Family and Children's Medicaid Admin. Letters

DMA ADMINISTRATIVE LETTER NO. 06-06, Medicaid/NCHC Inquiries and DMA Contact List

DATE: 05/08/06

Subject: Medicaid/North Carolina Health Choice Inquiries and DMA Contact List

Distribution: County Directors of Social Services
Income Maintenance Staff
Services 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.

I. general information

A. The DMA Internet site, http://www.dhhs.state.nc.us/dma, contains general information about DMA, Medicaid Eligibility Manuals on line, and monthly Medicaid Bulletins and Special Bulletins. Program and publication information available at the site includes:

1. North Carolina Health Choice (NCHC) – contains general information about the program, applications and instructions, a handbook, and information on special needs benefits.

2. Medicaid Services and Information- contain information about clinical coverage and billing for services. This information is located under the Provider Link.

3. Medicaid Eligibility – contains fact sheets and Consumer Guide Handbooks and helpful links to further information. This information is located under the Consumer Link.

4. Clinical Coverage Policies and Provider Manuals – contains links to policies for covered services. This information is located under the Provider Link.

5. Proposed Clinical Coverage Policies – provides proposed coverage policies for review and comment. This information is located under the Provider Link.

B. County Staff Inquiries

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.

C. Recipient Inquiries

1. North Carolina Health Choice changes in recipient’s name, address, date of birth or gender are handled by the county caseworker. This information must be corrected through the EIS system. BCBS staff cannot make changes to NCHC case/individual information. If information in EIS is correct but the card is incorrect, the caseworker should call DMA/EIS at (919) 855-4000 to report that the information did not update in the BCBS system.

Refer families to BCBS to request a replacement card only after you have ensured that the information is correct in both EIS and at BCBS. BCBS has been informed to refer the family back to the county DSS caseworker if changes for NCHC are reported directly to them rather than following the above procedures.

2. County DSS offices are responsible for handling recipient inquiries regarding eligibility and how to receive medical services. DSS staff may call DMA when information necessary to respond to the client is not accessible from county case files, state generated reports, registers, inquiry to EIS segments, eligibility manuals and appendices, Administrative Letters, etc. County staff should also utilize Client Services Data Warehouse to obtain information before calling DMA. The CSDW is a query system that allows users to find out information such as how many recipients are in a county, ages, etc. This warehouse is maintained by the Division of Social Services for use by counties and others.

The following is a sample of some situations that may necessitate assistance from DMA staff:

a. A recipient receives notification from a collection agency of past due accounts for medical services received while eligible for Medicaid. Advise the recipient to notify the provider of his Medicaid identification number and request the provider to bill Medicaid. If the problem cannot be resolved, call the DMA Claims Analysis Unit in Recipient and Provider Services at (919) 855-4045.

b. A recipient receives bills from providers who have accepted the Medicaid ID card for the services being billed or who are billing the recipient for the difference between the actual charges and the Medicaid reimbursement. You may call the DMA Claims Analysis Unit in Recipient and Provider Services at (919) 855-4045.

c. A provider refuses to accept Medicaid because the recipient has other insurance. A call to Third Party Recovery in the Program Integrity Section may help resolve the problem. Third Party Recovery can be reached at (919) 647-8100.

d. For questions about general Medicaid covered services, out-of-state services, co-payments, etc., refer to MA-3540, Medicaid Covered Services, in the Family and Children’s Medicaid Manual and MA-2905, Medicaid Covered Services, in Aged, Blind, and Disabled Medicaid Manual. This may provide the information needed to respond to the recipient. Recipients may also be referred to the Recipient Ombudsman in the Managed Care Unit of DMA at (919) 647-8170 or 1-888-245-0179.

e. For questions about EPSDT, contact the Clinical Policy Section at (919) 855-4260. Recipients under 21 years of age are eligible for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) or Medicaid for Children. EPSDT is a federal Medicaid requirement that provides recipients under 21 years of age with medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition identified through a screening examination. While there is no requirement that the service, product, or procedure be included in the State Medicaid Plan, the service, product, or procedure must be listed in the Social Security Act (the Act) at 1905(a). It should be noted that the Act does not require a state Medicaid agency to provide any service, product, or procedure that it determines to be unsafe, ineffective, or experimental.

Service limitations on scope, amount, duration, and/or frequency described in clinical coverage policies may be exceeded provided documentation supports it is medically necessary to exceed policy limitations in order to correct or ameliorate a defect, physical and mental illness, or a condition identified by a screening. In accordance with EPSDT requirements, health care services are provided in a frequency and amount to reasonably achieve their purpose and consistent with the recipient’s medical needs.

