10A NCAC 22F .0104. PREVENTION

(a)  Provider Education.  The Division may at its discretion, or shall upon the request of a provider, conduct on‑site educational visits to assist a provider in complying with requirements of the Medicaid Program.

(b)  Provider Manuals.  The Division will prepare and furnish each provider with a provider manual containing at least the following information:

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

(2)           participation standards;

(3)           penalties;

(4)           reimbursement rules;

(5)           claims filing instructions.

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

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

(e)  Claim Forms.  The Division's provider claim forms shall include the following requirements for provider participation and payment.  These requirements shall be binding upon the Division and the providers:

(1)           Medicaid payment constitutes 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 fully disclose the contents of his Medicaid financial and medical records to the Division and its agents.

(5)           Medicaid reimbursement shall only be made for medically necessary care and services.

(6)           The Division may suspend or terminate a provider for violations of Medicaid laws, regulations, policies, or guidelines.

(f)  Pharmacy and Institutional Provider Agreements.  All institutional and pharmacy providers shall be required to execute a written participation agreement as a condition for participating in the N.C. State Medical Assistance Program.

(g)  The Recipient Management LOCK‑IN System.  The Department of Health and Human Services, Division of Medical Assistance, will 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 can refer the recipient to other physicians as medically necessary.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 108A‑64; 42 C.F.R. Part 455;

Eff. May 1, 1984.