Medicaid Updates September 2010 Health Information Technology Incentives
o Medicare and Medicaid incentive payments will be available to eligible professionals and hospitals as early as January 2011.
o Special Note: AHEC is one of 60 federally-designated "Regional Extension Centers (RECs)" funded by the
select, implement and use EHRs to improve quality and safety of clinical care. To read about and request assistance through your local AHEC program, go t
Basic Medicaid Billing Guide and Seminars
o Seminars are scheduled for October 2010 in Lenoir, Greensboro, Greenville, Raleigh, and Charlotte. Pre-registration is
o The Basic Medicaid Billing Guide is the primary document that will be referenced during the seminar. This Guide has been
updated and is available There is also a summary of changes document
Medicaid Credit Balance Reports are due no later than 30 days following September 30th. Providers must report any unreported
outstanding credits owed to Medicaid using the form available Further instructions
are available on the form or on pages 11-14 of the bulletin.
NC Medicaid Enrollment Fees are collected from providers upon initial enrollment with Medicaid and at 3-year intervals when
providers are re-credentialed. An invoice will be mailed to providers when the fee is owed. The invoice will only be issued if the
tax identification number in the enrollment application does not identify the applicant as a currently enrolled Medicaid provider.
Payment should be remitted to the address on the invoice and not directly to CSC.
Carolina ACCESS Provider Management Reports
o Although these reports continue to be available online, DMA will no longer print and mail the Carolina ACCESS Referral
Report, the ER Management Report, or the Quarterly Utilization Report. The Carolina ACCESS Enrollment Report will
continue to be printed and mailed to providers monthly.
o Providers may view and download these reports via a secure web portal by completing the Provider Confidential Information
HIV Case Management policy has been revised to include criteria stating that recipients of this service must establish and
maintain a medical home with a CCNC or other primary care provider, and that case managers must maintain at least monthly contact with that PCP to ensure appropriate coordination of care. See Sections 1.0 and 5.0 of the policy for additional information
Urine Drug Screening
o Effective 4/1/10, Medicaid end-dated CPT code 80101 and replaced it with HCPCS code G0431 for initial urine drug
screenings. Any provider who receives an EOB 9 claim denial when billing CPT code 80101 from date of service 4/1/10 and forward, will need to resubmit a new claim using HCPCS code G0431 or G0431QW as appropriate.
o HCPCS code G0430 has also been added and was created to limit billing to one time per procedure and to remove the
limitation on the chromatographic method when it is not being used in the performance of the test.
o HCPCS code G0431 and G0430 should be billed without a modifier by those clinical labs that do not require a CLIA certificate
of waiver. Those labs that required a CLIA certificate of waiver should append modifier QW to the code.
o Providers should use CPT code 80100 when performing a qualitative drug screening test for multiple drug classes using
Family Planning Waiver (FPW), which was initially due to end on 9/30/10 at the end of the 5-year approved waiver period, will
continue beyond 9/30/10. CMS, through the State Eligibility Option for Family Planning Services, would allow states the additional
option to provide family planning services through an amendment to the Medicaid State Plan, without the formal process of
seeking approval for a waiver. The State has not made a decision regarding which option it will pursue long term, but has decided to extend coverage for at least another 12 months with no lapse in coverage.
o Denosumab Injection (Prolia) Billing Guidelines
Effective 6/5/10, Medicaid covers Prolia when billed with HCPCS code J3590. Prolia is available in a prefilled syringe and
should be administered in 60-mg doses as a single injection once every six months by a health care professional.
When billing Prolia, providers must use diagnosis code 733.00, 733.01, or 733.09. One unit of coverage is one 60-mg/1-
ml prefilled syringe. Providers must bill with an NDC and appropriate NDC units (ML should be reported for Prolia). See
page 24 of the Bulletin for additional information.
o OTC Second Generation Antihistamine and Decongestant Combinations
Effective 9/15/10, Medicaid will cover these over-the-counter products: cetirizine-D OTC, loratadine-D OTC 12 hour, and
loratadine-D OTC 24 hour. With a valid prescription, a recipient may receive up to a 102-day supply per 12 months.
o Preferred Drug List (PDL)
Duragesic Patches, Hyzaar, Cozaar, BenzaClin--Although generic drugs are usually considered preferred, the
Secretary of Health and Human Services is allowed to prevent substitution of a generic equivalent drug when the net cost of the brand-name drug is less than the cost of the generic equivalent. With the implementation of the next phase of the
PDL, on September 15, 2010, these four brand name drugs will be considered preferred over of their generic equivalents.
