General Notice of Reprocessing Reprocessing Notice for Evaluation and Management Code Claims Due to Rate Change

Please note that this is a generl notice of reprocessing. You may or may not have affected claims.

 

This reprocessing notice applies to claims with dates of service between Jan. 1, 2019 and Sept. 3, 2019, paid to primary care physicians, nurse practitioners and physician assistants submitted with Evaluation and Management (E & M) codes ranging from 99201 to 99499 and the corresponding taxonomies as defined in Section 1202 of the Affordable Care Act (ACA). In addition to the ACA primary care practitioners, obstetricians and gynecologists will also be included as primary care physicians. The revised rates and taxonomies can be found on the NC Medicaid website located at:  https://medicaid.ncdhhs.gov/fee-schedule/em-codes-fee-schedules.

 Issue: CMS approved a rate increase effective Jan. 1, 2019 for E & M Codes. As a result, claims submitted with dates of service between Jan. 1, 2019 and Sept. 3, 2019, have been identified as underpaid.

Action: The affected claims will be systematically reprocessed as adjustments to apply the rate increase. Please refer to the June 2019 Special Medicaid Bulletin. E & M procedure codes that did not receive an increase are still under review based on the State Plan Amendment criteria to ensure rate increase consideration. No provider action is required. 

Timing: Claims will be reprocessed in the Sept. 24, 2019 checkwrite.

Remittance Advice: Reprocessed claims will be displayed in a separate section of the paper Remittance Advice with the unique Explanation of Benefits (EOB) code 10307 – CLAIM REPROCESSED AS A RESULT OF THE CMS APPROVED E & M CODE RATE INCREASE EFFECTIVE 01-01-2019. The 835 electronic transactions will include the reprocessed claims along with other claims submitted for the checkwrite. (There is no separate 835.)

Important Reprocessing Information: Reprocessing does not guarantee payment of claims. Affected claims will be reprocessed. While some edits may be bypassed as part of the claim reprocessing, changes made to the system since the claims were originally adjudicated may apply to the reprocessed claims. Therefore, the reprocessed claims could deny.

If the reprocessed claim denies and there are not sufficient funds to satisfy the full recoupment amount from claims paid in the current checkwrite, an Accounts Receivable (AR) will be created. Recoupment of the AR will begin with the subsequent NCTracks checkwrite and will continue on each checkwrite until the full amount due is recouped.

If funds are insufficient to collect the full amount due from the NPI for which the AR was generated, NCTracks will automatically seek to recoup the AR from other NPIs with the same Internal Revenue Service Taxpayer Identification Number. For more information about the AR process, see the Feb. 29, 2016 announcement.