Medicare and Medicaid Information for North Carolina Pharmacists
Check here regularly for the latest information regarding Medicare and Medicaid.
UPDATED MONDAY, FEBRUARY 25, 2008
TAMPER-RESISTANT PRESCRIPTION PAD COMPLIANCE - Please see this letter from NC DHHS outlining further DMA guidance to providers regarding the upcoming deadlines for compliance with Federal requirements for tamper resistant prescription pads/paper. Beginning April 1, 2008, all written prescriptions for Medicaid fee-for-service recipients are required to have at least one of the industry recognized security features from one of the three categories of characteristics listed in DMA's September 6, 2007 guidance document. By October 1, 2008, written prescriptions will be required to have one industry recognized security feature from each of the three categories of characteristics to be in compliance with Federal law. Please find additional guidance regarding the requirements at:
http://www.dhhs.state.nc.us/dma/TamperResistantPrescriptionPads.pdf
UPDATED THURSDAY, JANUARY 3, 2008
Medicare-Approved Drug Benefits in NC (Updates and Reminders) provided by Senior PHARMAssist, Durham, NC
UPDATED MONDAY, OCTOBER 1, 2007
Notice from NC DMA - President Signs Bill Delaying Tamper-Resistant Prescription Pad Requirement - On Saturday, September 29, 2007, President George W. Bush signed the “Extenders Law,” delaying the implementation date for all paper Medicaid prescriptions to be written on tamper-resistant paper. Under the new law, all written Medicaid prescriptions must be on tamper-resistant prescription pads as of April 1, 2008. CMS will issue additional guidance on this implementation delay as it becomes available.
Any questions should be directed to NC DMA, (919) 855-4300.
UPDATED THURSDAY, SEPTEMBER 6, 2007
North Carolina Division of Medical Assistance Releases Guidelines for Tamper-Resistant Prescription Pads.
Pharmacists with questions should contact DMA directly at (919) 855-4300. The Board of Pharmacy does not administer the tamper-resistant prescription pad statute.
FROM THE CENTERS FOR MEDICARE AND MEDICAID SERVICE (CMS):
As we get closer to May 23, 2008, be sure to pay attention to information from Medicare and other health plans regarding NPI implementation timelines.
Important Message for Residents at Teaching Hospitals and Academic Medical Centers: Why get your NPI now?
If the hospitals’ residents want to enroll in Medicare, you will need to obtain NPIs before applying (enrolling) as a Medicare provider.
Other health plans may require you to obtain NPIs as a condition of enrollment.
If you prescribe medication, the pharmacies may need to know your NPI before dispensing the medications and submitting claims to health plans.
If you order or refer services, your NPI may be required on the claims from providers who actually furnished the services.
Future employers may require you to obtain NPIs as a condition of employment.
Important Information for Medicare Providers
Summary of Key Medicare Dates:
October 29, 2007 - By this date, all carriers, A/B MACs and DME MACs will be rejecting claims where the NPI/legacy identifier combination used in claims cannot be validated against the NPI crosswalk. Informational edits will no longer be issued once this happens, but will be replaced by reject reports that will assist providers in determining why the claim is being rejected.
January 1, 2008 - As of this date, 837I electronic claims and UB04 paper claims without an NPI in fields identifying the primary provider (billing and pay-to) will be rejected. Legacy identifiers paired with NPIs in the primary provider fields on the claim will still be acceptable as will legacy-only numbers in secondary provider fields (see clarification below).
CMS has not yet announced the date by which an NPI will be required for primary provider fields on 837 professional electronic claims and 1500 paper claims processed by carriers, A/B MACs and DME MACs. This will occur prior to May 23, 2008; a specific date will be announced once available.
May 23, 2008 - In keeping with the Contingency Guidance issued on April 3, 2007, CMS will lift its NPI contingency plan, meaning that only the NPI will be accepted on all HIPAA electronic transactions (837I, 837P, NCPDP, 276/277, 270/271 and 835), paper claims and SPR remittance advice. This also includes all secondary provider fields on the 837P and 837I. The reporting of legacy identifiers will result in the rejection of the transaction. CMS will also stop sending legacy identifiers on COB crossover claims at this time.
