North Dakota Medicaid Provider Newsletter June 2020

Photo credit: Theodore Roosevelt National Park

Welcome to the North Dakota Medicaid Provider newsletter. We hope this newsletter provides you with important and beneficial information about the North Dakota Medicaid Program. If you have any suggestions for future articles, please send your ideas to dhsmed@nd.gov.

In this edition, learn about:

  • Information on Medicaid provider COVID-19 relief funds
  • Available COVID-19 pandemic online resources
  • Medicaid 1915(i) State Plan amendment to expand home and community-based behavioral health services
  • Online monthly Medicaid claims payment information
  • Understanding denial, adjustment reason codes and other claims-related information
  • New members of the Medicaid Medical Advisory Committee and more

You are also being asked to complete a survey about the upcoming reprocurement of the Medicaid Expansion contract.

Thank you for being a North Dakota Medicaid provider serving North Dakota Medicaid members.

Sign up and get connected with North Dakota Medicaid

Medicaid providers and partners can now sign up for email updates from North Dakota Medicaid on various Medicaid-related news and information, including provider newsletters and press releases.

Human Services offers information on Medicaid provider COVID-19 relief funds

The North Dakota Department of Human Services is encouraging all health care providers who provide services to North Dakota Medicaid members to apply for Coronavirus Aid, Relief, and Economic Security (CARES) Act provider relief funds through the federal Department of Health and Human Services. The funds aim to support hospitals, clinics and other health care providers on the front lines of the COVID-19 pandemic.

Providers must apply for these COVID-19 relief funds on their own. North Dakota Medicaid cannot apply on behalf of providers.

“These funds will provide relief for many North Dakota Medicaid providers that have been affected by the COVID-19 pandemic,” said Caprice Knapp, the department's Medicaid Director. “Even if a provider is not sure if they will qualify to receive funds, we encourage them to apply. Changes in decisions at the federal level can happen quickly, and we want to ensure that as many North Dakota Medicaid providers as possible receive CARES Act provider relief funds.”

Interested providers can find more information and an application for the provider relief funds on this federal website.

The deadline to apply is July 20, 2020.

ND Medicaid Managed Care Survey

The North Dakota Department of Human Services is seeking feedback, through a survey, from health care providers, Medicaid members and the public on the procurement of its Medicaid Expansion managed care organization contract. In 2013, the department awarded Sanford Health Plan the managed care organization contract to administer the health care coverage for people who qualify for North Dakota’s Medicaid Expansion program.

The department’s current contract will expire in 2021. There are no additional contract extension options, so by law, the contract must be reprocured. The department is preparing to issue a request for proposal for managed care organizations to apply to administer North Dakota’s Medicaid Expansion program.

“We encourage everyone who is impacted by Medicaid managed care in North Dakota to complete this survey,” said Caprice Knapp, the department’s Medicaid Director. “We want to be thoughtful about how we can continue to improve care for our Medicaid Expansion coverage group under a new managed care organization contract.”

The department’s vision for Medicaid managed care is to develop and maintain a managed care program that provides high quality, efficient and effective services to enrolled Medicaid Expansion members in the state.

The survey asks questions about care management, value-based purchasing and ways that the managed care organization should communicate with providers and members.

Approved by North Dakota lawmakers in 2013 and authorized by the Affordable Care Act, Medicaid Expansion has made health care coverage available for qualifying low-income individuals between the ages of 19 to 64 with incomes up to 138 percent of the federal poverty level, which is about $23,000 for a household of two. About 20,000 individuals are enrolled in North Dakota’s Medicaid Expansion program.

You can complete a fillable survey by June 30, 2020 and return to dhsmed@nd.gov.

Use your discretion as to how many surveys your organization should complete. For example, if you have multiple service lines, it would be appropriate to fill out multiple surveys.

North Dakota Medicaid’s response to COVID-19

North Dakota Medicaid has issued several FAQs and temporary policies related to COVID-19. If you have any questions, email dhsmed@nd.gov.

Human Services submits Medicaid State Plan amendment to federal government to expand home and community-based behavioral health services

Did you know increasing a person’s access to home and community-based services (HCBS) may improve their overall health? In fact, research shows about 80 percent of our health is influenced by non-healthcare factors called social determinants of health.

Social determinants of health are the conditions in which people are born, grow, learn, work, live and age. When these conditions are impacted and not addressed, it can affect a person’s ability to live and thrive in their community. Addressing determinants of health is also a way to divert people from institutional settings, such as nursing homes or hospitals.

