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Family and Children's Medicaid MA-3535 RECIPIENT FRAUD AND ABUSE POLICY AND PROCEDURES

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XViiI. North Carolina Title XIX Medicaid/NCHC Recipient Profiles

REISSUED 03/01/11 - CHANGE NO. 05-11

(XVIII.B.)

REISSUED 03/01/11 - CHANGE NO. 05-11

(XVIII.B.3.)

REVISED 03/01/11 - CHANGE NO. 05-11

(XVIII.B.4.)

REISSUED 7/01/08 - CHANGE NO. 11-08

(XVIII.C.1.d.)

REISSUED 7/01/08 - CHANGE NO. 11-08

(XVIII.C.4.)

If you get other requests for profiles and this section does not address how to handle the requests, refer the requester to DMA Program Integrity (919) 647-8000.

REVISED 11/01/11 - CHANGE NO. 15-11

(XVIII.D.2.)

REISSUED 11/01/11 - CHANGE NO. 15-11

(XVIII.E.)

HMBR4002

NORTH CAROLINA TITLE XIX MEDICAID RECIPIENT

(555555555-N)

20071215

     

CURRENT PROFILE PG

8

3,145

 

REQ BY:CLERK=X013

FOR:PROV= ALL CLAIM TYPE:A

DATES= 08012006 10312007

NAME=SMITH JOHN

BASE ID=555555555-N

SEX=M

DOB=12121945

DOD=00000000

------------CLAIM---------------

         

CT

ICN

ST SI

PROV #

TP

SP

BILLED PAT-LIAB

SPEND-DN

NET-PD

FDOS

TO DOS

ST

DESCRIPTION

PAID

 

XOVER

FDOS

TDOS

TOT-BILL

TOT-DED

COINS

TOT-PAY

XOVER

FDOS

TDOS

ST

DTL-BIL

ALLOWED

PAID

COINS

DED

REISSUED 7/01/08 - CHANGE NO. 11-08

(XVIII.F.2.)

HMBR4002

The report number is used internally to identify reports to the system and to the users.

NORTHCAROLINA

TITLE XIX

Denotes the contract for which this information is presented; Title XIX Medicaid Program.

MEDICAID RECIPIENT

The Medicaid ID number for which claims are requested. If a cross-reference number was requested, the base ID will be presented in the BASE ID field below.

DATE

The date the information was produced. (In YYYMMDD format)

CURRENT or PURGED PROFILE

Indicates the type of profile requested.

PROFILE PG

The page numbers of the profile. The first number is the sequence number within this recipient's profile. The second number is the sequence number within the entire job.

REQ BY CLERK

The clerk ID for whom the profile is produced. (X plus the county's 3-digit county number.)

REQ FOR

This information determines the type of records presented. Default to All

Prov = If ALL, all providers are selected.

Claim Type = If A, all claim types are selected.

Dates = The range of dates of services requested. If ALL DATES REQUESTED, all claims will be selected regardless of date of service.

NAME

The name of the recipient on the date the profile was produced based upon the name on the eligibility file.

BASE ID

The Base ID number of the MID requested. This will differ from the above Medicaid Recipient ID if the number requested was a cross-reference ID.

SEX

The sex of the recipient.

DOB

The date of birth of the recipient.

DOD

The date of death of the recipient, if applicable

CT

Claim type. See Appendix A.

ICN

Internal Control Number assigned by EDS.

ST

The status of the claim. See Appendix B.

SI

Supplemental Pay Indicator. This field is used for adjustments only.

PROV NBR

Provider Number for the Billing Provider

TP

The provider type of the billing provider. (FYI only).

SP

The provider specialty of the billing provider. (FYI only).

REISSUED 7/01/08 - CHANGE NO. 11-08

(XVIII.F.3.)

BILLED

The total amount billed on the claim by the provider.

PAT-LIAB

The patient liability for this claim.

SPEND-DN

The amount of spend-down (deductible balance) for this claim.

NET-PD

The amount paid on this claim by Medicaid.

