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1
THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA
Committee on Social Service Programs
Statement of problem - The State Plan for Title XIX provides that payment under
the Medicaid program be made for services that are medically necessary and
reasonable. The responsibility for administering this program provision has
been delegated by contractual agreement to North Carolina Blue Cross and Blue
Shield. Based on a review of claims submitted by physicians during the first
eighteen months of the program, a number of physicians have been identified as
having a pattern of practice involving the use of injections and laboratory
services that is significantly above their peers.
In order to carry out the
Cross and Blue Shield util
and has a Corporate Medica
individual claims by these
magnitude that additional
this reason that the assis
the Medical Society of the
reasonable procedures for
involving injections and 1
guidelines to all practici
concepts relative to:
contractual responsibilities, North Carolina Blue
izes the services of several physician consultants
id Utilization Review Committee. Consideration of
consultants indicated that the problem was of such
counsel and advice should be obtained. It was for
tance of the Committee on Social Service Programs of
State of North Carolina was requested to develop
administering and reporting services specifically
aboratory tests and to communicate the resulting
ng physicians in the state. Following are some
A. Administration of injections:
1. It will be the policy of the Medicaid program to decline reimbursement
for parenteral medication when oral medications are deemed adequate by
Medicaid physician consultants. When injected drugs are utilized, an
explanation as to the reason, the name of the drug, and dosage are to
be entered on the claim form.
2. Specific exceptions include:
Vitamin B-12 can be considered specific therapy for certain anemias:
pernicious anemia; megaloblastic anemias; macrocytic anemias; fish
tapeworm anemia. Certain gastrointestinal disorders; gastrectomy;
malabsorption syndrome such as resection of the small intestine,
strictures, anastomoses, and blind loop syndrome. Certain neuropathies; posterolateral sclerosis, those associated with pernicious
anemia; during the acute phase or acute exacerbation of the following: multiple sclerosis, trigeminal and glossopharyngeal neuralgia,
malnutrition and alcoholism, tabes dorsalis, causalgia, post-
sympathectomy parathesias, diabetic neuropathies, herpes zoster and
other inflammatory neuritides not due to mechanical or traumatic
etiology.
(over)