Common Claims Problems/Errors Causing Rejections
The following problems/errors are due to providers billing with incompatible NPI/legacy pairs:
The type of NPI you use (Entity Type 1 or Entity Type 2) must match your Medicare enrollment PIN (individual or organization). When compatible NPI/legacy pairs are submitted on a claim, there is a much higher success rate for finding a match on the NPI crosswalk, thus further ensuring timely and accurate processing of your claim.
Those who are enrolled with Medicare as individuals but obtained an Organization (Entity type 2) NPI through NPPES (or vice versa) need to ensure their enrollment records are correct and their NPIs were obtained appropriately.
On professional claims (837P and CMS-1500), the NPI/PIN combination should identify the Billing, Pay-to, and Rendering Provider (the Pay-to Provider is identified only if it is different from the Billing Provider). This includes claims that are submitted by corporations that physicians and non-physician practitioners have formed or by physicians and non-physician practitioners who bill Medicare directly. For more information, please refer to MLN Matters article SE0744 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0744.pdf on the CMS website.
Other problems identified include:
· Providers are not taking proactive action based on the Part B informational edits and reject reports, despite extensive outreach and educational activities designed to make providers aware of the need to take action. Don’t let this happen to you. Pay attention to the informational edits prior to October 30 and the reject messages thereafter.
· CMS has received reports of clearinghouses and billing services that may be stripping the NPI from the claim and later adding the NPI back on the remittance advice. Make sure this is not unknowingly happening to your claims. If you suspect that your clearinghouse or billing service is stripping your NPI from claims, please contact your contractor to confirm that an NPI was not received.
Clarification: NPI Requirement on Medicare Institutional Claims for 1/1/08
At the beginning of October, CMS issued a notice that referred to institutional claims. We are further clarifying that effective 1/1/08, NPIs will be required to identify the primary providers (the Billing and Pay-to Providers) in Medicare electronic and paper institutional claims (i.e. 837I and UB-04 claims). You may continue to use the legacy identifier in these fields as long as you also use the NPI in these fields. This means that 837I and UB-04 claims with ONLY legacy identifiers in the Billing and Pay-to Provider fields will be rejected starting on 1/1/08. (Pay-to Provider is identified only if it is different from the Billing Provider.)
You may continue to use only legacy identifiers for the secondary provider fields in the 837I and UB-04 claims, until 5/23/08, if you choose.
Test Your Claims Now!
Medicare encourages submitters to send a small number of claims using NPIs only (no legacy identifiers). If no claims are rejected, the submitter may gradually increase the volume. And remember, Medicare will require the NPI on paper claims – be sure to begin the testing process now even if you bill paper!
Upcoming WEDI NPI Audiocast on Using the NPI Registry and the NPPES Downloadable File
The Workgroup for Electronic Data Interchange will host an NPI audiocast on October 31st. Visit http://www.wedi.org/npioi/index.shtml on the WEDI website to learn more. Please note that there is a cost to participate in WEDI events.
Still Confused?
Not sure what an NPI is and how you can get it, share it and use it? As always, more information and education on the NPI can be found through the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website. Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203. Having trouble viewing any of the URLs in this message? If so, try to cut and paste any URL in this message into your web browser to view the intended information.
Getting an NPI is free - not having one can be costly.
August 17, 2007: CMS Issues Guidance to State Medicaid Agencies on “Tamper Proof Prescriptions” – CMS issued this letter to state Medicaid agencies, which purports to provide guidance on implementation of the “tamper proof prescription” requirement for Medicaid prescriptions. This program goes into effect on October 1, 2007. Pharmacists with questions about this program should contact the North Carolina Division of Medical Assistance, CMS, or both. The North Carolina Board of Pharmacy does not administer this federal statute in any way. It is purely a Medicaid payment regulation and, as such, all questions should be directed to Medicaid agencies.
