ND Medicaid Provider Updates
Effective January 1, 2015 ND Medicaid requires, as specified in CFR 42 441.18 (a)(7) that providers performing and billing for Targeted Case Management (T1017) maintain records that document for following criteria to support services billed:
- The name of the individual.
- The dates of the case management services.
- The name of the provider agency (if relevant) and the person providing the case management service.
- The nature, content, units (total time) of the case management services received and whether goals specified in the care plan have been achieved.
- Whether the individual has declined services in the care plan.
- The need for and occurrences of coordination with other case managers.
- A timeline for obtaining needed services.
- A timeline for reevaluation of the plan.
N.D. Medicaid may conduct pre or post payment documentation review to ensure that the above criteria are met. Failure to comply with above criteria will result in claim denial or recoupment of payment.
Providers - Effective 10-1-14, please utilize the new Cochlear Implant and BAHA policy as these items will no longer be reviewed as Durable Medical Equipment (DME). Only replacement parts, batteries, etc., will continue to be review as DME using the SFN 1115 form. Please reference the 2014 DME fee schedules for items that are covered.
Durable Medical Equipment Providers (DME) - Effective December 1, 2014, DME providers are required to use the current Prior Authorization Request form. (SFN 1115) (8-2014).
If outdated versions are submitted for review after 12-1-2014, the request will be returned to the provider for resubmission using the current form located at www.nd.gov/eforms.
New and updated Claims Submission Guidelines, which outline policy and provider billing instructions for claims submitted to the North Dakota MMIS web portal have been posted to the Medicaid Systems Project webpage.
The Department of Human Services Medical Service Division has contracted with Automated Health Systems, Inc. (AHS) to conduct pre and post enrollment site visits in accordance with 42 Code of Federal Regulation §455.432.
David Woehl, AHS representative will be the person conducting the on-site visits. Questions regarding this activity may be directed to Department staff at 1-800-755-2604 or firstname.lastname@example.org.
Service authorization forms have been updated for services in preparation for the Medicaid Management Information System (MMIS) Replacement Project. These are for services that require any type of prior approval.
These forms can be found on the ND Medicaid website. Please call 1-800-755-2604 with questions.
Fee Schedule Update – Effective 07/01/2014 - In accordance with the legislative mandate to update provider rates with a 4.0% inflationary increase the second year of the biennium, we have increased provider rates effective for 7/1/2014 dates of service and after. Codes which are priced off a fee schedule have been adjusted with the 4% inflationary increase accordingly.
Codes which are priced using the Relative Value Unit (RVU) methodology have had the conversion factor adjusted. The adjustment in the conversion factor takes into account the implementation of the 2014 RVUs for dates of service on or after July 1, 2014. Based on previous calendar 12 month’s claims volume, the new relative value unit adjustments, and a 4% inflationary increase for the second year of the biennium, the resulting conversion factor effective for 07/01/2014 dates of service and after is $51.56. The previous conversion factor was $47.86. 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 4% increase.
As of 7/14/2014, the provider enrollment deadline date for the ND Health Enterprise is being extended. Please submit your enrollment application and required documentation as soon as possible. (Qualified Service Provider (QSP) and Developmental Disability (DD) enrollments are complete – no action required.)
An update has been made to the Breast Pump criteria in the Manual for Durable Medical Equipment, Orthotics, Prosthetics & Supplies.
Effective January 1, 2014, Medicaid recipients will not receive a Medicaid ID card unless they are covered under Sanford Health Plan (Medicaid Expansion) or Blue Cross and Blue Shield (Healthy Steps). The Medicaid/Client ID number will appear on eligibility notices sent to Medicaid recipients. The notices may be used as verification of the recipients Medicaid number in order to bill for North Dakota Medicaid services.
Providers that wish to continue billing and receive payment must be enrolled in MMIS-Health Enterprise by 9/1/2014.
Claims Submission Guidelines, which outline policy and provider billing instructions for claims submitted to the North Dakota MMIS web portal have been posted to the Medicaid Systems Project webpage.
Coordinated Services Program and Eligibility Verify Line Issue.
It was brought to the Department's attention that the Eligibility Verify Number of 701-328-2891 or 1-800-428-4140 is not releasing the information that would identify the Coordinated Services Program (CSP)/Lock-in status for recipients currently assigned to the program. This issue has been reported; however, the timeframe for correction is unknown. For a more accurate verification, please contact Provider Relations at 701-328-4043 or 1-800-755-2604.
North Dakota Medicaid has updated the Telemedicine Policy.
This letter is being sent to providers who do not appear in our new Medicaid Management Information System (Enterprise) that need to enroll in Enterprise in order to get paid once we transition to Enterprise.