Duoneb and some insulin cartridges and pens--Effective with implementation of the PDL on 9/15/10, these drugs will
have a non-preferred status. Pharmacists may substitute equivalent strength individual nebulizer dosage forms of
albuterol sulfate and ipratropium bromide for Duoneb, or substitute vial-packaged insulin products for cartridge, pen or
similarly packaged insulin products. The pharmacist is not required to obtain a new prescription when a substitution is allowed.
Leukotrienes, Statins, Orally Inhaled Steroids, and Second Generation Anticonsulsants (for seizure disorders only)--Effective with implementation of the PDL on 9/15/10, pharmacists will be able to override the prior authorization
(PA) requirement for these drugs if the prescriber indicates on the prescription that PA criteria is met. Prescribers may
either write “Meets PA Criteria” on the face of the prescription, or enter this statement in the comment block on e-prescriptions. If a prescribed drug in one of these drug classes has a generic version available, “medically necessary”
must also be indicated on the prescription. These overrides will be monitored by Program Integrity. Providers may
continue to contact ACS to request PA for these mediations.
Emend, Leudotrienes, Lidoderm, Orally Inhaled Corticosteroids, Statins, and Suboxone-- New PA policies for these
drugs will be in effect with implementation of the PDL.
Schedule II Narcotic Analgesics and Second Generation Anticonvulsants--Revisions have been made to the PA
criteria for these drugs.
All prior approval policies and criteria for the Enhanced Pharmacy Program are available at
Summation of Medicaid Benefit and Coverage Changes
o The following benefit and coverage change notifications have been mailed to Medicaid recipients, and provide a useful
reminder of recent Medicaid changes to providers (pages 10-11 of the bulletin). Policy changes for coverage of breast surgeries
Reductions to covered podiatry services (specific reductions still not published)
Elimination of Maternal Outreach Worker program
Limitations to refills for lost prescriptions
Implementation of a recipient management lock-in program for prescription drugs and changes to PDL
Coverage of prescription vitamins and mineral products Copayments: Effective 11/1/10, a copayment of up to $3.00 will be charged for clinical and outpatient services. The
copayment for non-emergency visits to hospital emergency rooms will increase to $6.00. Local health department
visits and outpatient behavioral health services will be subject to copayments.
Behavioral Health (http://www.ncdhhs.gov/dma/services/cabha.htm)
o Beginning 1/1/11, only providers certified as a Critical Access Behavioral Health Agency (CABHA) may be
reimbursed for Community Support team, Intensive In-Home, and Day Treatment services.
o Community Support Team services are limited to 32 hours every 60 days not to exceed six months per calendar
year, PA for outpatient behavioral health services for children is required after the 16th visit, and Community
Support Services for children and adults will be eliminated on 12/31/10.
In-home personal care services (PCS) and PCS-Plus are scheduled to be replaced in 2011 with two new in-home care
services: In-Home Care for Children (IHCC) and In-Home Care for Adults (IHCA)
Effective 11/1/10, Medicaid will no longer cover the following dental services for children under age 21 unless EPSDT
criteria can be met: full mouth series of x-rays for children under age 6 when rendered in the hospital or ambulatory
surgical center setting, and three bitewing x-rays on children under age 13.
Other Items of Interest
o CPT code 15830-Excision, excessive skin and subcutaneous tissue; abdomen, infraumbilical panniculectomy--will be end-
o Medicaid reimbursement rate fee schedules will NOT be reduced as previously proposed. Rates in effect as of 8/1/10 will
To view all Medicaid updates, go tclick on “For providers”, then September 2010 Medicaid Bulletin. All providers are encouraged to thoroughly read the monthly Medicaid Bulletin in order to stay informed of all updates pertinent to the individual practice.
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