HMBR4002 NORTH CAROLINA TITLE XIX MEDICAID RECIPIENT(900000000-L)

20071115

   

PURGE PROFILE PG

45

67

REQ BY: CLERK=ALW

REQ FOR PROV= ALL CLAIM TYPE:A:

DATES=

06112004

03042005

NAME=DANDURY RICKY

BASE ID=900000000-L

SEX=M

DOB-12201925

DOD=00000000

------------CLAIM-------------

 

PROVIDER SUMMARY INFORMATION

   

PROVIDER

PROVIDER

NUMBER

AMOUNT

AMOUNT

NUMBER

NAME

SERVICES

BILLED

PAID

0495000

PHARM SAVE III

0

6,316.81

4,314.08

00635000

WINYAH DISPENSARY OF

0

778.33

306.20

3400000

PRESBYTERIAN HSPITA

9

9,863.05

55.03

3403000

MEDICAL SERVICES

2

34.02

.00

3406000

AMERICAN MEDICAL RES

5

207.64

111.80

3406000

MECKLENBURY EMERGENC

1

19.66

.00

3416000

AVANTE AT CHARLOTTE

0

8,154.50

4,511.00

3425000

AVANTE AT CHARLOTTE

9

51,239.55

40,489.55

345000

WELLINGTON NURS & RE

0

4,950.00

1,485.00

 

TOTAL

 

26

81,563.56

51,272.66

REISSUED 7/01/08 - CHANGE NO. 11-08

(XVIII.F.4.)

PROVIDER NUMBER

Each provider which appears on the report. Report is sorted in provider number order.

PROVIDER NAME

The provider's name as it appears on the Provider Master File.

NUMBER SERVICES

Number of services is calculated by accumulating the quantity fields on most claims types. For crossover claims, one unit is accumulated. On inpatient and nursing home claims, one unit is counted for each accommodation and ancillary code, which appears, on the claim. On drug claims, one unit is counted for each NDC drug dispensed.

AMOUNT BILLED

The total amount billed, accumulated from the header, by this provider

AMOUNT PAID

The total amount paid, accumulated from the header, to this provider

HMBR4002 NORTH CAROLINA TITLE XIX MEDICAID RECIPIENT(900000000-L)

20071115

   

PURGE PROFILE PG

45

67

REQ BY: CLERK=ALW

REQ FOR PROV= ALL CLAIM TYPE:A:

DATES=

06112004

03042005

NAME=DANDURY RICKY

BASE ID=900000000-L

SEX=M

DOB-12201925

DOD=00000000

 

DATE OF SERVICE SUMMARY

 

SERVICE DATE

AMOUNT BILLED

AMOUNT PAID

06/04

.00

.00

07/04

1,817.63

829.35

08/04

2,093.07

961.85

10/04

29.96

29.96

11/04

2,760.00

.00

12/04

3,305.60

2,661.60

01/05

3,833.68

3,811.34

02/05

3,719.36

3,650.73

03/05

3,795.15

3,757.22

     

TOTAL

21,354.45

15,702.05

REISSUED 7/01/08 - CHANGE NO. 11-08

(XVIII.F.5.)

SERVICE DATE

The month in which the services were performed.

AMOUNT BILLED

The total amount billed by the provider for the services performed during the month.

AMOUNT PAID

The total amount paid by Medicaid for services performed during the month.

TOTAL

Total amount billed and total amount paid.

CLAIM TYPE

DESCRIPTION

D

Drug

J

Medical (Physicians. Etc.)

K

Dental

L

Health Check

M

Hospital Outpatient

P

Medical vendor (Optical, Ambulance)

Q

Home Health, Hospice, Personal Care Services

S

Hospital Inpatient

T

Nursing Home (SNF, ICF), Adult Care Home Transportation

W

Outpatient X-Over (Medicare)

X

Inpatient X-Over (Medicare)

O

Physician X-Over (Medicare)

CLAIM STATUS

DESCRIPTION OF CODE

COUNTABLE OR

NON-COUNTABLE

A

Paid posted

Count

B

Paid unposted

Count

C

Denied posted

Do not count

D

Denied unposted

Do not count

F

Full cash refund (Not reflected on DOS Summary.)

Do not count

G

Adjustment pending against original claim

Do not count

P

Partial refund or recoupment

Do not count

R

Accounts receivable active

Count

U

Claim returned to provider (for signature, etc.)

