wilmington. As you approach Wilmington, turn right onto MLK Parkway/74 West/Downtown. Continue on route to downtown and it will become 3rd Street. Follow 3rd Street for five blocks until you reach Red Cross Street. Turn right onto Red Cross Street and follow for two blocks. Turn right onto Nutt Street. Second drive way on left is the entrance to the convention center.

From Hwy 17 S. (Jacksonville area):  Stay on Hwy 17 S. as it turns into Market Street. Follow Market Street until you see the sign for 74 West / Downtown (MLK Parkway).  Take 74 West (MLK Parkway) to downtown (approx 4 miles), turn right on Red Cross Street, come 2 blocks, turn right on Nutt Street. Second drive way on left is the entrance to the convention center.

From Hwy 17 N. or Hwy 74-76 (Myrtle Beach or Fayetteville area):  Come across the Cape Fear Memorial Bridge into Wilmington.  Take a left at the first stoplight onto 3rd Street and come downtown.  Follow 3rd Street to Red Cross Street and turn left at the stoplight.  Go to the bottom of the hill (approximately 3 blocks).  Take a right onto Nutt Street, turn left into the main parking lot of the Coast Line Center.

Jane S. McKimmon Center - Raleigh
Traveling East on I-40: Take exit 295 and turn left onto Gorman Street. Travel approximately 2.5 miles. The McKimmon Center is located on the right corner of Gorman Street and Western Boulevard.

Traveling West on I-40: Take exit 295 and turn right into Gorman Street. Travel approximately 2.5 miles. The McKimmon Center is located on the right on the corner of Gorman Street and Western Boulevard.

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

Attention:  Durable Medical Equipment Providers

Medicare Part D Coverage of Supplies for Delivery of Insulin

Effective with date of service January 1, 2006, in most cases Medicaid no longer covers prescriptions for recipients who are covered by both Medicaid and Medicare (dually eligible).  Dually eligible recipients now receive their drug coverage from a Medicare approved Prescription Drug Plan (PDP).  This is called Medicare Part D.  In addition to prescriptions, Part D also covers certain medical supplies associated with the injection of insulin (syringes, needles, alcohol swabs, and gauze).

Therefore, N. C. Medicaid program must not be billed for these supplies for dually eligible recipients; bill the recipient’s PDP for these supplies.  If you have any questions about Medicare Part D coverage, please call 1-800-Medicare.

Effective with date of payment April 20, 2007, claims submitted by DME providers for these supplies will be denied.  Previously paid claims for date of service after December 31, 2005 will be recouped.  

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

Attention:  Maternity Care Coordination Providers

New Intake Screening and Pregnancy Outcome Summary Forms

Effective May 15, 2007 Maternity Care Coordination providers must complete the Maternity Care Coordination Intake Screening, DHHS T1513, and the Pregnancy Outcome Summary, DHHS T1514, for each new participant who enters the program.

The Intake Screening is a newly developed form; the Pregnancy Outcome Summary is a revised version of the Pregnancy Outcome Report, DMA-3002, which was last revised in September 1999.  Starting May 15, 2007, providers will be required to complete the Pregnancy Outcome Summary, DHHS T1514, instead of the DMA-3002.  All Maternity Care Coordination providers must complete both forms.

Providers with access to the Health Services Information System (HSIS) must input the information collected on the forms into HSIS. Both forms will be available through HSIS on May 15.   Non–health department providers, who do not utilize HSIS, can access the forms on the web at: http://wch.dhhs.state.nc.us/whs.htm  and must submit them to the Baby Love Program, Division of Public Health, Women’s Health Branch, 1929 Mail Service Center, Raleigh, NC 27699-1929.  Providers will also receive copies of the forms by mail. 

Clinical Policy
DMA, 919-855-4320

Attention: Mental Health Service Providers

Expansion of Billing Codes

Effective with date of service May 1, 2007, Licensed Clinical Supervisors and Licensed Clinical Addictions Specialists may bill CPT codes:




















This is in addition to the codes they now bill, H0031, H0001, H0005, and H0004 (with or without one of the following modifiers, as appropriate: HQ, HR or HS).

Behavioral Health Services
DMA, 919-855-4290

Attention: Optical Service Providers and Optometrists

Nash Optical Prescriptions and Lenses Available to Health Choice Participants

Effective March 1, 2007, vision care providers have a new option for obtaining prescription eyeglasses (frames and lenses) for N.C. Health Choice members 6–18 years of age: the Nash Optical Plant, a  division of N.C. Correction Enterprises. There is no requirement to take advantage of this option; if providers prefer, they may continue their current processes for providing eyeglasses to N.C. Health Choice members. An explanatory letter, request form, and instructions have been sent to providers from N.C. Health Choice.  

Becky W. Murray
North Carolina State Health Plan

Attention:  Personal Care Service (PCS) and Personal Care Service Plus (PCS Plus) Providers

PCS Provider Training Sessions

The Carolina Centers for Medical Excellence (CCME) announces continued provider training for Personal Care Services as approved by the Division of Medical Assistance (DMA).

