SUBCHAPTER 22g – REIMBURSEMENT PLANS

 

SECTION .0100 – REIMBURSEMENT FOR NURSING FACILITY SERVICES

 

10A NCAC 22G .0101       REIMBURSEMENT PRINCIPLES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C;

Eff. January 1, 1978;

Amended Eff. March 22, 1978;

Emergency Amendment [(a), (b), (c), (g), (m), (o), (p), (q)] Eff. April 1, 1978 for a Period of 120 Days to Expire on July 30, 1978;

Emergency Amendment [(a), (b), (c), (g), (m), (o), (p), (q)] Expired Eff. July 30, 1978;

Amended Eff. August 1, 1982;

Temporary Amendment Eff. October 1, 1984 for a Period of 120 Days to Expire on January 28, 1985;

Amended Eff. April 1, 1992; October 1, 1991; January 28, 1985;

Temporary Amendment Eff. June 26, 2003;

Temporary Amendment Expired April 27, 2004;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

10A NCAC 22G .0102       RATE SETTING METHODS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 29 C.F.R. 1910, Subpart Z; 42 C.F.R. 447, Subpart C; S.L. 1991, c. 689, s. 95;

Eff. January 1, 1978;

Temporary Amendment Eff. October 1, 1984 for a Period of 120 Days to Expire on January 28, 1985;

Temporary Amendment Eff. October 1, 1991 for a Period of 180 Days to Expire on March 31, 1992;

Amended Eff. April 1, 1992;

Temporary Amendment Eff. July 1, 1992 for a Period of 180 Days to Expire on December 31, 1992;

Amended Eff. May 1, 1995; February 1, 1993; January 1, 1993;

Temporary Amendment Eff. January 22, 1998;

Amended Eff. April 1, 1999;

Temporary Amendment Eff. November 9, 2001;

Temporary Amendment Expired August 30, 2002;

Amended Eff. April 1, 2003;

Temporary Amendment Eff. August 3, 2004;

Amended Eff. January 1, 2005;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0103       REASONABLE AND NON‑ALLOWABLE COSTS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C;

Eff. January 1, 1978;

Temporary Amendment Eff. October 1, 1984 for a Period of 120 Days to Expire on January 28, 1985;

Amended Eff. January 4, 1993; October 1, 1991; November 1, 1988; January 28, 1985;

Temporary Amendment Eff. August 3, 2004;

Amended January 1, 2005;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10a NCAC 22G .0104       COST REPORTING: AUDITING

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447, Subpart C;

Eff. January 1, 1978;

Amended Eff. March 22, 1978;

Emergency Amendment [(a), (h)] Eff. April 1, 1978 for a period of 120 days to expire on July 30, 1978;

Emergency Amendment [(a), (h)] Expired Eff. July 30, 1978;

Temporary Amendment Eff. October 1, 1984 for a period of 120 days to expire on January 28, 1985;

Amended Eff. August 1, 1998; June 1, 1995; January 4, 1993; October 1, 1991; December 1, 1988;

Temporary Amendment Eff. August 3, 2004;

Amended Eff. January 1, 2005;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0105       case-mix index calculation

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S. L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C;

Eff. January 1, 1978;

Amended Eff. March 25, 1980;

Temporary Amendment Eff. October 1, 1984 for a Period of 120 Days to Expire on January 28, 1985;

Amended Eff. March 1, 1994; April 1, 1988; January 28, 1985;

Temporary Amendment Eff. August 3, 2004;

Amended Eff. January 1, 2005;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0106       RECONSIDERATION REVIEWS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C;

Eff. January 1, 1978;

Temporary Amendment Eff. October 1, 1984 for a Period of 120 Days to Expire on January 28, 1985;

Amended Eff. January 4, 1993; November 1, 1991; May 1, 1990; June 1, 1989;

Temporary Amendment Eff. August 3, 2004;

Amended Eff. February 1, 2005;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10a NCAC 22G .0107       PAYMENT ASSURANCE

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; Section 95 of Chapter 689, 1991 Session Laws; 42 C.F.R. 447, Subpart C;

Temporary Rule Eff. October 1, 1984 for a Period of 120 Days to Expire on January 28, 1985;

