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OB Ultrasound Claims from PMH Providers to Bypass Service Limitations
NCTracks will be updated on February 5, 2017, to allow claims submitted for obstetrical ultrasounds to bypass service limitations when the provider has a Pregnancy Medical Home (PMH) indicator on its provider record for the service date. This provision includes professional claims where the rendering or ordering NPI is identified as a PMH provider, and institutional claims where the billing or referring NPI is identified as a PMH provider.
Previously, claims submitted might have denied with the Explanation of Benefits (EOB) 00762 - MEDICAL NECESSITY NOT APPARENT; SUBMIT CLAIM WITH RECORDS INDICATING MEDICAL NECESSITY when the service limit for obstetrical ultrasounds for the recipient had already been met.
Obstetrical ultrasound claims adjudicated after this update implementation will be subject to the new service limitation bypass if the service date is equal to or greater than January 1, 2016.
For more information regarding service limit exceptions for PMH providers, refer to the clinical coverage policies on the DMA website. PMH providers may also consult with Community Care of North Carolina (CCNC).
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