New Claims Billing Process for DME National Miscellaneous HCPCS Codes
Effective July 21, 2014, regardless of date of service, claims billed with A9900, B9998, E1399 and K0108 must include the Prior Approval (PA) number as well as the corresponding approved state/local code. This will allow claims to process appropriately when DME providers submit multi-line PA requests with multiple “W” codes (also known as local or state codes) that map to the same national code and submit a single national code multiple times on the same claim.

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Prior Approval
All of the above listed state/local HCPCS codes along with their corresponding national miscellaneous HCPCS codes require prior approval as of July 21, 2014(regardless of date of service.) This includes claims with Medicare primary insurance. Both the national miscellaneous HCPCS code and the state/local code must be indicated on the Certificate of Medical Necessity and Prior Approval Form (CMN/PA). Please refer to the Prior_Approval_Request_Inquiry CBT course and/or the Prior Approval Medical Participant User Guide in SkillPort for guidelines on how to submit prior approval requests.

Claim Submission
On an 837P enter the PA in REF segment and enter local/state code in the PWK segment. See the 837P Companion Guide for details at https://www.nctracks.nc.gov/content/public/providers/provider-trading-partners.html.

On the NCTracks Provider portal enter the PA # on the Claim Information tab in the Prior Auth # field. The local/state code is chosen from the service line in the Local Procedure Code drop down menu. For additional details, please refer to the forthcoming Job Aid “PA Using Local W Codes” on the Provider User Guides and Training page of the NCTracks Provider Portal, which will be posted shortly.

There is a new EOB 01673 with the description “Required DME local code and/or prior approval number is missing or invalid. Verify DME local code and/or prior approval number and resubmit as a new claim” that will be assigned to the denied claim if any of the following situations occur:

• PA number on claim is missing or invalid
• PA number on claim does not match to an approved corresponding state/local code
• State/local code on claim is missing or invalid
• State/local code on claim does not match to a prior approval

Upon receiving denial reason EOB 01673, review the approval you have on file, correct your claim as needed, and resubmit as a new claim.

For claims submitted prior to this implementation, if you feel you received a denial in error due to a manual pricing and/or national to state code issue, resubmit following these new guidelines. If you feel your payment received in the past was in error due to a manual pricing and/or national to state code issue, submit a replacement claim following these new guidelines.

The coverage criteria for these items have not changed. Refer to Clinical Policy 5A Durable Medical Equipment and Supplies at http://www.ncdhhs.gov/dma/mp/mpindex.htm.

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