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

August 2014 Medicaid Bulletin

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In This Issue . . .

All Providers:

Additional Podiatry Taxonomies
Payment Error Rate Measurement (PERM) Update: Mid-August Deadline For Medical Records Request
Upgrade to Prior Authorization Website for Outpatient Specialized Therapies
Omalizumab, 5 mg (Xolair, HCPCS Code J2357): Change in Coverage
NCTracks Tip of the Month: Using a Billing Agent
NCTracks Updates
ICD-10 Update
Providers Not Enrolled in Medicaid
Clinical Coverage Policies
Cumberland Hospital and Legal Immigrant Behavioral Health Authorizations

Community Care of N.C./Carolina Access Providers:

After-Hours Medical Advice Requirement

Health Departments:

Omalizumab, 5 mg (Xolair, HCPCS Code J2357):  Change in Coverage

Nurse Practitioners:

Omalizumab, 5 mg (Xolair, HCPCS Code J2357):  Change in Coverage

Outpatient Specialized Therapy Providers:

Upgrade to Prior Authorization Website for Outpatient Specialized Therapies

Personal Care Services Providers:

Personal Care Services (PCS) Recoupment/Repayment Plan


Omalizumab, 5 mg (Xolair, HCPCS Code J2357):  Change in Coverage

Physicians Assistants:

Omalizumab, 5 mg (Xolair, HCPCS Code J2357):  Change in Coverage

Pharmacists and Prescribers:

Prescribers Not Enrolled in Medicaid

Attention: All Providers

Additional Podiatry Taxonomies

Providers are receiving denials because podiatry taxonomies were inadvertently end-dated for the following CPT codes: 10060, 10120, 10140, 11101, 20220, 20680, 28805, 28810, 28820, 28825, 29405, 29425, 29445, 29450, 29540, 29580, 29581, 64450 and 64455.

NCTracks has been updated to include the following podiatry taxonomies:

  • 213EP1101X - Primary Podiatric Medicine
  • 213ES0103X - Foot & Ankle Surgery
  • 213ES0131X - Foot Surgery, and
  • 213E00000X - Podiatrist

Providers with these taxonomies who had claims denied for the above-listed CPT codes may resubmit the denied charges as new claims. The original claims must have been submitted within timely filing limits. An adjustment request is not necessary.

Questions should be directed to CSC at 1-800-688-6696.

Clinical Policy and Programs
DMA, 919-855-4260


Attention: All Providers

Payment Error Rate Measurement (PERM) Update: Mid-August Deadline For Medical Records Request

Medical records will be requested from selected providers this month for July, August and September 2013 claims by A+ Government Solutions on behalf of the federal Payment Error Rate Measurement (PERM) program. Providers who receive medical records requests must provide this documentation as soon as possible to A+ Government Solutions.

A+ Government Solutions is conducting this work as a contractor with the N.C. Division of Medical Assistance, Program Integrity Section.

The following deadlines must be met:

  • Mail documents to this address no later than August 14, 2014:

  • Perm Review Contractor
    Att: Health Information Management Manager
    A+ Government Solutions, LLC
    1300 Piccard Drive Suite 205
    Rockville, MD 20850

  • Fax documents to one of these numbers no later than August 18, 2014:

  • 1-301-987-2201 or 1-877-619-7850

Place the PERM Cover Sheet on top of each record submission.

Those with question should contact Linda Marsh at 919-814-0134.

Program Integrity


Attention: All Providers and Oupatient Specialized Therapy Providers

Upgrade to Prior Authorization Website for Outpatient Specialized Therapies

The Carolinas Center for Medical Excellence (CCME) is the N.C. Division of Medical Assistance (DMA) contractor handling prior authorization (PA) requests for outpatient specialized therapies.

Effective September 1, 2014, CCME will upgrade to the ChoicePA website. Providers need to re-register to use the website and are encouraged to attend web-based training addressing the changes and enhanced features. Additional information about registration and training opportunities is available at

Clinical Policy and Programs
DMA, 919-855-4260


Attention: All Providers, Health Departments, Nurse Practitioners, Physicians Assistants and Physicians

Omalizumab, 5 mg (Xolair, HCPCS Code J2357): Change in Coverage

This is a reminder that, effective with date of service on or after May 16, 2011, the N.C. Medicaid Program covers Xolair ONLY through the Outpatient Pharmacy Program. Xolair is not covered when billed through the Physician’s Drug Program (PDP) with HCPCS code J2357. Claims submitted for Xolair with HCPCS code J2357 will be denied.

