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Provider Update Newsletter

May 2001, Volume 103

All Providers

HIPAA Happenings
Group Providers
Crossover Claims
EMC Deadline Extension
Rite Share

Dental Providers

Denture Procedure Codes
Dental Boxes

HIPAA Happenings

As you may have heard, President Bush has put a hold on the HIPAA Privacy Final Rule that was issued on December 28, 2000. There has been much healthcare industry comment on this regulation, most notably, the requirements that all players can only transmit minimum necessary health care information to other requestors. The requirement also includes that healthcare providers obtain consent for most healthcare information disclosures. In addition, several national healthcare organizations have been lobbying strongly for a delay in all HIPAA Rule compliance until each and every HIPAA Rule is finally approved and published in the Federal Register.

While DHS is continuing to work on HIPAA Assessments within the Department and with our trading partners in order to comply with the HIPAA provisions thus issued, we will continue to monitor and publish any changes as they become known. Please visit the  DHS HIPAA page for current information on DHS and local HIPAA activities.

Group Providers

Group providers please use the newer version of the “Group Provider Agreement Form”. The old forms do not contain enough information to complete the process.

A copy of the agreement form can be found at the provider form page.

Any of the other group provider agreement forms submitted to EDS will be returned to you.

Crossover Claims

When a claim involves a recipient with dual eligibility, Medicare transfers the claim to Medicaid electronically. These “crossover” claims are identified on your Medicare EOMB as “transferred to Medicaid of RI”. The transfer of the claim can take up to eight weeks to appear on your Medicaid Remittance Advice. It is important that you review both your Medicare EOMB and your Medicaid Remittance Advice before sending in these claims on paper with the Medicare EOMB attached.

If you have any questions regarding Medicaid Remittance Advice interpretation, please refer to Provider Update Volume 64, dated February 1998 or contact the Customer Service Help Desk at 401-784-8100 for local and long distance calls or 1-800-964-6211 for instate toll calls and border communities.

EMC Deadline Extension

In order to better serve the provider community, EDS is extending the deadline for submission of electronic media claims (EMC) before each processing cycle. With the new deadlines, providers will have an additional 2 days to submit their EMC claims! All EMC, with the exception of nursing homes, will be due by 5:00 PM the Friday of a processing cycle. Nursing Home EMC will be due by 12 PM the Friday of a processing cycle but nursing home paper claims will still be due on the earlier designated date.

Below is an updated Processing and Payment Schedule for your reference. Should you have any questions, please contact the EDS Customer Service Help Desk at 401-784-8100 for local and long distance calls or 800-964-6211 for instate toll calls and border communities.

We are excited about the opportunity to serve you better!

Month	Nursing Home paper claims-due as indicated	Nursing Home EMC-due by 12:00 noon	All other EMC due by 5 PM	Direct Deposit/ Paper Checks Date
	12:00 PM			5/4/01
May	5/7/01	5/11/01	5/11/01	5/18/01
	N/A	N/A	5/25/01	6/1/01
June	6/5/01	6/8/01	6/8/01	6/15/01
	N/A	N/A	6/22/01	6/29/01

RIte Share/ Fact Sheet

RIte Share is a public/private partnership that helps low and middle-income employees participate in their employer’s health insurance plan. RIte Share will pay the employees’ share of the employer’s family health insurance premium.

Eligible employees are able to enroll their entire family into their employer’s existing health insurance plan, at no cost to them. RIte Share may also pay for eligible employee’s co-payments.

Who can qualify for RIte Share?

RIte Share is designed for low and middle-income working families with children under the age of 19.

Employees apply directly to the Department of Human Services (DHS) to determine if they qualify for RIte Share. If the employee qualifies for RIte Share, DHS assists the employee with the enrollment into the employer’s health plan.

How will I know that a patient is on RIte Share?

RIte Share members will be issued two cards - a commercial identification card and a Rhode Island Medical Assistance identification card. They have been instructed to present both cards at the time of service. Additionally, if you are either a Rhode Island Medical Assistance Provider or a RIte Share Co-Pay Only Provider, you will have access to the EDS Recipient Eligibility Verification System (REVS) that will provide you with member enrollment information.

What are the benefits to providers for participating in RIte Share?

·    You will receive commercially-contracted rates for RIte Share enrollees
·    You will be reimbursed patient co-payments from DHS
·    You will maintain your current patient panel
·    Participating will help make commercial coverage accessible to working families

How can I become a RIte Share provider?

If you are currently participating in the Rhode Island Medical Assistance Program, simply use your existing provider number to bill EDS for co-payments.

If you are not currently participating in the Rhode Island Medical Assistance Program, please complete a RIte Share Co-Pay Only Provider Enrollment Form. You will then receive a provider number that can be used to bill co-payments only.

Please note that participation in the RIte Share Program does not obligate you to participate in the Rhode Island Medical Assistance Program and except Medicaid Fee-for-service clients.

For further Assistance call the EDS Customer Service Help Desk at 784-8100 or 800-964-6211.

For more information about Rite Share, contact the employer Contact Unit at 462-0311 or email us at:

RIteShare@gw.dhs.state.ri.us

Denture Procedure Codes

Please note the following changes to the Medicaid Dental Policy effective 2/22/2001

Prior Authorization (PA) restrictions for the following Denture Procedure Codes have been removed: D5110, D5120, D5211, D5212, D5213 and D5214. However, retroactive reviews will take place as needed. The 3-month waiting period between extractions and denture impressions has also been removed. Please be sure to identify medical necessity for the dentures by considering the following:

1.    Can the patient tolerate the denture process?
2.    Will the patient’s nutrition be enhanced?
3.    Will the patient be cooperative in wearing dentures?
4.    In your opinion, would the patient benefit from this procedure?

One (1) complete or partial set of dentures is allowed per client during a 5 year (1825-day) period. The current policy of including all adjustments/repairs within the first 6 months after delivery remains the same. No reimbursement for these services will be made for the client until 6 months after the delivery of the denture. Clients are allowed one denture adjustment per calendar year after the initial
6-month period.

After the 6-month period from delivery, a reline is allowed once per year as deemed necessary. A rebase will be covered 2 years (730 days) from the date of delivery of the dentures and then once every 2 years as deemed medically necessary. The MMIS is being enhanced to reflect all policy and procedure changes with the activation and/or addition of edits and audits.

Complete or partial dentures will not be replaced if lost or damaged for a period of 5 years from the time the dentures were first made.

In addition, up front Prior Authorization restrictions have been lifted for the Bitewing code, D0274 – (Four films). Please be sure to identify necessity for the bitewings at time of provision.

Limits for Bitewing services D0270 (Single film), D0272 (Two films) and D0274 (Four films) are once every calendar year, per client. D0274 continues to be limited to once per calendar year, per client, and cannot be performed with D0272 – Bitewings (Two films) on the same day per client.

As stated previously, although up front prior authorization will not be required, retroactive reviews will take place as needed.

Also please contact the Recipient Eligibility Verification (REVS) line 401-784-8100 to verify if a client has exhausted benefit use for complete or partial dentures.

Dental Boxes