Claims Reprocessing Due to PDN Rate Increase

As previously communicated in the April 2016 Special Medicaid bulletin, N.C. Session Law 2015-241, section 12H.22 required the N.C. Department of Health and Human Services (DHHS) to submit N.C. State Plan Amendment (SPA) 16-001 to the Centers for Medicare & Medicaid Services (CMS) requesting approval for a 10% rate increase for Private Duty Nursing (PDN) with an effective date of January 1, 2016. CMS approved this SPA on April 14, 2016 and the rate was implemented in NC Tracks on April 22, 2016. Beginning April 22, 2016, claims for PDN will be reimbursed at the lessor of this new rate, $9.90 per 15 minutes, or billed charges. Providers are reminded to bill their usual and customary charges.

Claims with dates of service January 1, 2016 through April 22, 2016 will be systematically reprocessed in the June 14, 2016 checkwrite. No action is required on the part of providers.

Note that reprocessing does not guarantee payment for the claim. While some edits may be bypassed as part of the claim reprocessing, changes made to the system since the claims were originally adjudicated may apply to reprocessed claims. Therefore, the reprocessed claim could deny.

[From the May 2016 Medicaid Special Bulletin]