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Provider Update Newsletter

August 2001, Volume 106

All Providers

HIPAA Happenings
RIte Share
Billing for RIte Share
Payment Schedule
Timely Filing
Database Maintenance Schedule
Documentation of Services

Ambulance Providers

Billing for Mileage

HIPAA Happenings

Over the past several weeks DHS has been meeting with our sister State
agencies as part of our HIPAA Enterprise Assessment. Our goal is to make
certain that we are aware of every touchpoint and interface that involves
“Individually Identifiable Healthcare Information” that is stored or transmitted
between our agencies. While we thought that we knew our common business
functions fairly well, we have discovered some nuances in our business
relationships that were not clear at the outset.

There are many interactions between our agencies that will also require
HIPAA attention in order to ensure that we become compliant with all aspects
of HIPAA regulation. We urge you to perform a similar assessment at your place
of business in order avoid fines, sanctions, or interruptions in service delivery to
our constituents.

Also of note, US DHHS Secretary Tommy Thompson recently announced the
restructuring of HCFA into the Center for Medicare and Medicaid Services (CMS).
The new configuration will be comprised of three Centers as follows:

Center for Beneficiary Choices (Medicare + Choice Program)
Center for Medicare Management (fee-for-service Medicare)
Center for Medicaid and State Operations (including S-CHIP)

They will continue to have oversight of HIPAA implementation.

In addition, CMS has recently posted a substantive set of answers to
“submitted questions” concerning HIPAA implementation on their primary
“Administrative Simplification Web site“.

Timely Filing

Under 42 CFR 447.45 (d)(1) the Medicaid Management Information System
(MMIS) will be enforcing 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.

Providers will have 365 days from the remittance date in which to re-submit for claims
that were denied by EDS and will need to be sent to the Provider Representative for
review and special handling. Paid claims that require adjusting must be submitted within
365 days from the original remittance date. Claims with unusual circumstances need to be
reviewed by the Provider
Representative.

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.

Payment Schedule

Month	TAD's Due	EMC Claims Due	Cycle Date	EDS Wire Transfer
June	6/5/01	6/8/01	6/9/01	6/15/01
		6/22/01	6/23/01	6/29/01
July	7/5/01	7/13/01	7/14/01	7/20/01	2
August		7/27/01	7/28/01	8/3/01
	8/6/01	8/10/01	8/11/01	8/17/01
		8/24/01	8/25/01	8/31/01
September	9/5/01	9/14/01	9/15/01	9/20/01	1,2
October		9/28/01	9/29/01	10/05/01
	10/05/01	10/12/01	10/13/01	10/19/01
November		10/26/01	10/27/01	11/2/01
	11/5/01	11/9/01	11/10/01	11/16/01
		11/23/01	11/24/01	11/30/01
December	12/5/01	12/14/01	12/15/01	12/20/01	1,2
		12/28/01	12/29/01	1/4/02
January	1/7/02	1/11/02	1/12/02	1/18/02
February		1/25/02	1/26/02	2/1/02
	2/5/02	2/8/02	2/9/02	2/15/02
March		2/22/02	2/23/02	3/1/02
	3/5/02	3/8/02	3/9/02	3/15/02
		3/22/02	3/23/02	3/29/02
April	4/5/02	4/12/02	4/13/02	4/19/02	2
May		4/26/02	4/27/02	5/3/02
	5/6/02	5/10/02	5/11/02	5/17/02
		5/24/02	5/25/02	5/31/02
June	6/5/02	6/7/02	6/8/02	6/14/02
		6/21/02	6/22/02	6/28/02
July	7/5/02	7/12/02	7/13/02	7/19/02

1     Thursday Provider check date.
2     3-week cycle

RIte Share

RIteShare members will be issued two cards - a commercial identification card
and a RhodeIsland MedicalAssistance 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 RIteShare 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 RIteShare?

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


How can I become a RIteShare 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 RIteShare Co-Pay Only Provider Enrollment Form, call EDS to
request a 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 accept 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 RIteShare, contact the Unit at 462-0311 or email us at:
RIteShare@gw.dhs.state.ri.us

Billing for RIte Share

When providing treatment to a RIteShare member, providers should deliver care
based on commercial benefit limits with individual carriers then bill that carrier
accordingly. For member co-payments, providers should bill RIMAP through EDS
using the following:

Physicians and Other Medical Professionals:
·    CPT code X0700 for reimbursement of co-payments.

