Author Topic: NC medicaid  (Read 2262 times)

lsw

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NC medicaid
« on: September 29, 2009, 02:06:21 PM »
Hi, I have a questions that concerns billing for a LPC to NC medicaid. If the patient is Carolina Access you use the referring CA PCP for the referring doctor but if the patient is not CA, just straight medicaid, you have to use a CA participating psychiatrist or LME for a referral These charges were incurred without getting a referral. There is not a CA participating psychiatrist in Western NC to use and the LME will not do a retroactive referal. Is there any way to get these claims paid? 

PMRNC

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Re: NC medicaid
« Reply #1 on: September 29, 2009, 03:38:38 PM »
I think your S.O.L since their plan type is managed care and requires authorization. The patient could have sought PRIOR approval before the visit for an OON referral which may have been granted, but if it's after the fact, I think you are out of luck.
Linda Walker
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Pay_My_Claims

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Re: NC medicaid
« Reply #2 on: September 29, 2009, 10:47:56 PM »
Hi, I have a questions that concerns billing for a LPC to NC medicaid. If the patient is Carolina Access you use the referring CA PCP for the referring doctor but if the patient is not CA, just straight medicaid, you have to use a CA participating psychiatrist or LME for a referral These charges were incurred without getting a referral. There is not a CA participating psychiatrist in Western NC to use and the LME will not do a retroactive referal. Is there any way to get these claims paid? 

I'm confused by your post. I live in NC and bill NC medicaid. You said if they are NOT CA (carolina access) you have to use a CA participating psychiatrist or LME for a referral?? Why if they are straight Medicaid??

For outpatient behavioral health visits they must have a referal from their CA PCP. a LME or a MEDICAID enrolled psychiatrist prior to the first visit.  If they are straight Medicaid then they would need a ref from a Medicaid enrolled psychiatrist.

http://www.ncdhhs.gov/dma/mp/8A.pdf

If I am misunderstanding something, please inform me.

PMRNC

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Re: NC medicaid
« Reply #3 on: September 30, 2009, 06:14:26 AM »
I'm a tad confused unless this provider pars with CA but not Medicaid...but it might still be Moot

Quote
but if the patient is not CA, just straight medicaid, you have to use a CA participating psychiatrist or LME for a referral These charges were incurred without getting a referral.

In most states Medicaid requires pre-authorization, if there are NO other Medicaid providers in a given area they may give a pre-approval but it has to be done BEFORE the visit as they won't give retro referals/Auths
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

rachel

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Re: NC medicaid
« Reply #4 on: September 30, 2009, 08:48:35 AM »
I am not sure if your situation would qualify but I was advised that there is a way to override and get a claim submitted. You go to the DMA website under Providers, then to Community Care of NC, in the list is the CA Override Request, fill out and fax.  I personally have not utilized this form so I have no other info to provide...sorry...good luck...Let me know how it works out!  Hope this helps!

Pay_My_Claims

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Re: NC medicaid
« Reply #5 on: September 30, 2009, 02:26:02 PM »
I'm a tad confused unless this provider pars with CA but not Medicaid...but it might still be Moot

Quote
but if the patient is not CA, just straight medicaid, you have to use a CA participating psychiatrist or LME for a referral These charges were incurred without getting a referral.

In most states Medicaid requires pre-authorization, if there are NO other Medicaid providers in a given area they may give a pre-approval but it has to be done BEFORE the visit as they won't give retro referals/Auths

there is a difference between a CA Medicaid Provider and a Medicaid Provider. You can enroll in the NC Medicaid program, and you can also become a CA Provider...which means you are a NC Medicaid Provider but also CA (carolina access). You can't part with Carolina Access unless you are a NC Medicaid provider. thats impossible.

Pay_My_Claims

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Re: NC medicaid
« Reply #6 on: September 30, 2009, 02:28:36 PM »
I am not sure if your situation would qualify but I was advised that there is a way to override and get a claim submitted. You go to the DMA website under Providers, then to Community Care of NC, in the list is the CA Override Request, fill out and fax.  I personally have not utilized this form so I have no other info to provide...sorry...good luck...Let me know how it works out!  Hope this helps!

YES you can get a CA override, but that is generally in situations where the patient needs emergent care and or the PCP refuses to give you the CA# because of some bogus reasons. If the patient never saw his PCP or wasn't referred by a NC Medicaid Provider prior to this visit. they are more than likely SOL, but it can never hurt to try to get the override.