Recipients under 21 years of age and/or his/her legal representative(s) who wish to request a non-covered state Medicaid Plan service or to request services that exceed policy limitations should contact their physician or other licensed clinician to discuss their need for services. Requests for non-state plan covered services should be submitted to DMA PRIOR to rendering the service. For claims that exceed established policy limitations, claims and documentation describing why it is medically necessary to exceed policy limitations to correct or ameliorate a defect, physical and mental illness, or a condition should be submitted to the fiscal agent.

For additional information about EPSDT, please review the resources identified below.

• DMA EPSDT Policy Instructions
http://www.dhhs.state.nc.us/dma/epsdt_policy.pdf


• DMA Special Bulletin entitled “Prior Approval Process and Request for Non-Covered Services” published in January 2006
http://www.dhhs.state.nc.us/dma/bulletin/0105bulletin.pdf

f. For general information about the appeals process, inquiries to request a hearing or to check the status of a requested Medicaid appeal/informal appeal, a state hearing, or a formal appeal before the Office of Administration (OAH), county DSS staff should determine what type of hearing the recipient is referencing before referring the applicant/recipient. For appeals involving Medicaid services, contact DHHS Hearings and Appeals at (919) 647-8200. For appeals regarding Medicaid eligibility denials and terminations, contact DHHS Hearings and Appeals at (919) 733-3289. Information regarding OAH can be obtained by calling (919) 733-2698. Recipients can be referred to either office through the CARE-LINE, Information and Referral Service, at 1-800-662-7030 or in the Triangle area (919) 855-4400.

g. County DSS staff must handle inquiries regarding a recipient’s failure to receive Medicaid cards. Only if DSS staff cannot determine why a card was not received, should the county worker contact the Medicaid EIS Unit at (919) 855-4000. DO NOT REFER THE RECIPIENT TO DMA. This should be handled by the county workers.

2. In order for DMA staff to respond more quickly and efficiently to inquiries about billing, please provide:

Recipient’s MID number
Provider’s name(s)
Date(s) of service,
Amount billed, and
Did the provider accept recipient as a Medicaid patient?

3. Do not refer recipients to DMA’s fiscal agent or to other DMA contractors for prior approvals. The provider is responsible for seeking prior approval.

4. When recipients with a problem or inquiry are referred to the state for assistance, give them:

a. The toll free CARE-LINE, Information and Referral Service, number, 1-800-662-7030 or (919) 855-4400 in the Triangle area, or TTY 1-877-452-2514 or (919) 733-4851, and

b. The name of the DMA unit or section they need to contact.

D. Provider Inquiries

1. Filing Claims and Payments

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.

2. Prior Approvals

a. Private Duty Nursing, please call DMA Clinical Policy Unit at (919) 855-4380.

b. Psychiatric or substance abuse hospital admissions for recipients over 65 years of age. For Medicaid recipients under 21 years of age, a certificate of need is required for all admissions to freestanding psychiatric hospitals. This pre-authorization/prior approval is obtained by contacting ValueOptions at 1-888-510-1150.

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.

c. Prior approval requirements for other services can be determined by referring to the clinical coverage policies section under the provider link on the DMA website.

3. Questions regarding third party payments are referred to DMA Third Party Recovery staff. The Third Party Recovery Unit can be reached at (919) 647-8100.

4. Inquiries about provider enrollment can be referred to the information on the DMA website, http://www.dhhs.state.nc.us/dma, or to DMA Provider Services staff at (919) 855-4050.

5. Requests for override of the one year billing time limit are submitted to DMA by the county DSS. See MA-2395/MA-3530, Corrective Actions and Responsibility for Errors.

6. A toll free eligibility verification inquiry line is available to assist enrolled providers in obtaining Medicaid eligibility information for a recipient who fails to present a Medicaid identification card when requesting or receiving medical services. The county DSS provides verification of eligibility to providers according to the circumstances listed in MA-300/MA-3500, Confidentiality. Tell the providers to call:

• 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,

OR

• DMA at (919) 855-4045 to obtain the MID number only or to verify dates of service over 12 months old.

7. When an out-of-state provider submits a claim to the county DSS, forward the claim to the Claims Analysis Unit. (See II. below). Please review the recipient’s address on the claim and if an out-of-state address is given, verify the recipient’s continued residence in North Carolina. Both out-of-state and North Carolina providers choose whether to be Medicaid providers.

8. Providers who have claims denied for eligibility reasons should first verify that the MID number and name have been entered correctly on the claim, and that only eligible dates have been billed. (See eligibility denial codes below). If these items are correct, the provider may ask for assistance by sending copies of the claim, the Remittance Advice (RA), and MID card to the Claims Analysis Unit. See II. below.

