Author: GDIT, (800) 688-6696
NC Medicaid will reprocess claims with dates of service between Jan. 1, 2019 and Sept. 3, 2019, paid to primary care physicians, nurse practitioners and physician assistants submitted with E&M codes ranging from 99201 to 99499 and the corresponding taxonomies as defined in Section 1202 of the Affordable Care Act (ACA). In addition to the ACA primary care practitioners, obstetricians and gynecologists will also be included as primary care physicians.
The Centers for Medicare and Medicaid Services (CMS) approved a rate increase effective Jan. 1, 2019 for E&M Codes. As a result, claims submitted with dates of service between Jan. 1, 2019 and Sept. 3, 2019, have been identified as underpaid.
The affected claims will be systematically reprocessed as adjustments to apply the rate increase. Please refer to the June 2019 Special Medicaid Bulletin. E&M procedure codes that did not receive an increase are still under review based on the SPA criteria to ensure rate increase consideration. Additional information will be communicated through future Medicaid Bulletin when it is available. No provider action is required.
Claims will be reprocessed in the Sept. 24, 2019 checkwrite. Reprocessed claims will be displayed in a separate section of the paper Remittance Advice with the unique Explanation of Benefits (EOB) code 10307 – CLAIM REPROCESSED AS A RESULT OF THE CMS APPROVED E&M CODE RATE INCREASE EFFECTIVE 01-01-2019. The 835 electronic transactions will include the reprocessed claims along with other claims submitted for the checkwrite. (There is no separate 835.)