NPI Electronic Mailing List Message 7/30/2007
N.C. Medicaid would like to encourage providers to begin submitting immediately both the NPI and the Medicaid Provider Number on all claims. This information is needed for testing the NPI changes to MMIS.
If your software is not updated to submit the NPI number, please contact your clearinghouse or software vendor as soon as possible to obtain the appropriate updates. Please ensure that you keep the capability to submit the Medicaid Provider Number along with the NPI. N.C. Medicaid will continue to process claims using the Medicaid Provider Number until NPI is implemented.
North Carolina Medicaid Implements New Proton Pump Inhibitor Program
Click here to read the May 2007 DHHS/DMA Newsletter
Joint Statement from the N.C. Board of Pharmacy and the N.C. Division of Medical Assistance
The North Carolina General Assembly mandates pharmacists participating in the Medicaid program to substitute generic drugs for brand name drugs unless the prescriber indicates “medically necessary” on the face of prescriptions for brand name drugs. In support of this mandate, the North Carolina Board of Pharmacy and the North Carolina Division of Medical Assistance would like to notify pharmacists that prescriptions for brand name Prilosec 40mg may be substituted with the equivalent dose of generic omeprazole 20mg.
Pharmacists should consult with their Medicaid patients that they are receiving an appropriate generically equivalent medication and should also take care to consult these patients on the appropriate use of the medication.
NPI Announcement - May 10, 2007
Based on the CMS announced delay for the NPI implementation, DMA will continue collecting NPI information, but will not be requiring the NPI on claims effective May 18, 2007 as previously announced. Remember, with the delay in implementation, claims submitted without a Medicaid provider number will not be processed.
Further information regarding our new implementation date will be communicated when available. DMA will be communicating all NPI updates first via email from our NPI Mailing List. If you have not subscribed to our email list, please do so immediately by visiting our website at http://www.dhhs.state.nc.us/dma/NPI.htm and clicking on the NPI Mailing List, in red at the top of the page.
Once subscription to our mailing list is complete, NPI information and updates will be available. NPI information will also be communicated to the provider community via bulletins, RA banner messages, email blasts and the DMA webpage.
NPI Update
Medicare Part B Drug Competitive Acquisition Program (CAP): Medicare Part B Drug
NPI: Get It. Share It. Use It.
Over 2 million providers have their NPIs – do you have your NPI yet? Covered entities (including health plans, covered health care providers and clearinghouses) across the country are making decisions regarding their need for contingency plans for NPI implementation. It is more important than ever to obtain an NPI as soon as possible and begin testing it on claims, as directed by your health plan.
Medicare providers should pay special attention to the Medicare information section below for important news on the Medicare FFS Contingency Plan.
New Compliance Contingency Guidance FAQs
CMS has posted new FAQs related to the previously posted NPI Compliance Contingency Guidance. Questions include:
· What are the exact dates for the National Provider Identifier (NPI) contingency plan?
· If a complaint is filed against me for not being in compliance with the National Provider Identifier (NPI) after May 23, 2007, what will happen?
· What happens if a complaint for not being in compliance with the National Provider Identifier (NPI) is filed against me after May 23, 2008?
· Is it acceptable for a health plan to announce their National Provider Identifier (NPI) contingency now?
· Is the National Provider Identifier (NPI) contingency plan voluntary?
· Am I allowed to give my National Provider Identifier (NPI) to other providers as well as to the health plans with whom I exchange transactions?
To view these FAQs, you should:
1) Go to the CMS dedicated NPI web page at www.cms.hhs.gov/NationalProvIdentStand
2) Scroll down to the section that says “Related Links Inside CMS”
3) Click on NPI Frequently Asked Questions. To find the latest FAQs, click on the arrows next to “Date Updated”. Look for the word “NEW” in red font to appear beside the most recent FAQs.
Obtain Information on Contingency Plans
CMS strongly urges providers to pay attention to information from the health plans they bill so that they are aware if, and when, a specific health plan announces its own contingency plan.