Prior authorization (PA) through the Outpatient Pharmacy Program is required for coverage of Xolair for dates of service on and after May 16, 2011. If PA is granted, the length of authorization is 12 months.

Prescribers must request PA by contacting CSC at 1-866-246-8505 (telephone) or 1-855-710-1969 (fax). The criteria and PA request form are available from NCTracks at

More information can be found at the N.C. Division of Medical Assistance (DMA) Outpatient Pharmacy Program web page at DMA’s approved PDP list is found at

CSC, 1-866-246-8505


Attention: All Providers

NCTracks Tip of the Month: Using a Billing Agent

Providers must have Billing Agent in Their Provider Record

Providers who use a billing agent need to ensure their NCTracks provider record reflects the correct information. Instructions for adding (or confirming) a billing agent relationship in NCTracks are outlined in the user guide titled “How to Select a Billing Agent and Other Claims Submission Options in NCTracks.” The guide is located on the NCTracks Provider User Guides and Training page at

If the billing agent relationship is not established on the provider record, the billing agent will not be able to submit claims on the provider’s behalf. This relationship must be established for every billing National Provider Identifier (NPI) submitted by the billing agent, except for retail pharmacy claims submitted through a switch vendor.

A single billing NPI can have more than one billing agent associated with it. However, the provider will need to designate on their provider record which billing agent will receive the 835 transaction. This applies to all providers, including pharmacies.

CSC, 1-800-688-6696


Attention: All Providers

NCTracks Updates

Reminder re: FAQs and Forms to Update Office Administrator

There are several Frequently Asked Questions (FAQs) on the NCTracks Provider Portal related to updating Office Administrator information. Each FAQ addresses a different situation in which information may need to be changed regarding a provider’s Office Administrator.

The FAQs are found on the NCTracks User Setup & Maintenance FAQ page at

The FAQs are:

  • I have forgotten my Office Administrator password and I am unable to answer my security question to reset my password. What do I do?
  • The Office Administrator is no longer available and I am unable to access the NCTracks provider record - Individual Providers
  • The Office Administrator is no longer available and I am unable to access the NCTracks provider record - Organization Providers
  • How do I update the Office Administrator on a Terminated Provider Record?

Each FAQ links to an appropriate form. The forms can also be accessed from the Provider Policies, Manuals and Guidelines page at

Common Errors on Consent Forms

Following are common errors found on consent forms submitted for hysterectomies and sterilizations. Ensuring the accuracy of consent forms when they are submitted expedites processing and approval.


  • Incorrect Hysterectomy Consent Form - Refer to the article titled Hysterectomy Statement Form Requirements in the July 2013 and November 2013 Medicaid Bulletins (

  • Providers began receiving denials for using the incorrect form on November 1, 2013 for Hysterectomy Statement Forms signed on or after August 1, 2013. Old forms are denied as not correctable after that date.

  • If corrections are needed to the new form, providers should follow the instructions in Subsection 5.3 of the clinical coverage policy,1E-1, Hysterectomy, which can be found on the N.C. Division of Medical Assistance (DMA) website at

  • Missing NPI on Hysterectomy Consent Form - Providers must add their National Provider Identifier (NPI) and Recipient Identification Number (RID), in their respective areas on the upper left and right of the form, for proper matching of the Hysterectomy Statement Form and claim.

  • Note: The RID was previously known as the Medicaid Identification Number (MID).


  • Incorrect Sterilization Consent Form - Refer to the article titled Sterilization Consent Form Requirements in the November 2013 Medicaid Bulletin ( 

  • The Centers for Medicare & Medicaid Services (CMS) has revised the Sterilization Consent Form. Consents dated October 1, 2013 and after must use the consent form located in DMA’s Provider Forms web page at