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.

9. Recipients who are currently in a medication management program and would like to change the pharmacy that they are assigned to should have either the pharmacy or their primary care physician contact DMA at (919) 855-4260.

II. dma contacts

A. Addresses

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

B. Director’s Office

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.

C. Managed Care………………………………………………(919) 647-8170
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.

Recipient Ombudsman ………………………………………919) 647-8170

Serves as division’s representative for recipients and other agencies related to medical care and services covered by the Medicaid program.

D. Budget Management ………………………………………(919) 855-4140
Deborah Atkinson, Assistant Director

Responsible for budget and forecasting, purchasing and contracting, as well as contract management, and special projects.

E. Finance Management ………………………………………(919) 855-4180
Tom Galligan, Assistant Director

Duties include auditing, management of Disproportionate Share Hospital (DSH), rate setting, and financial analysis.

F. Recipient and Provider Services……………………(919) 855-4000
Angela Floyd, 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 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.

Provider Services……………………………………………(919) 855-4050
Functions include Medicaid provider enrollment and disenrollment, monthly Medicaid Bulletins and Manuals, coordination of all provider workshops, and oversight of the EDS Provider Relations unit.

G. Program Integrity………………………………………(919) 647-8000
Lynne Testa, Assistant Director

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.

Pharmacy Reviews
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.

Quality Assurance……………………………………………(919) 647-8140
Responsible for conducting the federally mandated quality control reviews to establish the Medicaid eligibility payment error rates and assist 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.

H. Clinical Policy and Programs………………………………(919) 855-4260
Tara Larson, Assistant Director

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:

Physicians
Chiropractors
Podiatrists
Clinics
Federally Qualified Health Centers
Rural Health Center
Public Health Departments
Hospital Outpatient Departments
Laboratories/X-rays
Ambulance
Dialysis
Ambulatory Surgery
Independent Diagnostic Treatment Facilities
Nurse Practitioners/Certified Nurse Midwives
Anesthesia
Baby Love/Child Service Coordination
Family Planning
Telemedicine
Transportation

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
Transplant Services

Hospitals……………………………………………………….(919) 855-4340
Nursing Facilities
PASARR
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
Hospice
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
Independent Practioners
Injectable Drugs
Local Education Agencies
Medications
Optical/Hearing Aids
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)

I. Dental Program………………………………………………….919-855-4280
David McDaniel, Interim Dental Director

The Dental Program oversees policies and procedures for coverage of dental and orthodontic services delivered to Medicaid recipients.

III. DMA Fiscal Contractor contacts

A. Electronic Data Service (EDS) Directors…………………...919-851-8888
Cheryll Collier, Executive Director, NC Title XIX
Cathy Waters, Deputy Director

B. EDS Mailing Addresses

1. EDS
P.O. 30968
Raleigh, NC 27622

2. When sending mail Certified, UPS or Federal Express, send to:

EDS
4905 Waters Edge Drive
Raleigh, NC 27606

Prior Approval Address:

Prior Approval Unit
P.O. Box 31188
Raleigh, NC 27622

C. Telephone Contacts

1. Automated Voice Response (AVR)……………………….1-800-723-4337
Providers receive recorded information on:
Claims status
Pre-admission certification
Prior approval status
Eligibility verification
Checkwrite information
Procedure code pricing
Drug coverage
Modifier code verification
Dental benefit limitations

2. EDS Provider Services ……………………...919-851-8888(Out of state)
…………..………………………………………...1-800-688-6696(In state)
Providers will be directed to a Service or Representative for assistance with:
Billing, coverage issues
Prior approval services
Denials, other than eligibility
Forms, orders, information
Bulletins, and billing guides

iv. other state agency contacts

A. Division of Facility Services 919-855-3850

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.

B. Division of Aging and Adult Services 919-733-3983

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.

Ombudsman 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.

C. Office of Citizen Services……………1-800-662-7030 or 919-855-4400
……………………………………… TTY 1-877-452-2514 or 919-733-4851
Provides information and referrals to the proper department and agency. Also, assists with problem resolution for concerns or complaints related to department services.

CARE-LINE

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.

D. North Carolina Board of Nursing

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.

E. DHHS Hearings and Appeals Office
Mary Jane Coward, Chief Hearing Officer ………….......(919) 647-8200
Edward Feltman, Chief Hearing Officer…………………(919) 733-3289

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.

F. State Division of Social Services (919)733-7831

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
Medical Assistance

(This material was researched and written by Trenita Dawkins, Policy Consultant, Medicaid Eligibility Unit).