Eff. January 28, 1985;

Amended Eff. December 1, 1988;

Temporary Amendment Eff. August 1, 1991 For a Period of 180 Days to Expire on January 31, 1992;

Amended Eff. February 1, 1992; October 1, 1991;

Temporary Amendment Eff. August 3, 2004;

Amended Eff. January 1, 2005;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0108       REIMBURSEMENT METHODS FOR STATE‑OPERATED FACILITIES

(a)  A NC Division of Health Service Regulation certified State‑operated nursing facility shall be reimbursed for the reasonable costs that are necessary to efficiently meet the needs of its patients and to comply with federal and state laws and regulations.  The costs shall be determined in accordance with Rules .0103 and .0104 of this Section, except that annual cost reports shall be required for the fiscal year beginning on July 1 and ending on the following June 30 and must be submitted to the Division of Medical Assistance within 150 days after their fiscal year end.  Payments shall be suspended if reports are not filed.  The Division of Medical Assistance shall extend the deadline for filing the report if the Division determines good cause.  "Good cause" is an action uncontrollable by the provider.  The Medicare principles for the reimbursement of skilled nursing facilities shall be utilized for the cost principles that are not specifically addressed in this Section.

(b)  A per diem rate based on the providers estimated annual cost divided by patient days shall be used to make interim payments.  A desk audit and a tentative settlement shall be performed on each annual cost report to determine the amount of Medicaid reasonable cost and the amount of interim payments received by the provider.

(c)  Any payments in excess of costs shall be refunded to the Division. Any costs in excess of payments shall be paid to the provider.  An annual field audit shall be performed by a qualified independent auditor to determine the final settlement amounts.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C;

Eff. January 1, 1992;

Temporary Amendment Eff. August 3, 2004;

Amended Eff. January 1, 2005.

 

10A NCAC 22G .0109       PROVIDER ASSESSMENT

(a)  In accordance with 42 USC 1396b(w) and 42 CFR, Part 433, Subpart B; and consistent with the CMS Federal Waiver approved April 5, 2004 with an effective date of October 1, 2003 including subsequent amendments and revisions, a monthly nursing facility assessment based on all occupied nursing facility bed days of service is imposed on all nursing bed days in licensed nursing facilities, except:

(1)           Any nursing facility bed day of service provided by a Continuing Care Retirement Community (CCRC), as defined by GS 58-64 and licensed by the North Carolina Department of Insurance;

(2)           Any nursing facility bed day of service paid for under the Medicare program established under Title XVIII of the Social Security Act.

A copy of the Waiver may be obtained by contacting the Division of Medical Assistance, 2501 Mail Service Center, Raleigh, North Carolina 27699-2501, (919) 857-4016.

(b)  Effective October 1, 2003, the assessment is payable monthly and due to the Department of Health and Human Services or designee of the Department within 15 days of the last day of the reporting month. Facilities shall submit payment and an account of all actual patient days during the month. Failure to provide accurate and timely reporting of days and payment of assessment shall result in a 10% reduction in facility rates for Medicaid participating facilities and recoupment per the Department Cash Management Plan.

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 108A-55; S.L. 2003-284, Sec. 10.28; CMS Waiver approved April 5, 2004; 42 CFR Part 433, Subpart B;

Temporary Adoption Eff. August 3, 2004;

Eff. January 1, 2005.

 

10A NCAC 22G .0110       DEFINITIONS

"Public nursing facility", as used in 10A NCAC 22G, means any nursing facility that is:

(1)           Owned or operated by the State or any department or instrumentality of the State or by county, city, hospital district, or hospital authority; or

(2)           Is operated by a nonprofit corporation or association, a majority of whose board of directors or trustees are appointed by the State or any department or instrumentality of the State or by the governing body of a county, city, hospital district, or hospital authority; or

(3)           Is operated by a hospital that is a "public hospital" under G.S. 159-39(a); or

(4)           Is operated by a hospital that has verified its status by certifying State, local, hospital district or authority governmental control on the most recent version of the Form CMS 1514; or

(5)           Is a facility to which the State or any department or instrumentality of the State or a city or a county makes current appropriations (other than appropriations for the cost of medical care to prisoners or indigents).

