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Provider Update Newsletter

April 2002, Volume 114
 

All Providers

HIPAA Happenings
GPA Benefits
RIte Care & RIte Share Programs
EDS Provider Representatives
Randon Drug Screenings
Timely Filing
Documentation of Services
Billing Tips

Pharmacy & Prescribing Physician Providers

Maintenance Medications Policy Reminder

HIPAA Happenings

As we’ve mentioned previously, compliance with HIPAA Transaction and Code Sets has been extended to October 16, 2003 for most providers – certain smaller providers have until October 16, 2004. The extended deadline now gives affected entities longer to implement required system changes, however, widens the gap during which providers can go “live” with their HIPAA compliant systems. It is likely that some payers, insurers and carriers will stagger implementation of discrete Transaction Sets instead of going live with all of them on October 16, 2003.

As example, DHS is planning to implement the new version of Pharmacy POS – NCPDP v 5.1 later this year – well before mandated compliance. In order to eliminate the need of running two (dual) POS processing systems, i.e., the “old” version 3.2 and the new 5.1, it means that our pharmacy trading partners will need to be on a similar track in order for us to test examples before switching over.

We are in the process of refining and finalizing our HIPAA Transaction and Code Set remediation, testing and implementation timeframes and working with several providers and insurers to coordinate implementation. If you need further information about HIPAA and how it may affect your business, please call us at 401-462-6392. We encourage you to visit the below-listed Web sites to obtain even more detailed information.

US Department of Health and Human Services
Centers for Medicare and Medicaid Services
Washington Publishing Company
Workgroup for Electronic Data Interchange
American Hospital Association
DHS HIPAA Page

GPA Benefits

The scope of General Public Assistance benefits are limited. The following list offers those codes that are covered by GPA. Should you have any questions if a procedure is covered please call the Customer service Help Desk at 784-8100 or 1-800-964-6211.

GPA COVERED PROCEDURE CODES
99201	Office or other Outpatient visit for the evaluation and management of a new patient.
99202	Office or other Outpatient visit for the evaluation and management of a new patient.
99203	Office or other Outpatient visit for the evaluation and management of a new patient.
99204	Office or other Outpatient visit for the evaluation and management of a new patient.
99205	Office or other Outpatient visit for the evaluation and management of a new patient.
99211	Office or other Outpatient visit for the evaluation and management of an established patient.
99212	Office or other Outpatient visit for the evaluation and management of an established patient.
99214	Office or other Outpatient visit for the evaluation and management of an established patient.
99215	Office or other Outpatient visit for the evaluation and management of an established patient.
99217	Observation Care discharge day management.
92002	Opthalmological Services : Medical Examination and evaluation with initiation of Diagnostic and treatment program: intermediate, new patient.
92004	Opthalmological Services: Medical Examination and evaluation with initiation of Diagnostic and treatment program: comprehensive, new patient, one or more visits.
92012	Opthalmological Services : Medical Examination and evaluation with initiation or Continuation of Diagnostic and treatment program: intermediate, established patient.
92014	Opthalmological Services : Medical Examination and evaluation with initiation or Continuation of Diagnostic and treatment program: comprehensive, established patient, one or more visits.
A4253	Diabetic Supply
A4255	Diabetic Supply
A4258	Diabetic Supply
A4310-A4421	Diabetic Supply
A5051-A5149	Diabetic Supply
E0607	Diabetic Supply
E0609	Diabetic Supply
K0277-K0281	Ostomy Supply
K0407-K0411	Ostomy Supply
K0419-K0439	Ostomy Supply

RIte Care & RIte Share Programs

Cost Sharing in the RIte Care and RIte Share Programs: Update

Beginning in December 2001, enrollees over 150% of the Federal Poverty Level (FPL),/($26,475 per year for a family of four) in the RIte Care and RIte Share program began receiving bills for their health insurance coverage through the Medical Assistance Program. The cost varies depending on a family’s income, however, the range is between $43 and $58 per month. Approximately 10% of the RIte Care and RIte Share membership will be subject to this cost sharing. Members under 150% of the FPL will continue to receive health insurance through Medical Assistance at no cost to them.

The timeliness of payment is important because a family who fails to pay two months of premium will be discontinued from their Medical Assistance health insurance coverage for a period of four months. Providers are encouraged to always check with the REVS line to see if a client or patient is eligible for Medical Assistance. Please note that pregnant women and infants under one year will not be discontinued from coverage for failure to pay.

RIte Share Premium Assistance Program

The Department of Human Services, as mandated by legislation, has also implemented the RIte Share Premium Assistance Program. This program provides coverage to eligible families who have access to qualifying employer coverage by enrolling them in their employer’s plan. DHS pays the monthly employee share of that coverage, either by paying the employer or the employee.

