Provider Update Newsletter
October 2001, Vol 108
All Providers
HIPAA Happenings
New Provider Services Manager
Customer Service Help Desk
RIteShare
Provider Representative Assignments
Provider Change of Information Form
Personal Care Providers
Personal Care or Combine Homemaker Services
Long Term Care Providers
TAD's Reminder
Waiver Providers
Emergency Response System
Home Care Providers
Pediatric Home Nursing Care
Mental Health Providers
Independent Licensed Mental Health Clinicians
HIPAA Happenings
It is now one year (October 16, 2002) to HIPAA compliance for Transactions and Code
sets. As time marches on, DHS and EDS are actively engaged in the development of a HIPAA
implementation plan to support HIPAA-compliant MMIS claims processing.
We are currently finalizing a solution that will ensure that the MMIS will be able to
accept and process HIPAA Transactions including the 837 Institutional, Professional and
Dental formats. We are also working on upgrading our REVS (Recipient Eligibility
Verification) System) in order to support the 270/271 eligibility request and response
Transactions. We are also working on the 276/277 health care claim status (request and
response) Transaction so our providers can access the most current information regarding
submitted Medicaid claims on-line. We are also working on a plan to upgrade our pharmacy
Point-of-Sale system to the new HIPAA-compliant version of 5.1.
We continue to offer HIPAA education and outreach to our provider community so they too
will be ready for the implementation of these Federally mandated standards. If your
organization wishes a HIPAA 101 seminar, please contact us at 462-6392.
New Provider Services Manager
Fran Daly has joined the Rhode Island EDS team as the Provider Service Manager. Fran
has been with EDS for 13 years and brings a wealth of healthcare experience. Prior to
moving to Rhode Island, she was a Project Manager for Delaware’s Health Benefits
Manager (HBM). The HBM serves as the enrollment broker for Delaware’s managed care
programs, including the Medicaid program and the Delaware Healthy Children Program. Fran
has overseen client enrollment, client education, and program outreach from
Delaware’s move to managed care in 1996 through the more recent implementation of the
Delaware CHIP program. Fran has also managed underwriting, customer service, and
collection teams for EDS, Northwestern Mutual Life, New England Life, and Cigna Insurance
Companies.
When asked why she came to Rhode Island, Fran replied, “The Provider Service Manager
position offered the opportunity to work with an EDS team that is excited and serious
about its commitment to the RI Medical Assistance Program and the Ocean State community. I
am also happy to have moved closer to my adult daughters, who live in Massachusetts.”
Fran envisions providing service excellence by doing what ever it takes to help the RI
medical providers and DHS staff meet the objective of delivering accessible, quality
health care to families and individuals. “We’re here to minimize the
administrative challenges for providers so they can focus on health care and
patients.”
Customer Service Help Desk
Please do not give out EDS Customer Service Help Desk (CSHD) phone number to
recipients. The help desk representatives are unable to assist the recipients with their
questions. Recipients should be directed to call their
local welfare office or Rite Care information line.
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.
Revised Provider Change of Information Form
Please keep this on file in case you need to notify EDS of any address changes, changes
in ownership, license action, or bankruptcy filing. Questions can be directed to the
Customer Service Help Desk at 1-401-784-8100 for local and long distance callers or at
1-800-964-6211 for long distance within Rhode Island and border communities. The form can
be downloaded from the Provider Form Page.
Descriptions of the address fields are listed below to assist you in completion of the
form:
Service Address: Location where services are rendered.
Pay-To-Address: Must be the same as on the W-9 form. If you want your check sent
to an address different from the one on your W-9, write your provider name; then on the
next line write "c/o" and the name and a address to which you want it sent.
Mail-To-Address: Indicate the address where all other program information should be
sent.
Billing Service Address: If using an outside billing service, enter the address and
telephone number of your billing service.
way to submit your Medical Assistance claims to EDS. Submitting your claims
electronically saves time, reduces clerical effort, eliminates mailing and paper
Provider Representative Assignments
The provider representative provider responsibilities can be viewed on the Provider Representative Lisitings Page.
Personal Care or Combine Homemaker Services
Procedures are as follows:
All clients must be assessed every six months.
Fax Cover Sheet must include the first and last name of the client , their Social Security
number, the fax number and name of person who sent the fax.
High Acuity:
Acuity starts on the date the Minimum Data Set (MDS) form is faxed or is received by mail.
In order to avoid interruption of the enhanced rate, the MDS form must be received prior
to the high acuity end date. Clients without acuity segments should be billed without the
CL modifier.
Low Acuity Clients:
Only the initial MDS form should be faxed to EDS. A change in the clients’
level of care requires a new MDS form to be submitted to EDS.
TAD's Reminder
Paper TAD's are due by 3:00 pm on the 5th day of each month unless otherwise specified
in the Provider Update for August 2001, Volume 106.
Electronic Billing of Long Term Care is due by 12:00 pm the Friday before the
disbursement date unless other wise specified in the Provider Update for August 2001, Volume 106.
Please refer to the Provider Update for August 2001, Volume 106
for more detailed information.
Failure to meet deadlines may result in delay of payment to the next scheduled Nursing Home Cycle.
Emergency Response System
Procedure codes W2630 (Emergency Response system Installation AD Waiver) and W5630
(Emergency Response system Installation DEA Waiver) NO LONGER require Prior Authorization.
If you have any questions, please contact Dana
Ciampanelli at (401) 784-3889.
Pediatric Home Nursing Care
As of September 1, 2001, DHS has streamlined the process for authorization of pediatric
private duty nursing and certified nursing assistant services. The highlights of
these changes are as follows:
- The Center for Child and Family Health (CCFH) clinician will continue to determine the
level of care and hours required for nursing and certified nursing assistant services.
Changes in clinical conditions should continue to be reported to the CCFH
clinician.
- Once services have been approved, EDS clinical staff will assume allocation of hours of
care between providers when more than one agency is involved in caring for a patient.
They will also be responsible for schedule changes, PA changes or corrections on an
ongoing basis. The EDS provider representative and clinical staff will continue to
provide support for billing and/or authorization related questions.
- Prior Authorization forms will no longer be required for certified nusring assistant
services ( X0087 and X0089 ).
- Pediatric Private Duty Nursing Services ( X0088, X0987 and X0988 ) will continue to
require a PA. Forms should be sent to EDS.
Independent Licensed Mental Health Clinicians
Independent licensed mental health clinicians are only authorized to provide mental
health services to Medical Assistance Recipients under the age of 21. Adult mental
health services for recipients over the age of 21 can only be received at Community
Mental Health Centers. If you have further questions, please contact the EDS provider
representative Michael Brandley at
(401) 784-3823.
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