The 2nd calendar quarter training sessions (PCS Provider Training Session IV) of 2007 will be conducted in June 2007.  The training is recommended for registered nurses, agency administrators, and agency owners who have a working knowledge of the PCS program and applicable DMA policies. 

Pre-registration is required and space is limited to 200 participants at each morning or afternoon session.  Registrations will be accepted online or by fax.  Considering the probable need for air conditioning at this time of year, please be prepared with an extra clothing layer for your comfort in case the room temperature is above or below your personal liking.

Sign-in will start at 8:00 a.m. at each location.  The presentations will begin at 9:00 a.m. and continue until 1:30 p.m. with one 15-minute break.  Please plan ahead for the late lunch hour, as coffee, hot tea, and water will be the only refreshments provided.  This schedule allows us to offer 4.25 Continuing Nursing Education (CNE) contact hours to all nurses.  Other participants will receive a Certificate of Attendance that can be applied to other professional associations’ continuing education requirements.

The dates and locations are as follows.


Day & Date


Telephone No.


Monday, June 4

Hilton Raleigh–Durham Airport at Research Triangle Park

4810 Old Page Rd.

Durham 27703

(919) 941-6000


Friday, June 8

Hilton Greenville

207 SW Greenville Blvd., 27834-6907

(252) 355-5000


Wednesday, June 13

Holiday Inn Fayetteville I-95 South

I-95 & 53 1944 Cedar Creek Road, 28302

(910) 323-1600


Wednesday, June 20

Crowne Plaza Resort Asheville

One Resort Drive, 28806

(828) 254-3211


Thursday, June 21

Hawthorne Inn & Conference Center

420 High St.,  27101

(336) 777-3000

To register online, go to Carolina Centers for Medical Excellence (CCME) and follow the instructions for registration.  A computer-generated confirmation number will confirm your registration.  To register via fax, complete the form following this announcement and fax it to the attention of Jennifer Manning at 919-380-9457.  A member of the PCS team will contact you with a registration number.

If you need to cancel at any time, please contact Jennifer Manning at 919-380-9860, x2018, to allow others to attend.

Questions about registration or the agenda can be directed to Jennifer Manning via e-mail: jmanning@thecarolinascenter.org.

Attention:  Personal Care Services Providers (In-home)

Revised PACT Form

In an ongoing effort to improve the services provided to medically needy Medicaid recipients, and in response to feedback from stakeholders, the Division of Medical Assistance (DMA) has revised the Physician’s Authorization for Certification and Treatment (PACT) form.  Providers may begin using the new form now and should discontinue using the old form as of May 2, 2007.

The revised PACT form, its instructions, revised time and task guidance, and an implementation plan for using the new PACT form have been posted to the PCS Services web page.

Facility and Community Care Section
DMA, 919 855-4360

Attention: Physicians

Service Billing Guidelines for End-Stage Renal Disease for Undocumented Aliens and Deceased Recipients

Providers must continue to bill monthly end-stage renal disease (ESRD)-related services described by HCPCS procedure codes G0308 through G0323 once per month, using the last day of the month as the date of service. However, if a recipient dies prior to the last day of the month, show either the date of death or the last date the recipient was seen in the FROM/TO date of service field on the claim detail, instead of the last day of the month. When billing services for an undocumented alien, bill the last day the recipient was eligible for the month.

Claims that were previously denied for recipients in these categories may be refiled if the reason for the denial was that the date of service was prior to the end of the month.

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

Attention:  Physicians, Hospitals, Nursing Facility Providers, Adult Care Home Providers, Home Health Agencies, Hospice Providers, Personal Care Providers,  Community Alternatives Program Case Managers, Rural Health Centers, Departments of Social Services, Health Departments, Carolina ACCESS Providers, Aging and Disability Resource Centers, Aging Network

Introduction to Medicaid’s Uniform Screening Program – A Web-Based System Set for Implementation in October 2007

In an effort to improve the process for entry to Medicaid long-term-care services and to facilitate appropriate placement decisions for Medicaid applicants and recipients needing long-term-care services, the Division of Medical Assistance is planning to implement the Uniform Screening Program by October 1, 2007.  This article is the first in a series that will provide information on the program.

The Uniform Screening Program contract, which was awarded to EDS, encompasses the following:

Overview of the Uniform Screening Process
The Uniform Screening Tool will replace the FL2, the FL2e, the PASARR Level I screen, telephone prior approvals for skilled nursing facility level of care, and several other forms used to screen applicants to document their medical, functional, and behavioral health status.  Initially, the Uniform Screening Tool will be used prior to entry to the following Medicaid services:

Authorized and trained screeners (local professionals) will enter the medical, functional, and behavioral health information into the automated Web-based tool.  The data will be processed through a rules engine that contains the Medicaid clinical policies.  A “best fit” service will be presented to the screener along with other service options for which the recipient may apply.  The screener and the applicant will jointly determine which service option will be selected and then a referral can be made to the service provider.

The Uniform Screening Program is under intense review and discussion by the Division of Medical Assistance, EDS, and a Technical Advisory Group (TAG) composed of Medicaid provider representatives and other State agencies.  There are discussions about the qualifications of local screeners, local screening entities, and the impact of this new system on current business processes.   Future bulletin articles will provide additional information as the plans progress.  In addition, questions about the Uniform Screening Program may be sent to the following e-mail address:  USPquestions@eds.com.

