Medicaid updates

Medicaid and North Carolina Health Choice Updates
November 2011

CSC Updates and Information
o The enrollment requirement for Physician Assistants (PA) and Nurse Practitioners (NP) is being delayed until further notice from DMA. A State Plan Amendment has been submitted to CMS to allow the direct enrollment of PAs. NPs are already allowed to direct enroll with Medicaid. The Medicaid enrollment application is available at  Email Alerts
o NC Medicaid allows all providers to sign up for email alerts when there is important information to share outside of the general Medicaid Provider bulletins. To receive email alerts, subscribe at Contact information including email address and provider type of specialty is essential for the subscription process. You may unsubscribe at any time. Email addresses are never shared, sold, or used for any purpose other than  Notice of Rate Reduction
o Although some services experienced a rate reduction, the physician services fee schedule remains unchanged.  Medicaid Fraud, Waste and Abuse
o In accordance with Federal requirements, DMA is required to suspend payments of providers having a credible allegation of fraud. In addition, DHHS may suspend payments to all provider numbers who share the same IRS EIN or corporate parent as the provider who owes the repayment or has a credible allegation of fraud.  HIPAA 5010 Implementation--scheduled to begin 1/1/12
o HP Enterprise Services (HPES) will begin dual processing of transactions on November 4, 2011. HIPAA Companion Guides are available at If your Trading Partner Agreement has been updated, you will receive both the ASC X12 versions 4010 and ASC X12 versions 5010 of the 835 transaction beginning with the November 8, 2011 check write. o Providers are asked to contact your vendors/trading partners and inform them to update their Trading Partner Agreement - Appendix A in preparation for 5010 testing and implementation. Complete and mail the form, with original signature, to HP Enterprise Services. You will be emailed a letter with instructions on how to proceed with 5010 transaction testing.  Medicaid HER Incentive Program Update
o Eligible Professionals (EPs) began receiving incentive payments in March 2011 and over 83 payments have been made since then with additional payments going out each week. To determine if you are eligible to receive a NC Medicaid EHR payment, follow this lin  February 29, 2012: Last day for EPs to register and attest for an incentive payment for calendar year 2011  NCCI Edits: Profession Duplicates
o Medicaid and NCHC will be implementing edits that detect where duplicate submissions of a service were submitted on separate claims. The analytics examine codes that cannot be billed more than once on the same date, within a defined data range, or over a lifetime of the patient. For examples and additional information, see page 19 - 20 of the bulletin.  NCHC Information and updates
o Outpatient Specialized Therapies (PT/OT/ST)--CCME will be completing Health Choice prior approval reviews and post payment validations.  Prior approvals for NCHC patients will not be required for dates of service prior to 12/5/11. Providers may begin submitting their PA requests on 11/7/11 for dates of service on or after 12/5/11.  Other Items of Interest
o Effective 1/1/10, CPT code 17263 can be billed with modifiers 58 and 78. Providers who had claims deny and have kept the claims timely, may resubmit the denied charge as a new claim. o The NC Office of Medicaid Management Information System Services (OMMISS) provides oversight for the development and installation of the multi-payer system, NCTracks. Visit the OMMISS website at o The 2012 Check Write Schedule is available on page 22 - 23 of the bulletin. To view all Medicaid updates, go to, click on “For providers”, then November 2011 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.

Outpatient Pharmacy
o Vusion Ointment & Xolair Injection --prior approval is required beginning 11/1/11. The form to request PA is available (scroll to bottom of page for specific form). o Vacation Supply Prescriptions are limited to one fill during a five day span once per year. This is effective 10/1/11 and applies to non-controlled medications only. Vacation supply and lost prescriptions are not allowed for controlled substances. o Makena--Effective 11/1/11, Makena will no longer be covered under the Outpatient Pharmacy program. Makena will continue to be covered under the Physicians Drug Program. The compounded version of 17P continues to be covered under both programs. See the July 2011 General Bulletin for billing information for compounded 17P and Makena. o Lidoderm & Provigil/Nuvigil--Changes were made to the PA criteria for these drugs. See the above link for additional o Preferred Drug List Changes--Effective 11/15/11, DMA will make the following changes to the PDL:  Addition of NCHC
 Addition of these drug classes: Tetracycline Derivatives, Pancreatic Enzymes, and Topical Steroids
 Addition of one-time POS override for Pradaxa and new oral anticoagulants
 Removal of coverage from the outpatient pharmacy program of the IV medications Actemra, Orencia, Remicade,
Boniva, pamidronate disodium, Reclast, Xgena, and Zometa (coverage continues under the Physician Drug  Updates to the list of preferred drugs: Brand Name
Generic Name
To view all Medicaid updates, go to, click on “For providers”, then November 2011 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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