Feedback Wanted – Manage Change Request Processing
The North Carolina Division of Medical Assistance (DMA) and Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) are seeking feedback on Manage Change Request (MCR) processing.
If you have submitted a MCR anytime in the last year that took longer than three weeks to process, or is still outstanding, please contact us. Send the following information to firstname.lastname@example.org:
- Provider Name
- Date of MCR Submission
- MCR ID#
- MCR Description
- Status (approved, denied, in review, unable to submit)
Thank you for your assistance!
Prior Authorization Required – Trauma Focused Cognitive Behavioral Therapy Codes
Please note that the following Trauma Focused Cognitive Behavioral Therapy codes require prior authorization.
90837Z1: Psychotherapy Trauma Focused 60 minutes — This code can be authorized in 90-day increments for up to 13 units:
The following codes can be authorized in 90-day increments for up to 13 units combined:
- 90846ZI: Family Therapy without Patient Trauma-Focused
- 90847Z1: Family Therapy with Patient Trauma-Focused
There are no unmanaged visits for any of the codes listed above. Claims will deny if you have not requested and received an authorization.
It seems the communication about prior authorization being required was not widely distributed. This led to several denied claims.
Given that issue, Partners wants to assist providers with denied claims currently in the system:
- Utilization Management staff will enter authorizations in the system to cover the Dates of Service through March 31, 2017. These authorizations will have an end date of March 31, 2017.
- Once the authorizations are entered, Partners Claims Department will re-adjudicate the denied claims for Dates of Service through March 31, 2017.
Providers should start submitting service authorization requests for these codes that have a start date of April 1, 2017 as soon as possible. UM cannot honor any retro-authorizations requests for dates of service beginning April 1, 2017.
If you have questions, please contact Lynne Grey, Utilization Management Manager, at email@example.com.
Program Integrity –Billing Requirements
Partners is committed to protecting taxpayer and trust fund dollars, while also protecting the consumer’s access to care. It is important that program integrity efforts extend beyond dollars and health care costs alone. It is fundamentally about protecting the beneficiaries and ensuring we have the resources to provide for their care.
The goal of Partners Program Integrity Department is to correct behaviors in need of change and prevent future inappropriate billing. It is our priority to minimize potential future losses to the Medicaid and State Trust Fund through targeted claims reviews while using resources efficiently and treating providers and consumers fairly. Please review the following information to ensure that you are properly billing for services delivered.
Clinical Coverage Policy 8C: Coordination of Benefits, states that “Any provider who serves dually eligible beneficiaries (i.e., Medicaid and Medicare or other insurance carriers) shall be enrolled as a participating provider with each of the identified insurance carriers in order to be reimbursed.”
Partners BHM Claims Adjudication Policy states that “Claims with Coordination of Benefits (COB) should be submitted within 180 days of service and include the COB information on the claim.” If the consumer is currently enrolled in the Partners AlphaMCS system and obtains third party coverage, or the provider is made aware of other third party coverage, it is the provider’s responsibility to ensure this information is added to the system.
On March 28, 2003, the US Department of Health and Human Services and the Centers for Medicare and Medicaid Services released Program Memorandum Intermediaries/Carriers Transmittal AB-03-037 Subject: Provider Education Article: Medicare Payments for Part B Mental Health Services, which states: “Medicare recognizes the following providers who are eligible under Part B to furnish diagnostic and/or therapeutic treatment for mental, psychoneurotic, and personality disorders. Those professionals are as follows:
- Physicians (MD) and Doctors of Osteopathy (DO); particularly
- Clinical Psychologist (CP);
- Clinical Social Workers (CSW);
- Clinical Nurse Specialists (CNS);
- Nurse Practitioners (NP);
- Physician Assistants (PA);
- Certified Nurse-Midwives (CNM) and
- Independently Practicing Psychologist (IPP).
All services provided to Medicare patients must be furnished by practitioners who by virtue of their specific State licensure certification and training are professionally qualified to provide medically necessary services; and who are impaneled with Medicare, have the right to bill directly and collect and retain the fee for their services.”
If you have questions, please contact Partners’ Program Integrity Department by email at ProgramIntegrity@partnersbhm.org, or call 1-877-864-1454 and ask to speak to a member of the Program Integrity Department.