Medicaid Bulletin

In response to provider requests and to align more closely with Medicare coverage for Independent Diagnostic Testing Facilities (IDTF), effective June 1, 2019, NC Medicaid will add coverage for additional procedure codes outlined in the attached document.

Health Management System is under contract with North Carolina Medicaid as NC Medicaid’s Recovery Audit II Contractor, pursuant to Section 6411 of the Patient Protection and Affordable Care Act of 2010.

The Food and Drug Administration (FDA) previously approved a Risk Evaluation and Mitigation Strategies (REMS) for Mifeprex (mifepristone) to mitigate the risk of serious adverse events. After reviewing the supplemental application, the FDA determined that a REMS is necessary to ensure the safe use of Mifeprex.

This communication serves as an advisory notice for all Providers. The intent is to increase awareness of the Medicare Advantage Plan. The statement below should be used to gain further clarification regarding claims denied for Medicare Part C coverage.           

Effective March 1, 2019, the North Carolina Medicaid and NC Health Choice programs cover dexamethasone intraocular suspension 9%, for intraocular administration (Dexycu) for use in the Physician Administered Drug Program when billed with HCPCS code J1095 - Injection, dexamethasone 9%, intraocular, 1 microgram.

North Carolina’s Department of Health and Human Services, Division of Health Benefits (DHB) has contracted with Health Management Systems (HMS) to conduct Overpayment Recovery Reviews for Medicaid/Health Choice recipients.

NC Medicaid has adopted the American Medical Association's new Current Procedural Terminology® (CPT) Category I codes for Research Based Behavioral Health Treatment, effective for dates of service on or after Jan. 1, 2019.

Psychiatric collaborative care management services must be rendered under the direction of a treating physician or non-physician practitioner, typically in a primary care setting.  These services are rendered when a beneficiary has a diagnosed psychiatric disorder and requires assessment, care planning and provision of brief interventions. 

New or amended clinical coverage policies are available on Telemedicine and Telepsychiatry, Outpatient Specialized Therapies and Bone Mass Measurement 

Bone Mass Measurement policy has been updated to reflect the addition of anorexia nervosa as an approved diagnosis for beneficiaries with other conditions or currently receiving medical therapies known to cause low bone mass.