Subject: Medicaid Inquiries and DMA Contact List
Distribution: County Directors of Social Services
Income Maintenance Staff
The Division of Medical Assistance (DMA) now has new telephone numbers. This letter provides the new telephone numbers and new key contacts for the division. The issuance of this letter obsoletes DMA Administrative Letter No. 12-04 dated February 11, 2004.
Also, the DMA Hearings Office and the Division of Social Services (DSS) Office of Hearings and Appeals have been added to the contact list. This information contains a clarification on which appeals are handled by each office.
County DSS staff should contact their Medicaid Program Representative (MPR) when they have policy questions. If the county’s MPR is unavailable, they may contact another MPR or the Medicaid Eligibility Unit in DMA. See II. F. below.
Recipient’s MID number
Date(s) of service,
Amount billed, and
Did the provider accept recipient as a Medicaid patient?
DO NOT REFER RECIPIENTS TO DMA’s FISCAL AGENT OR
TO OTHER DMA CONTRACTORS FOR INPATIENT PRIOR APPROVALS.
Inquiries about procedures for filing claims or payment amounts are referred to EDS, the state Medicaid fiscal agent. The fiscal agent is responsible for claims processing, claims payment, and provider relations and education.
See III. below for telephone numbers.
The following requires prior approval:
For emergency admissions, the hospital must call ValueOptions within 2 work days of the admission. For more information, the provider should call DMA Behavioral Health Services at (919) 855-4290.
• The Automated Voice Response (AVR) System at 1-800-723-4334, if they have the recipient’s MID number or the Social Security number and date of birth,
• DMA at (919) 855-4045 to obtain the MID number only or to verify dates of service over 12 months old.
The eligibility denial codes appearing on the provider’s RA report are:
010 - Diagnosis or service invalid for recipient age
011 - Recipient not eligible on service date
012 - Diagnosis or services invalid for recipient sex
093 - Patient deceased per state eligibility file
120 - Recipient MID number missing
139 - Services limited to presumptive eligibility
143 - Medicaid ID number not on state eligibility file
191 - Medicaid number does not match patient name
292 - Qualified Medicare Beneficiary – MQB recipient. Medicare payment must be indicated either as a crossover prior to 10/1/02 or third party if after 10/1/02. No payment made if not covered by Medicare.
953 - Individual has restricted coverage – Medicaid only pays Part B premium.
For Third Party Recovery or Health Insurance Premium Payment Program (HIPP), the address is:
Division of Medical Assistance
2508 Mail Service Center
Raleigh, NC 27699-2508
For all other sections, the address is:
Name of DMA section/unit or individual
Division of Medical Assistance
2501 Mail Service Center
Raleigh, NC 27699-2501
Gary Fuquay, Director (919) 855-4100
Dr. Nancy Henley, Deputy Director for Clinical Affairs (919) 855-4100
Mark Benton, Deputy Director for Financial Operations (919) 855-4100
Ellen Pittman, Human Resources Manager (919) 855-4120
The DMA Director oversees the management and coordination of the Medicaid programs to ensure cost-effective health care services are available across the state. The Human Resources manager coordinates services and programs to assist in the development of a qualified and effective staff.
Jeffrey Simms, Assistant Director
Managed Care oversees the primary care case management program, Community Care of North Carolina (Carolina ACCESS), and risk contracts with HMO’s and Health Check.
Serves as division’s representative for recipients and other agencies related to medical care and services covered by the Medicaid program.
Deborah Atkinson, Assistant Director
Responsible for budget and forecasting, purchasing and contracting, as well as contract management, and special projects.
Tom Galligan, Assistant Director
Duties include auditing, management of Disproportionate Share Hospital (DSH), rate setting, and financial analysis.
Lacey Barnes, Assistant Director
Medicaid Eligibility Unit (919) 855-4000
Responds to issues related to eligibility requirements for Medicaid and NC Health Choice for Children, eligibility determinations, and policy interpretations.
