This bulletin was updated on Jan. 10, 2022, to include information about nursing homes and home health and on Jan. 11, 2022, to provide better clarity on SMAC reimbursement. Additional information is also found in SPECIAL BULLETIN COVID-19 #215, posted on Jan. 14, 2022. An update on over-the-counter tests for home use is included in SPECIAL BULLETIN COVID-19 #219, posted on Jan. 21, 2022.
Reinstatement of temporary suspension of prior authorization for inpatient rehabilitation hospital and long-term care hospital admissions under NC Medicaid Managed Care
Due to COVID-19 demands on hospitals, and to expedite a hospital’s ability to discharge patients to lower levels of care when medically appropriate, the prior authorization waiver for medically necessary inpatient rehabilitation and long-term care hospital admissions is reinstated from Jan. 10, 2022, to Feb. 14, 2022.
Standard Plans are permitted to require notification of inpatient rehabilitation and long-term care hospital admissions within three calendar days of admission to those facilities in order to facilitate care management and appropriate transitions of care to alternative care settings as clinically appropriate.
The prior authorization waiver also applies to transfers from acute inpatient hospitals to same levels of care, if necessary, to manage COVID-19 surge levels. Standard Plans are permitted to require notification of acute-to-acute facility transfers within three calendar days of transfer/admission. All claims are subject to audit.
Note: Under NC Medicaid Direct currently, prior approval is not required for an acute inpatient hospital or long-term care hospital admission.
Reinstatement of temporary suspension of prior authorizations for new nursing home admissions being directly discharged from a hospital
Due to the COVID-19 demands on hospitals and to expedite a hospital’s ability to discharge patients to lower levels of care when medically appropriate, the prior authorization (PA) waiver for medically necessary new admissions who are being directly discharged from a hospital setting into a nursing home (NH) is reinstated from Jan. 10, 2022, to Feb. 14, 2022.
The PA waiver applies to members receiving services under both NC Medicaid Direct and NC Medicaid Managed Care Standard Plans. Standard Plans are permitted to require notification within three calendar days of skilled nursing facility admissions to facilitate care management and transitions to other care settings as clinically appropriate.
If the individual is expected to remain in the nursing facility past Feb. 14, 2022, the admitting nursing facility is responsible for verifying long-term care Medicaid eligibility with the local Department of Social Services (DSS) and following the prior approval requirements noted in NH Clinical Policy 2B-1. The date on the FL2 form for NC Medicaid Direct beneficiaries should be the NH admission date. All claims are subject to audit.
Home Health Skilled Nursing Visits Reminder: Prior authorization is not required prior to discharge from the hospital.
Due to the COVID-19 PHE and to expedite a hospital’s ability to discharge patients to a lower level of care when medically appropriate, NC Medicaid beneficiaries who would require medically necessary home health skilled nursing visits post-hospitalization do not require prior authorization. This applies to members receiving services under both NC Medicaid Direct and the NC Medicaid Managed Care Standard Plans. Standard Plans are permitted to require notification within three calendar days of home health admission to facilitate care management and care transitions. Home health providers can begin services with verbal orders from the physician or as per CMS Interim Final Rule 42 CFR 440.70, licensed practitioners, as defined by CMS. See SPECIAL BULLETIN COVID-19 #72: Additional Home Health Clinical Coverage Policy Provisions for more information.
Swing Beds
Reminder: NC Medicaid implemented a targeted enhanced swing bed reimbursement rate to provide additional financial support to hospitals and to allow flexibility in bed utilization, which remains in effect. Please refer to SPECIAL BULLETIN COVID-19 #115: Targeted Rate Increase and Associated Requirements for Swing Bed Services for details about the rate increase and associated requirements.
Remdesivir Ambulatory Infusion
Remdesivir Injection, for Intravenous use (Veklury®) HCPCS code J0248 - Injection, remdesivir, 1 mg: Billing Guidelines
The National institute of Health (NIH) Panel recommends using remdesivir in patients age ≥12 years and weighing ≥40 kg for non-hospitalized patients with mild to moderate COVID-19 who are at high risk of disease progression.
Medicaid and NC Health Choice will follow the NIH recommendations to allow the use of Remdesivir in outpatient hospitals/clinic settings for clinically appropriate cases. Effective with date of service Jan. 10, 2022 the Medicaid and NC Health Choice programs cover remdesivir injection, for intravenous use (Veklury®) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J0248 - Injection, remdesivir, 1 mg.
Recommended Dose:
Single loading dose of 200 mg on Day 1 followed by once-daily maintenance doses of 100 mg on Days 2 and 3, initiated as soon as possible and within seven days of symptom onset
Strength/Package Size(s):
- For injection: 100 mg of remdesivir as a lyophilized powder, in a single-dose vial.
- Injection: 100 mg/20 mL (5 mg/mL) remdesivir, in a single-dose vial.
