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ND Medicaid Provider Updates

Posted 12-7-2017

Attention all Medicaid Providers – North Dakota Medicaid has a long standing policy that the primary insurance must be billed prior to billing Medicaid for payment. ND Medicaid has noted that many providers are billing the primary insurer and Medicaid at the same time. This is against billing guidelines. Claims must be submitted to the primary insurance and once the claim(s) are adjudicated by the primary insurance the provider can bill Medicaid and include the primary’s explanation of payment.

Please review the policy below regarding an update to claims processing for certain prenatal and preventive pediatric services for individuals who have third party coverage that are liable to pay part, or all, of the services furnished under a Medicaid state plan. Third party coverage can include payment resources available from both private and public health insurance or from other responsible sources, such as liability and casualty insurance, court-ordered health coverage, or worker’s compensation.

For specific prenatal and preventive pediatric claims received on or after January 1, 2018, North Dakota Medicaid will process those claims based on Section 1902(a)(25)(E) of the Social Security Act (SSA): SEC. 1902. [42 U.S.C. 1396a] (a) A State plan for medical assistance must— (25) provide—

(E) that in the case of prenatal or preventive pediatric care (including early and periodic screening and diagnosis services under section 1905(a)(4)(B)) covered under the State plan, the State shall—

(i) make payment for such service in accordance with the usual payment schedule under such plan for such services without regard to the liability of a third party for payment for such services, except that the State may, if the State determines doing so is cost-effective and will not adversely affect access to care, only make such payment if a third party so liable has not made payment within 90 days after the date the provider of such services has initially submitted a claim to such third party for payment for such services; and

(ii) seek reimbursement from such third party in accordance with subparagraph (B).

(FYI - subparagraph (B) states in any case where such a legal liability is found to exist, the Medicaid agency will seek reimbursement for such assistance)

Since the implementation of Health Enterprise MMIS, claims meeting the specified diagnosis criteria for prenatal and preventive pediatric care have been initially paid by North Dakota Medicaid without regard if the member had third party liability coverage. For specific prenatal and preventive pediatric claims received on or after January 1, 2018, providers will no longer be paid by Medicaid when the member has third party insurance on file and the timeframe is within 90 days after the date the provider of these services has initially submitted a claim to the primary third party coverage source for payment. Claims will be denied if an active third party coverage source is on file with North Dakota Medicaid for the date(s) services were rendered and the prenatal and preventive pediatric criteria are met along with the 90 day primary third party submission period.

Providers will receive a remittance advice for claims processed under this policy with a claim adjustment reason code of 22“This care may be covered by another payer per coordination of benefits”. This is the provider’s notice that ND Medicaid has primary insurance on file. If the provider is not aware of other insurance they will need to contact the member for their other insurance information. The provider then must bill the primary insurance and rebill Medicaid supplying the other insurance explanation of payment. Here is a list of prenatal and preventive diagnosis codes subject to Section 1902(a)(25)(E) of the Social Security Act (SSA).

Posted 12-1-2017

Attention Providers with Medicaid Recipients in the Primary Care Case Management (PCCM) Program - There is an identified system issue in the ND Health Enterprise MMIS associated with bypassing the PCP referral requirements when a recipient is seen by a Primary Care Provider (PCP) who is a substitute/colleague of the recipient’s usual PCP and is affiliated with the same group provider as the recipient’s usual PCP.

Referrals are not required for those members seen by a covering provider in the absence of their usual PCP. However, due to this system issue, some claims are being denied for requiring a referral when the recipient was seen by the covering PCP. The system issue has been identified and is currently being worked on to resolve the issue.

If you have claims you feel were denied in error for no PCP referral that meet the criteria outlined above, you should send the Transaction Control Number (TCN) of the claim and include a statement indicating the claim was denied in error with a PR 165 (Referral absent or exceeded) exception, as well as information supporting the need to reprocess the incorrect denial to Provider Relations at mmisinfo@nd.gov. These claims will then be reprocessed according to the PCP Substitute/Colleague Referral Policy.

If the information provided meets the Substitute/Colleague Referral Policy requirements, the reprocessed claims will then be adjudicated for payment unless another unrelated exception is posted that would be reason for denial of the claim.

