Search

Provider Update Newsletter

September 2001, Volume 107
 

All Providers

HIPAA Happenings
Payment Schedule
Remittance Advice Interpretation
RIteShare

Homemaker Providers

Base Rate Reimbursement
Requesting Additional Hours

DEA Providers

Protocol for Resolving DEA Billing

Mental Health Providers

Documentation of Services

Pharmacy Providers

POS Claims Reversal Reminder

Assisted Living Providers

Award for Excellence

HIPAA Happenings

You may be aware that several House and Senate bills have recently been sent to Congress seeking an extension of HIPAA Rule implementation. While it’s becoming more likely that we will see some type of delay, the clock is still ticking on Transaction and Code Sets and Privacy compliance. Even if an extension is ultimately granted, it still behooves our Provider communities to begin down the path toward HIPAA compliance now.

As you are aware, the compliance date for Transactions and Code Sets is October 16, 2002. If you have not started an assessment of HIPAA impact on your business, you need to begin this immediately. Our DHS MMIS assessment has indicated the need for substantial system changes that we will be diligently working on for the next 14 months. It will still be a challenge to become fully HIPAA compliant considering the fact that there are still outstanding Final Rules to be published regarding HIPAA Security and National Identifier standards. However, even though CMS (formerly HCFA) is able to impose fines and sanctions for non-compliance, any due diligence efforts you make toward compliance will be viewed favorably.

Also, in some of our HIPAA 101 presentations to providers, we have heard that their expected solution to the Transaction and Code Set Final Rule will simply be to purchase new software. This is only a partial solution as billing staffs must also be aware of the new Code Sets required to populate the new Transaction Sets. While your current medical software vendor may provide you with HIPAA compliant billing software, you must make sure that your office staff is able to populate the required fields with the required Code Set standards. We suggest you contact your vendors to find out where they are in the HIPAA compliance process.

It will also be necessary to become compliant with the HIPAA Privacy Final Rule. The CMS Office of Civil Rights (OCR) has been designated as the Privacy compliance oversight entity. The OCR recently published Additional Guidance on the Privacy Rule, including FAQ’s. This Web site is also a good source of information regarding all facets of HIPAA Rulemaking.

SFY2002 Medicaid Program Payment Schedule

Providers 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 on the Friday of a processing cycle; nursing home paper claims are still due on the earlier designated date.

Below is the Processing and Payment Schedule for your reference.

1  Thursday Provider check day.
2  3-week-cycle

Month	TAD's Due	Nursing Home EMC Claims Due by 12:00 noon	Cycle Date	EDS Wire Transfer
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	2

Remittance Advice Interpretation

Enclosed is information to assist you with understanding the various sections of your Remittance Advice (RA). We have listed the names and descriptions of all sections of the RA. Any questions can be directed to the EDS CSHD.

BANNER PAGE — The first page of the Remittance Advice (RA) is the "Banner Page". Official Notices from the Department of Human Services and/or announcements from EDS may appear on this page.

·    Providers should read these messages carefully!

·    Banner messages can be customized by provider type

·    This is the most timely, efficient way to relay information

PAID CLAIMS (HCFA 1500) — This section of the RA reports new day, non-Crossover paid claims. A summary of the number of claims paid and the total dollar amount paid for the current payment period can be found on the last page of the Paid Claims section.

PAID CLAIMS (PROFESSIONAL CROSSOVER) — This section of the RA reports paid Crossover (X-Over) claims. A summary of the number of X-Over claims paid and the total dollar amount paid for the current payment period is found on the last page of the Paid Claims/Professional X-Over section. The last page of this section also reports the combined total number of X-over and non-X-Over paid claims and the total dollar amount.

DENIED CLAIMS (HCFA 1500) — This section of the RA reports denied claims. Three digit EOB (Explanation of Benefits) codes, also called ‘Finalized Claim Codes’, are provided to explain the denial reason. A list of applicable Finalized Claim Codes with detailed information is provided on the last page of the RA, the Earnings Data page.