Eligibility Information System (EIS) (919) 855-4000
Responsible for EIS reports, screens, processing and the Income Eligibility Information System (IEVS).
Claims Analysis and Medicare Buy-In (919) 855-4045
Responsible for the override of billing time limit, research of claims denied for eligibility reasons, Medicaid covered services billed to the recipient and Medicare buy in for Parts A and B.
Functions include provider enrollments, Provider Bulletins and Manuals, and EDS Provider Relations.
Robert B. Nowell, Assistant Director
The Program Integrity website, http://www.dhhs.state.nc.us/dma/pi.html#wwa, has names, phone numbers, and email addresses for keys contacts for all units listed below.
Provider Administrative Reviews
Performs post-payment administrative reviews of providers (except Pharmacy) claims and services to determine the appropriateness of claim submission practices and verify providers’ compliance with Medicaid coverage, billing policies and Provider Participation Agreements/Contracts.
Provider Medical Reviews
Performs post-payment reviews of services to determine if the services were medically necessary, were of acceptable quality, and conform to Medicaid coverage and billing policies. Reviews involve examination of claims/payment data, medical record documentation, and research and application of Medicaid coverage policy.
Conducts post-payment reviews of claims on site. Recovers overpayments, resolves pharmacy complaint calls and educates providers regarding policy and/or problem areas. This section also provides support and resources to the Attorney General’s Medicaid Investigations Unit.
Home Care Reviews
Responsible for post-payment reviews of Medicaid recipients receiving home and community based services. The Nurse Reviewers determine if Home Health, Personal Care Services, Durable Medical Equipment, Hospice, Home Infusion Therapy, etc. are provided to recipients, are medically needed and appropriate and are of high quality. Reviews are often conducted on site unannounced.
Responsible for conducting the federally mandated Quality Control reviews to establish the Medicaid eligibility payment error rates and assisting in correcting problems. They also provide policy consultation and coordination for recipient fraud and abuse investigations with the county program integrity investigators, and investigate recipient complaints of overcharging and inappropriate billing for Medicaid covered services.
Third Party Recovery (TPR) (919) 647-8100
Primarily responsible for the recovery of Medicaid payments for services that should have been paid by health insurance plans and liability insurance. TPR ensures accurate insurance information is on recipient files before Medicaid pays claims. TPR also recovers certain Medicaid payments from the estates of deceased Medicaid recipients.
Marcia Rao, Assistant Director (919) 855-4261
William Lawrence, MD, Medical Director (919) 855-4261
Clinical Policy is responsible for the development and oversight of rules, policies, criteria, and procedures for Medicaid-covered services and waiver programs. This section is responsible for the following coverage areas:
Practitioner and Clinic Services- Clarence Ervin, Chief (919) 855-4320
This section is responsible for Medicaid services related to:
Federally Qualified Health Centers
Rural Health Center
Public Health Departments
Hospital Outpatient Departments
Independent Diagnostic Treatment Facilities
Nurse Practitioners/Certified Nurse Midwives
Home Infusion Therapy
Baby Love/Child Service Coordination
Institutional and Community Care – Lynne Perrin, Chief (919) 855-4350
Adult Care Homes (919) 855-4360
Personal Care Services
Community Alternatives Program for Disabled Adults
Personal Care Services
Home Health Services (919) 855-4380
HIV Case Management
Community Alternatives Program for Persons with AIDS
Community Alternatives Program for Children
Private Duty Nursing (919) 855-4390
General (919) 855-4357
Psych (919) 855-4290
Pharmacy and Ancillary Services – Tom D’Andrea, Chief (919) 855-4300
This section is responsible for Medicaid services related to:
Durable Medical Equipment
Behavioral Health Services –Carol Robertson, Chief (919) 855-4290
This section is responsible for the following services:
Mental Health/Developmental Disability/Substance Abuse Services
Community Alternatives Program for Persons with Mental Retardation
Community Alternatives Program for Persons with a Developmental Disability
Residential Treatment (Residential Child Care, Psychiatric Residential Treatment Facilities)
Developmental Evaluation Centers/Children’s Developmental Service Agencies (919) 855-4350
Outpatient Specialized Therapies (919) 855-4290
Independent Practitioners (919) 855-4310
Local Education Agencies (LEAs)
Psychological Services in Health Departments and School Based Health Centers Sponsored by Health Departments to the Under 21 Population
Ronald Venezie, DDS, MS, Dental Director
The Dental Program oversees policies and procedures for coverage of dental and orthodontic services delivered to Medicaid recipients.