Reminder – Sharing NPIs
Once providers have received their NPIs, they should share their NPIs with other providers with whom they do business, and with health plans that request their NPIs. In fact, as outlined in current regulation, providers who are covered entities under HIPAA must share their NPIs with any entities that need them for billing purposes -- including those who need them for designation of ordering or referring physician. Providers should also consider letting health plans, or institutions for whom they work, share their NPIs for them.
Reminder – Enumerating a Group Practice
A group practice that conducts any of the HIPAA standard transactions is a covered healthcare provider (a covered entity under HIPAA) and, as such, must obtain an NPI. The physicians employed by the group practice, on the other hand, are furnishing services at the group office(s) but they are not conducting any of the HIPAA standard transactions (such as submitting claims, checking eligibility and claim status). As such, the physicians would not be covered health care providers and are not required by the NPI Final Rule to obtain NPIs. However, as the employer, the group could require these physicians to obtain NPIs and use the NPIs to identify them as the rendering providers in the claims that the group submits. If these physicians prescribe medication, the pharmacies may require their NPIs in the claims that the pharmacies submit to health plans. Additionally, health plans can require enrolled physicians to obtain NPIs in order to participate in that plan. Medicare is an example of a health plan with this requirement.
Reminder – Applying for an NPI Does Not Enroll a Health Care Provider in a Health Plan
Applying for an NPI and enrolling in a health plan are two completely separate activities. Having an NPI does not guarantee payment by any health plan.
When to Contact the NPI Enumerator for Assistance
Providers should remember that the NPI Enumerator can only answer/address the following types of questions/issues:
Status of an application
Forgotten/lost NPI
Lost NPI notification letter (i.e., for those providers enumerated via paper or web-based applications)
Trouble accessing NPPES
Forgotten password/User ID
Need to request a paper application
· Need clarification on information that is to be supplied in the NPI application
Providers needing this type of assistance may contact the enumerator at 1-800-465-3203, TTY 1-800-692-2326, or email the request to the NPI Enumerator at CustomerService@NPIenumerator.com .
Please Note: The NPI Enumerator’s operation is closed on federal holidays. The federal holidays observed are: New Year's Day, Independence Day, Veteran’s Day, Christmas Day, Martin Luther King's Birthday, Washington's Birthday, Memorial Day, Labor Day, Columbus Day, and Thanksgiving.
Important Information for Medicare Providers
Medicare Fee-For-Service (FFS) Contingency Plan Announced!
FFS Medicare has announced its contingency plan. View the associated Change Request at http://www.cms.hhs.gov/transmittals/downloads/R1227CP.pdf, as well as the related MLN Matters article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5595.pdf on the CMS website. Please note that these materials were recently revised; please be sure to visit the links above for the latest information. This information will also be available shortly on CMS’ dedicated NPI web page.
A national NPI Roundtable on the Medicare FFS Contingency Plan is scheduled for May 10, 2007 from 2-3:30PM EDT. Registration details to follow.
Reporting a Group Practice NPI on Claims
Medicare has identified instances where the Multi-Carrier System (MCS) is correcting billing or pay-to provider data on Part B claims submitted by group practices. As of May 18, 2007, the MCS Part B claims processing systems will no longer correct claims submitted by group practices that are reporting the individual rendering Provider Identification Number (PIN) or individual rendering NPI in either the billing or pay-to provider identifier fields. Groups should enter either their group NPI or group NPI and legacy PIN number pair in either of these fields.
Reminder – Medicare Extending Date for Accepting Form CMS-1500 (12-90)
While Medicare began to accept the revised Form CMS-1500 (08-05) on January 1, 2007 and was positioned to completely cutover to the new form on April 1, 2007, it has recently come to our attention that there are incorrectly formatted versions of the revised form being sold by the Government Printing Office (GPO). After reviewing the situation, the GPO has determined that the source files they received from the NUCC’s authorized forms designer were improperly formatted. The error resulted in the sale of both printed forms and negatives which do not comply with the form specifications. However, not all of the new forms are in error.