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 108A-55; 159-39(a);

Temporary Adoption Eff. August 3, 2004;

Eff. January 1, 2005;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

section .0200 – hospital inpatient reimbursement plan

 

10A NCAC 22G .0201       REIMBURSEMENT PRINCIPLES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447, Subpart C;

Eff. February 1, 1995;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0202       DRG RATE SETTING METHODOLOGY

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447, Subpart C;

Eff. March 1, 1995;

Temporary Amendment Eff. January 22, 1998;

Amended Eff. April 1, 1999;

Temporary Amendment Eff. November 9, 2001;

Temporary Amendment Expired August 30, 2002;

Amended Eff. August 1, 2004;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A ncac 22G .0203       EXCEPTIONS TO DRG REIMBURSEMENT

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55(c); 42 C.F.R. 447, Subpart C; 42 C.F.R. 447.321;

Eff. February 1, 1995;

Temporary Amendment Eff. September 15, 1995, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Amended Eff. January 1, 1996;

Temporary Amendment Eff. September 25, 1996;

Temporary Amendment Eff. September 30, 1997;

Temporary Amendment Expired July 31, 1998;

Temporary Amendment Eff. September 16, 1998;

Temporary Amendment Expired June 13, 1999;

Temporary Amendment Eff. September 22, 1999;

Temporary Amendment Expired July 11, 2000;

Temporary Amendment Eff. June 13, 2001; September 21, 2000;

Temporary Amendment Eff. May 15, 2002;

Amended Eff. April 1, 2003;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0204       DISPROPORTIONATE SHARE HOSPITALS (DSH)

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 108A-55; 42 C.F.R. 447, Subpart C;

Eff. February 1, 1995;

Amended Eff. July 1, 1995;

Temporary Amendment Eff. September 15, 1995, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Temporary Amendment Eff. September 29, 1995, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Amended Eff. January 1, 1996;

Temporary Amendment Eff. September 16, 1998; September 30, 1997; April 15, 1997; September 25, 1996;

Temporary Amendment Expired on June 13, 1999;

Temporary Amendment Eff. September 22, 1999;

Temporary Amendment Expired on July 11, 2000;

Temporary Amendment Eff. May 15, 2002; June 1, 2001; December 10, 2001; September 21, 2000;

Amended Eff. August 1, 2004; April 1, 2003;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0205       OUT OF STATE HOSPITALS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447, Subpart C;

Eff. February 1, 1995;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A ncac 22G .0206       SPECIAL SITUATION

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447 Subpart C;

Eff. February 1, 1995;

Temporary Amendment Eff. December 10, 2001;

Temporary Amendment Expired September 29, 2002;

Amended Eff. August 1, 2004;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0207       COST REPORTING AND AUDITS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447, Subpart C;

Eff. February 1, 1995;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0208       ADMINISTRATIVE RECONSIDERATION REVIEWS

Reconsideration reviews of rate determinations shall be processed in accordance with the provisions of 10A NCAC 22J.  Requests for reconsideration reviews shall be submitted to the Division of Medical Assistance within 60 days after rate notification, unless unexpected conditions causing intense financial hardship arise, in which case a reconsideration review may be considered at any time.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447, Subpart C;

Eff. February 1, 1995.

 

10A NCAC 22G .0209       BILLING STANDARDS

10A NCAC 22G .0210       PAYMENT OF MEDICARE PART A DEDUCTIBLES

10A NCAC 22G .0211       PAYMENT ASSURANCES

10A NCAC 22G .0212       PROVIDER PARTICIPATION

10A NCAC 22G .0213       PAYMENT IN FULL

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447, Subpart C;

Eff. February 1, 1995;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

SECTION .0300 ‑ ICF‑MR PROSPECTIVE RATE PLAN

 

10A NCAC 22G .0301       PAYMENT FOR SERVS‑PROSPECTIVE REIMBURSEMENT PLAN ICF‑MR FACILITIES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C;

Eff. January 1, 1982;

Temporary Amendment Eff. July 8, 1993 for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Amended Eff. November 1, 1993;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0302       REPORTING REQUIREMENTS

 

History Note:        Temporary Amendment Eff. July 8, 1993, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner.

Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447, Subpart C;

Eff. January 1, 1982;

Amended Eff. August 1, 1995; November 1, 1993; May 1, 1990; April 1, 1988;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0303       REQUIREMENTS FOR FINANCIAL RECORDS

 

History Note:        Temporary Amendment Eff. July 8, 1993, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Temporary Amendment Eff. July 1, 1992 for a period of 180 days to expire on

December 31, 1992;

Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. Part 447, Subpart C;

Eff. January 1, 1982;

Amended Eff. November 1, 1993; January 4, 1993; January 1, 1993; December 1, 1989;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0304       RATE SETTING METHOD FOR NON-STATE FACILITIES

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 108A-55; 42 C.F.R. Part 447, Subpart C;

Eff. December 1, 1984;

Amended Eff. March 1, 1988; January 1, 1987;

Temporary Amendment Eff. July 8, 1993 for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Amended Eff. August 1, 1995; November 1, 1993;

Temporary Amendment Eff. September 8, 1999; August 7, 1998;

Amended Eff. March 19, 2001; August 1, 2000;

Temporary Amendment Eff. December 10, 2001;

Temporary Amendment Expired September 29, 2002;

Amended Eff. August 1, 2004;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0305       ALLOWABLE COSTS

10A NCAC 22G .0306       PAYMENT ASSURANCE

10A NCAC 22G .0307       REIMBURSEMENT METHODS FOR STATE‑OPERATED FACILITIES

10A NCAC 22G .0308       RATE APPEALS

10A NCAC 22G .0309       AUDITS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C;

Temporary Adoption Eff. July 8, 1993 for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Eff. November 1, 1993;

Amended Eff. August 1, 1995;

Temporary Amendment Eff. June 26, 2003;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

section .0400 - PROVIDER FEE SCHEDULES

 

10A ncac 22G .0401       PHYSICIAN’S FEE SCHEDULE

 

History Note:        Authority G.S. 108A-25(b);

Eff. October 1, 1982;

Amended Eff. July 1, 1997; July 1, 1995; January 4, 1993; June 1, 1990; December 1, 1988;

Temporary Amendment Eff. July 22, 1998; January 22, 1998;

Amended Eff. April 1, 1999;

Temporary Amendment Eff. January 1, 2000 (This temporary amendment amends and replaces a permanent rulemaking originally proposed to be effective August 2000);

Amended Eff. March 19, 2001;

Temporary Amendment Eff. September 10, 2001;

Temporary Amendment Expired June 28, 2002;

Amended Eff. April 1, 2003;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A ncac 22G .0402       OTHER SERVICES PERFORMED BY PHYSICIANS AND OTHER PRACTITIONERS

 

History Note:        Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86;

Eff. January 4, 1993;

Temporary Amendment Eff. March 7, 2002;

Temporary Amendment Expired December 27, 2002;

Amended Eff. August 1, 2004;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A;

 

section .0500 – reimbursement for services

 

10a NCAC 22G .0501       CLINIC SERVICES

 

History Note:        Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86;

Eff. February 1, 1984;

Temporary Amendment Eff. November 9, 2001;

Temporary Amendment Expired August 30, 2002;

Amended Eff. April 1, 2003;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10a NCAC 22G .0502       MENTAL HEALTH CLINIC SERVICES

Reimbursement for mental health clinic services will be made based on a fee schedule as developed by the Division of Medical Assistance.

 

History Note:        Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86;

Eff. February 1, 1984.

 

10A NCAC 22G .0503       INPATIENT HOSPITAL: INAPPROPRIATE LEVEL OF CARE

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 447.253; S.L. 1985, c. 479, s. 86;

Eff. May 1, 1984;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0504       HEALTH MAINTENANCE ORGANIZATIONS AND PREPAID HEALTH PLANS

Reimbursement to Health Maintenance Organizations and Prepaid Health Plans for services rendered will be paid as a monthly capitation fee developed by the Division of Medical Assistance.

 

History Note:        Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86; 42 C.F.R. Part 434;

Eff. August 1, 1984;

Amended Eff. February 1, 1985.