DME only:
·    CPT code X0701 to bill for co-payments.

Hospitals/Home Health:
·    Utilize bill type 994 for reimbursement.

Pharmacies:
·    Bill on paper with the mock NDC 99999-1111-11.

RIteShare members are given two health insurance identification cards
·    one from their employer-based coverage,
·    one from the Medical Assistance Program.

RIteShare members can be identified through the REVS line by calling the Customer
Service Help Desk at 784-8100.

A packet outlining the details of the RIteShare Program was mailed to all providers
in late April.

If you did not receive this packet or if you need further assistance, please call
the Customer Service Help Desk at 784-8100.

Scheduled Database Maintenance

Scheduled Database Maintenance & POS

Scheduled database maintenance time is 15 minutes each morning between 5:30 AM-
6:00 AM and 12 times yearly on Sunday evenings, from 10:00 PM - 1:00 AM. During
these scheduled times, POS runs in Claims Capture mode which allows claims to be
submitted but does not automatically pay or deny claims. For your convenience, listed
below are the next 12 pre-scheduled Sunday dates in which POS will be in Capture Mode:

07/22/2001	01/20/2002
09/02/2001	02/17/2002
09/23/2001	03/31/2002
10/21/2001	04/23/2002
12/02/2001	06/02/2002
12/23/2001	06/30/2002

Documentation of Services

Recommendations from the SUR unit regarding documentation for medical
review and claims processing for unlisted procedure codes.

Medical records are frequently requested to evaluate services rendered to
recipients and to compare services billed to the medical record. Although this
information is well known to our providers, here are some reminders regarding
documentation of services.

Records documenting medical services rendered comprise many types of
information including but not limited to:

(a) identifying data such as the name, date of birth, or identification number of
the recipient and provider,
(b) recording the start and end times of units of service. For example,
CPST services,
(c) from and through dates of services incurred,
(d) types of services,
(e) fees,
(f) units of service
(g) description of service rendered,
(h) any assessment, plan for intervention, consultation, summary reports and/or
testing reports,
(i) signature of person rendering care with appropriate credentials (RN, PT, MD, etc)
(j) location of service, and
(k) any release of information obtained.

There should never be blank spaces on any progress notes. All lines on a medical
progress note should have data on them; blank lines should be crossed out to ensure
that entries can not beadded at a later date. Areas on forms which are not applicable
should be indicated as such,and NOT be left blank.

Providers must maintain accurate, current, and pertinent records of medical
services to a reasonable degree as required by the RI Medical Assistance Program.
Sufficient detail must be shown to permit planning for continuity in the event that
another practitioner takes over delivery of services, including, in the event of death,
disability, and retirement. In addition, providers must maintain records in sufficient
detail for regulatory and administrative review of service delivery of information arising
from their own delivery of services, or the services provided by others working
under their supervision.

Records may be maintained in a variety of media, so long as their utility, confidentiality
and durability are assured. All records, active and inactive, must be maintained safely,
with properly limited access, and from which timely retrieval is possible.

Remember, “if it’s not documented, then it did not happen”. Services that are not
documented or are inadequately documented are viewed as not rendered and can
be recouped.

Claims processing for “99” + “Unlisted Procedure” Codes


To ensure the timely processing of claims involving an unlisted procedure code, please
be sure that you include all the required documentation as an attachment. Failure to do
so will result in the claim being returned to you thereby delaying payment. Every effort is
made to review the claim with its attached documentation and process it as soon as possible.
Those claims lacking the necessary documentation will have to be returned to the provider
with a request for the required material before review can be completed.

Billing for Mileage

Ambulance Providers Billing for Mileage Ten Miles or Greater

Ambulance providers billing for mileage greater than ten miles should use a
combination of procedure codes A0888, “Non-Covered Ambulance Mileage”, which will
be zero paid, and A0425, “BLS Mileage (Per Mile)”. The following is an example of how
to bill appropriately for 12 ambulance miles when traveling from a physician’s office to
a non-hospital dialysis facility.