NCTracks Coming Attractions Reminder Updates to the NCTracks System Arriving this Sunday

NCTracks System Updates are arriving this Sunday, July 29, 2018! Get the run down on the new NCTracks features and policies below.

Taxonomy for Clinical Pharmacist Practitioner Added to NCTracks

Effective July 29, 2018, Clinical Pharmacist Practitioner (CPP) taxonomy code 1835P0018X will be added to allow in-state, border, and out-of-state individual Medicaid/Health Choice providers to enroll in NCTracks. CPPs will be authorized to act as an ordering, prescribing, referring (OPR) and/or rendering provider working under the direction or supervision of a licensed physician. Therefore, CPPs must complete the individual application (full enrollment) to bill for services rendered instead of the OPR Lite abbreviated application. 

Required licensure and certification for the CPP taxonomy are:

  • Full and unrestricted license to practice as a pharmacist in North Carolina or the state in which the provider resides
  • Full and unrestricted certificate to practice as a CPP in North Carolina

Out-of-state providers must be certified to practice as a CPP according to the rules of the state in which they practice.

The following enrollment requirements will apply:

  • $100 application fee
  • Credentialing and criminal background checks
  • Re-credentialing every five years
  • Manage Change Request (MCR) submission to update or end date the provider record

Note: The NPI Exemption List deadline is August 31, 2018. CPPs are encouraged to begin the enrollment process on July 30, 2018.

Per 21 N.C.A.C. 46.3101, a CPP is approved to provide drug therapy management, including controlled substances, under the direction or supervision of a licensed physician only.

If a claim is submitted with a CPP's NPI and taxonomy as the billing provider, the claim will be denied with Explanation of Benefits (EOB) 01877 - PROVIDER IS NOT AUTHORIZED TO ACT AS A BILLING PROVIDER.

 

Additional Procedure Code Covered for Balloon Sinus Ostial Dilation (BOD)

As previously announced, new coverage was added for the following BOD procedures effective February 1, 2018:

  • CPT 31295 - Nasal/sinus endoscopy, surgical, with dilation of maxillary sinus ostium, e.g. Balloon dilation, transnasal or via canine fossa,
  • CPT 31296 - Nasal/sinus endoscopy, surgical, with dilation of frontal sinus ostium, and
  • CPT 31297 - Nasal/sinusendoscopy, surgical, with dilation of sphenoid sinus ostium.

Effective July 29, 2018, CPT 31298 - Nasal/sinus endoscopy, surgical, with dilation of frontal and sphenoid sinus ostia (e.g., balloon dilation) will also be added to BOD coverage.

These procedures will be covered in:

  • Inpatient hospitals
  • Outpatient hospitals
  • Ambulatory surgical centers
  • Office settings

For more information, providers should refer to Clinical Coverage Policy 1A-42, Balloon Ostial Dilation.

With prior approval, Medicaid will pay each code one time, per side, in the recipient lifetime. Because of this limitation, it will be necessary that the provider indicate whether the service is being performed unilaterally or bilaterally by using modifier -LT (left), -RT (right), or -50 (bilateral).

Claim details submitted without the required modifier will be automatically denied with EOB 02011 - BALLOON OSTIAL DILATION SERVICE REQUIRES MODIFIER LT, RT, OR 50. Claims submitted for patients that have already had the indicated procedure done will deny with EOB 59210 - BALLOON OSTIAL DILATION ALLOWED ONCE PER SINUS PER LIFETIME.

Balloon Ostial Dilation (BOD), also known as balloon sinuplasty, was approved by the U.S. Food and Drug Administration (FDA) in April 2005 and is used to treat chronic and recurrent acute rhinosinusitis when medical management efforts fail and surgery is deemed necessary.

This article was taken in part from the January 2018 Medicaid Bulletin, which is available on the DMA 2018 Medicaid Bulletin page. This is an update to a previous announcement.

 

Pharmacy Prior Approval Changes

Effective July 29, 2018, prior approval (PA) updates will be made for several drugs in NCTracks. Please review these important changes.

PA Formatting Changes

Electronic PA requests on the Provider Portal for Nucala and Fasenra will be combined with the Xolair PA as one page under the title Monoclonal Antibody Therapy.

Psoriatic arthritis will now be available to select as a Disease Process for Taltz and Xeljanz on the Immunomodulators electronic form. Renflexis will also be added to the electronic Immunomodulators PA form.

Electronic PA submissions will be available for Emflaza (deflazacort) and Lupus Medication (Benlysta).

New paper version PA request forms will be individually available for Nucala and Fasenra due to the difference in criteria between these drugs and Xolair. New paper version PA request forms will also be available for Benlysta (under lupus medications) and Emflaza.