Last session, North Dakota lawmakers authorized the Department of Human Services to create a 1915(i) Medicaid State Plan amendment to expand home and community-based behavioral health services for children and adults. The development of the application draft has been a collaborative effort between the department’s Behavioral Health and Medical Services Divisions along with community partners.

There was great interest in this effort. More than 200 comments were received from stakeholders last fall at community meetings held throughout the state, and over 100 stakeholder comments were received during a public comment period, which ended March 19, 2020. This public input was instrumental in crafting the draft plan.

Team members are proud of the work that has resulted from this effort and are excited to announce that the draft Medicaid 1915(i) State Plan amendment was submitted to the federal Centers for Medicare and Medicaid Services (CMS) on April 29, 2020. Once approved by the federal government, the Medicaid 1915(i) state plan amendment will allow North Dakota Medicaid to pay for additional in-home and community-based services for individuals with mental health conditions, substance use disorders and/or brain injuries. These services include:

  • Educational, employment and housing supports,
  • Community transition services,
  • peer support,
  • care coordination,
  • respite care and other supportive services.

The department expects final approval of the Medicaid 1915(i) state plan amendment by fall.

Exciting work lies ahead. Home and community-based service providers play a very important role by creating a safety net of community support for individuals to access services in the lowest level of care necessary to support their long-term recovery.

Strong provider networks are key to delivering the right balance of quality, affordability and choice for individuals. The department looks forward to partnering with providers to improve the lives of the people we serve.

Introducing new Medicaid Medical Advisory Committee members

Earlier this year, the department’s Medical Services Division accepted nominations for membership on its North Dakota Medicaid Medical Advisory Committee.

The purpose of the 25-person committee is to provide a forum where the Medicaid program and its statewide partners, including health care providers, members and their families, and advocates, can:

  • Review and recommend changes to existing Medicaid policies,
  • Propose and discuss new Medicaid policies that are brought forth by the department, statewide partners, as well as legislative and executive branch members and their staff,
  • Review and discuss proposed changes to the Medicaid State Plan and waivers,
  • Provide and receive updates on key Medicaid initiatives or activities, and
  • At the start of each biennium, review the quality, access, and expenditures of the Medicaid program of the prior biennium.

The members include:

  • Matuor Alier, Cass County Human Service Zone eligibility worker;
  • Judy Bahe, Sanford Health – Bismarck, Children’s Therapies;
  • Brenda Bergsrud, Consumer Family Network and Amachi Mentoring (Free Through Recovery provider);
  • Melissa Bingham, Community member;
  • Tim Blasl, North Dakota Hospital Association;
  • Dr. Joan Connell, UND Center for Family Medicine and North Dakota Department of Health;
  • Darko Draganic, United Tribes Technical College;
  • Donene Feist, Family Voices of North Dakota;
  • Jessica Gilbertson, Community Healthcare Association of the Dakotas;
  • Trina Gress, Community Options;
  • Courtney Koebele, North Dakota Medical Association;
  • Nancy Kopp, North Dakota Optometric Association;
  • Sen. Judy Lee, North Dakota Senate Human Services Committee;
  • Sen. Tim Mathern, Prairie St. John's and North Dakota Senate Appropriations Committee;
  • Janelle Moos, AARP;
  • Lisa Murry, ELEVATE Nursing, LLC (QSP services/training);
  • Stephen Olson, Pediatric Partners;
  • Shelly Peterson, North Dakota Long Term Care Association;
  • Emma Quinn, F5 Project;
  • Mike Schwab, North Dakota Pharmacists Association;
  • William Sherwin, North Dakota Dental Association;
  • Dr. Andrew Stahl, North Dakota Department of Health;
  • Sara Stallman, Lutheran Social Services of North Dakota;
  • Beth Larson Steckler, Community member; and
  • Rep. Robin Weisz, North Dakota House of Representatives Human Services Committee

The committee will convene on September 8 and December 8 from 5 to 8 p.m. The meetings are open to the public.

Monthly Medicaid claims payment information is now available online

As part of the department’s ongoing efforts to increase transparency, North Dakota Medicaid is sharing monthly operational outcome data on claims processing on its website.

This data provides taxpayers, Medicaid providers and members and other stakeholders better insight into the department’s work.

Coming soon to the web page is Medicaid pharmacy information.

