September 2001 Medicaid Bulletin title image

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In This Issue . . .

All Providers: Carolina ACCESS Providers: CAP/DA Providers: Cost Report Preparers: Federally Qualified Health Centers: Health Departments: Hospitals: ICF-I/DD Facility Providers: Mental Health Providers: Nursing Facility Providers: Nurse Practitioners: Physicians: Rural Health Clinics: Surgical Sterilization Procedure Providers:

Attention: All Providers

Holiday Observance

The Division of Medical Assistance (DMA) and EDS will be closed on Monday, September 3, in observance of Labor Day.

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

Attention: All Providers

New Director Named for the Division of Medical Assistance

On July 16, 2001, Nina Yeager joined the N.C. Department of Health and Human Services (DHHS) as the Director of the Division of Medical Assistance (DMA). Ms. Yeager succeeds Dick Perruzzi who retired from the position.

Prior to her appointment, Ms. Yeager served as the budget administrator for health, human resources, and public safety in the Office of State Budget, Planning, and Management. Ms. Yeager began her career as a county caseworker in New York and North Carolina and later gained budget experience as a fiscal analyst in the General Assembly where she served on human resources subcommittees including the Appropriations Subcommittee on Health and Human Services.

DMA, 919-857-4011

Attention: Acute Care Hospitals, Rehabilitation Hospitals, and Physicians

Certification of Need for Inpatient Hospital Care

Effective with date of service September 1, 2001, the separate physician statement certifying the need for inpatient hospital care will no longer be required. In lieu of the specific statement about this need, the physician orders for admission and treatment, history and physical, progress notes or discharge summary are considered acceptable certification for Medicaid recipients.

Certification of need is still a requirement for admission to freestanding psychiatric hospitals and psychiatric residential treatment facilities. That process is unchanged.

Ann H. Kimbrell, R.N., Medical Policy Section
DMA, 919-857-4020

Attention: Physicians, Nurse Practitioners, Health Departments, Federally Qualified Health Centers, and Rural Health Clinics

Immune Globulin (IgIV, Human, for Intravenous Use, CPT 90283) Coverage Clarification

The N.C. Medicaid program covers immune globulin (IgIV), human, for intravenous use. Each unit of the immune globulin is 500 mg. Effective January 1, 2001, the maximum reimbursement rate is $42.84 for one unit. Providers must bill their usual and customary rate. An example of how to bill is shown below.
Amount Given Units to be Billed
30 Grams


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

Attention: Hospitals

Utilization Review Update for Acute Care Hospitals

Effective with claims processed beginning October 1, 2001, the InterQual® Decision Support Criteria will be used by Medical Review of North Carolina (MRNC) as the screening tool for postpayment reviews of inpatient hospital care for the N.C. Medicaid program.

These criteria, used by MRNC in screening Medicare claims, now will be employed for Medicaid hospital reviews as well. Medical records that fail to meet these criteria will be referred to a physician consultant for individual consideration.

Ann H. Kimbrell, R.N., Medical Policy Section
DMA, 919-857-4020

Attention: All Providers

Removal of Sutures under Anesthesia by Same Surgeon (CPT Code 15850)

The N.C. Medicaid program does not allow separate reimbursement to the same surgeon for the removal of sutures under anesthesia. The global surgical package is an all-inclusive package associated with a procedure and includes the removal of sutures. CPT procedure code 15850 must not be billed separately.

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

Attention: Carolina ACCESS Providers

Carolina ACCESS Primary Care Provider Reapplication After Contract Termination

Effective June 21, 2001, the Carolina ACCESS (CA) provider sanction process has been revised to address the reapplication of a provider whose CA contract has been terminated or who has resigned to avoid termination. These providers are prohibited from reapplying for a minimum of one year, with a maximum to be determined on a case-by-case basis by the Managed Care Physician Advisory Committee (PAC) along with recommendations from the Quality Management Unit. The decision will be predicated on the extent or severity of the contract violation necessitating the termination or resignation.

Flynn King, R.N., Managed Care Section, Quality Management Unit
DMA, 919-857-4022

Attention: Carolina ACCESS Providers

Carolina ACCESS Provider Information Changes

Due to budget constraints for the July 2001 - June 2002 fiscal year, some counties may be without a Managed Care Representative for a period of time. Therefore, please notify the Division of Medical Assistance (DMA) Managed Care Section of all changes occurring within your practice by completing the Carolina ACCESS Provider Information Change form. The completed form should be faxed to 919-715-0844. Please keep copies of the form on hand. It is extremely important that the information on file with DMA for all Carolina ACCESS practices remains current and accurate to avoid potential claim denials or contract sanctions. Providers are also responsible for ensuring that information on file with the Medicaid program for their practice or facility remains up-to-date. (Please refer to the January 2001 Special Bulletin I, Provider Enrollment Guidelines for information on notifying Medicaid of a change within your practice.)

