ND Medicaid Provider Updates
System updates have been made to the North Dakota Health Enterprise Medicaid Management Information System (ND HE MMIS) that make Primary Care Provider (PCP) information available to providers through use of the 270/271 (Health Care Eligibility Benefit Inquiry and Response) electronic data interchange transactions. Please note the ND HE MMIS Web Portal and Automated Voice Response System (AVRS) may also be used to access PCP information.
Due to the system issues associated with PCP assignment and retrieval experienced since the implementation of ND HE MMIS, edits impacting claims processing in relation to the Primary Care Case Management (PCCM) program and associated with PCP referrals will receive an exemption through June 30, 2016. System updates have been made in ND HE MMIS which have corrected these various issues along with making PCP information available via the 270/271 transaction.
Providers will need to resubmit all claims that may have been denied in relation to these PCP-related issues. These are claims that would have denied with either a Claim Adjustment Reason Code ‘38’, or a Claim Adjustment Reason Code ‘243’, on your remittance advice. Please note that timely claims submission requirements (providers must submit all claims no later than 12 months from the date of service) still apply to all claims. However, if you have submitted a claim and it has been denied, you have one year from the last remittance advice date of the denied claim to resubmit or adjust the claim.
As mentioned above, claims that have been denied in ND HE MMIS since implementation due to PCP-related referral purposes may be resubmitted for processing in order to obtain the edit exemption.
Reminder to Medicaid Providers about Timely Claims Submission requirements: The Department of Human Services (Department) wants to remind Medicaid providers of the requirements about timely claims submission within 42 CFR 447.45 (d)(1).
42 CFR 447.45 (d)(1) states, “The Medicaid agency must require providers to submit all claims no later than 12 months from the date of service.“ The Department is exploring options for processing outstanding claims impacted by a system defect; however, it is important that Medicaid providers are ensuring that all claims are submitted within 12 months of the date of service.
You have the Department’s continued assurance that we, along with Xerox, are working diligently to address all ND HE MMIS issues as quickly as possible.
ND Department of Human Services
Effective July 1, 2016, Non-Emergent Medical Transportation providers will be responsible for documenting transportation services for procedure code A0080. See the additional information listed below for further information and guidance regarding this requirement.
- Memo to Non-Emergency Medical Providers
- Billing Guidelines for Procedure Code A0080
- Travel, Meals, and Lodging Provider Manual
- Sample Documentation Form
Attention Anesthesia Providers: Effective for dates of service on or after July 1, 2016, reimbursement for Labor Epidurals (CPT® 01967) will be capped at a maximum of 75 minutes. This includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor.
According to the American Society of Anesthesiologists, time related to neuraxial labor anesthesia is different than operative anesthesia and the professional charges and payment policies should reasonably reflect the costs of providing labor anesthesia services as well as the intensity and time involved in preparation, insertion and monitoring of the epidural.
The number of minutes and charges billed should only reflect the time the anesthesiologist or certified registered nurse anesthetist (CRNA) is present for preparation, insertion and monitoring of the epidural. Time submitted should not reflect the full time the epidural catheter is in unless complications are present that require the constant attendance of the anesthesiologist or CRNA.
System updates have been made in the North Dakota Health Enterprise Medicaid Management Information System (MMIS), which have corrected various issues that impacted claims processing in relation to the Primary Care Case Management (PCCM) program and edits associated with Primary Care Provider (PCP) referrals.
The updates and improvements involved areas such as exempting certain services and/or provider specialties that do not require PCP referrals as well as correcting PCPs that may have been incorrectly auto-assigned to recipients.
Please resubmit any claims from October 2015 forward that you feel may have been incorrectly denied for a PCCM/PCP referral edit. These claims would have been denied with either a Claim Adjustment Reason Code ‘38’, or a Claim Adjustment Reason Code ‘243’ on your remittance advice.
Since the system updates are now in place, if the claim should have not been denied due to an exemption from the PCCM program rules, the resubmitted claim will now adjudicate with the exemption in place rather than being denied. Please note that some of the denials were valid. However, if you feel the claim should have not been denied for PCP referral reasons, please resubmit your claim(s).
Attention Ambulance Providers: The North Dakota Department of Human Services Medical Services Division issued this memo on billing requirements for mileage charges.
Effective April 1, 2016, Rural Health Clinics, including Rural Health Clinics exempt from electronic reporting under Section 424.32(d)(3), are required to report the appropriate Healthcare Common Procedure Coding System (HCPCS) code for each service line along with the revenue code, and other required billing codes. Payment for Rural Health Clinic services will continue to be made under the All-Inclusive Rate (AIR) system when all of the program requirements are met.
Attention Chiropractic Providers: The Chiropractic Services Coding Guideline has been updated with several additional diagnosis for dates of service effective October 1, 2015. Please resubmit for reprocessing any claims that denied with a PR 204 that contained a diagnosis that appears on the list as payable.
Attention all Dental Providers: A new dental policy has been published for CDT Code D9410 – House/Extended Care Facility Call. This dental policy is effective 04/01/2016 and can be viewed at www.nd.gov/dhs/services/medicalserv/medicaid/provider-all.html.
There has been an issue with claims denying with remark code N173, No qualifying hospital stay dates were provided for this episode of care, for an inpatient hospital stay of less than 24 hours. ND Medicaid will not require that an inpatient hospital stay be at least 24 hours. An inpatient hospital stay of 24 hours or less may still be reviewed by our quality review organization. Providers who have had a claim deny with remark code N173 should resubmit the claim.
Attention DME Providers: Effective 2-15-16 - The Certificate of Medical Necessity SFN 580 Certificate of Medical Necessity/Cranial Remolding Orthosis will be required to be submitted for ALL service authorization. Please make sure that ALL areas are completed and that the form is signed and dated or the service authorization will be denied as incomplete and unable to process the request.
Attention all DME Providers: The following HCPCS codes have been deleted from the DME Fee Schedule effective 1-1-2016:
- E0450 - Volume control ventilator, without pressure support mode, may include pressure control mode, used with invasive interface (E.G., tracheostomy tube)
- E0460 - Negative pressure ventilator; portable or stationary
- E0461 - Volume control ventilator, without pressure support mode, may include pressure control mode, used with non-invasive interface (E.G., mask)
- E0463 - Press support ventilator with volume control mode, may include pressure control mode, used with invasive interface (E.G. tracheostomy tube)
- E0464 - Press support ventilator with volume control mode, may include pressure control mode, used with non-invasive interface (E.G. mask)
Effective for claims with DOS on or after January 1, 2016, all products classified as ventilators must be billed using one of the following HCPCS codes:
- E0465 - Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)
- E0466 - Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)
Products previously assigned to HCPCS codes E0450 and E0463 must use HCPCS code E0465. Products previously assigned to HCPCS codes E0460, E0461 and E0464 must use HCPCS code E0466. New rental and purchase rates are listed below.
There has been an issue with claims inaccurately denying with remark code 38, Services not provided or authorized by designated (network/primary care) providers.
A provider billing for Emergency Room, Obstetric Care, Dental, or Vision Services and have had claims deny in Health Enterprise with remark code 38 should resubmit their claims.
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