New Claims Editing for Validation for Out of State Unique Product Providers

Certain out-of-state Durable Medical Equipment (DME), Orthotics and Prosthetics (O&P), and Auditory Implant Parts providers are enrolled in NCTracks to provide unique products that are not available from in-state providers. The products (and associated HCPCS codes) that each out-of-state provider is authorized to provide are determined at the time of enrollment.

Effective May 3, 2015, new NCTracks claims editing validates the requesting and billing providers’ enrollment and authorization to bill and be paid for specific procedure codes. Claims submitted for these procedure codes by an unauthorized provider will deny at the detail level with explanation of benefits (EOB) 00426 – PROCEDURE CODE INVALID FOR BILLING PROVIDER. Additionally,if an authorized out-of-state provider bills a procedure code not identified at enrollment, the claim detail will deny with EOB 01732 – BILLING PROVIDER NOT ALLOWED TO SUBMIT CLAIMS FOR THIS PROCEDURE CODE.

This additional claims editing will ensure services are provided in accordance with existing N.C. Division of Medical Assistance (DMA) Clinical Coverage Policy for DME, O&P, and Auditory Implant External Parts providers.