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

Attention: Carolina ACCESS Providers

Revision of the Carolina ACCESS Hospital Admitting Privileges Policy

Carolina ACCESS (CA) requires that all primary care providers (PCPs) establish and maintain hospital admitting privileges or a formal agreement with another physician or group practice for the management of inpatient hospital admissions of enrollees. The intent of this requirement is to ensure access and continuity of care for our enrollees.

Continuity and access to care issues arise when a provider maintains admitting privileges at a hospital that is located an "unreasonable driving distance" from the enrollee's county of residence. Effective September 1, 2001, PCPs must maintain admitting privileges or a formal agreement for the management of inpatient admissions of CA enrollees at a hospital that is within thirty (30) miles distance or forty-five (45) minutes drive time from the primary care provider's office. Note: If there is no hospital that meets the geographic criteria listed above, the hospital geographically closest to the CA PCP's (i.e., Applicant's) practice will be accepted.

Questions regarding the CA Hospital Admitting Privileges Policy should be directed to the Division of Medical Assistance Managed Care Section at 919-857-4022.

Vickie Dean, R.N., B.S.N., Managed Care Section
DMA, 919-857-4022

If you are currently filing claims electronically
change vendors or billing services

Please call EDS at 1-800-688-6696 (option "1")

It is not necessary to complete a new ECS agreement


Attention: All Providers

New Name for the Health Care Financing Administration

On June 14, 2001, Tommy G. Thompson, Secretary of the U.S. Department of Health and Human Services (HHS), announced that the Health Care Financing Administration (HCFA), which governs Medicare and Medicaid, has been renamed to the Centers for Medicare and Medicaid Services (CMS). CMS is comprised of three specific agencies with the Center for Medicaid and State Operations focusing on programs administered by the states, including Medicaid, the State Children's Health Insurance Program, and insurance regulation.

Renaming the agency that governs Medicare and Medicaid is only the first in a series of reforms proposed by Secretary Thompson. Among the changes proposed is the plan to name a Medicaid representative for each state to HHS's regional and main offices, which will ensure that each state has a direct link to HHS. Although the majority of the proposed changes are specific to Medicare, all of the changes are designed to make the agency more consumer-friendly and more responsive to the needs of the providers.

EDS, 1-800-688-6696 or 919-851-8888
Need a form?

The most frequently requested Mediciad forms are now available online at:


Attention: Nursing Facility Providers, ICF-I/DD Facility Providers, and Cost Report Preparers

Division of Medical Assistance Audit Section Website

The Division of Medical Assistance (DMA) Audit Section website is available for downloading Medicaid cost reporting software, the user manual, and guidance for cost report preparation. Each of the files can be downloaded by clicking on the appropriate entry on the left side of the screen. A completed cost reporting diskette and other required documents noted in the guidance for cost report preparation must be mailed to DMA's Audit Section within the same time frame as in the past. Effective with the 2001 cost reports, software will not be mailed to providers. A transition period during the first year of implementation will allow DMA's Audit Section to mail the cost reporting diskette and user manual upon request.

Harold Wiggins, Audit Section Chief
DMA, 919-733-6390

Attention: Hospitals and Physicians

Billing Diagnostic Procedure Codes During an Inpatient Stay

Recently there has been some confusion regarding physicians billing services when their office is located in an acute care hospital and the recipient is an inpatient. The N.C. Medicaid program defines inpatient hospital services as those services that are ordinarily furnished for the care and treatment of a recipient, either by the hospital or by others under arrangements with the hospital.

Hospitals are required to bill all services that a recipient receives during an inpatient stay. The Diagnostic Related Grouping (DRG) payment is considered payment in full for the services a recipient receives during the inpatient stay, which includes the technical component of diagnostic procedures.

Physician office space that is located within a hospital's physical structure must be leased at fair market value. The space must be designated as the provider's office and not available for any other purpose.

Physicians are required to bill the professional component of the diagnostic procedure code by appending modifier 26 with an inpatient place of service. Diagnostic procedure codes billed with a technical component modifier or as a complete service when the recipient is an inpatient will be denied.