Effective January 1, 2014 a new CMS-1500 claim form version 02/12 will be available for claims submission. The form with instructions can be found at www.nucc.org per the National Uniform Claim Committee.
Changes being made to the claim form are primarily in the diagnosis code sections within the CMS-1500 claim form for the implementation of the ICD-10 code set.
N.D. Medicaid will require all claims be submitted on the new CMS-1500 claim form version 02/12 effective April 1, 2014. Claims received by the department after April 1, 2014 will be returned to all providers.
Provider Education for Prior Authorization and Adjustment Submittals
All Prior Authorization and Prior Adjustment requests will be processed according to the completion requirements listed in the Durable Medical Equipment Manual on pages 16-19. the manual can be found at:
The links to the guides are listed below. North Dakota Medicaid recommends that Providers save the links as favorites to insure the most current versions are used. Each link includes the SFN 1115 form.
Prior Authorization Completion Guide: http://www.nd.gov/dhs/services/medicalserv/medicaid/docs/dme/dme-pa-guide.pdf
Prior Adjustment Completion Guide: http://www.nd.gov/dhs/services/medicalserv/medicaid/docs/dme/dme-adj-guide.pdf
Possible reasons for denial of prior authorization/adjustment requests:
- Missing modifiers.
- A correct submittal includes the use of proper modifiers (Example – nua5500rtlt). Providers will need to use lowercase letters to fit in this section if using more than 10 spaces.
- Incorrect/missing “Dates of Service Start/Stop”
- Please note, North Dakota Medicaid allows 6 months for purchases.
- Incorrect/missing “Months of Rental/Quantity Prescribed”
- Incorrect HCPC code
- No documents sent to support medical necessity
- No detailed labor invoice submitted for repairs. Providers must also submit documentation to support reason for repairs.
- No Certificate of Medical Necessity submitted
- No “Customary or Usual Retail” and/or “Acquisition Cost”
- No comments as to why an adjustment is being requested
- When a Prior Authorization is returned for corrections or asking for a response from the Provider. Providers will have 90 days to make the corrections or reply and resubmit the request. If requests are not received within that time, the request will be denied as “Untimely Filing, Provider liable.”
- A Timely Filing Policy has been written and posted online; it is also accessible on the Medicaid Medical and Administrative Policies Web page.
- Effective for claims received on or after January 1, 2014: If a Medicaid provider number cannot be determined from the information submitted on the claim, the claim will be denied. This applies to billing, attending, and referring providers.
- North Dakota Medicaid Will Follow Additional Time to Establish Protocols for Newly Required Face-to-Face Encounters for Durable Medical Equipment (DME) by CMS
Due to continued concerns that some providers and suppliers may need additional time to establish operational protocols necessary to comply with face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for certain items of DME, the Centers for Medicare & Medicaid Services (CMS) will start actively enforcing, and will expect full compliance with the DME face-to-face requirements beginning by a date that will be announced in Calendar Year 2014.
Section 6401 of the ACA established a face-to-face encounter requirement for certain items of DME. The law requires that providers must document that a physician, nurse practitioner, physician assistant, or clinical nurse specialist has had a face-to-face encounter with the patient. This encounter must occur within the 6 months before the order is written for the DME.
- The following Medicaid Coding Guidelines are retired effective 11/1/2013:
- Casts, Splints, and Strapping
- Continuous Glucose Monitoring System
- Endometrial Ablation
- Surgical (sterile) Tray List
More information on retired coding guidelines is available on the ND Medicaid Medical Coding Guidelines page. Please contact the ND Medicaid medical coders with any questions regarding these guidelines at (701) 328-4825.
- The next Durable Medical Equipment (DME) Task Force Meeting has been scheduled for November 14th; questions prior to the meeting will be accepted. Please see the DME Providers Web page for additional information.
- Effective September 16, 2013, the North Dakota Department of Human Services requires all third party billers to submit inquiries via secure email. The Department's policy can be viewed on the Medicaid Provider Policies Web page.
- Taxi Transportation Providers: A memo concerning the Voucher Requirement for Taxi Services has been sent out on September 10, 2013 clarifying reimbursement policies.
- A new Chiropractic Services Manual has been created outlining the Chiropractic Services Clinical Policy. This Manual can be found on the Medicaid Provider Manuals Web page.
- Officials Discuss Medicaid Information System Schedule
The N.D. Department of Human Services is anticipating a delay in the scheduled launch of the new Medicaid Management Information System (MMIS). The computer system has a contracted completion date of Oct. 1, 2013; however, the Department and Xerox State Healthcare are discussing a revised work plan for the project's completion and a new "go live" date. The department anticipates the new "go-live" date to shift to the second quarter of calendar year 2014.