Given the circumstances, CMS is extending the acceptance period of the Form CMS-1500 (12-90) version beyond the original April 1, 2007 deadline while this situation is resolved. Medicare contractors will be directed to continue to accept the Form CMS-1500 (12-90) until notified by CMS to cease. At present, we are targeting June 1, 2007 as that date. During the interim, contractors will be directed to return, not manually key, any Form CMS-1500 (08-05) forms received which are not printed to specification. By returning the incorrectly formatted claim forms back to providers, we are able to make them aware of the situation so they can begin communications with their form suppliers.
For more details, and to learn how to identify the proper version of the new form, visit a recent MLN Matters article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5568.pdf on the CMS website.
Still Confused?
Not sure what an NPI is and how you can get it, share it and use it? As always, more information and education on the NPI can be found at the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website. Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203.
Getting an NPI is free - not having one can be costly.
Medicare Part B Drug Competitive Acquisition Program (CAP): Medicare Part B Drug Competitive Acquisition Program (CAP): Additional Physician Election Period and “Ask-the-Contractor” Teleconference.
The Centers for Medicare & Medicaid Services will be conducting an “Ask-the-Contractor” teleconference to discuss the additional 2007 CAP physician election period. The call will be hosted by the CAP designated carrier, Noridian Administrative Services (NAS). All interested providers and contractor staff are invited to participate.
Call Details:
Date: Wednesday, May 2, 2007, 10:30 – 11:30 AM CT
Call: 888-423-3275
Passcode: CAP
Call Leader: Audrey Aberle
A PowerPoint slide presentation, that will accompany the “Ask-the-Contractor” teleconference, will be posted in the Downloads section at http://www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp on CMS’ CAP Information for Physicians webpage. The slides will be available at least one day prior to the teleconference. After the presentation, there will be a question and answer session for physicians who are not yet participating in the CAP and are interested in participation during 2007.
For security reasons, you will be required to give the passcode and leader’s name in order to join the call. The conference operator will also ask you for the name of your company and the spelling of your name.
April 3, 2007
NPI: Get It. Share It. Use It. (A message from The Centers for Medicare & Medicaid Services)
The Centers for Medicare & Medicaid Services (CMS) announced that it is implementing a contingency plan for covered entities (other than small health plans) who will not meet the May 23, 2007, deadline for compliance with the National Provider Identifier (NPI) regulations under the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
The final rule establishing the NPI as the standard unique health provider identifier for health care providers was published in 2004 and requires all covered entities to be in compliance with its provisions by May 23, 2007, except for small health plans, which must be in compliance by May 23, 2008.
CMS encourages health plans to assess the readiness of their provider communities to determine the need to implement contingency plans to maintain the flow of payments while continuing to work toward compliance. Likewise, we encourage health care providers that have not yet obtained NPIs to do so immediately, and to use their NPIs in HIPAA transactions as soon as possible. Applying for an NPI is fast, easy and free. Visit the National Plan/Provider Enumeration System (NPPES) website at https://nppes.cms.hhs.gov/.
A critical aspect of implementing the NPI is the ability for covered entities to match a provider’s NPI with the many legacy provider identifiers that have been used to process administrative transactions. CMS plans to make data available from the NPPES system that will assist covered entities in developing these “crosswalks.”
To view this guidance, visit http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_Contingency.pdf on the CMS website.
A press release on this topic is also available at http://www.cms.hhs.gov/apps/media/press_releases.asp on the web.
As always, more information and education on the NPI can be found at the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website.
Getting an NPI is free - not having one can be costly.
February 1, 2007 - Information for pharmacists regarding NC Medicare drug plan - NCRx (North Carolina’s new program to help seniors with incomes at or below 175% of the federal poverty level pay their Medicare Part D monthly premiums), has EXTENDED its enrollment period. Read about it here.