  • Consents signed on or after October 1, 2013 using the old form are being denied with an Explanation of Benefits (EOB) which states, “The consent form submitted is invalid. It is not the federally mandated form. Refer to DMA clinical coverage policy 1-E3, Sterilization Procedures. This is not correctable.
  • Clinical coverage policy 1E-3, Sterilization Procedures, can be found on DMA’s website at
  • Wite-Out® or Erasure When Correcting Consent Form – Providers whose sterilization consent forms are denied by DMA’s fiscal agent due to an error that can be changed must strikethrough the error once on the original consent, make the correction, and send a copy to the fiscal agent. The use of Wite-Out® or erasures is prohibited. 
  • Not using full name of Physician scheduled to perform the surgery – As per state policy, the full name of the physician scheduled to do the surgery must be on the form. Abbreviations, initials, or “doctor on call” are unacceptable. Providers may use the phrase “Physician on call for Any Provider OB/GYN clinic.”
  • Missing NPI on Sterilization Consent Form – National Provider Identifiers (NPI) are now required on each Sterilization Consent Form. This information must be completed by the billing provider (surgeon) of the sterilization procedure. Other providers can bill using the consent form on file from the billing provider (surgeon). When the NPI on the claim does not match the NPI on the consent form, the claim pends in order to determine if an ancillary service is appropriate for the consent procedure.
  • Illegible Consent Form Copies – In order to process the consent, all fields must be legible.

New User Guide for Provider Affiliation in NCTracks

A new user guide titled, How to Affiliate an Individual Provider Record to a Group-Organization in NCTracks, has been added to the NCTracks Provider Portal. The document shows individual providers how to affiliate (or change affiliations) with a group or organization, such as a hospital.

The guide can be found under the heading of “Provider Record Maintenance” on the Provider User Guides and Training web page at

Update to Notice of Change in the Orthodontic Prior Approval Process

To correct problems with NCTracks regarding payment of the panoramic films rendered as part of the orthodontic records claim, CSC will grant prior approval (PA) of orthodontic records. PA for the orthodontic records will be granted regardless of the outcome of the review (approval or denial), as long as the beneficiary has not exceeded the once per lifetime policy limit for orthodontic records.

Effective immediately, orthodontic records rendered on or after May 1, 2014 should be included on the request for orthodontic prior approval.

Providers should include orthodontic records for procedure codes D0330, D0340, D0470, and D8080.

Providers should not include orthodontic records for procedure codes D0150 or D8670.

CSC PA Staff will add Procedure code D8670 for cases that are approved for orthodontic services.

In addition, the date of service for the orthodontic records should be included in the “Request Begin Date” field on the provider portal. If submitted via mail or fax, the date of service should be included on the American Dental Association (ADA) claim form in field 24.

New Claims and Secondary Claims Web Pages on Provider Portal

Two new web pages have been added to the NCTracks Provider Portal.

  • Claims: A claims page has been added to give providers a single location to find all of the key information regarding claims submission and processing in NCTracks. The page includes links to user guides, fact sheets, manuals and FAQs, as well as links to key DMA websites and forms.
  • Secondary Claims: Related to the Claims page, this page was created to address issues unique to the submission and processing of secondary claims in NCTracks, including third party insurance and Medicare crossovers.

Combining claims information on two web pages will make it easier for providers to find answers to claims-related questions. However, the original links have been retained for providers accustomed to finding the information in its previous location.

Click on the Claims tab in the menu on the left side of the Provider Portal Home Page ( to access the new Claims and Secondary Claims web pages.

Reminder Re: Pharmacy PA Fax Number

As of December 2013, the new pharmacy PA fax number is 1-855-710-1969. The old Pharmacy PA fax number is still available, but may be phased out. Providers are encouraged to use the new Pharmacy PA fax number so their claims are routed faster.

Update to Provider Claims and Billing Assistance Guide

The Provider Claims and Billing Assistance Guide has been updated with current information regarding the NCTracks Provider Representatives and the counties they support. The Guide can be found on the Provider Policies, Manuals, and Guidelines page of the NCTracks Provider Portal. Additional updates will be made to reflect changes in the NCTracks system.

CSC, 1-800-688-6696


Attention: All Providers

ICD-10 Update

The deadline for ICD-10 implementation has been postponed until October 1, 2015 – at the earliest. This gives providers time to update business software or work with billing clearinghouses to make sure they are ready.

The Centers for Medicare & Medicaid Services (CMS) offers several tools on its website at to help providers with the transition. Small practices will find help in the “Road to 10” tool. In addition, “eHealthuniversity” offers information on several federal initiatives, including ICD-10. There are links to short (less than one hour) webcasts that address ICD-10 documentation and coding concepts for different specialties – such as pediatrics, family practice and OB-GYN. New webcasts are under development.

Any practice or facility currently using ICD-9 codes will have to transition to ICD-10 to submit claims to all public and private payors, including the N.C. Department of Health and Human Services.

