House Bill 5 Temporary Funding for Group Homes and Special Care Units & Carolina Access NPI

1. House Bill 5 Temporary Funding for Group Homes and Special Care Units & Carolina Access NPI Sabrena Lea NC Division of Medical Assistance March 14, 2013

2. The Ruling An Act Requiring The Department of Health and Human Services to Provide Temporary, Short-Term Financial Assistance To (1) Group Homes Serving Residents Determined Not to be Eligible for Medicaid-Covered Personal Care Services As A Result of Changes To Eligibility Criteria That Became Effective On January 1, 2013, and (2) Special Care Units Serving Residents Who Qualify For Medicaid-Covered Personal Care Services on or After January 1, 2013 http://www.ncleg.net/Sessions/2013/Bills/House/PDF/H5v5.pdf

3. Temporary Funding for 5600 facilities • (1) The amount of the Monthly payments authorized by this section shall not exceed six hundred ninety-four dollars ($694.00) per month for each resident who becomes ineligible for Medicaid-covered PCS on or after January 1, 2013 due to Medicaid State Plan changes in PCS eligibility criteria, for a period not to exceed three (3) months for each resident. At the expiration of this 3 month period, the monthly payment for each resident shall be reduced by twenty-five percent (25%) and shall not exceed five hundred twenty dollars and fifty cents ($520.50) per month per resident.

4. Temporary Funding for Special Care Units Section 1. (c) The Department of Health and Human Services shall provide temporary, short-term financial assistance in the form of a supplemental monthly payment to a SPECIAL CARE UNIT licensed under Chapter 131D or Chapter 131E of the General Statues, on behalf of a resident who was eligible for PCS prior to January 1, 2013, and is determined to be eligible for PCS on or after January 1, 2013 based on the eligibility criteria Specified in Section 10.9 F of S.L. 2012-142, as amended by Section 3.7 of S.L. 2012-145 and Section 70 of S. L. 2012-194. Notwithstanding any other provision of law, The Department shall only be required to make these supplemental monthly payments from the 39,700,000 appropriated for the 2012-2013 fiscal year. These special monthly payments shall be subject to all of the following requirements and limitations: (1) The amount of the supplemental monthly payments authorized by this section shall not exceed two hundred sixty-eight dollars ($268.00) per month for each resident who qualifies for PCS on or after January 1, 2013

5. Procedures for Access the Funds • Certification is not required for Group Homes or Special Care Units • Submit a CMS 1500 usingHCPCS code S 5126 (Attendant care services; per diem) • AND one of the following: • SE modifier (*) for dates of service up to 90th day or 06/30/13 whichever is earlier OR • TS modifier (**) for dates of service from 91st day to 180th day or until 06/30/13 whichever is earlier • FOR SCU only : HC modifier to access $268 monthly funds (3/01/13 til 06/3013 or until funds depleted. • Dates of service • Use dates of services on 1500 billing • Interrupted dates of service such as hospitalizations should not to be submitted. Upon return to facility, dates of service can resume for these funds • Payment • made every check write (*)SE Modifier description: “State and or Federally funded programs/services” will be used with S 5126 to indicate the higher rate (**) TS Modifier description: “Follow up service” will be used with S5126 to indicate the lower rate

6. Procedures for Access the Funds Submit a CMS 1500 usingHCPCS code S 5126 (Attendant care services; per diem) • AND one of the following: • SE modifier for dates of service up to 90th day or 06/30/13 whichever is earlier OR • TS modifier for dates of service from 91st day to 180th day or until 06/30/13 whichever is earlier • Dates of service • Once certified, interrupted dates of service such as hospitalizations should not to be submitted. Upon return to facility, dates of service can resume for these funds • Payment • Made every check write • Payment calculated on a per diem basis • SE modifier $23.13 daily • TS modifier: $17.35 daily • HC modifier SCU only: $8.93 daily

7. Carolina Access NPI Numbers • ACH Services now require a referral from the recipient’s Carolina Access Primary Care Provider if one is assigned to them for the dates of service being billed on the claim. Failure to do so correctly will result in one of the following Explanation of Benefits (EOB) Denials

8. Error Codes • EOB 286 -INCORRECT AUTHORIZATION NUMBER ON CLAIM FORM, VERIFY NUMBER AND REFILE CLAIM. • This means that there is a Referring NPI Number on the claim but it is not one which is associated with the Primary Care Provider assigned by the Department of Social Services to the recipient for the dates of service on the claim. • EOB 270 -BILLING PROVDIER IS NOT THE RECIPINET’S CAROLINA ACCESS PCP. AUTHORIZATION IS MISSING OR UNRESOLVED. CONTACT PCP FOR AUTHORIZATION OR HP PROV SVCS IF AUTHORIZATION IS CORRECT. • This means that there is not a Referring NPI on the claim, the recipient does have a Primary Care Provider assigned to them for the dates of service being billed and the provider needs to input this information before resubmitting the claim.