Claims Corner: Understanding denial, adjustment reason codes and more

A new feature in the North Dakota Medicaid provider newsletter is a section called Claims Corner. Its purpose is like a learning lab - to educate providers on various claims-related topics and to help alleviate some common claim denials.

In this article, learn about:

  • denial codes,
  • claim adjustment reason codes,
  • remittance advice remark codes and
  • common reasons for swing bed claim denials.

Understanding Denial Codes

  • Claim Adjustment Reason Codes (CARCS) are used to communicate a reason for a payment adjustment that describes why a claim or service line was paid differently than it was billed.
  • Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing.

The list of reason and remark codes is located at the end of each provider remittance advice.

Claim Adjustment Reason Codes

CO 16-Claim/Service lacks information or has submission billing error(s)

This adjustment reason code will always have a remark code that coincides with it. Make sure to check for the remark code as well. The remark code will tell you what information is needed or what billing error needs to be corrected.

CO 18-Exact duplicate service

This reason code will post to a service or services that have been previously paid. It will not post to any denied services.

CO 22-This care may be covered by another payer per coordination of benefits

This adjustment reason code will post when a primary insurance is located on the member’s enrollment file.

Remittance Advice Remark Codes

N255-Missing/incomplete/invalid billing provider taxonomy

This remark code will post if the billing provider taxonomy is missing from the claim or the one that was submitted differs from what is on file in the Medicaid Management Information System (MMIS).

MA32-Missing/incomplete/invalid number of covered days during the billing period

To avoid this denial, ensure that the number of covered days in boxes 39-41 on the UB04 are submitted correctly. Value code 80 (covered days) or if applicable value code 81 (non-covered days) should equal your from and through statement period.

8 Most Common Reasons for Swing-Bed Claims Denials

1. N79/A1 – Service billed is not compatible with patient location information

a. Verify the dates of services are billed correctly. If not, correct claim and resubmit. If yes, proceed to step below.

b. Contact the eligibility worker at the human service zone office (formerly called county social service office) to verify that the living arrangement is long term and covers the dates of service being billed. If updates were needed and completed, refile the claim.

2. N146/16 – Missing screening document

a. Medicaid payment alert form is missing/invalid.

b. Swing-bed level of care (LOC) has not been submitted to Maximus (DDM Ascend).

c. Long-term care span (LTC) does not cover all the days billed on the claim.

d. Day of discharge is not billed on a separate line.

3. M53/N345/16 - Accommodation days are not equal to covered days

a. Verify field locators (FL) 04, 39 and 46 on the UB04 claim form all equal

b. Statement covers period (FL 04) from and through dates

Example: January 1 through January 31 = 31

c. Value code (FL 39) is 80 and the value amount (days)

Example: Value code 80 = 31.00

d. Service units (days in FL 46) on all the detail lines must equal the number of days in the statement covered period and value code amount.

4. M50/MA30/16/8 – Ancillary charges filed with swing-bed taxonomy

a. Ancillary charges that are not included in the swing-bed rate, such as x-ray, lab, drugs, etc., must be billed by the provider furnishing the service.

b. Bill with the acute provider’s NPI and taxonomy number with a bill type of 0131.

5. N538/190 – Service is included in the swing-bed rate

a. The rate established for swing-bed facilities is an all-inclusive rate for routine services. Routine services include supplies, therapies, nursing supplies, equipment, transportation and non-legend drugs. Separate billings for these items will not be paid.

b. Only the room and board charges should be submitted on the claim. Do not enter ancillary charges.

6. B9 – Member elected hospice services

a. North Dakota Medicaid cannot make payment for swing-bed services to the swing-bed provider for a resident who is receiving hospice care.

b. The hospice is paid the swing-bed rate, and the hospice is responsible for payment of the swing-bed services provided to a Medicaid member.

c. Once a member has elected hospice benefits, the swing-bed provider may not submit a claim for services provided while the member is on hospice.

7. M53/16 - Line date of service conflict with discharge status

a. Verify if the member was discharged from the facility. If yes, proceed to step below.

b. Bill the day of discharge on a separate line and count this day as a covered day.

8. M52/16 – Line date of service outside from and through date

a. Verify field locators (FL) 04, 39 and 46 on the UB04 claim form all equal

b. Statement covers period (FL 04) from and through dates

Ex: January 1 through January 31 = 31

c. Value code (FL 39) is 80 value code and the value amount (days)

Ex: Value Code 80 = 31.00

d. Service units (days in FL 46) on all the detail lines must equal the number of days in the statement covered period and value code amount.