Some important benchmarks have already been reached. Construction of the base system is complete and provider enrollment has been underway since April 2013. However, work continues to ensure that information from the department's 1970s era Legacy MMIS system is not compromised during the conversion to the new system.
Xerox is also under contract with other states, and North Dakota is tracking the success of the New Hampshire system (implemented in March 2013), and the Alaska project (set to be implemented in October 2013).
- Please note that there has been a change in Checkwrite dates for North Dakota Medicaid Claims Payment, as noted below. A more complete Checkwrite date schedule can be viewed on the Checkwrite Dates page.
- Monday, July 22nd - Checkwrite
- Thursday, July 25th - Checkwrite
- Monday, July 29th - NO CHECKWRITE
- Monday, August 5th - Resume normal Checkwrite schedule
- Additional Time to Establish Protocols for Newly Required Face-to-Face Encounters for DME
Effective October 1, 2013, North Dakota Medicaid and CMS will start enforcing full compliance with the DME face-to-face requirements mandated by the Affordable Care Act (ACA) for certain items of Durable Medical Equipment (DME).
Section 6401 of the ACA established a face-to-face encounter requirement for certain items of DME. The law requires that a physician must document that a physician, nurse practitioner, physician assistant, or clinical nurse specialist has had a face-to-face encounter with the patient. This encounter must occur within the 6 months before the order is written for the DME.
- Effective June 15, 2013, all DME repair/replacement prior authorization requests that list a Third Party Payer (TPP) will, if approved, have the verbiage of "Please bill all other insurance(s) prior to Medicaid and pay only if Primary pays". This replaces the statement of "does not total more than 75% of replacement cost" only when there is a TPP.
If North Dakota Medicaid is the only insurer, the DME repair/replacement prior authorization request will be reviewed and may be approved as long as the accumulative repair/replacement cost is not more than 75% of the replacement cost from purchase date of the item. If accumulative repair/replacement cost exceeds 75%, the request will be denied and a new prior authorization can be submitted for purchase.
- Effective 8/1/2013, ND Medicaid will be implementing two additional Local Coverage Determinations (LCDs) into its claims processing and payment system. (LCDs can be viewed in their entirety at the CMS.gov LCD Web page) Those two LCDs are:
- Chest X-Ray Policy (L32844)
- MRI and CT Scans of the Head, Brain, and Neck (L32848)
- Fee Schedule Update - Effective 7/1/2013
In accordance with the appropriation provided by the assembly to update provider rates with a 4% inflationary increase the first year of the biennium, we have increased provider rates effective for 7/1/2013 dates of services and after. Codes which are priced off a fee schedule have been adjusted with the 4% inflationary increase accordingly.
Codes which are priced using the Relative Value Unit (RVU) methodology have had the converstion factor adjusted. The adjustment in the conversion factor takes into account the implementation of the 2013 RVUs for dates of service on or after July 1, 2013. Based on previous twelve calendar months' claims volume, the new relative value unit adjustments, and a 4% inflationary increase for the first year of the biennium, the resulting conversion factor effective for 7/1/2013 dates of service and after is $47.86. The prvious converstion factor was $46.38. 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 mthodology will see a 4% increase.
- Non-Emergent Transportation & Lodging Provider rates have also increased. Please view:
- ND Medicaid has updated the Provider Supervision Requirements to include PHysician Assistants (PA) and Clinical Nurse Specialisits (CNS) effective 1/1/2013. This policy can be View on the Medicaid Medical Policy page.
- Effective 7/1/2013, ND Medicaid will be implementing coverage of S2083 - Adjustment of Gastric Band via subcutaneous port by injection or aspirations of saline. Please view this guideline on the Medicaid Coding Guildelines page.
- A comment period has opened for a proposed Chiropractic Manual for Providers. Please see the ND Medicaid Provider Manuals page to review this document and to submit comments.
- The Immunization Administration for Vaccines/Toxoids coding guideline has now been updated online. Please see the ND Medicaid Coding Guidelines page to view this updated policy.
- On May 17, 2013, the Medical Servcies Division released information containing a self-attestation form relative to the enhanced payments for vaccine administrations rendered by certain primary care physicians (PCPs). The increased payments are in accordance with Section 1202 of the Affordable Care Act (ACA).
Qualifying physicians interested in receiving the higher Medicaid payment for vaccination administration must submit a completed Self-Attestation form. Please note that the original documentation stated that the Attestation is due on or before June 17, 2013 in order to receive the retrospective payment consideration back to January 1, 2013. THE DUE DATE FOR THE ATTESTATIONS HAS BEEN EXTENDED TO AUGUST 17, 2013. Physicians who submit a Self-Attestation after August 17, 2013 will continue to be aligible for the enhanced rates on a prospective basis effective the date they are received.