All providers are required to maintain compliance with the requirements of the Stark Act.

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

Attention: All Direct-Enrolled Licensed Psychologists, Licensed Clinical Social Workers, Advanced Practice Psychiatric Nurse Practitioners, and Advanced Practice Clinical Nurse Specialists

Place of Service for Outpatient Therapy

Effective with dates of service September 1, 2001, school will be added as a place of service (POS) to provide outpatient psychotherapy and testing. This is billed with a POS of 99 in block 24B on the HFCA-1500 claim form. This POS may be billed in addition to the office, hospital or clinic as previously indicated.

Carol Robertson, Medical Policy Section
DMA, 919-857-4020

Medical Doctors * Opticians * Chiropractors * Podiatrists * Dentists

Report changes in
site or billing addresses
the addition or deletion of a physician to or from a group

to Your Local Blue Cross Representative

Do Not Notify DMA or EDS
Blue Cross will forward the updated information to DMA's Provider Services Unit

*Enrolled providers within 40 miles of North Carolina 


Attention: Providers of Surgical Sterilization Procedures

New Procedures for Submitting Sterilization Consent Forms to EDS

Effective September 1, 2001, providers must submit all sterilization consent forms separately from and prior to submitting electronic or paper claims for sterilization services.

The process for separate submission of paper consent forms has been in place for a number of years to allow sterilization claims to be submitted electronically. This requirement is now being expanded to include the separate submission of all sterilization consent forms, regardless of whether the claim is submitted electronically or on paper.

When a sterilization consent form is completed, the recipient's Medicaid identification number (MID) must be written in the upper right corner of the form. If the recipient's MID is not present, the consent form will not be reviewed or processed. All information on the form must be correct and legible prior to submission. If an illegible consent form is received from a provider, the claim will not be approved for payment. Refer to the June 2000 general Medicaid bulletin for sterilization consent guidelines.

Providers must submit the original (white) copy of the consent form to EDS. Submission of the original white copy will eliminate illegible pink and yellow copies being sent to EDS for review.

Distribute the 3-page consent form as follows:

  1. White copy: to EDS prior to and separate from claim submission to the following address:

  2. EDS
    P.O. Box 300012
    Raleigh, North Carolina 27622
  3. Yellow copy: for the provider's files
  4. Pink copy: to the patient

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

Attention: Carolina ACCESS Providers

Change in Contacts for Carolina ACCESS Providers

Due to budget constraints, the General Assembly eliminated state funding for the local Managed Care Representatives (MCR). This means that Carolina ACCESS (CA) providers may no longer have a county contact to resolve Medicaid eligibility and claims issues.

For assistance, providers should call the Automated Voice Response (AVR) system to verify Medicaid eligibility or a recipient's CA provider. The toll free number for the AVR system is 1-800-723-4337. It is available 24 hours a day. For billing issues and claims resolution, contact your provider representative at EDS. The number is 1-800-688-6696 or 919-851-8888. To request a CA override or for other questions or concerns, contact your Managed Care Regional consultant. A current list with telephone numbers is provided below.
Jerry Law
Rosemary Long
Lisa Gibson
Daryl Frazier
Lisa Catron
Beaufort  Bladen  Alamance  Cabarrus  Alexander 
Bertie  Brunswick  Anson  Gaston  Alleghany 
Camden  Carteret  Caswell  Iredell  Ashe 
Chowan  Columbus  Chatham  Lincoln  Avery 
Currituck  Craven  Davie  Mecklenburg  Buncombe 
Dare  Cumberland  Davidson  Union  Burke 
Edgecombe  Duplin  Durham    Caldwell 
Franklin  Greene  Forsyth    Catawba 
Gates  Harnett  Guilford    Cherokee 
Granville  Hoke  Lee    Clay 
Halifax  Johnston  Montgomery    Cleveland 
Hertford  Jones  Moore    Graham 
Hyde  Lenoir  Orange    Haywood 
Martin  New Hanover  Person    Henderson 
Nash  Onslow  Randolph    Jackson 
Northhampton  Pamlico  Richmond    Macon 
Pasquotank  Pender  Rockingham    Madison 
Perquimans  Robeson  Rowan    McDowell 
Pitt  Sampson  Stanley    Mitchell 
Terrell  Scotland  Stokes    Polk 
Vance  Wayne  Surry    Rutherford 
Wake  Wilson  Yadkin    Swain 
Warren        Transylvania 
Washington        Watauga 