The regional training sessions for the new N.C. Medicaid USP, scheduled for June and July 2007, are designed to educate providers on the changes to procedures and processes in the Medicaid long-term-care services request and on use of the Web-based system.  The training sessions are for agency professionals who currently help applicants and recipients obtain access to Medicaid long-term-care services. 

Pre-registration is required and may be accomplished by completing and submitting the registration form that follows or by using the registration form available online beginning May 1, 2007.  A confirmation notice will be mailed to each registered participant.  The deadline for registration is the date of each training session.  Attendees should train colleagues unable to attend.

The training sessions begin at 8:30 a.m. and end at 1:30 p.m.  Providers should arrive at least 30 minutes early to complete the registration process.  Lunch will not be served. 

Note:  Training sessions are subject to change.  If a training session is postponed and you are registered for that session, you will be notified by email




McKimmon Center
Gorman St. & Western Blvd.


Hilton Greenville
207 SW Greenville Blvd.


Crowne Plaza Hotel and Resort
One Resort  Drive


Hickory Metro Convention Center
1960 13th Ave. Dr. SE


Crystal Coast Convention Center
3505 Arendell St.
Morehead City


Coast Line Convention Center
501 Nutt St.


Harris Conference Center
Central Piedmont Community College
3216 CPCC West Campus Dr.


Holiday Inn Select
5790 University Parkway


Holiday Inn
530 Jake Alexander Blvd. South


Hampton Inn
115 Hampton Drive


Hilton Greenville
207 SW Greenville Blvd.


New Bern Riverfront Convention Center 
203 S. Front St.
New Bern


Harris Conference Center
Central Piedmont Community College
3216 CPCC West Campus Drive


McKimmon Center
Gorman St. & Western Blvd.

Attention: Pharmacy Providers

Large Volume Synagis Pharmacy Distributors

Pharmacy distributors with a large volume of Synagis claims should submit information from the North Carolina Medicaid Synagis for RSV Prophylaxis forms on a diskette. Microsoft Access is preferred, but an Excel spreadsheet is acceptable; file structure is very specific and the most important element of compatibility. Please call Charlene Sampson at (919) 855-4300 for specific instructions and further assistance on diskette submissions.  All diskette must be sent to DMA by May 31, 2007. 

Please mail diskettes to:

NC Division of Medical Assistance
Pharmacy Program
2501 Mail Service Center
Raleigh, NC  27699-2501

Please remember payment of Synagis claims will be reviewed and may be subject to recoupment by Program Integrity if the appropriate forms are not on file or if diskettes are not submitted in the correct format.

Clinical Policy
DMA, 919-855-4300

Attention: Pharmacy Providers

New Pharmacy Prior Authorization Program for Proton Pump Inhibitors

Effective no later than June 1, 2007, the N.C. Medicaid outpatient pharmacy program will require prior authorization for use of brand name proton pump inhibitors.  The criteria for use of these medications will include the following:

  • Failure with a 30-day trial of no less than 40mg of omeprazole during a 12-month time period; OR
  • Use of esomeprazole magnesium (Nexium) 40mg for diagnosis of erosive esophagitis Grade C or D. Other proton pump inhibitors may be indicated for specific patients for unusual mitigating circumstances. In these circumstances, additional information should be provided on the Request for Patient Exemption From Prior Authorization Criteria form; OR
  • Brand name solutab and liquid dosage formulations may be used with documented inability to swallow capsules or tablets.
  • Pharmacists will be able to override the point-of-sale, prior authorization edit if the prescriber writes on the face of the prescription in his/her own handwriting one of the following phrases:

    1. “Failed Omeprazole 40mg for 30 days”
    2. “Esophagitis Grade C”
    3. “Esophagitis Grade D”
    4. “Cannot swallow tablets”
    5. “Cannot swallow capsules”

    If a brand name proton pump inhibitor medication has a generic version available, "medically necessary" must also be written on the face of the prescription in order to dispense the brand name drug.  Prior authorization will not be required for recipients who are pregnant, breastfeeding or who are under 6 years of age.

    Prescribers will also be able to contact ACS at 866-246-8505 (telephone) or 866-246-8507 (fax) to request prior authorization for these medications.  The prior authorization criteria and form for proton pump inhibitors will be available on the DMA ACS Prior Authorization website prior to implementation of the program.

    Additional information on specific procedures related to this prior authorization program will follow in subsequent pharmacy newsletters and general Medicaid bulletin articles.

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

    Proposed Clinical Coverage Policies

    In accordance with Session Law 2005-276, 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 website.  Providers without Internet access can submit written comments to the address listed below.

    Loretta Bohn
    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.

    2007 Checkwrite Schedule


    Electronic Cut-Off Date

    Checkwrite Date










































































    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.

    Mark T. Benton, Senior Deputy Director and Chief Operating Officer   Cheryll Collier
    Division of Medical Assistance   Executive Director
    Department of Health and Human Services   EDS

    DMA Home