Participants in the RIte Share Premium Assistance Program are eligible to receive additional Medical Assistance benefits that are part of the RIte Care benefit package but not typically offered through employer-sponsored plans. These include office visit and pharmacy co-pays, transportation (usually bus transportation) and interpreter services. (To arrange transportation and interpreter services, the client should call (401) 459-6659.) When obtaining services, a RIte Share member should always present two identification cards---the commercial insurance ID card and the Medical Assistance ID card.

For more information on the RIte Care and RIte Share Programs, please check the Department of Human Services website at www.dhs.state.ri.us or call the RIte Care/RIte Share Info Line at 462-1300 or 462-5300 (English) or 462-1500 (Spanish). For specific information on billing procedures for RIte Share members, please contact the EDS Customer Service Help Desk at 784-8100 (local and long distance) or (800) 964-6211 (border communities).

EDS Provider Representatives

To find your representative, click on the following link. Provider Representatives

Random Drug Screenings

Services that are not medically necessary to treat the patient’s condition, or are not directly related to the patient’s diagnosis, symptoms or medical history are not reimbursable under the Medical Assistance Program.

Random drug screenings are not billable to the Medical Assistance Program; request for reimbursement for these services should be directed to the agency requesting the testing..

Timely Filing

Please include a copy of your Remittance Advice when submitting claims for timely filing that have denied within the year. This information will improve processing time for these submissions.

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 include but are 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 cannot be added 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 proper 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 Tips

Did you know that approximately 20% of all claims received by EDS are returned to the provider due to two reasons? The first is the Billing Provider original signature is missing or invalid. The second is that the Provider Number is illegible, missing or invalid.

These are not issues when billing electronically!

For a copy of our free Provider Electronic Solutions software package, which includes free installation, training, and handbook, please call the Customer Service Help Desk at (401) 784-8100 directly, or at 1-800-964-6211 for long distance within Rhode Island and border communities.

Tips to speed your claims through without them being returned:

·    Do NOT use staples or tape on claims or on any attachments that accompany the claims (the claims are taken out of the envelopes in the order they were put in – attachments are retained behind each claim, so there is no need to staple or tape them)
Staples or tape may damage your claims as well as EDS’ scanning equipment.
·    Be sure all details on an EOMB are legible.
·    Remove any carbon paper from claims.
·    White out is acceptable on claims.

Electronic billing has faster turnaround time, saves on postage, eliminates data entry errors, has a lower suspense rate, and improves your office productivity.

 

Maintenance Medications Policy Reminder

Below are policy reminders regarding the refill of Maintenance Medications as well as the corresponding edits and descriptions. Detailed policy is found in section 300-60-8 through 300-60-9. Please note that recipients residing in Long Term Care Facilities having an active Long Term Care Eligibility segment at the Date of Dispense (DOS) are exempt from the following policies. In the event that Medicaid is secondary to another primary insurance (having a 30 day maximum supply policy) and until an automated solution is achieved, providers are asked to submit on paper attaching the payment EOB/screen print of the primary insurer. Paper claim submissions will be reviewed and the edits will be by-passed when appropriate.

Maintenance Medications Quantity/ Days Supply Policy Reminder
The following categories of medication are considered maintenance and are required to be
dispensed in specified quantities:

·    Anti-diabetic preparations (including insulin and needles and syringes).
·    Anti-convulsants (excluding barbiturates, benzodiazepines).
·    Anti-hypertensives
·    Cardiovascular preparations (excluding patches, oral solutions)
·    Diuretics (excluding oral solutions)
·    Hormones (excluding patches and medroxyprogesterone)
·    Thyroid preparations
·    Vitamins, hematinics

The original prescription may be dispensed in the quantity that the prescribing provider indicates on the prescription. Refills are to be dispensed in quantities of 100 tablets, capsules or one (1) pint of liquid or a 30-day supply, whichever is greater, to a maximum of 200 capsules or tablets or pint of liquid.

As of February 9, 2002, a newly created edit & denial reason code, 651, Drug Quantity and/or Days Supply Less Than Minimum Quantity

Maintenance Medications Quantity Policy Reminder
The following maintenance medications must be dispensed in quantities of 100 capsules or tablets or one (1) pint of liquid at all times: Vitamins, Hematinics, and Nitroglycerin (excluding patches). Prescriptions for quantities of less than 100 or one (1) pint of liquid require Prior Authorization.

As of December 16, 2001, a newly created edit & denial reason code, 666, Billed Quantity not Within Drug Rx Minimum/Maximum Values, was implemented as enforcement to the maintenance medications policy.