SUSPENDED CLAIMS (HCFA 1500) — This section of the RA provides the status of suspended claims. Three digit Suspended Claim Codes, also known as ‘Error Status Codes’, are provided to explain the reason for a pending claim in process. A list of applicable Suspended Claim Codes with detailed information is provided on the last page of the RA, the Earnings data page.

PAID ADJUSTED CLAIMS - This section of the RA delineates the status of paid adjusted claims.

·    An adjusted claim is a claim that was previously paid and appeared in Paid Claims section of your RA (even if the amount paid was $0.00) and now requires changes and/or reprocessing to accurately reflect the services provided

·    The Adjustment Process requires the original claim to be recouped (withheld). The claim is reprocessed in the SAME financial cycle. If paid, the Net Adjustment Amount will reflect the difference (+/-) between the original claim and the adjusted version

·    The original claim, which shows how the claim originally processed, is displayed before the adjusted claim. The adjusted version shows the claim as processed following changes and/or reprocessing

·    The flower box at the end of the Adjusted Claims section 3, reports the number of original claims and the total original paid amount of the claims prior to being adjusted.

DENIED ADJUSTED CLAIMS -This section of the RA reports the previously paid claims that were denied when reprocessed as part of the Adjustment Process

·    The Adjustment Process requires the original claim to be recouped (withheld). The claim is reprocessed in the SAME financial cycle. If the claim denies, no new payment will be made to the provider and the original paid claim amount will be recouped

·    The first flower box 1, on the bottom of the last page of the Denied Adjusted Claims section shows the total dollar amount the claims originally paid prior to being reprocessed as part of the adjustment process

·    The second flower box 2, on the bottom of the last page of the Denied Adjusted Claims section shows the dollar amount related to original paid claims that either paid or denied when reprocessed in the adjustment process

SUSPENDED ADJUSTED CLAIMS - This section of the RA provides the status of adjusted claims that suspended when reprocessed. Recoupment to the original claim will not be applied (withheld) until the claim has been finalized (either paid or denied). Providers should not resubmit suspended adjustment claims until the claim has been finalized.

FINANCIAL ITEMS - The Financial Items section of the RA reports financial activities.

Voids, Refunds and Specific Claim Recoupments

Void: A financial transaction that is the result of a check returned from the provider resulting in the ‘voiding’ of all claims associated with the check.

Refund: A financial transaction that is the result of a provider writing and sending a check to EDS. Refund checks may be claim specific or non-claim specific. Claim related refunds result in the reversal of payment of a specific claim(s).

Specific Claim Recoupments: A financial transaction that is the result of a request to reverse payment of a claim with no subsequent processing.

Note: The above mentioned financial transactions will ONLY appear in the Financial Items section of the RA

The following codes are used to provide specific reasons for the set up of the above mentioned financial transactions:
048 Provider - Wrong Prov. Number
049 Provider - Wrong Recipient Number
050 Provider - Wrong Proc/Drug Code
051 Provider - Wrong Proc Modifier
052 Provider - Wrong Units of Service
053 Provider - Wrong Submitted Charge
054 Provider - Wrong TPL Payment
055 Provider - Duplicate Payment
056 Provider - Payment to Wrong Provider
058 Provider - Provider Misc. or Unspecified error

Miscellaneous Payout: A payment generated through either the system or manually.

The following are the reason codes pertaining to these types of financial transactions:

057 Provider - Miscellaneous Payout (system payout / interim payment)

040 DHS Adjust - Miscellaneous or unspecified Error (manual payout)

Miscellaneous payout amounts that are "set up" to be recovered will appear with the following reason code in the Financial Items section of the RA:

061 Recoupment of Provider Payout

Adjustments: A transaction that is the result of the take back (recoup) of a paid claim as part of the adjustment process.

Note: A specific code will be provided explaining the reason for the set up of this type of financial transaction.

