Attention: All Providers Service Limits Available Nov 1 in Eligibility Verification Response

Beginning November 1, 2015, DMA service limit data will be more readily available to providers. NCTracks will provide used and available service limit amounts on the eligibility verification response for the Automated Voice Response System (AVRS), the NCTracks secure Provider Portal, and the 270/271 X12 transaction for services used in the current fiscal year.

This new enhancement will allow providers to access the service limit amounts for the following services: Skilled Nursing visits, Home Health Aide visits and procedure code T1999 (Miscellaneous therapeutic items and supplies, retail purchases, not otherwise classified).

Procedure code T1999 will have new limitations applied beginning November 1, 2015. Providers should refer to the NCTracks announcement and the DMA Clinical Coverage Policy 3A, Home Health Services for additional information, which can be found on the DMA website.

Note: If an eligibility verification response does not return service limit data, it indicates that within the current fiscal year July 1-June 30, services with limits have not been used or claims with services limits have not been paid at the time of the inquiry.

Important: Accumulation of service amounts

Also beginning November 1, NCTracks will post a “pay and report” edit to the paper Remittance Advice (RA) every time a service subject to limitations is paid. The edits posted are the same ones currently used to indicate that the service limit has been exceeded. However, instead of posting only when the service limit is exceeded, the edits will now post every time a service subject to limitations is adjudicated, whether paid or denied. To determine whether the edit has posted as “pay and report” or a denial, the provider will need to check the paid amount for that claim line item. The edits affected are:

Edit 44890 - EXCDS LMT FOR MANDATORY SRV FY (EOB 09825 - EXCEEDS LEGISLATIVE LIMITS FOR PROVIDER VISITS FOR FISCAL YEAR)

Edit 44900 - EXCDS LMT FOR OPTIONAL SRV FY (EOB 09825 - EXCEEDS LEGISLATIVE LIMITS FOR PROVIDER VISITS FOR FISCAL YEAR)

Edit 55100 - HHPA REQD T1999 > $250 IN SFY (EOB 55100 - HOME HEALTH PA REQUIRED FOR T1999 WITH ACCUMULATED SERVICES GREATER THAN $250 WITHIN THE SFY. PLEASE REQUEST HOME HEALTH PA.)

Edit 55110 - SVCS FOR T1999 > $1500 IN SFY (EOB 55110 - EXCEEDS $1500 MAXIMUM LIMITATION ALLOWED PER STATE FISCAL YEAR)

Edit 54810 - FISCAL YEAR LIMIT (EOB 02476 - SERVICE DENIED. EXCEEDS THE LIMITATION OF UNITS ALLOWED PER STATE FISCAL YEAR)

Edit 53150 - UNIT LIMITATION EXCEEDED FOR SFY (EOB 02476 - SERVICE DENIED. EXCEEDS THE LIMITATION OF UNITS ALLOWED PER STATE FISCAL YEAR)

 

271 Health Care Eligibility Benefit Response: A number of segments in the 271 Health Care Eligibility Benefit Response, Loop 2110C, will be used for service limits. Trading Partners should refer to the 270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide on the Trading Partner Information page of the NCTracks Provider Portal for additional information on service limits.

Note: T1999 services will be measured in dollars while Home Health Aide or Skilled Nurse services will continue to be measured in visits.