Posted 11-21-2017

Attention all DME Providers - The Department has become aware that some providers are experiencing issues submitting the required information (primary insurer, DOP of equipment, member owned prior to entering facility, etc.) in the SA Notes Section as it is not saving the information when using the copy option when submitting the SA.

Thanks to Christine, a DME provider, for suggesting a workable solution until our design staff can resolve this problem. Please utilize the following process if resubmitting a SA using the copy option:

1. Enter all required information, then submit the SA, then close it.

2. Open the newly submitted “pending” SA, and check the Note section to see if the entered required information is there.

3. If entered information is missing, reenter the needed information and resubmit the SA.

The Department will allow until November 28th, 2017, for providers to check all their pending SAs to see if the required information is appearing in the Notes Section and if not utilize the above process to correct. After November 28th, 2017, if the required information is still missing, the SA will denied and will require the SA to be resubmitted with corrections made.

Please continue to utilize the above process until further notice to prevent future denials.

Posted 10-19-2017

Reminder: North Dakota Medicaid eligible individuals may have a card or Medicaid ID with a 9-digit number that starts with ND, or a 9 digit number that has leading zeroes. Both formats are valid and clients should not be turned away based on which format of Medicaid ID they provide.

Posted 10-13-2017

All DME providers will be required to electronically attach all required supporting documents directly to their web-submitted service authorizations effective November 1, 2017. This option allows providers to electronically attach any files that contain required supporting documents for the DME SA. For example, doctor visit notes, sleep study, prescription, certificates of medical necessity (CMN), audiogram, and etc.

Using the electronically attaching option replaces the need to fax documents to the Department. Any DME faxes received by the Department will be returned to the sending provider with instructions on how to submit them directly to the service authorization. The Provider Instruction Handout provides step-by-step instructions on how to electronically submit the required supporting documents.

Posted 10-6-2017

North Dakota Medicaid's Program Integrity Unit recently hosted a provider training on topics relating to provider coding, billing, and enrollment, and Medicaid fraud, waste and abuse practices on Sept. 28, 2017. If you have any further questions, e-mail them to auditresponse@nd.gov.

Training PowerPoint presentation. Training Q and A.

Posted 9-18-2017

Bilateral Procedure Reporting - North Dakota Medicaid continues to see a high volume of claims reporting bilateral procedures on two lines. Effective October 5th, 2015, bilateral procedures should be reported on a single line utilizing modifier 50. This was communicated to providers in the September 2015 MMIS Bulletin, as well as the North Dakota MMIS System Changes document posted in March 2014.

Modifier -50 is used to report bilateral procedures that are performed at the same operative session as a single line item. Do not use modifiers RT and LT when modifier -50 applies. Do not submit two line items to report a bilateral procedure using modifier -50. Modifier -50 applies to any bilateral procedure performed on both sides at the same operative session. The bilateral modifier -50 is restricted to operative sessions only.

Modifier -50 may not be used:

  • To report surgical procedures identified by their terminology as “bilateral,” or
  • To report surgical procedures identified by their terminology as “unilateral or bilateral”. The unit entry to use when modifier -50 is reported is one.

Posted 9-18-2017

Attention all DME Providers - The DME Purchase Fee Schedule and DME Rental Fee Schedule are now online. Review them as they have a new look to make them easier to use.

Please notice the following changes:

  • The pink highlighted areas under the SA (service auth. required) column. These were previously no but due to the confusion providers were submitting SA requests already so it was decided to change them to yes.
  • A couple of HCPC codes have “to be determined” under the Medicaid Fee column. The rate is currently being worked on and will be posted to the fee schedule when set. Providers may submit SA requests for review.
  • New columns labeled Nursing Home, Swing Bed, and ICF/IID Responsibility that are highlighted either red or green. Red is facility responsibility and green is when a DME provider can submit to the Department for separate payment. Please review the codes SA column to see if needs a SA and then review the related policy as needed.
  • Also note that the CMN column has been removed. Review the appropriate policy as there is now a CMN section that has the CMN number listed if applicable. Click on the CMN number for the actual form.

Be advised that the DME policies also have a new format. Most are complete and are listed individually under the Quick Reference: DME Policy section on the DME webpage. This was done in response to DME provider’s request to clarify wording.