All of the above mentioned financial transactions, with the exception of refunds, will appear again on the same or a future RA indicating that funds have been applied to the original set up amount. The amount being applied to the set up amount is indicated in the TXN AMT column on the Financial Items page of the RA. If funds are applied to a portion of the set up amount, the outstanding / remaining balance will appear in the BAL AMT column. The balance amount must be zero for the transactions to be considered complete. If not, the outstanding transaction(s) will be carried over to the next financial cycle where there may be additional funds to apply towards the balance amount.

Financial Transactions where funds are applied to the original set up amount are reported with a reason code of:

103 Recoupment Applied to Account Receivable

EARNINGS DATA - This section contains a financial summary for the current pay period that is listed for the RA date (in example 12/19/97); and year-to-date information. All finalized and suspended messages for the current RA are also listed. The information provided in each category is shown below. Examples are illustrated on the following page:

· No. of Claims Processed: Total number of paid and denied claims (new day, x-over, and adjusted)

· Claims Paid Amount: Total dollar amount processed (new day, x-over, and adjusted)

· System Payout Amount: Dollar amount paid out to the provider through an automated process

· Recoup Amount Withheld: Dollar amount withheld from the provider as a result of system payout, manual payout, or claim adjustments (mass/single adjustments + any claim specific recoupments)

· Payment Amount: Total dollar amount paid to the provider. This amount is determined by adding the ‘Claims Paid Amount’, plus (+) the ‘System Payout Amount’, minus (-) the ‘Recoupment Amount Withheld’

· Manual Payout Amount: Dollar amount paid out to a provider through a manual process

· Net Earnings: Claims paid amount, plus system payout, plus manual payout, minus recoupment, minus credit items

· Credit Items: Dollar amount related to any credit items. These include State void transactions, and refund transactions

Net Adjustment Amount: Total net adjustment amount from the adjusted claims processed (both adjusted paid and adjusted denied). This is a result of all positive and negative adjusted claims plus any denied adjusted claims. The total net adjustment may result in a positive or a negative.

RIteShare

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:
·    State code X0700 for reimbursement of co-payments.

DME only:
·    State 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 401-784-8100.

Home Health Base Rates

Below is a list of base Home Health Rates which became Effective July 1, 2001

Procedure Code	Description	New Base Rate Effective 7/1/2000
I2100	Homemaker Only - Non-Waiver (1 Hour)	$13.96
W1100	Homemaker Only - MR/DD Waiver ( 1 Hour)	$13.96
W2100	Homemaker Only - Aged and Disabled (AD) Waiver (1 Hour)	$13.96
I2101	Homemaker Only -1/2 Hour, Non-Waiver	$6.98
W1101	Homemaker Only -MR/DD Waiver (1/2 Hour)	$6.98
W2101	Homemaker Only -Aged and Disabled (AD) Waiver (1/2 Hour)	$6.98
W5101	Homemaker Only - Department of Elderly Affairs (DEA) Waiver (1/2 HOUR)	$6.98
W1400	Homemaker, LPN MR/DD Waiver	$30.17
I2200	Personal Care Only - Non-Waiver (1 Hour)	$14.88
W1200	Personal Care Only - MR/DD Waiver (1 Hour)	$14.88
W2200	Personal Care Only - AD Waiver (1 Hour)	$14.88
X0041	Home Health Aide, First Hour	$14.88
X0043	Home Health Nursing and Therapy Visits	$63.84
I2201	Personal Care Attendant - Non-Waiver (1/2 Hour)	$7.44
W1201	Personal Care Aid Only - MR/DD Waiver (1/2 Hour)	$7.44
W2201	Personal Care Only - AD Waiver (1/2 Hour)	$7.44
W5201	Personal Care Only - DEA Waiver (1/2 Hour)	$7.44
X0044	Home Health Aide, (1/2 Hour)	$7.44
I2300	Combined Homemaker/PCA - Non-Waiver (1 Hour)	$14.36
W1300	Combined Homemaker and Personal Care - MR/DD Waiver (1 Hour)	$14.35
W2300	Combined Homemaker and Personal Care - AD Waiver (1 Hour)	$14.35
I2301	Combined Homemaker/PCA - Non-Waiver (1/2 Hour)	$7.18
W1301	Combined Homemaker and Personal Care - MR/DD Waiver (1/2 Hour)	$7.18
W2301	Combined Homemaker and Personal Care - AD Waiver (1/2 Hour)	$7.18
W5301	Combined Homemaker and Personal Care - DEA Waiver (1/2 HOUR)	$7.18

