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APPROVED RULES

10A NCAC 26C .0606REMOVAL OF LME FUNCTION

(a)  The LME shall be considered to have a material breach if the LME fails to achieve and maintain for a period of two consecutive months, the required outcome expectations on the designated performance indicator(s) after the six month period occurs as specified in Rule .0605 of this Section.  
(b)  Upon identifying the LME as having an uncorrected material breach and within a timeframe not to exceed 30 working days, the Secretary shall arrange for a contract with another LME to implement the function associated with the deficient critical performance indicator as set forth in G.S. 122C-115.4(d)(3).  Prior to the removal of the function, the Secretary shall send written notification to the LME stating:
(1)the LME function that is being removed;
(2)the date of the removal of the function;
(3)the entity identified to implement the function being removed;
(4)the amount of fund reallocation from the deficient LME to the receiving entity; and
(5)the expectation that the deficient LME shall cooperate with the Secretary and receiving entity as necessary to ensure a smooth, seamless transition of the function.

History Note:Authority G.S. 122C-115.4(f)(3);

Eff. May 1, 2008.

* * * * * * * * * * * * * * * * * * * *

10A NCAC 27A .0301SCOPE

This Section governs the requirements that constitute a clean claim for purposes of billing.  These Rules are applicable to local management entities (LMEs) and public and private providers who seek to provide services that are payable from funds administered by an LME.  

History Note:Authority G.S. 122C-3(30b); 122C-112.1(a)(32); S.L. 2006-142;

Eff. May 1, 2008.

10A NCAC 27A .0302definitions

(a)  "Claim" means an itemized statement with standardized elements that is submitted for payment by a provider to the authorizing LME.
(b)  "Clean Claim" means an itemized statement with standardized elements, completed in its entirety in a format as set forth in Rule .0303 of this Section.  

History Note:Authority G.S. 122C-112.1(a)(32); S.L. 2006-142;

Eff. May 1, 2008.

10A NCAC 27A .0303clean claim format

requirements

(a)  A provider of a service that is payable from funds administered by an LME shall submit a claim for payment to the authorizing LME.  The provider shall submit the claim in one of the formats listed as follows:
(1)HIPAA compliant 837;
(2)CMS-1500;
(3)the standardized billing format provided by the DMH/DD/SAS; or
(4)a single web based direct data entry system.
The provider shall complete each element contained in the selected format.
(b)  The billing format provided by the DMH/DD/SAS shall contain standardized elements including:
(1)date of claim;
(2)provider information including:

(A)name; and

(B)number.

(3)client information including:

(A)name;

(B)identification number;

(C)target population code; and

(D)ICD-9 diagnosis code.

(4)service information including:

(A)name;

(B)date;

(C)units delivered;

(D)billing code; and

(E)authorization number.

History Note:Authority G.S. 122C-112.1(a)(32); S.L. 2006-142;

Eff. May 1, 2008.

10A Ncac 27A .0304claims review

procedures

(a)  The LME shall review the claim to determine if it is clean.  The determination shall be based on whether the claim is submitted as follows:
(1)the claim is submitted in one of the formats as set forth in Rule .0303 of this Section; and
(2)the information requested in each element of the selected format is complete.
(b)  When a claim meets the requirements as set forth in Paragraph (a) of this Rule, it shall be considered a clean claim. (c)  The LME shall deny a claim that does not meet the requirements as set forth in Paragraph (a) of this Rule.  The LME shall notify the provider of the denied claim. The notification shall specify the reason for denial and include the steps to be followed for resubmission.

History Note:Authority G.S. 122C-112.1(a)(32); S.L. 2006-142;

Eff. May 1, 2008.

10A NCAC 27G .0507AREA BOARD ANNUAL

EVALUATION OF AN AREA DIRECTOR

(a)  This Rule governs the annual evaluation of Area Directors.
(b)  Area Boards shall evaluate, but not be limited to, the Area Director's performance in each of the following areas:
(1)Relationship with the Board of Directors and CFAC;

22:23                                                               NORTH CAROLINA REGISTER                                           JUNE 2, 2008

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