Reprocessing of Vaccine Administration claims for ACA payments

The Affordable Care Act (ACA) requires that the Medicaid program pay providers who have attested at the Medicare rate for certain primary care services and to reimburse 100% Medicare Cost Share for services paid in calendar years 2013 and 2014. The majority of Medicaid claims paid prior to implementation of the ACA reimbursement rate in NCTracks were reprocessed earlier this year, except for the vaccine administration codes. A change to the reimbursement rate for vaccine administration codes was made on August 17, 2014.

The claims from ACA eligible physicians for ACA eligible vaccine administration codes paid between January 1, 2013, and August 17, 2014, will be reprocessed in the September 23, 2014, checkwrite. The specific ACA eligible vaccine administration codes are 90471, 90472, 90473, and 90474, both with and without the EP modifier. The reprocessed claims will bypass the lower of logic and pay the ACA rate regardless of the amount billed.

In addition, NCTracks was adjusted on May 14, 2014, to process ACA payment eligibility at the NPI level rather than at the specific combination of NPI and Location Code. The claims processed with ACA payment eligibility incorrectly determined at the specific NPI and Location Code combination will also be reprocessed in the September 23, 2014 checkwrite.

The reprocessed claims will be reported on the Remittance Advice (RA) of affected providers in the September 23rd checkwrite. On the paper RAs only, the reprocessed claims will be listed in a separate section of the RA and the claims will be reported with an EOB code of 06040 - "CLAIM REPROCESSED FOR ACA ADJUSTED PAYMENT."

The 835 transactions will include the reprocessed claims along with other claims submitted for the checkwrite. (There is no separate 835.)

If providers have any questions about the reprocessed claims, please contact the NCTracks Call Center at 1-800-688-6696 or NCTracksProvider@nctracks.com.

Note: The Centers for Medicare and Medicaid Services (CMS) recently approved a North Carolina State Plan Amendment which changed the allowable attestation date from June 30, 2013, to June 30, 2014, for retroactive ACA payment eligibility back to January 1, 2013. ACA eligible claims affected by this CMS approval will be reprocessed in a later checkwrite.