Requesting Additional Hours

When you are requesting additional hours to an Existing Prior Authorization the steps are as follows:

    1. Use the original request for Prior Authorization
    2. Enter the approved Prior Authorization number on to the original request
    3. Enter the Words (Additional Requested Hours)
    4. Enter the number of Additional Hours you are requesting.
    5. Sign the Prior Authorization again and submit this to EDS.

Protocol for Resolving DEA Billing

Effective immediately, the Protocol for resolving DEA billing:

·    Vendors must address any problems with DEA claims with the EDS Customer Service Help Desk (CSHD) 401-784-8100

If the CSHD is unable to help, you will be referred to Dana Ciampanelli.
Dana will continue to work with vendors to resolve any difficulties.

DEA will NOT and can NOT accept requests from vendors to look into problems.
Please do NOT call or fax any information to DEA.

·    DEA will concentrate it efforts on completing an electronic link to EDS that will improve this process. Both EDS and DHS are assisting DEA in the process.

·    EDS will intensify efforts to provide vendor training and technical assistance. Vendors must be responsible for contacting Dana if new staff are assigned to billing and require training, or if existing staff needs help.

·    When we have had a chance to fully implement this system you will receive a satisfaction/feedback survey from DEA. If additional improvements are needed, they will be made.

If you have any questions please feel free to contact Dana Ciampanelli at 401-784-3889 or Kathy McKeon at 401-222-2858 ext. 202.
Thanks for your cooperation.

Documentation of Services

Documentation of services must include,

1. Recipient’s name or other identifying information on every page of the notes.

2. Narrative, summary or log entry of all services provided. “If a service is not documented then it did not happen”

3. Diagnosis that meets the DSM–IV as a primary diagnosis.

4. Type of service provided and or program name.

5. Attending provider’s signature with credentials, MD, RN, LISCW, BA, etc

6. Start and end time of services: this would include the actual units of time such as minutes and or hours of service.

7. Full dates of service.

8. Place of service.

Never leave any blank spaces on any progress notes.

Recipients who are on a Mobile Treatment Team cannot receive any other services that are billed to the Community Mental Health Medicaid Program. The exceptions to this are for occasional crisis services or for services specifically required to maintain an individual on Clozaril. Services billed for MTT clients beyond the scope of the MTT will be recouped.

Documentation for The Day Program (code X0343) must be sufficiently detailed to show that a client was in a day program and the amount of time for which Medicaid was billed on any given day.

If the Day Program services are recorded as a monthly summary, then full back up documentation such as attendance logs must also be maintained and made available for utilization review.

POS Claims Reversal Reminder

This is a reminder to Pharmacy Providers that the window of time in which a POS claim can be reversed has been increased.  Claims submitted and adjudicated from Saturday at 12:00 AM through Friday at 11:59 PM can be reversed up until FRiday night at 11:59 PM.

Award for Excellence for Affordable Assisted Living

NCB Development Corporation (NCBDC) and the American Association of Homes and Services for the Aging (AAHSA) present the 2nd annual Award for Excellent in the Affordable Assisted Living.

The award recognizes and disseminates operating examples of affordable, licensed or certified assisted living projects that exhibit excellence in services, environment, and support for aging-in-place.

To receive a call for entries, please send your contact information to Lindsay Maher or fax 1-510-496-0404.