Mary Coward, Chief Hearing Officer
The DMA Hearing Office provides an informal administrative hearing process for both recipients and providers of Medicaid services. Recipients can appeal denials, reductions and terminations of Medicaid covered medical services. This includes appeals regarding prior approval for certain surgical procedures (e.g., breast reduction, gastric by-pass) and prescription drugs, outpatient specialized therapies such as physical, occupational and speech therapy, requests for out of state medical treatment, requests for specific medical services such as private duty nursing, psychiatric hospital length of stay appeals, and CAP/C, CAP/DA and ICF/MR level of care decisions. The DMA Hearing Office also handles appeals from Medicaid providers (e.g., hospitals, physicians, pharmacies, home health agencies, etc.) regarding post-payment review recoupment determinations made by DMA’s Program Integrity section as well as provider contract termination decisions.
In addition, the DMA Hearing Office also holds hearings regarding the involuntary discharge of residents (including those who are not Medicaid recipients) from nursing facilities and adult care homes, as well as appeals of Preadmission Screening and Annual Resident Review (PASARR) decisions.
The DMA Hearing Office should not be confused with the DSS Hearings and Appeals Unit (919-733-3289) which handles Medicaid eligibility and program termination appeals.
Cheryll Collier, Executive Director, NC Title XIX
Cathy Waters, Deputy Director
Raleigh, NC 27622
4905 Waters Edge Drive
Raleigh, NC 27606
Prior Approval Address:
Prior Approval Unit
P.O. Box 31188
Raleigh, NC 27622
Providers receive recorded information on:
Prior approval status
Procedure code pricing
Modifier code verification
Dental benefit limitations
Providers will be directed to a Service or
Representative for assistance with: 1-800-688-6696
Billing, coverage issues
Prior approval services
Denials, other than eligibility
Forms, orders, information
Manuals, bulletins, and policy questions
Inspects, certifies, registers and licenses hospitals, nursing homes, adult care homes, mental facilities, home care programs and other health facilities. Also handles complaints regarding quality of care.
This division provides a listing of Nursing Aide I’s. The Division approves Nursing Aide I training programs, and handles complaint investigation of Nursing Aide I and Nursing Aide I training programs.
Responsible for the planning, administering, coordinating, and evaluating the activities developed under the federal Older Americans Act and the programs for older adults funded by the NC General Assembly.
Long Term Care Ombudsmen serve as advocates for residents in nursing homes and adult care homes (rest homes/assisted living) throughout North Carolina. Ombudsmen receive and investigate complaints made by or on behalf of long term care residents and work for their resolution. The Ombudsman Program is an advocacy program, not a regulatory agency.
Provides information and referrals to the proper department and agency. Also, assists with problem resolutions for concerns or complaints related to department services.
This Information and Referral Service provides citizens with information and referrals on human service agencies in government, non-profit agencies and support groups. Specialists answer questions and make appropriate referrals to persons seeking assistance or information on available human service programs.
Responsible for regulation of nursing practice, licensed and unlicensed personnel. It also approves and regulates Nursing Aide II training programs and handles complaint investigations of licensed nurses and Nursing Aide II’s.
Responsible for handling all appeals regarding Medicaid eligibility denials and terminations. This includes Medicaid denials based on a disability.
Please address questions concerning this letter to your Medicaid Program Representative.
Gary H. Fuquay
(This material was researched and written by Angela Saddler, Policy Consultant, Medicaid Eligibility Unit.)
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.