DMA has received approval to implement a new procedure code and rate for Targeted Case Management-for Individuals with Intellectual and Developmental Disability (TCM-IDD) for direct enrolled providers. Effective with date of service August 1, 2010, or the date of enrollment, whichever is the later date, direct enrolled providers may be reimbursed for T1017HE at the new weekly rate of $62.26. T1017HE may be billed only by the direct enrolled providers. HP will not process any systematic recoupment of T1017 HI and repayment for code of T1017 HE.

Medicaid cost containment initiatives will affect the reimbursement rate for TCM-MH/SA and TCM-IDD. All Medicaid services will have a 1.35% rate reduction effective with date of service September 1, 2010. The impact for TCM-IDD will be a reduction to $61.42 per week for T1017 HE.

Provider Enrollment Information
The effective date of enrollment for direct enrolled providers will be the date requested by the provider but no earlier than August 1, 2010, or the date a complete enrollment package is received by CSC, if a date is not requested by the provider.

Until providers are directly enrolled, they may continue to bill TCM-IDD services through the Local Management Entities (LMEs) with T1017 HI and T1017 HI SC, at the current rate of $17.67 per unit. Effective January 1, 2011, LMEs will no longer process TCM-IDD claims.

Service Authorization
This service must be prior authorized for non-CAP Waiver recipients prior to submitting claims. (TCM for CAP Wavier recipients does not require prior authorization.) Following enrollment, the provider will be able to request authorization for TCM-IDD for new non-CAP Waiver recipients in accordance with current procedures and documentation requirements. Providers may fax authorization requests to VO at 877-339-8754. For current recipients with an existing authorization, providers may request transfer of authorizations from T1017 HI to T1017 HE and transfer of the authorization from an LME to their TCM-IDD Medicaid Provider number through the ValueOptions' TCM Provider Change Request Form here. ValueOptions (VO) will retroactively authorize the new code as requested starting August 1, 2010, or the actual provider enrollment date, whichever is later. There will be no charge to provider for this transfer of authorizations.

Additional Claims Processing Information

 

Claims Submission: The billing limit is one unit per week which runs from Sunday to Saturday.If the claim identifies a span of dates, (e.g. August 2-6, 2010), the claim will be denied. In order to bill, providers must provide at least 15 minutes of service per week. However, the expectation is that service will be provided and documented according to the needs of the recipient. Electronic claims submitted by Direct Enrolled Providers prior to the 8/19/2010 cutoff for procedure code T1017 HE will adjudicate on the 8/26/2010 check write. Claims processed after the 8/19/2010 cutoff will adjudicate according to the current check write schedule. Please note: System audits have been developed to deny claims billed with T1017 HE or T1017 HI if billed during the same calendar week. The first claim processed and paid for a recipient will result in the denial of any other claim for TCM during the same week.

Electronic Funds Transfer: Providers must submit to HP a completed EFT form specific to TCM -IDD. Claims will suspend if this EFT form is not on file. Although many providers have completed the enrollment process and been issued a Medicaid Provider Number, many have not completed an Electronic Funds Transfer (EFT) Authorization Agreement for Automatic Deposit form needed for payment. You can access the form from DMA's website at http://www.ncdhhs.gov/dma/provider/forms.htm.