9. How to obtain PCP Information • Step 1 – Verify what PCP is assigned to the recipient for the date of service being billed. This information can be accessed by using the NCECS WEBTOOL or AVRS 1-800-723-4337, by selecting Option 6. Please reference Appendix 6 of the Basic Medicaid Billing Guide for reference. • Step 2 – Call the Primary Care Provider and obtain their NPI for the date of service being billed. • Step 3 – Input this NPI in the Referring NPI field of your claim. For CMS 1500 paper claims this is block 17B. • For claims submitted through the NCECS Web Tool this would be input in the field marked “Referring Physician NPI: (Carolina ACCESS Physician NPI)” • Please refer PCS Technical Assistance Webinar – January 15, 2013 under Seminar Presentations at http://www.ncdhhs.gov/dma/provider/seminars.htm

10. Providers using different billing software • Refer to Section 10 – Submitting Claims in the Basic Medicaid and NC Health Choice Billing Guide or to HIPAA Companion Guide 837Pv.2 to determine the correct field for the referring NPI.

11. Additional Information • In the event that the provider is not able to obtain the PCP NPI they can file a Carolina Access Override Request Formhttp://www.ncdhhs.gov/dma/Forms/caoverride.pdf within six months of the date of service on the claim and submit it for review. If this request is approved the provider would be given a Carolina Access Override Request Number. • This Number would be input on block 17A of a paper CMS 1500 or in the field marked “Referring Physician Provider Number (Carolina Access Physician Number)” on the NCECS Web Tool. In case the provider submits claims through a different software, they can reference Section 10 – Submitting Claims in the Basic Medicaid and NC Health Choice Billing Guide” or to HIPAA Companion Guide 837Pv.2 to determine the correct field.

12. Additional Information • Because the Primary Care Provider assigned to the recipient can be changed every month by the Department of Social Services, it is recommended that the provider check who the primary care provider assigned to their recipient is every month. Please reference Personal Care Services Webinar- January 10, 2013: http://www.ncdhhs.gov/dma/provider/seminars.htm for. • Reference – http://www.ncdhhs.gov/dma/provider/seminars.htm -PCS Billing and Special Payment to ACH Provider’s Webinar-Dec 13, 2012

13. What Billing topics can be addressed by CCME Billing Department? • Inquiries about Personal Care Service error codes • 2222- no documentation on file • 0023- services require prior approval • 5129/5111- provider number on claims does not match provider number on record • 5308- authorized units are exceeded • 5130/5112- procedure coded billed does not match procedure code on record

14. What Billing Questions are directed to HP? • Denials • Wrong Carolina Access Number • Wrong CPT code • Assistance with the Web Tool • Request for on site visit

15. Follow Up HB 5 Conference Calls Question & Answer Conference Call. • Wednesday March 20, 2013 10:00am-11:00am – For all 5600 a & c Providers • Thursday March 21, 2013 10:00am-11:00am – For all Special Care Unit (SCU) Providers. • Conference call in number for both days: 1-866-409-2889 Conference Code: 7631220923

16. RESOURCES • HP Enterprise Services (HPES) – Provider Services Toll Free Number: 800-688-6696 • Division of Medical Assistance (DMA) - http://www.ncdhhs.gov/dma/index.htm • Basic Medicaid and NC Health Choice Billing Guide - http://www.ncdhhs.gov/dma/basicmed • DMA Personal Care Services (PCS) webpage http://www.ncdhhs.gov/dma/pcs/pas.html

17. RESOURCES • The Carolinas Center for Medical Excellence (CCME)- www.thecarolinascenter.org • Email: PCSAssessment@thecarolinascenter.org • CCME’s Call Center is available Monday through Friday from 8:00 a.m. – 5:00 p.m. • Toll Free Number: 800-228-3365 • Option 2 - Independent Assessment • Option 3 - Personal Care Services Claims

18. Thank you!