ALERT - From the NC Department of Justice
Subject: Senior Fraud Alert: Another Medicare Part D-Related Scam?
Date: Wed, 3 Jan 2007
TO MEMBERS OF THE NORTH CAROLINA SENIOR CONSUMER FRAUD TASK FORCE:
****** Fraud Alert #150 ******
Stephanie Bias, the statewide coordinator for the NC Department of Insurance's SMP program (formerly "Medicare Lookout") shares with us the following information about a supposed drug benefit plan that is placing calls to seniors in several states:
Officials in Connecticut, Mississippi, Missouri and Iowa report that older consumers are receiving calls informing them that they can be enrolled in a program that meets their prescription drug needs for only $389. The program is not affiliated with or sanctioned by the Medicare Part D prescription drug program, but consumers may be getting that impression from the callers. Connecticut and Iowa officials report that callers possessed foreign accents. They pitched the plan and sought account information so that the consumers' bank accounts could be debited for the supposed enrollment fee. Upon calling the toll-free number that was given to an older consumer in her state, a Connecticut official spoke with a company representative who acknowledged that they had no connection to Medicare and were "an independent supplier that offered 30-50% discount on prescription drugs." The company representative refused to send any information on the company's program until after the fee was paid. The representative offered the following as the website for her company: www.pharmabay.net. That website is registered to parties in Montreal, Quebec, Canada.
Medicaid Clarifies Its Use of Physician DEA Numbers
Item 2119 in the July 2006 Newsletter suggested that NC Medicaid Auditors were enforcing requirements of a DEA number for non-controlled prescriptions for purposes of payment. NC Medicaid states that this is not accurate. North Carolina Medicaid does not recoup monies based on missing or incomplete DEA numbers as part of a prescription. This is not an area that is part of routine Medicaid Pharmacy audits. Pharmacists are reminded that they can call EDS for claims submission assistance at 1-800-688-6696 and can call DMA for general post payment review audit questions at 919-647-8000.
Important information for Medicaid providers - Please visit http://ncleads.dhhs.state.nc.us/ for an update regarding the termination of the NCMMIS replacement contract with ACS.
Medicare Part D: Post Initial Enrollment Update 2006
Attention: Prescribers and Pharmacists
Prescription Limitations - Effective no earlier than June 1, 2006, the monthly prescription limitation will change from 6 prescriptions per recipient per month to 8 prescriptions per recipient per month. Pharmacists will be able to override the monthly prescription limit with three additional prescriptions per recipient per month. Overrides will be available at the discretion of the pharmacist and in consultation with the recipient's physician based on the assessment of the recipient's need for additional medications during the month of service.
Some recipients have clinical indications that warrant more prescriptions than are allowed under the monthly prescription limitations and will be exempt from the monthly limitations. DMA will require that recipients receiving more than 11 prescriptions per month be evaluated as part of a medication therapy management program.
Recipients identified for the medication therapy management program who require more than 11 prescriptions each month will be restricted to a single pharmacy. Pharmacies participating in this program will be eligible for a monthly medication therapy management fee for each Medicaid recipient being managed. The recipient's physician and pharmacist will be reviewing the recipient's medication profile to ensure clinically appropriate and cost effective use of drug therapy.
For more detail information, please refer to the May 2006 Special Bulletin, Outpatient Pharmacy Program from DMA's website at http://www.dhhs.state.nc.us/dma/bulletin.htm.
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Medicare Part D Resource Fact Sheet
Long-Term Care Association Letter HPMS
Subspecialty Groups Letter HPMS
Part D Drugs/Part D Excluded Drugs
Medicare Part D Prescription Drug Plans and Temporary First Fill Policies
CMS Process to Ensure Effective Transition to Medicare Part D Prescription Drug Coverage
Quick Answers to FAQs on Processing Claims for Dual Eligible Beneficiaries
Information to Assist Pharmacists in Completing Pharmacy Transactions
Pharmacy Transition Policies Reminder
For CSR Describing the POS "WellPoint" Process to a Pharmacy
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