If you have any questions, please contact Cindy Sheldon by phone at (701) 328-4626 or via email at email@example.com.
- Section 1202 of the Affordable Care Act (ACA) requires that Medicaid payment for certain evaluation and management (E&M) services and immunization services furnished in calendar years 2013 and 2014 by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine are to be at a rate not less than 100 percent of the payment rate that applies to such services under Medicare. Because North Dakota Medicaid currently reimburses above the Medicare payment rate for E&M codes, the enhanced payment only applies to vaccine administration codes.
In order to be eligible for the increased payment, physicians must be enrolled as family medicine, general internal medicine, pediatric medicine or a sub-specialty thereof; and must self-attest as qualifying either by board certification or show that 60% of all Medicaid services they bill are for the specified E&M and vaccine administration codes. Details of the eligibility requirements may be found at http://www.gpo.gov/fdsys/pkg/FR-2012-11-06/pdf/2012-26507.pdf.
Qualifying physicians interested in receiving the higher payment for vaccination administration for North Dakota Medicaid recipients must submit the completed Self-Attestation form on or before June 17, 2013 in order to receive retrospective payment consideration back to January 1, 2013. Attestations received after June 17, 2013 will result in the enhanced rates on a prospective basis. The Self-Attestation (SFN 1508) can be found below or by visiting http://www.nd.gov/eforms/Doc/sfn01508.pdf.
- Enhanced Payments Overview - Memo dated 5/14/13
- 2013 Changes for Vaccine Administration - Enclosure
- Primary Care Enhanced Payment Increase Self-Attestation - SFN 1508
- Effective 3-1-2012, ND Medicaid will require prior authorization through North Dakota Healthcare Review for CPT 43775 - Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy). If approved, ND Medicaid will reimburse this procedure. The ICD-9-CM Volume 3 codes also requiring prior authorization for the sleeve gastrectomy procedures are 43.82 - Laparoscopic vertical (sleeve) gastrectomy and 43.89 - Open and other partial gastrectomy. Prior authorization can be requested through:
ND Healthcare Review, Inc.
3520 North Broadway
Minot, ND 58703
701-838-6009 (Review Fax only)
- The ND Medicaid Coding Guideline for LICSW/LCSW Allowed Services has been updated to reflect the 2013 Psychiatry Code Updates per CPT. The updated Coding Guideline may be viewed on the ND Medicaid Coding Guidelines page.
- The Swing Bed Rate for 2013 has been updated on the Main Provider page.
- An Available Primary Care Provider (PCP) List has been updated, and may be reviewed, on the Medicaid Managed Care page.
- The Dental Provider Manual for North Dakota Medicaid has been updated. Please see the Provider Manuals page for more information.
- Checkwrite dates through June 2013 have been updated on the Medicaid Checkwrite page.
- The most recent Provider Bulletin dated February 2013 has been posted to the Provider Main page.
- Two Completion Guides for Durable Medical Equipment (DME) have been added for providers' reference. Please see the Medicaid DME Provider Web page to access these documents.
- The American Medical Association (AMA) made significant changes to Current Procedural Terminology (CPT) codes for psychiatry and psychotherapy services effective January 1, 2013. North Dakota Medicaid has now implemented these changes with the 2013 Psychiatry CPT codes 90785-90840 effective for dates of service January 1, 2013 and after.
If you have submitted claims with these CPT codes for dates of service January 1, 2013 and after that have been denied due to code implementation, please resubmit those claims to ND Medicaid.
If you have submitted claims with dates of service January 1, 2013 and after using the obsolete psychiatry CPT codes (codes that were effective previous to 01/01/13), you must submit an adjustment to deny the claim in conjunction with the submission of a revised corrected claim using the current psychiatry CPT codes by July 1, 2013. If you do not submit an adjustment by July 2, 2013, ND Medicaid will adjust the claim and deny it for invalid procedure code.
- A new Provider Policy regarding Medical Record Retention has been placed on the Medicaid Provider Policies page. Important information pertaining to medical records formats is included in this policy.
- There is a new version of the Medicaid Program Provider Agreement available for providers to update their enrollment. The retention period of this form has also changed from 5 years to 7 years. The new SFN 615 can found at http://www.nd.gov/eforms/Doc/sfn00615.pdf, or on the Provider Enrollment Web pages.
- The Partial Hospitalization Prior (PHP) Authorization/Continued Stay (SFN 73) form has been updated this month. Please discard all older version of this form and use this most recent version. It may also be found on www.nd.gov/eforms.
- A new informative page regarding the Federal Payment Error Rate Measurement (PERM) audit has been created. You may visit this ND Medicaid PERM page for example letters and general information. This page is also accessible through the main Department of Human Services Providers page (www.nd.gov/dhs/providers).
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