New Edit for Individual Practitioners Claims Billed Outside Nursing Facility Per Diem

On May 3, 2015, a new edit will be implemented in NCTracks to deny payment for certain supplies and equipment billed by individual practitioners when the Medicaid recipient is a resident in a Skilled Nursing Facility. The cost for these supplies and equipment is considered to be included in the Nursing Facility per diem paid to the facility. Nursing Facility services included in the per diem rate that is reimbursed to the facility may not be reimbursed to an individual practitioner for dates of service that a recipient is residing in a Nursing Facility.

See Section 5.4.1. and Attachment B of Clinical Policy No 2B-1 for Nursing Facilities for a list of services included in the per diem rate that is reimbursed to a Nursing Facility. The policy can be found on the N.C. Division of Medical Assistance (DMA) Clinical Coverage Policy webpage at http://www.ncdhhs.gov/dma/mp/index.htm.

The new edit will affect claims submitted to NCTracks on or after May 3, regardless of dates of service. A new explanation of benefits (EOB) 01792 - MEDICAL SUPPLIES/EQUIPMENT ARE INCLUDED IN THE NURSING FACILITY PER DIEM PACKAGE will post to the paper Remittance Advice (RA) for claim details that fail the edit.