NORTH CAROLINA
NC Caid BH AUTH or ICM BH ABA If ABA request (per SSG)
For Virginia CAID, how to we handle Personal Care Service (PCS) auth requests?
Connect provider to Home and Community Based Services (HCBS) phone # 844-842-6910 (Per SSG)
If provider needs a Home and Community Services Case built for a DC Medicaid member where would you refer the provider?
The Case Manager listed in ICUE Or United at Home contact # 855-409-7073 if no Case Manager is listed. (Per SSG)
How should we handle a request from a provider to refer a member to TN Choices or ECF Choices?
First, make sure their Tenncare Medicaid plan is active with UHC. If they are active with UHC submit a member assignment in ICUE and use the member referral template to submit the referral.
For TN Medicaid how do we handle Vanderbilt Intake Requests?
Refer to the Facility Exceptions - Authorization Requirements line to verify Vanderbilt facility or Provider Tax Ids.
Determine if Provider is In-Network or Out-of-Network.
In-Network Provider Request:
Create case and refer to the service specific line and follow directions for Prior Authorization requirements
Out-of-Network Provider Request:
1. Create case.
2. Refer to the service specific line of request for Prior Authorization requirements and proceed as follows:
- If service does not require a Prior Authorization, Administratively Approve.
- If unable to Administratively Approve, assign case. Refer to the Work Queues line for applicable work queues.
What code is For Personal Care Services (PCS) for NC Medicaid?
99509 (Per SSG)
True or False: On vaccine claims, Virginia Medicaid pays on the serum code rather than the vaccine administration code, and the administration code is not required to be on the claim.
True (Per the Vaccine’s for Children Reimbursement policy)
If member has DC DSNP plan that is QMB do they have full Medicaid benefits?
No Medicaid only covers Medicare cost share amounts. (Per provider manual)
What SOP gives me information about the TN Prepayment Process for R70-R99 Claim denials?
Fraud Waste Abuse – Medicaid State Specifics. In the SOP under member drop down select TN. This will open a drop down review the TN Prepayment Review in detail and how to assist provider with these denials.
Is there a PCP Lock In on TN Medicaid plans?
Yes – Found in CSP Lock In SOP.
What is the max Benefit Limit for Home Health Care visits per fiscal year?
100 (per B360 & SSG)
Where would you locate a list of Non-covered codes for Virginia Medicaid?
The Non-Covered & Covered Codes Reimbursement Policy
For TN Medicaid plans how should advocates handle Out of Network Authorization requests?
A Prior Authorization request from a Primary Care Provider or Participating Physician for Out-of-Network request is not required for Members. All Out-of-Network requests must be reviewed. Do not redirect. Create Case regardless of requesting physician network status.
TNLTSSCHOICES
What POS does NC not recognize?
02 &10 (found in the Procedure to Place of Service Reimbursement Policy)
What are the Chiropractic Benefits and restrictions for Virginia Medicaid?
6 Visits per calendar year to INN provider & Member must be 21 or older. (Per B360)
What are the steps in CSP Facets to locate a members TN Health Link Provider?
• In Facets CSP, select Transfer.
• Select Subscriber/Family.
• Select Open Customer.
• The Subscriber/Family tab will open.
• Select Member from the tabs at the top of the page.
• Select Health Status tab.
• Review the following fields:
• Code: TNHL
• Last: Effective date
• Next: Term date
• Comments: Current TIN and provider name
10. What DOS are processed using the New TN Medicare/Medicaid Crossover process?
DOS 1/1/2024 and going forward.
Can OON providers start auths for NC Caid members?
Yes (Per SSG)
Where do we check to see if the Provider is registered with Virginia Medicaid?
We use the ClaimsEditReport and/or the Pending provider Spreadsheets on the C&S Projects- Home Sharepoint (per NPI/taxonomy Section of the Claim research Job Aid)
If a Provider disagrees with the dates of attribution for a TN Health Link Provider what do we advise?
We should advise the provider to email bh_payment_reform@uhc.com
Are crossover claims processed according to the provider’s fee schedule or the state’s fee schedule?
Crossover claims will be processed according to state fee schedules.