Medicaid provider survey results, North Dakota Medicaid announces provider training opportunity

In January 2020, North Dakota Medicaid sent out a brief survey to gather feedback on improving support to Medicaid providers. The questions were targeted towards billing, coding, provider enrollment and claims processing.

Nearly 500 providers completed the survey.

Some common provider survey responses include:

  • More training on proper billing processes to reduce electronic claim denials,
  • More frequent updates by email,
  • Provider enrollment completed within 60 days,
  • Quicker turnaround time on claims, and
  • Quicker turnaround time on prior authorizations.

On June 24, North Dakota Medicaid will hold an in depth training on the North Dakota Health Enterprise Medicaid Management Information System (MMIS) portal. The training will be held from 1 to 3 p.m. CT using Microsoft Teams and by phone at 701-328-0950, Conference ID: 453 899 354#.

Attendees will learn how to:

  • Review claims on the MMIS portal,
  • Submit claims using the MMIS portal,
  • Submit claims if a member has primary insurance,
  • And MORE.

There will also be time for questions and answers towards the end of the training.

In other training news

Over the past eight months, provider relations team members have provided training to Medicaid Call Center representatives on various Medicaid claims and benefits-related topics. They are also working one-on-one with providers to assist with the transition from paper to electronic claims.

Ongoing training will continue to be a priority for North Dakota Medicaid to better serve providers.

Photo credit: ND Tourism

Third party liability reminder

It’s important for providers to understand third party liability, which is commonly referred to as TPL.

By law, Medicaid programs are the payer of last resort. If another insurer or program has the responsibility to pay for medical costs incurred by a Medicaid-eligible individual, that entity is generally required to pay all or part of the cost of the claim prior to Medicaid making any payment. This is known as “third party liability” or TPL.

Third parties that may be liable to pay for services include private health insurance, Medicare, employer-sponsored health insurance, settlements from a liability insurer, workers' compensation, long-term care insurance, and other State and Federal programs (unless specifically excluded by Federal statute). Third party payers are not responsible for reimbursing Medicaid for any services that are not covered under the Medicaid State Plan.

Providers must identify liable third party payers and bill the third party payers before billing North Dakota Medicaid. With few exceptions, North Dakota Medicaid is the payer of last resort.

Providers must collect information about a member’s health care coverage from the member, the member’s representative, the human service zone office, formerly called county social service office, or through the information provided by the Medicaid remittance advice on the Explanation of Benefits.

Providers should get an assignment of benefits from the member to ensure direct payment from the third party payer. For Medicaid purposes, health insurance is defined as any third party benefit that is available to the eligible Medicaid members for medical treatment and related services.

Medicare claims should be billed as follows:

  • If the patient has Medicare Part A, charges for an inpatient stay must be billed entirely on a UB-04 claim form.
  • If the patient has only Medicare Part B and incurs charges during an inpatient stay, the Part B charges must first be submitted to Medicare. The claim should then be submitted to Medicaid on a UB-04 claim form and include all charges for the inpatient stay. The UB-04 claim must include the Medicare Part B payment amount.
  • If the patient receives Medicare Part B services on an outpatient basis, all charges must be billed on a UB-04 claim form.

Any questions regarding TPL can be directed to MedicaidTPL@nd.gov.

Photo credit: ND Tourism

Developmental screenings and brief behavioral assessments for children

North Dakota Medicaid allows billing for current procedural terminology (CPT) 96110 - Developmental screen (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument and CPT 96127- Brief emotional/behavioral assessment [e.g., depression inventory, attention-deficit/hyperactivity disorder (ADHD) scale], with scoring and documentation, per standardized instrument when billed in conjunction with a preventative medicine service, evaluation and management service, or EPSDT service.

Code 96110 should be used to report screening for healthy, physical development (speech and language development, physical growth).

Code 96127 should be used to report a brief assessment for ADHD, depression, suicidal risk, anxiety, substance abuse, eating disorders, etc.

Code 96127 was created in response to the Affordable Care Act’s federal mandate to include mental health services as part of the essential benefits that must be included in all insurance plans offered in individual and small group markets. The mandate covers services such as depression screening for adolescents, alcohol and drug use in adolescents, and behavioral assessments in children and adolescents.