Also, make sure to check the last page of the policies for any additions and deletions to the policy. Not all DME policies have been reformatted yet, but hopefully will be completed soon.

Posted 8-3-2017

Fee Schedule Update – The fee schedules for dates of services July 1, 2017, have been posted to the website. Provider rates will not receive an inflationary increase for the first year of the biennium in accordance with the legislative mandate.

No changes were made for codes which are priced off a fee schedule. Codes which are priced using the Relative Value Unit (RVU) methodology have had the conversion factor adjusted. The adjustment of the conversion factor takes into account the implementation of the 2017 RVUs for dates of service on or after July 1, 2017.

Based on the previous calendar 12 month’s claims volume, the new relative value unit adjustments, and a zero percent inflationary increase for the first year of the biennium, the resulting conversion factor effective for July 1, 2017 dates of service and after is $35.8902. The previous conversion factor was $35.80. Based on the changes to the relative value units, some fees will increase while others may stay the same or decrease. In the aggregate, the providers whose claims are priced off the RVU methodology will see a zero percent increase in their reimbursement.

Posted 7-26-2017

The Centers for Medicare and Medicaid Services (CMS) has approved Medicaid coverage for Applied Behavior Analysis (ABA) services to qualifying individuals up to age 21 diagnosed with autism spectrum disorder (ASD).

The approved services include program oversight and skills training for an individual with an ASD and their caregivers. Previously, the services were covered under the state’s ASD Medicaid wavier.

Agencies interested in providing services under the Medicaid State Plan must be enrolled as a Medicaid provider. The billable services include autism program oversight and autism skills training.

Information on provider eligibility and qualifications is online at www.nd.gov/dhs/autism/docs/autism-aba-service-policy-and-procedures.pdf (North Dakota Medicaid Policy and Procedures for the Autism Applied Behavior Analysis Service).

Agencies and providers rendering services must enroll. All providers must have an NPI. Learn more at Provider Enrollment.

Posted 6-26-2017

The Centers for Medicare and Medicaid Services (CMS) has issued a requirement that goes into effect for North Dakota Medicaid members on July 1, 2017. The rule requires for the initial ordering of home health services (nursing services and home health aide services), physicians or certain authorized non-physician practitioners (NPPS) must document that a face-to-face encounter, which is related to the primary reason the beneficiary requires home health services, occurred no more than 90 days before or 30 days after the start of home health services.

This face-to-face encounter may be performed by a physician, nurse practitioner, clinical nurse specialist or physician assistant, all who must be working under the supervision of a physician. The practitioner performing the face-to-face must communicate the clinical findings of the encounter to the ordering physician. Communication between the practitioner conducting the face-to-face and the ordering physician is to be documented in the medical record.

Medical necessity for the home health services must be supported in the medical record. The visit may be performed via telehealth or in person; telephone encounter is not sufficient.

Posted 6-22-2017

ND Medicaid Policy – Revenue Code 278

Revenue Code 278: Medical/Surgical Supplies: Other implants
Effective Date: January 1, 2013
Amended Date: July 1, 2017

  • Code indicates charges for supply items required for patient care
  • Revenue code 278 always requires a valid HCPCS on outpatient claims

Inpatient Hospital Claims

  • This policy applies to all hospitals reimbursed on a cost-to-charge ratio for inpatient services.
  • Billed charges over $15,000.00 for revenue code 278 will require a vendor’s invoice to support supplies used that correspond to the services rendered.
  • The HCPCS code associated with each detail line billed with revenue code 278 must be clearly illustrated on the vendor’s invoice(s) submitted with the claim. If the supplies on the invoice do not match the HCPCS billed under revenue code 278 on the claim, or the HCPCS code(s) connected to the supplies are not clearly noted on the invoice, the corresponding detail line with revenue code 278 will be denied as a contractual obligation to the provider.
  • The units billed for the revenue code 278 must match the units on the vendor’s invoice(s) – these units must be clearly indicated on the vendor’s invoice(s) submitted with the claim. If the units on the invoice do not match what was billed under revenue code 278 on the claim, or are not clearly noted on the invoice, the corresponding detail line with revenue code 278 will be denied as a contractual obligation to the provider. If supplies are purchased by the provider in bulk, the units that apply to the corresponding detail line billed with revenue code 278 on the claim billed must be noted on the invoice or the corresponding detail line with revenue code 278 will be denied as a contractual obligation to the provider.
  • If vendor invoices support the payment of the revenue code 278, claims will be reimbursed at invoice price plus 20 percent.
  • Hospitals reimbursed on a cost to charge ratio, must submit vendor invoices with the initial submission of the revenue code 278. Without vendor invoices the revenue code 278 will be denied as a contractual obligation to the provider.
  • Charges billed under $15,000.00 for revenue code 278 will be audited randomly on post payment review.