Switching to ICD-10 will have benefits. As CMS reports: “ICD-10’s impact will be disruptive in the short-term, but positive over the longer term. The new code sets will benefit the delivery of care by indicating diagnoses and matching payment to care more precisely. In time, it will promote efficiencies and improvements in care documentation, claims processing, and business intelligence.”

Updates will be posted to the ICD-10 web page on the NCTracks website at

DMA, 919-855-4220


Attention: All Providers

Providers Not Enrolled in Medicaid

42 CFR 455.410 requires that all ordering, rendering  and referring physicians – as well as other professionals providing services under the N.C. Medicaid, N.C. Health Choice (NCHC) or their respective waiver programs – be enrolled as participating providers. This includes anyone who orders or refers Medicaid and NCHC beneficiaries for items (such as pharmaceuticals) or services and seeks reimbursement.

The National Provider Identifier (NPI) of the ordering or referring health care professional must be included in all claims for payment.

Enrollment criteria are being developed for providers with taxonomy codes that aren’t currently being processed by NCTracks. The information will be posted on the DMA Website and an announcement will be made via NCTracks.

Provider Relations
DMA, 919-855-4050


Attention: All Providers

Clinical Coverage Policies

The following new or amended combined N.C. Medicaid and N.C. Health Choice (NCHC) clinical coverage policies are available on DMA’s Clinical Coverage Policy Web page at

  • 1A-34, End-Stage Renal Disease (ESRD) Services (8/1/14)
  • 8-A, Enhanced Mental Health and Substance Abuse Services (8/1/14)
  • 8-B, Inpatient Behavioral Health Services (8/1/14)
  • 8-C, Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers (8/1/14)
  • 8-D-1, Psychiatric Residential Treatment Facilities for Children under the Age of 21 (8/1/14)
  • 8-D-2, Residential Treatment Services (8/1/14)
  • 8-E, Intermediate Care Facilities for Individuals with Intellectual Disabilities (8/1/14)
  • 8-I, Psychological Services in Health Departments and School-Based Health Centers Sponsored by Health Departments to the under-21 Population (8/1/14)
  • 8-J, Children's Developmental Service Agencies (CDSAs) (8/1/14)
  • 8-L, Mental Health/Substance Abuse Targeted Case Management (8/1/14)
  • 8-O, Services for Individuals with Intellectual and Developmental Disabilities and Mental Health or Substance Abuse Co-Occurring Disorders (8/1/14)
  • 8-P, North Carolina Innovations (8/1/14)

These policies supersede previously published policies and procedures.

Clinical Policy and Programs
DMA, 919-855-4260


Attention: All Providers

Cumberland Hospital and Legal Immigrant Behavioral Health Authorizations

Effective June 1, 2014, requests for behavioral health authorizations for the following will be submitted to ValueOptions:

  • N.C. Medicaid legal aliens and children 0-3 years of age
  • N.C. Medicaid admissions to Cumberland Hospital, and
  • N.C. Health Choice beneficiaries

When a Medicaid beneficiary is admitted to Cumberland Hospital, the hospital and ValueOptions will communicate with the appropriate Local Management Entity/Managed Care Organization (LME/MCO) to ensure coordination of care and appropriate transitions to community services. When requested, LME/MCO participation in conference calls regarding complex cases is encouraged.

Laura Beaver, 919-674-2644,
William Boone, 919-674-2023,


Attention: Community Care of N.C/Carolina Access Providers

After-Hours Medical Advice Requirement

This is a reminder that all Community Care of N.C./Carolina ACCESS (CCNC/CA) providers are required to offer after-hours medical advice 24-hours-a-day, 7-days-a-week, to all Medicaid beneficiaries enrolled with their practice. This requirement is part of the Carolina Access Provider Participation Agreement which providers signed during their enrollment process. CCNC/CA beneficiaries must be reminded they have access to these services and that they should consider contacting their primary CCNC/CA provider instead of visiting a hospital Emergency Department for non-emergent care.

CCNC/CA providers with questions may contact their Regional Consultant. Contact information for Regional Consultants is available at

CCNC/CA Managed Care Section
DMA, 919-855-4780


Attention:  Personal Care Services (PCS) Providers

Personal Care Services (PCS) Recoupment/Repayment Plan

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

As required by the N.C. Session Law 2013-306, the N.C. Department of Health and Human Services (DHHS) submitted N.C. State Plan Amendment (SPA) 13-009 to The Centers for Medicare & Medicaid Services (CMS) requesting approval to implement additional safeguards for qualified individuals. CMS approved SPA 13-009 on May 19, 2014.

