Provider Update Newsletter

June 2001, Volume 104

All Providers

HIPAA Happenings
Timely Filing
Payment Schedule

Pharmacy Providers

DEA Numbers
Drugs Which Require PA
Novolin Billed By Millilters

Physician, Health Centers, Pharmacy Providers

Vaccines

HIPAA Happenings

The HIPAA Privacy Rule is final again !

However, Secretary Thompson says there will be some revisions to the current Rule over the next 30 days and so, we encourage you to visit HCFA’s Web site for the latest changes to this important legislation.

During the week of April 23, 2001, several DHS and EDS staff attended HCFA’s HIPAA Conference in Baltimore, MD. One of the major Agenda items discussed was the deployment and use of HCFA’s MHCCM – the Medicaid HIPAA Compliant Concept Model.

The model outlines Medicaid Business Processes and functionality's and includes a section on general administration and enterprise relationships. While your business may not need to evaluate every single item in the model, the model provides an excellent framework for evaluating the effects of HIPAA on your business.

We are also in the process of setting up HIPAA education and training seminars in order to apprise our local provider communities of DHS HIPAA Assessment activities and results that have occurred over the past several months.

We urge you to begin a formal HIPAA assessment and evaluation plan at your business in order to become knowledgeable of HIPAA impacts on your operations and the potential need to make system or policy changes before the effective HIPAA compliance dates.

Please contact the Webmaster if you’d like a “HIPAA – 101” presentation performed at your business or, if you need more information from DHS.

Timely Filing

Effective July 1, 2001. This is a federal requirement under 42 CFR 447.45 (d)(1).

EDS and the Department of Human Services are enhancing the Medicaid Management Information System (MMIS) to enforce a claim submission restriction of twelve (12) months from the last date of service provided to Medical Assistance clients. A claim for services provided to a Medicaid client, with no other health insurance, has to be received by EDS within twelve months of the through date of service in order to be processed for adjudication. Any claim with a date greater than twelve months will be denied for timely filing.

Claims that involve a third party payer must be submitted within twelve months from the date of payment of the other payer. This will be verified against the other insurance Explanation of Benefits (EOB). Any claim received with a date greater than the twelve months from payment of the other third party will be denied for timely filing.

In the situation of claims related to an accident, the claim must be received within the twelve-month period. The claim may suspend. If resolution of the accident claim exceeds the twelve-month period and payment is due, DHS will make payment provided that the suspended claim is in the system. If the claim is not submitted until after resolution of the accident and it is greater than twelve months, the claim will be denied for timely filing.

If you have claims that are aged and have not been submitted, you are advised to do so prior to June 30, 2001 to avoid the claim being denied.

Payment Schedule

1     Thursday Provider check date.
2     3-week cycle

DEA Numbers

Attention all Pharmacy Providers:
               
This is to inform you that due to internal issues arising during our latest DEA file update on 03/28/01, a number of prescribing physician DEA numbers were inactivated in error. Consequently a number of pharmacy claims denied inappropriately for invalid/missing DEA number, EOB 926 on the 04/20/01 RA.

The problem was identified and resolved on 04/16/01. Any claims submitted between 03/28/01 - 04/13/01 may have been subject to inappropriate denial. Denials received for invalid/missing DEA number, EOB 926, on the 04/20/01 RA should be resubmitted.

EDS apologizes for any inconvenience this issue may have caused.

Drugs Which Require PA

Prior authorization for all prescriptions and/or over the counter (OTC) drugs need to be obtained from the Department of Human Services at 401-462-6317.

Once the pharmacy receives the PA, the claim then needs to be billed on a paper Pharmacy Claim Form. If the pharmacy bills the drug electronically via POS, Provider Electronic Solutions, or EMC the claim will deny with an Error Status Code of 429 "NDC requires Prior Authorization".

Novolin Billed By Milliliters

When billing for the following NDC's please bill by the milliliter (ml) and not by the pre-filled cartridge.
A single box of 5 pre-filled cartridges would be 7.5 mls billed as 8 mls because our system does not accept the decimal point.

Drug Name	Strength	Units	NDC
NOVOLIN 70/30	70-30U/ML	1.5	00169-0017-71
NOVOLIN R	150U/1.5 ML	1.5	00169-0044-71
NOVOLIN N	100U/ML	1.5	00169-0045-71
NOVOLIN R	100U/ML	1.5	00169-1833-17
NOVOLIN N	100U/ML	1.5	00169-1834-17
NOVOLIN 70/30	70-30U/ML	1.5	00169-1837-17

                             

Vaccines

Attention Physician, Health Centers, Pharmacy Providers.

Effective immediately

Covered vaccines for “Fee-for-service recipients 21 and over” will no longer be reimbursable through the Pharmacy program.

Physicians, Clinics and Health Centers can now bill directly using the appropriate HCPC code.

Vaccines for children are covered through the Department of Health Program only.