 

10A ncac 22G .0505       PERSONAL CARE SERVICES

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 108A-55; 131D-4.1; 131D-4.2; S.L. 1995 c. 507, s. 23.10; 42 C.F.R. 440.170(f);

Eff. January 1, 1986;

Temporary Amendment Eff. April 22, 1996; January 9, 1997;

Amended Eff. August 1, 1998;

Temporary Amendment Eff. January 1, 2000;

Temporary Amendment Expired on October 28, 2000;

Temporary Amendment Eff. July 1, 2002;

Amended Eff. August 1, 2002;

Temporary Amendment Eff. January 13, 2003;

Amended Eff. August 1, 2004;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0506       INDEPENDENT LABORATORY SERVICES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; P.L. 93‑369; P.L. 99‑272; 42 C.F.R. 447.10; 42 C.F.R. 447.342;

Eff. March 1, 1987;

Amended Eff. September 1, 1991;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0507       DURABLE MEDICAL EQUIPMENT AND RELATED SUPPLIES

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 447, Subpart D; 1991 S.L, s. 95, c. 689;

Eff. March 1, 1990;

Temporary Amendment Eff. August 1, 1991 for a period of 180 days to expire on

January 31, 1992;

Amended Eff. December 1, 1995; February 1, 1992;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0508       PRIVATE DUTY NURSING

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 42 C.F.R. 440.80;

Eff. January 1, 1994;

Temporary Amendment Eff. December 20, 2002; July 1, 2002;

Temporary Amendment Expired November 28, 2003;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0509       REIMBURSEMENT PRINCIPLES, HEARING AIDS/ACCESSORIES/BATTERIES

(a)  Payment for hearing aids and accessories, earmolds, repairs, loaner and rental aids are reimbursed at invoice cost.

(b)  Payment for fitting and dispensing services is based on the lower of:

(1)           The provider's actual (submitted) charge, or

(2)           A fixed reimbursement fee based on estimated average statewide fees.  The estimated average statewide fees are determined based on surveys of actual fees charged by providers in the State.

(c)  Payment for batteries used with hearing aids are limited to six claims per year per recipient.  Each claim is reimbursed at the lower of:

(1)           The provider's actual (submitted) charge, or

(2)           A maximum payment amount per claim based on estimates of average usual and customary retail charges as determined based on surveys of retail prices of batteries for hearing aids.

(d)  A dispensing fee for batteries is not allowed.

 

History Note:        Authority G.S. 108A-25(b); 108A-54;

Eff. January 4, 1993;

Recodified from 10 NCAC 26H .0509 Eff. January 1, 1994.

 

10A NCAC 22G .0510       CASE MANAGEMENT SERVICES

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 1915 (g) of the Social Security Act;

Eff. April 1, 1994;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

SECTION .0600 ‑ HOME HEALTH PROSPECTIVE REIMBURSEMENT

 

10A NCAC 22G .0601       REIMBURSEMENT PRINCIPLES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.70;

Eff. October 1, 1987;

Amended Eff. October 1, 1992;

Temporary Amendment Eff. August 1, 1991 for a period of 180 days to expire on

January 31, 1992;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10a NCAC 22G .0602       REIMBURSEMENT METHODS

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 108A-55; S.L. 1985, c.479, s. 86; 42 C.F.R. 440.70;

Eff. October 1, 1987;

Amended Eff. October 1, 1992; May 1, 1990;

Temporary Amendment Eff. October 4, 1996;

Amended Eff. April 1, 1997;

Temporary Amendment Eff. July 25, 1997;

Amended Eff. August 1, 1998;

Temporary Amendment Eff. November 9, 2001;

Temporary Amendment Expired August 30, 2002;

Amended Eff. April 1, 2003;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0603       APPEALS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985. c. 479, s. 86; 42 C.F.R. 440.70;

Eff. October 1, 1987;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0604       COST REPORTING AND AUDITING

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.70;

Eff. October 1, 1987;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0605       PAYMENT ASSURANCES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S. L. 1985, c. 479, s. 86; 42 C.F.R. 440.70;

Eff. October 1, 1987;

Amended Eff. October 1, 1992; May 1, 1990;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.