Do not count

V

Original claim voided due to full recoupment or recoup/repay done on original claim

Do not count

AR

Void original claim and repay provider

Count

AF

Void original claim and full recoupment

Do not count

1

Claim paid but not yet posted

Count

4

Pending claim for an edit

Do not count

5

Pending claim for an audit

Do not count

REISSUED 7/01/08 - CHANGE NO. 11-08

(XVIII.G.)

SERVICE CODE

CLAIM TYPE

DESCRIPTION

01

S,X

Inpatient Hospital

02

M,W

Outpatient Hospital

03

K

Dental

04

D

Drugs

05

J,L,O,P

Physician

06

Q

Home Health, Hospice, Personal Care Services

09

N/A

Medicare Premium (Not found on Recipient Profiles)

11

T

Nursing Home (SNF, ICF) & Personal Care Services in Adult Care Home

67

N/A

NC Health Choice (Not found on Recipient Profiles.

71

N/A

Medical Transportation (Not found on Recipient Profiles.

REISSUED 7/01/08 - CHANGE NO. 11-08

(XVIII.H.1.a.)

NET-PD

The amount Medicaid paid on this claim

HMBR4002

NORTH CAROLINA TITLE XIX MEDICAID RECIPIENT

(901000000-T)

20071115

     

CURRENT PROFILE PG

1

152

 

REQ BY:CLERK=D015

FOR:PROV= ALL CLAIM TYPE:A

DATES= 05012006 06302007

NAME=HOUGHY AMYEE

BASE ID=901000000-T

SEX=F

DOB=12301978

DOD=00000000

------------CLAIM---------------

         

CT

ICN

ST SI

PROV #

TP

SP

BILLED PAT-LIAB

SPEND-DN

NET-PD

FDOS

TO DOS

ST

DESCRIPTION

PAID

XOVER

FDOS

TDOS

TOT-BILL

TOT-DED

COINS

TOT-PAY

XOVER

FDOS

TDOS

ST

DTL-BIL

ALLOWED

PAID

COINS

DED

K

102007155602170

A

8993665 027 072

85.00

.00

.00

38.20

 

052807 052807

A

AMALGAM-TWO SURFACES, PERMANENT

38.20

 

J

252007088011539

A

890287X 022 020

304.00

.00

.00

101.78

 

032507 032507

A

OV NEW PT, COMPLEX-PHYS TIME APPROX 45 MIN

87.53

 

032507 032507

A

SPINE COMPLETE

14.25

 

S

252007182317660

A

3400014 060 080

2739.50

.00

.00

1950.26

 

062307 062507

A

ROOM AND BOARD-PRIVATE OB

1950.26

 

062307 062507

C

ROOM AND BOARD-PRIVATE OB

.00

 

062307 062507

C

MED/SURG SUPPLIES & DEVICES-GEN CLASS

.00

 

062307 062507

C

RECOVERY ROOM-GEN CLASS

.00

 

062307 062507

C

LABOR ROOM/DELIVERY-LABOR

.00

Of days minus any patient liability or any third party payment.

T

252007195309226

A

3415131 080 086

708.00

623.40

.00

84.60

 

062507 063007

A

ALL-INCLUSIVE R&B PLUS ANCILLARY

.00

 

T

252007197324929

A

3415131 080 086

826.00

.00

.00

727.30

 

070907 071507

A

ALL-INCLUSIVE R&B PLUS ANCILLARY

727.30

REISSUED 7/01/08 - CHANGE NO. 11-08

(XVIII.H.1.a.)

Line 2

FROM-DOS-TO DOS

The from and thru dates of service.

ST

Status of claim. See Appendix B

DESCRIPTION

The diagnosis description. If the diagnosis code billed is invalid, no description will print.

PAID

The amount determined to be payable by Medicaid for this line item.