Outpatient Hospital Claims

  • This policy applies to all hospitals reimbursed on a cost-to-charge ratio for outpatient services.
  • Billed charges over $3,000.00 for revenue code 278 will require a vendor’s invoice to support supplies used that correspond to the services rendered.
  • The HCPCS code associated with each detail line billed with revenue code 278 must be clearly illustrated on the vendor’s invoice(s) submitted with the claim. If the supplies on the invoice do not match the HCPCS billed under revenue code 278 on the claim, or the HCPCS code(s) connected to the supplies are not clearly noted on the invoice, the corresponding detail line with revenue code 278 will be denied as a contractual obligation to the provider.
  • The units billed for the revenue code 278 must match the units on the vendor’s invoice(s) – these units must be clearly indicated on the vendor’s invoice(s) submitted with the claim. If the units on the invoice do not match what was billed under revenue code 278 on the claim, or are not clearly noted on the invoice, the corresponding detail line with revenue code 278 will be denied as a contractual obligation to the provider. If supplies are purchased by the provider in bulk, the units that apply to the corresponding detail line billed with revenue code 278 on the claim billed must be noted on the invoice or the corresponding detail line with revenue code 278 will be denied as a contractual obligation to the provider.
  • If vendor invoices support the payment of the revenue code 278, claims will be reimbursed at invoice price plus 20 percent.
  • If no HCPCS code is appended to revenue code 278, it will be denied as a contractual obligation to the provider.

Posted 4-7-2017

Attention all Durable Medical Equipment (DME) Providers: The Electronic DME Service Authorization (SA) attachment option is now available. This option allows providers to electronically attach any files that contain required supporting documents for the DME SA. For example, doctor visit notes, sleep study, prescriptions, certificates of medical necessity (CMN), audiogram, etc. Using the electronically attaching option replaces the need to fax documents to the Department.

A provider instruction handout is available on the DME website to assist with step-by-step instructions on how to electronically submit the required supporting documents.

Posted 3-24-2017

A new coding guideline for Vaccines/Toxoids is now available.

Posted 3-7-2017

Attention all Dental Providers: A revised dental policy has been published for CDT Code D9410 – House/Extended Care Facility Call. This revised dental policy is effective 04/01/2017.

Posted 1-5-2017

ER Copayment and PT, OT and Speech Limits - Effective for dates of service on or after January 1, 2017, there is no longer a Medicaid copayment for non-emergent use of the Emergency Department. The previous copayment was $3.00.

Also, effective for dates of service on or after January 1, 2017, there will be no service limits on physical, occupational and speech therapy visits and evaluations for Medicaid recipients under the age of 21. All services submitted to ND Medicaid for payment must continue to be supported by medical records and documentation of medical necessity.

The Department initiated the necessary North Dakota Administrative Code and MMIS updates for both of these changes.

Posted 1-4-2017

Attention all DME Enrolled Providers - The following added/deleted HCPC codes and narrative changes to HCPC codes are effective for dates of service on or after Jan. 1, 2017.

The following HCPC codes have been deleted from the provider price file.

B9000
K0901

K0902

The following HCPC codes have been added to the provider price file.

A4224
A4225

Narrative changes have been made to the following codes.

B9002
E0627
E0629
E0967
E0995
E2206
E2220
E2221
E2222
K0045
K0019
K0037
K0042
K0043
K0044
K0069
K0046
K0047
K0050
K0051
K0052
L1906
K0071
K0072
K0077
K0098
K0552

More detailed information on these changes can be found in the 2017 Narrative Changes Summary.


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