Subject: Medicaid/North Carolina Health Choice Inquiries and DMA Contact List
Distribution: County Directors of Social Services
Income Maintenance Staff
This letter updates the telephone numbers and key contacts for the division. The issuance of this letter obsoletes DMA Administrative Letter No. 05-05 dated October 27, 2004.
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.
• DMA EPSDT Policy Instructions
• DMA Special Bulletin entitled “Prior Approval Process and Request for Non-Covered Services” published in January 2006
Recipient’s MID number
Date(s) of service,
Amount billed, and
Did the provider accept recipient as a Medicaid patient?
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.
For emergency admissions, the hospital must call ValueOptions within two business 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
L. Allen Dobson, Jr., Asst. Secretary for Health Policy and Medical Assistance (919) 855-4100
Mark Benton, Deputy Director and Chief Operating Officer (919) 855-4100
William W. Lawrence, Jr., M.D., Deputy Director for Clinical Affairs (919)855-4100
Ellen Pittman, Human Resources Manager (919) 855-4120
The Assistant Secretary 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.
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.
Responsible for budget and forecasting, purchasing and contracting, as well as contract management, and special projects.
Duties include auditing, management of Disproportionate Share Hospital (DSH), rate setting, and financial analysis.
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 Verification System (IEVS).
Claims Analysis and Medicare Buy-I…………………(919) 855-4045
Responsible for the approval of time limit overrides, research of claims denied for eligibility, erroneous billings to Medicaid recipients, Medicare buy in for Parts A and B and incorrect information for Medicare Part D.
The Program Integrity website, http://www.dhhs.state.nc.us/dma/pi.html, has names, phone numbers, and email addresses for key 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 Review
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. provided to recipients are medically necessary, appropriate and are of high quality. Reviews are often conducted on site and unannounced.
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.
Clinical Policy and Programs is responsible for the development and oversight of rules, policies, criteria, and procedures for Medicaid-covered services and waiver programs as well as the administration of EPSDT and due process or appeal rights for recipients. This section is also responsible for the coverage areas specified below.
Practitioner and Clinic Services……………………………… (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
Baby Love/Child Service Coordination
Institutional and Community Care – Lynne Perrin, Chief (919) 855-4340
Adult Care Homes
Case Management Services for Children at Risk for Abuse, Neglect or Exploitation
General (Level I)
Psychiatric (Level II)
Community Alternatives Program for Disabled Adults……(919) 855-4360
Personal Care Services
Community Alternatives Program for Persons with AIDS...(919) 855-4380
Community Alternatives Program for Children
Home Health Services
Home Infusion Therapy
HIV Case Management
Private Duty Nursing
Pharmacy and Ancillary Services – Tom D’Andrea, Chief.....(919) 855-4300
This section is responsible for Medicaid services related to:
Durable Medical Equipment
Local Education Agencies
Orthotics and Prosthetics
Outpatient Specialized Therapies
Behavioral Health Services –Carol Robertson, Chief………..(919) 855-4290
This section is responsible for the following services:
Case Management Services for Adults At Risk for Abuse, Neglect or Exploitation
Community Alternatives Program for Persons with Mental Retardation/Developmental Disability
Early Intervention Services (through Children’s Developmental Services Agencies)
Enhanced Mental Health Services
School-Based Psychological Services
Residential Treatment Facilities (Residential Child Care, Psychiatric Residential Treatment Facilities)
The Dental Program oversees policies and procedures for coverage of dental and orthodontic services delivered to Medicaid recipients.
4905 Waters Edge Drive
Raleigh, NC 27606
Prior Approval Address:
Prior Approval Unit
P.O. Box 31188
Raleigh, NC 27622
Inspects, certifies, registers and licenses hospitals, nursing homes, adult care homes, mental facilities, home care programs and other types of health care agencies and facilities. Also, handles complaints regarding quality of care.
This Division also maintains the Nurse Aide I and Health Care Personnel Registry. The Division approves Nurse Aide I training and competency evaluation programs and handles complaint investigations against an individual Nurse Aide I as well as training programs.
Responsible for the planning, administration, coordination, and evaluation of the activities developed under the federal Older Americans Act and the programs for older adults funded by the NC General Assembly. This division is also responsible for the state/county Special Assistance program.
Long-Term Care Ombudsmen serve as advocates for residents in nursing facilities 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.
This Information and Referral Service provides citizens with information on and referrals to 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 educational programs for registered nurses, licensed practical nurses and Nursing Aide II training and competency evaluation programs. The Board also handles complaint investigations against an individual licensed nurse or Nurse Aide II.
The former DMA and DSS hearing offices merged to form the DHHS Hearings and Appeals Office.
The hearing officers managed by Mr. Feltman are responsible for handling all state appeals regarding Medicaid eligibility denials and terminations. This includes Medicaid denials based on disability.
The hearing officers managed by Mrs. Coward provide an informal administrative hearing process for both recipients and providers of Medicaid services. Recipients can appeal denials, reductions and terminations of Medicaid covered and non-covered state Medicaid Plan services. This includes appeals regarding prior approval for certain surgical procedures (e.g., breast reduction, gastric by-pass), prescription drugs, outpatient specialized therapies (physical, occupational and speech therapy), requests for out-of-state medical treatment, and requests for specific medical services such as private duty nursing, psychiatric hospital length of stay, and CAP/C, CAP/DA, CAP-AIDS, and ICF/MR level of care decisions. These hearing officers also handle 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, these hearing officers hold 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.
Responsible for Work First and Food Stamp policies.
Please address questions concerning this letter to your Medicaid Program Representative.
L. Allen Dobson, Jr., M.D.
Assistant Secretary for Health Policy and
(This material was researched and written by Trenita Dawkins, Policy Consultant, Medicaid Eligibility Unit).
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.