HMBR4002

NORTH CAROLINA TITLE XIX MEDICAID RECIPIENT

(900000000-P)

20071115

 

CURRENT PROFILE PG

1

76

REQ BY:CLERK=D003

FOR:PROV= ALL CLAIM TYPE:A

DATES= 07012007 08312007

NAME=CLAYE KANDY

BASE ID=900000000-P

SEX=F

DOB=07031975

DOD=00000000

------------CLAIM---------------

         

CT

ICN

ST SI

PROV #

TP

SP

BILLED PAT-LIAB

SPEND-DN

NET-PD

FDOS

TO DOS

ST

DESCRIPTION

PAID

XOVER

FDOS

TDOS

TOT-BILL

TOT-DED

COINS

TOT-PAY

XOVER

FDOS

TDOS

ST

DTL-BIL

ALLOWED

PAID

COINS

DED

 

P

252007216215300

A

8802023 075 091

20.69

.00

.00

20.69

 

072007 072007

A

FRAME ZYLONITE COMBINATION

10.95

 

072007 072007

A

SINGLE VISION, GL/PL,SPH+OR-PLANO TO 3.0

9.74

REISSUED 7/01/08 - CHANGE NO. 11-08

(XVIII.H.1.c.)

NET-PD

The amount Medicaid paid on this claim.

HMBR4002

NORTH CAROLINA TITLE XIX MEDICAID RECIPIENT

(900000000-L)

20071115

 

CURRENT PROFILE PG

21

55

REQ BY:CLERK=CE01

FOR:PROV= ALL CLAIM TYPE:A

DATES= 02202007 07312007

NAME=BLACK SANDY

BASE ID=900000000-L

SEX=M

DOB=04121961

DOD=00000000

------------CLAIM---------------

         

CT

ICN

ST SI

PROV #

TP

SP

BILLED PAT-LIAB

SPEND-DN

NET-PD

FDOS

TO DOS

ST

DESCRIPTION

PAID

XOVER

FDOS

TDOS

TOT-BILL

TOT-DED

COINS

TOT-PAY

XOVER

FDOS

TDOS

ST

DTL-BIL

ALLOWED

PAID

COINS

DED

 

D

052007145028819

A

0505123 026 085

27.45

24.27

 

050307

A

HUMULIN N 100U/ML VIAL

D

052007145028570

A

0505123 026 085

147.80

132.58

 

052507

A

REZULIN 400MG TABLET

Line 3

XOVER

Indicates Medicare Crossover.

FDOS

From date of service.

TDOS

To date of service.

TOT-BILL

Total Billed to Medicare

TOT-DED

Total Medicare Deductible.

COINS

Coinsurance (20% not paid by Medicare).

TOT- PAY

Medicare Payment.

Lines 01 - XX

Breakdown of the Medicare Claim into Line Items

REISSUED 7/01/08 - CHANGE NO. 11-08

(XVIII.1.d.)

 

HMBR4002

NORTH CAROLINA TITLE XIX MEDICAID RECIPIENT

(900000000-L)

20061115

 
 

*PURGE* PROFILE PG

16

38

REQ BY:CLERK=ALW

FOR:PROV= ALL CLAIM TYPE:A

DATES= 06112004 03042005

NAME=DANDURY RICKY

BASE ID=900000000-L

SEX=M

DOB=12201925

DOD=00000000

------------CLAIM---------------

         

CT

ICN

ST SI

PROV #

TP

SP

BILLED PAT-LIAB

SPEND-DN

NET-PD

FDOS

TO DOS

ST

DESCRIPTION

PAID

XOVER

FDOS

TDOS

TOT-BILL

TOT-DED

COINS

TOT-PAY

XOVER

FDOS

TDOS

ST

DTL-BIL

ALLOWED

PAID

COINS

DED

 

O

102005149673330

A*

8901612 022 018

8.37

.00

.00

8.37

 
 

ROUTINE MEDICAL EXAM

 

XOVER

102804 102804

56.00

.00

8.37

33.49

01

102804 102804 A

56.00

41.86

33.49

8.37

.00

 

W

102005079879900

A

3435134 080 086

155.60

.00

.00

155.60

 

ROUTINE MEDICAL EXAM

XOVER

010305 011705

2880.00

100.00

55.60

928.00

01

010305 011705

.00

.00

.00

.00

.00

* The Status code on this line is the Medicaid Status code. The status code on Line 4 is the Medicare status code. The Medicare Status code is irrelevant to the Medicaid Fraud Investigator. The only status the Investigator needs to be concerned with is the Medicaid status, and the amount Medicaid paid on the claim.

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  For questions or clarification on any of the policy contained in these manuals, please contact your local county office.


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