Photo credit: ND Tourism

Billing group enrollment requirements – social security numbers

As part of the enrollment and revalidation process for a billing group, the following types of individuals are required to submit their dates of birth and social security numbers (SSN):

  • Authorized Signer/Managing Employee – This is anyone that has been authorized to sign documents on behalf of the organization.
  • Board of Director/Trustee Members – Board members help influence and vote on decisions that are implemented by an organization.

All state Medicaid agencies are required to follow screening guidelines. This screening requires SSNs and dates of birth for these individuals to prevent fraudulent providers from enrolling or continuing to participate in Medicaid and the Children’s Health Insurance Program.

This information must be provided, along with the SFN 1168 Ownership/Controlling Interest and Conviction Information form, as part of enrollment applications, revalidation applications, reactivation applications, and within 35 days after any changes in ownership.

Reference: 42 C.F.R. § 455.104(b)(1)

Photo Credit: Heather Steffl

Member choice of pharmacy

North Dakota Medicaid does not have a preferred pharmacy, but does require medications to be dispensed from an in-state/border state (ND, MN, SD, or MT) pharmacy whenever possible.

If a member’s preferred in-state pharmacy is able to dispense a medication, such as Humira, Copaxone, Enbrel, etc., prescriptions should be relocated back or sent to the member’s preferred pharmacy.

Some specialty medications are not able to be dispensed from in-state pharmacies due to manufacturer or U.S. Food and Drug Administration restrictions. In these cases, North Dakota Medicaid does not have a preferred out-of-state specialty pharmacy. A prior authorization must be completed to authorize an out-of-state pharmacy to fill these medications.

Click here for out-of-state form, then navigate to the PA Forms tab.

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Primary Care Case Management (PCCM) Program update

Effective May 1, 2020, for North Dakota Medicaid members enrolled in the Primary Care Case Management Program, a primary care provider (PCP) referral will no longer be required for inpatient services provided in a hospital.

North Dakota Medicaid has implemented system changes so that inpatient services provided in a hospital will no longer require a PCP referral. These changes were made to support our members by making navigating the program requirements for inpatient hospital services easier while also decreasing the administrative burden of hospitals and PCP providers.

The department encourages hospitals and members to keep PCP providers informed of inpatient services, so the PCP remains aware of all health concerns the member is dealing with.

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Updates to state forms

The following forms have been updated to remove the social security number field. North Dakota Medicaid providers should use the updated versions immediately.

  • SFN 247 – Minimum Data Set Appeal Request
  • SFN 572 – Health Insurance Questionnaire
  • SFN 991 – Medicaid Payment Alert

Updated Contact Information for Coordinated Services Program

The Coordinated Services Program (CSP) has implemented a new email and phone line.

All questions regarding the CSP from either a provider, member or a human service zone eligibility worker should be directed to the new email address at MedicaidCSP@nd.gov or 701-328-2346.

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North Dakota Medicaid Call Center hours of operation

The North Dakota Medicaid Call Center hours of operation are Monday-Friday from 8 a.m. to 5 p.m. CT.

The call center will be closed on the following dates and times for training. Providers can leave a voicemail and call center representatives will return the call.

  • June 26 from 12:15 to 2:45 p.m. CT
  • July 10 from 12:15 to 2:45 p.m. CT
  • July 17 from 12:15 to 2:45 p.m. CT
  • July 24 from 12:15 to 2:45 p.m. CT
  • Aug. 7 from 12:15 to 2:45 p.m. CT
  • Aug. 14 from 12:15 to 2:45 p.m. CT
  • Aug. 28 from 12:15 to 2:45 p.m. CT
  • Sept. 4 from 12:15 to 2:45 p.m. CT
  • Sept. 18 from 12:15 to 2:45 p.m. CT
  • Sept. 25 from 12:15 to 2:45 p.m. CT
  • Oct. 9 from 12:15 to 2:45 p.m. CT
  • Oct. 16 from 12:15 to 2:45 p.m. CT
  • Oct. 23 from 12:15 to 2:45 p.m. CT
  • Nov. 6 from 12:15 to 2:45 p.m. CT
  • Nov. 13 from 12:15 to 2:45 p.m. CT
  • Nov. 20 from 12:15 to 2:45 p.m. CT
  • Dec. 4 from 12:15 to 2:45 p.m. CT
  • Dec. 11 from 12:15 to 2:45 p.m. CT
  • Dec. 18 from 12:15 to 2:45 p.m. CT

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