PCS Rates

The PCS fee schedule can be found on DMA’s Fee Schedule Web page at Below is a summary of the PCS rates.

Dates of Service

(Per 15 minutes)

Per Hour (15 min x4)

Prior to Oct. 1, 2013



Oct. 1, 2013 – Dec. 31, 2013



Jan. 1, 2014 Forward



PCS Recoupment/Repayment Plan

Recoupment/Repayment will be processed in three phases based on the quarters in which services were provided.

  • Claims with dates of service from October 1 through December 31, 2013 will be reprocessed during the first checkwrite of September 2014. 
  • Claims with Dates of Service January 1, 2014 to March 31, 2014 will be reprocessed during the first checkwrite of November 2014. 
  • Claims with Dates of Service April 1, 2014 through May 22, 2014 will be reprocessed during the first checkwrite of January 2015.



Service Begin Date

Service End Date

Date of Impacted



Oct. 1, 2013

Dec. 31, 2013

Sept. 3, 2014



Jan. 1, 2014

March 31, 2014

Nov. 4, 2014



April 1, 2014

May 22, 2014

Jan. 8, 2015*

         * The checkwrite calendar for calendar year 2015 is not available.  The date of the third recoupment is estimated and will be confirmed.

Adjustments and Refunds

To learn more about adjustments and refunds to claims submitted through NCTracks visit

Adjusting a Claim through the Void and Replacement Process

To comply with the Health Insurance Portability and Accountability Act (HIPAA), standard claims may now be filed electronically. Electronic adjustments are the preferred method to report an overpayment or underpayment to NC Medicaid. There are two separate actions that may be filed:

  • Void – Providers should use “void” when they need to cancel or submit a refund for a previously paid claim. The entire claim will be recouped.
  • Replace – Providers should “replace” claims if they are updating claim information or changing incorrectly billed information. This term is interchangeable with adjusting a claim. The entire claim will be recouped and reprocessed.

Additional Information

Additional information regarding PCS recoupment/repayment is available on DMA’s PCS web page at:

Provider Reimbursement
DMA, 919-814-0060


Attention: Pharmacists and Providers

Prescribers Not Enrolled in Medicaid

The Affordable Care Act (ACA) established a new rule that prohibits Medicaid and Children’s Health Insurance Programs [such as N.C. Health Choice (NCHC)] from paying for prescriptions written by prescribers who are not enrolled in Medicaid and NCHC programs.

On January 1, 2013, pharmacy providers began to receive a message at point-of-sale for prescriptions written by prescribers not enrolled in the Medicaid program. The edit, 00951 states “M/I Presc ID – No ID on File” with an Explanation of Benefit (EOB) 02951 message “Prescriber NPI not on file. Contact prescriber and refile with Correct NPI.”

Claims will deny starting on November 1, 2014. This will hold true for originals and refills.

Outpatient Pharmacy
DMA, 919-855-4300


Proposed Clinical Coverage Policies

In accordance with NCGS §108A-54.2, proposed new or amended Medicaid clinical coverage policies are available for review and comment on DMA's website. To submit a comment related to a policy, refer to the instructions on the Proposed Clinical Coverage Policies web page at Providers without Internet access can submit written comments to:

Richard K. Davis
Division of Medical Assistance
Clinical Policy Section
2501 Mail Service Center
Raleigh NC 27699-2501

The initial comment period for each proposed policy is 45 days. An additional 15-day comment period will follow if a proposed policy is substantively revised as a result of the initial comment period. If the adoption of a new or amended medical coverage policy is necessitated by an act of the General Assembly or a change in federal law, then the 45 and 15-day time periods shall instead be 30 and 10-day time periods.

2014 Checkwrite Schedule
Checkwrite Cycle Cutoff Date Checkwrite Date EFT Effective Date
August 8/07/2014 8/12/2014 8/13/2014
8/14/2014 8/19/2014 8/20/2014
8/21/2014 8/26/2014 8/24/2014
8/28/2014 9/03/2014 9/04/2014
September 9/04/2014 9/09/2014 9/10/2014
9/11/2014 9/16/2014 9/17/2014
9/18/2014 9/23/2014 9/24/2014
9/25/2014 9/30/2014 10/1/2014

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.

Sandra Terrell, MS, RN
Acting Chief Operating Officer
Division of Medical Assistance
Department of Health and Human Services

Paul Guthery
Executive Account Director
Computer Sciences Corp. (CSC






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