This bulletin applies to NC Medicaid Managed Care and NC Medicaid Direct.
Drug Codes and Applicable Fee Schedule Rates:
Effective Feb. 3, 2025, unless communicated otherwise by the Department, drug codes and rates previously listed on the Medicaid fee schedules listed below will be removed and shall be reimbursed at the applicable drug code rate listed on the Physician Administered Drug Program (PADP) fee schedule. NCTracks FFS reimbursement is not affected by this change. Health plans will have 45 days from Feb. 3, 2025, to revise the fee schedules listed below to reflect this change.
Fee Schedules Affected by this Change:
- Physician Services
- Physician Assistants
- Nurse Practitioners
- Nurse Midwives
- Clinical Pharmacist Practitioner
"To be eligible to bill for procedures, products, and services related to this policy, providers shall
a. meet Medicaid qualifications for participation;
b. be currently Medicaid - enrolled; and
c. bill only for procedures, products, and services that are within the scope of their clinical practice, as defined by the appropriate licensing entity."
Fee Schedules Exempted from this Change:
The Local Health Department (LHD) fee schedule will continue to reflect applicable drug codes and rates.
Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) drug reimbursement shall continue to follow the State Plan reimbursement methodology. Drug codes reimbursed separately will be listed on their respective fee schedules including the rate. Drug codes that are included in the PPS APM reimbursement will be listed on the fee schedule to indicate coverage only, excluding a rate.
Contact
Medicaid.Provderreimbursement@dhhs.nc.gov