Dec 2015 Reprocessing of Claims Subject to 3 Pct Rate Reduction

North Carolina Session Law 2013-360, subsequently modified by Session Law 2014-100, required a 3% rate reduction in 10 Medicaid and N.C. Health Choice services. The 3% rate reduction for physician services was implemented March 1, 2015, for current claims and going forward. The rate reduction was applied to the majority of previously paid claims over multiple checkwrites earlier this year.

For more information, see the April 2015 Special Medicaid Bulletin.

However, some claims reprocessed during this time did not result in the repayment of the rate reduction, due to various claim adjudication edits posting during the reprocessing. Therefore, a reprocessing of these claims to apply the 3% rate reduction has occurred and was reflected in the December 15 checkwrite. An email was sent to affected providers.

The reprocessing was accomplished by voiding the original claim (recouping the original paid amount) and submitting a new claim, to which the reduced rate would apply. In some cases, the new claim denied for other reasons. Changes made to the system that were effective with date of processing apply to reprocessed claims, regardless of the date of service.

Claims reprocessed in the December 15 checkwrite appear in a separate section of the paper Remittance Advice (RA). The voided original claim has a unique Explanation of Benefits (EOB) code: 06017 – Reprocessed for 3% Reduced Physician Rate. Reprocessed claims that denied reflect the specific denial EOB. Providers whose reprocessed claims denied will need to correct any issues on the reprocessed claim and rebill the claim to NCTracks.