Laurie Giles, Managed Care Section
DMA, 919-857-4022

Attention: Providers of Community Alternatives Program for Disabled Adults

Seminars for the Community Alternatives Program for Disabled Adults

Seminars for CAP/DA providers are scheduled for October 2001. These seminars will focus on issues of common interest that are shared with DMA by CAP/DA providers (CAP/DA Overview, Knowledge of CAP/DA Referral Process, Provider Issues, Monitoring Requirements, and Importance of Communication Between the Provider Agency and the CAP/DA Lead Agency), billing instructions and issues. Enrolled CAP/DA waiver services providers (i.e., providers of Adult Day Health, CAP/DA In-Home Aide Levels II and III, Preparation and Delivery of Meals, Respite Care, and Telephone Alert) as well as the CAP/DA Lead Agencies are encouraged to attend.

Due to limited seating, preregistration is required. Unregistered providers are welcome to attend when reserved space is adequate to accommodate.

Please select the most convenient site and return the completed registration form to EDS as soon as possible. Seminars begin at 10:00 a.m. and end at 1:00 p.m. Providers are encouraged to arrive by 9:45 a.m. to complete registration.

Note: All CAP/DA providers are requested to bring their most updated Community Care manual. This manual is available free of charge on DMA's website. Additional manuals will be available at the seminar for purchase at $20.00. (The Community Care manual includes the January 1999 reprint, the October 1999 revision, and the October 2000 revision.)

Return the CAP/DA Seminar Registration form to:

     Provider Services
     P.O. Box 300009
     Raleigh, N.C. 27622

Directions to the sites
Tuesday, October 2, 2001
Martin Community College
Kehakee Park Road
Williamston, NC
Tuesday, October 9, 2001
Catawba Valley Technical College
Highway 64-70
Hickory, NC
Wednesday, October 17, 2001
Coast Line Convention Center
501 Nutt St
Wilmington, NC 
Tuesday, October 23, 2001
Wake Med
Andrews Conference Center
3000 New Bern Avenue
Raleigh, NC 

Directions to the CAP/DA Seminars


Take Highway 64 into Williamston. Martin Community College is located approximately 1 to 2 miles west of Williamston. The Auditorium is located in Building 2.


Take I-40 to exit 125. Travel approximately ½ mile to Highway 70. Travel east on Highway 70. The college is approximately 1½ miles on the right. Ample parking is available. The entrance to the Auditorium is between Student Services and the Maintenance Center. Follow sidewalk (toward satellite dish) and turn right to Auditorium entrance.


Take I-40 east to Wilmington. Take the Highway 17 exit. Turn left onto Market Street. Travel approximately 4 or 5 miles to Water Street. Turn right onto Water Street. The Coast Line Inn is located one block from the Hilton on Nutt Street behind the Railroad Museum.


Driving and Parking Directions
Take the I-440 Raleigh Beltline to New Bern Avenue, exit 13A (New Bern Avenue, Downtown). Travel toward Wake Med. Turn left onto Sunnybrook Road.

Parking is available at the former CCB Bank parking lot, a short walk to the conference facility. The entrance to the Conference Center is at the top of the stairs to Wake Med's Andrews Conference Center.

Parking is also available on the top two levels of Parking Deck P3. To reach this deck, exit the I-440 Beltline, exit 13A. Proceed to the Emergency entrance of the hospital (on the left). Follow the access road up the hill to the gate for Parking Deck P3. After parking in P3, walk down the hill past the Medical Office Building and past the side of the Andrews Conference Center. Turn right at the front entrance of the building and follow the sidewalk to the Conference Center entrance.

Illegally parked vehicles will be towed. Parking is not permitted at East Square Medical Plaza, Wake County Human Services, the P4 parking lot or in front of the Conference Center.

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

Checkwrite Schedule
September 5, 2001 
October 9, 2001 
November 6, 2001 
September 11, 2001 
October 16, 2001 
November 14, 2001 
September 18, 2001 
October 25, 2001 
November 20, 2001 
September 27, 2001 
November 29, 2001 

Electronic Cut-Off Schedule
September 7, 2001 
October 5, 2001 
November 2, 2001 
September 14, 2001 
October 12, 2001 
November 9, 2001 
September 21, 2001 
October 19, 2001 
November 16, 2001 
November 21, 2001 

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.
______________________ _______________________
Nina M. Yeager, Director Ricky Pope
Division of Medical Assitance Executive Director
Department of Health and Human Services                   EDS

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