This bulletin provides updates on NC Medicaid programs that received legislative increases to service rates in the Current Operations Appropriations Act of 2023 (SL 2023-134) and in SL 2023-129, respectively. The information in this bulletin applies to both NC Medicaid Direct and NC Medicaid Managed Care.
Durable Medical Equipment (DME)
Effective Nov. 1, 2023, NC Medicaid Direct and NC Medicaid Managed Care will apply rate increases to the following select group of DME codes to be reimbursed Nov. 1, 2023, through June 30, 2024:
A7520, A7521, A4623, B4158, B4160, T4544, T4543, A4351, K0005, K0861, E1007, E1161, K0739
The selected codes and the rate increase that will be applied to the codes were proposed to NC Medicaid by the Atlantic Coast Equipment Services Association (ACMESA) representing DME industry providers and mutually agreed upon in consideration of the appropriations awarded in Section 9E.13B of SL 2023-134, HB 259 by the General Assembly.
The revised rates relevant to the DME codes above can be found in the NC Medicaid Fee Schedule and Covered Code Portal. NC Medicaid is in the process of revising the DME published fee schedule to reflect the rate changes.
Ambulatory Surgical Centers (ASC) Dental Surgery -CPT G0330
Effective Oct. 4, 2023, NC Medicaid Direct will reimburse Ambulatory Surgical Centers for services billed under procedure code G0330 at $1,636.31, equivalent to 95% of the total payment rate listed on the Medicare Part B Hospital Outpatient Prospective Payment System (OPPS) in effect as of Jan. 1, 2023. Regardless of the amount of time required to complete the service, providers will be reimbursed the published fee schedule flat rate for procedure code G0330.
Due to the delay in the release of the final 2023 budget, NC Medicaid was not able to meet the Center for Medicare and Medicaid Services (CMS) state plan amendment (SPA) submission deadline required to preserve the authority for the July 1, 2023, effective date stated in S.L. 2023-129. The rate increase is being made effective on the earliest possible date, given CMS requirements and operational requirements for system implementation. Starting Jan. 1, 2024, and each year thereafter, rates will be updated annually to be 95% of the Medicare Part B OPPS payment rate in effect as of January 1.
The revised ASC rate can be found in the NC Medicaid Fee Schedule and Covered Code Portal. As Ambulatory Surgical Centers (ASC) Dental Surgery codes are not subject to the rate floor requirements in NC Medicaid Managed Care, the Standard Plans will not be required to make these fee schedule adjustments, NC Medicaid is in the process of revising the published fee schedule to reflect the rate changes described above.
NC Medicaid Direct: Retroactive Dates of Service Claims That Require Reprocessing
For each legislated rate increase listed above, NC Medicaid Direct will systematically reprocess all claims with dates of service occurring between the retroactive effective date and the actual NCTracks rate implementation date for all affected programs. NC Medicaid Direct will provide additional communication to advise affected providers once more detail is known regarding reprocessing schedules.
NC Medicaid Managed Care: Standard Plan Prepaid Health Plans (PHP) Rates
NC Medicaid Managed Care Standard Plan are required by contract to adjust provider reimbursement rates for the Durable Medical Equipment (DME) codes described above . To reflect the changes noted in this bulletin, PHPs are required to adjust rates for services covered in their plans within 45 days of the fee schedule update and reprocess all affected claims within 30 days after the fee schedule update is implemented. The revised fee schedule was posted on Nov. 9. 2023.
NCTracks Contact Center: 800-688-6696
Standard Plan contact information is available on the NC Medicaid Health Plan Contacts and Resources webpage.