10A N.C. Admin. Code 22F.0104

Current through Register Vol. 39, No. 12, December 1, 2024

Section 22F .0104 - PREVENTION

(a) Provider Education. Upon the request of a provider, the Division may conduct on-site educational visits to assist a provider in complying with requirements of the Medicaid Program.

(b) Provider Manuals. The Division shall prepare and make available a provider manual containing at least the following information:

(1) amount, duration, and scope of assistance;

(2) participation standards;

(3) penalties;

(4) reimbursement rules; and

(5) claims filing instructions.

(c) Prepayment Claims Review. The Division shall check eligibility, duplicate payments, third party liability, and unauthorized or uncovered services by means of prepayment review, computer edits and audits, and investigation.

(d) Prior Approval. The Division shall require prior approval for certain specified covered services as set forth in the Medicaid State Plan.

(e) Claims. The following terms and conditions shall apply to the submission of claims:

(1) Medicaid payment shall constitute payment in full;

(2) charges to Medicaid recipients for the same items and services shall not be higher than for private paying patients;

(3) the provider shall keep all records as necessary to support the services claimed for reimbursement;

(4) the provider shall disclose the contents of his Medicaid financial and medical records to the Division and its agents; and

(5) Medicaid reimbursement shall only be made for medically necessary care and services as defined in 10A NCAC 25A .0201.

(f) Provider Administrative Participation Agreements. All providers shall execute a written participation agreement as a condition for participating in the N.C. State Medicaid Program.

(g) The Recipient Management LOCK-IN System. The Division shall establish a lock-in system to control recipient overutilization of provider services. A lock-in system restricts an overutilizing recipient to the use of one physician and one pharmacy, of the recipient's choice, provided the recipient's physician is able to refer the recipient to other physicians as medically necessary, as defined in 10A NCAC 25A .0201.

10A N.C. Admin. Code 22F .0104

Authority G.S. 108A-25(b); 108A-54; 108A-54.1B; 108A-63; 108A-64; 108C; 42 C.F.R. Part 455; 42 CFR 455.23; 42 C.F.R. 447.15;
Eff. May 1, 1984;
Readopted Eff. September 1, 2018.

Authority G.S. 108A-25(b); 108A-63; 108A-64; 42 C.F.R. Part 455;
Eff. May 1, 1984.

Readopted by North Carolina Register Volume 33, Issue 07, October 1, 2018 effective 9/1/2018.