For Medicaid and NC Health Choice Billing:
- The ICD-10-CM diagnosis codes required for billing are:
- U07.1 - COVID-19
- Use additional code to identify pneumonia or other manifestations:
- B34.2 - Coronavirus infection, unspecified;
- B97.21 - SARS-associated coronavirus as the cause of diseases classified elsewhere
- Providers must bill with HCPCS code: J0248 - Injection, remdesivir, 1 mg
- One Medicaid and Health Choice unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $5.62
- Standard IV infusion administration reimbursement rates will be applied
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs is/are:
- Veklury 100 mg vial: 61958-2901-02
- Remdesivir 100 mg vial: 61958-2901-01
- Remdesivir 100 mg/20 mL vial: 61958-2902-01
- The NDC units should be reported as "UN1"
- The fee schedule for the PADP is available on DHB's PADP web page.
COVID-19 Vaccine Counseling
NC Medicaid remains committed to creating opportunities for beneficiaries to receive the COVID-19 vaccine and for providers to assist in overcoming misinformation and vaccine hesitancy. To that end, we continue to reimburse for the COVID-19 vaccine counseling code, 99401, as well as outreach. Please refer to Special Bulletin COVID-19 #192: Vaccination Outreach Code Reimbursement for more details. Because this code is being used for the unique purpose of COVID-19 vaccine counseling with the modifier CR, original CPT code limitations such as nights and weekends do not apply for the express use of this code for COVID-19 vaccine counseling.
Please follow the below guidance on modifiers to use with 99401:
- Requires CR if provided in person
- Requires CR and GT modifiers if provided via telehealth
- Requires CR and KX modifiers if provided telephonically
- Requires CR and HM modifiers if provided by office staff phoning unvaccinated members on their patient list.
COVID-19 Vaccine Administration Reimbursement
NC Medicaid is increasing the reimbursement for COVID vaccine administration from $40 to $65. The effective date of the rate change will be retroactive to April 1, 2021. All claims previously submitted with dates of service from April 1, 2021 through the NCTracks implementation date of the rate change will be systematically reprocessed. No action will be required by providers to receive the retroactive rate increase. NC Medicaid recognizes the importance of trusted health care professionals in the provision of COVID-19 vaccine and the added burden in staffing costs, supplies, and workforce required to provide this critical service in these unprecedented times. Medicaid beneficiaries are vaccinated at a rate far below that of other populations and NC Medicaid is committed to supporting Medicaid providers in being reliable, trusted partners.
Over-the-Counter COVID-19 Tests for Home Use
NOTE: An update on over-the-counter tests for home use is included in SPECIAL BULLETIN COVID-19 #219, posted on Jan. 21, 2022.
Effective Jan. 10, 2022, NC Medicaid-enrolled pharmacies may bill for FDA approved over-the-counter (OTC) COVID-19 tests dispensed for use by NC Medicaid beneficiaries in a home setting, with or without a prescription issued by a NC Medicaid-enrolled provider. NC Medicaid Direct beneficiary implementation date is Jan. 10, 2022. Refer to beneficiaries’ managed care plan for guidance on the specific plan’s implementation date.
NC Medicaid will cover one kit per claim per date of service, with a maximum of four test kits every 30 days. Covered test kits are listed below. Please note that some kits will include two tests.
Pharmacists must submit the enrolled pharmacy’s NPI number on the claim unless prescribed by a provider.
Pharmacies must follow the NCPDP standard and use the NDC found on the package. Pharmacies will be reimbursed at State Maximum Allowable Cost (SMAC) per kit, specific to the NDC. Copayment will not apply.
|
Test Name |
NDC |
# Tests in Kit |
Billing Unit |
SMAC |
|
Quickvue At-Home Covid-19 Test |
14613033972 |
2 |
2 |
$14.50/test; $29.00/ kit |
|
Inteliswab Covid-19 Rapid Test |
08337000158 |
2 |
2 |
$14.50/test; $29.00/kit |
|
IHEALTH Covid-19 AG Rapid Test |
56362000589 |
2 |
2 |
$10.50/test; $21.00/kit |
|
Flowflex Covid-19 AG Home Test |
82607066027 |
2 |
2 |
$12.49/test; $24.98/kit |
|
Flowflex Covid-19 AG Home Test |
82607066026 |
1 |
1 |
$14.99/test; $14.99/kit |
|
Ellume Covid-19 Home Test |
56964000000 |
2 |
2 |
$18.77/test; $37.54/kit |
|
Carestart Covid-19 AG Home Test |
50010022431 |
2 |
2 |
$16.23/test; $32.46/kit |
|
Binaxnow Covid-19 AG Self Test |
11877001140 |
2 |
2 |
$13.83/test; $27.66/kit |
|
Pixel Covid-19 Home Collection Kit |
00042022224 |
1 |
1 |
$129.99/test; $129.99/kit |
|
Lucira Check-It Covid-19 Test |
10055097004 |
1 |
1 |
$80.00/test; $80.00/kit |
|
Everlywell Covid-19 Home Collection Kit |
51044000842 |
1 |
1 |
$114.00/test; $114.00/kit |
CONTACT:
NC Medicaid Contact Center: 888-245-0179