ND Medicaid Provider Updates
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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