Provider Update Newsletter
May 2002, Volume 115
All Providers
HIPAA Happenings
Introduction to Medicaid Billing
Cost Sharing in the RIte Care & RIte Share Programs: Update
RIte Share Premium Assistance Program
EMC Submission Information
Prior Authorization (PA) Request Information
Pharmacy Providers
Attention
Long Term Care Providers
Billing Cut Off Dates and Time Updates
Home Health Providers
Procedure Code X0088
Minimum Data Set
HIPAA Happenings
CMS published revisions to the HIPAA Privacy on March 21, 2002, that will affect the
regulations due to go into effect on April 14, 2003. The following highlights have been
reprinted from CMS’ Web site. For a complete text of the revisions, please visit www.hhs.gov/ocr/hipaa.
Strengthen notice provisions and remove consent requirements hindering access
to care. As written, the privacy rule's general requirement that patients give
prior consent on privacy practices before receiving treatment created serious unintended
consequences that interfere with patients' access to health care. For example, patients
could be required to visit a pharmacy in person to sign paperwork before a pharmacist
could fill their prescriptions. Similar barriers could arise when a patient is referred to
a specialist and in other situations. In addition, doctors could refuse to treat patients
who refused to sign their privacy consent form. To fix these problems, the proposal would
promote access to care by removing the consent requirements for treatment, payment, and
health care operations that could interfere with efficient delivery of health care, while
strengthening requirements for providers to notify patients about their privacy rights and
practices. Patients would be asked to acknowledge the privacy notice, but doctors and
other providers could treat them if they did not. This change would ensure that patients
can consider a provider's privacy policies before making health care decisions, but would
eliminate barriers to patients' access to care.
Maintains the "minimum necessary" rule, while allowing
treatment-related conversations. By covering oral communications and limiting the
use of personal health information to the "minimum necessary," the privacy rule
raised concerns that routine conversations between doctors and patients, nurses and others
involved in a patient's care could violate the rule. This could stifle essential
communication necessary to provide the highest quality care possible. Today's proposed
changes would continue to cover oral communications and maintain the "minimum
necessary" requirement, but would make clear that doctors could discuss a patient's
treatment with other doctors and professionals involved in their care without fear that
their conversations could lead to a violation. As long as a covered entity met the minimum
necessary standards and took reasonable safeguards to protect personal health information,
incidental disclosures - such as another patient hearing a snippet of conversation --
would not be subject to penalties. Improper disclosures would still violate the rule.
Assures appropriate parental access to their children's records. The
current rule may have unintentionally limited a parent's access to their child's medical
records. The proposal clarifies that state law governs disclosures to parents. In cases
where state law is silent or unclear, the revisions would preserve state law and
professional practice by permitting a health care provider to use discretion to provide or
deny a parent access to such records as long as that decision is consistent with state or
other law.
"These are common-sense revisions that eliminate serious obstacles to patients
getting needed care and services quickly while continuing to protect patients'
privacy," Secretary Thompson said. "For example, sick patients will not be
forced to visit the pharmacy themselves to pick up prescriptions -- and could send a
family member or friend instead. Doctors will be able to consult with nurses and others
involved in a patient's care to ensure that they get the best care." The proposal
also would make other revisions to simplify the rule's paperwork requirements while
preserving the rule's strong privacy protections. The changes reflect Secretary Thompson's
commitment to making regulatory requirements simpler and easier to implement - without
reducing their effectiveness.
Introduction to Medicaid Billing
Does the idea of Medical
Assistance billing challenge you? Are you
questioning which fields need to be completed on the claim form? If so, we have the workshop designed especially
for you.
Come learn all you need to
know about billing Medical Assistance. You’ll
see how easy it is to verify eligibility by phone or computer, submit a claim either on
paper or electronically, interpret a remittance advice and much more.
If this sounds like it would interest you then, please join
the EDS Provider Representatives for our Monthly Billing Workshop. The next sessions will
be held on: May 21, June 25, July 23 and August 22. For your convenience there are two to
choose from, the morning session will be from 9am to 12pm or the afternoon session will be
from 1pm to 4pm. Both will be held at 1471 Elmwood Ave. Cranston, RI.
Please notify us by telephone at 401-784–8100 if you
are interested in attending; our customer service representatives will put you through to
your Provider Representative for scheduling. If you have a particular interest in a topic
please let your representative know when you call.
Cost Sharing in the RIte Care & RIte Share Programs:
Update
Beginning in
December 2001, enrollees with income over 150% of the Federal Poverty Level
(FPL),/($27,150 per year for a family of four) in the RIte Care and RIte Share programs
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 are subject to
this cost sharing. Members under 150% of the FPL 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 at 784-8100 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 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.
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).
EMC Submission Information
The EDS Systems Support department would like to pass along some helpful information
regarding the submission of electronic claims.
1. Please put you provider name and number on both the transmittal
control sheet and the diskette. This makes it easier to ensure that the correct sheet
stays with the correct diskette.
2. Check to see what other file(s) are on the diskette before the
claims are submitted. Duplicate files, “temp” files, as well as Microsoft Word
and Excel files on the same diskette as the electronic claims submission have been seen in
recent months.
3. Check to see that the “Total # of Claims” is the sum of
each of the “Number of Claims”. This is especially important if more than one
file is intended to be submitted or if submitting file(s) under multiple provider numbers.
Prior Authorization (PA) Request Information
There have been an overwhelming number of Prior Authorization (PA)
requests received which have missing or invalid documentation resulting in the request
being returned to the provider (RTP). The following information should help to expedite
the PA process and minimize the number of RTP’d PA requests. A Certificate of Medical
Necessity (CMN) approved by Medicare or Medicaid, depending on the service being
requested, must be completed by the prescribing physician and must accompany the PA
request.
When submitting a PA for oxygen and/or nutrition please use the Medicare
approved CMN. It must be filled out completely and signed by the prescribing physician.
For all other Durable Medical Equipment please use the Rhode Island
Department of Human Services Medical Assistance CMN found in your provider manual. This
CMN must be filled out completely and signed by the prescribing physician.
Rhode Island Medicaid timely filing guidelines apply to all PA requests.
Requests, which are greater than 365 days old will be returned to the provider, although
extenuating circumstances may be taken into consideration.
Tips to expedite the PA process:
1. Complete, sign and date a Medical Assistance PA form.
2. Obtain a completed and signed CMN from the prescribing physician.
3. Attach all related Price lists for Wheelchairs, Ramps, Assistive
Devices, etc.
4. Provide any supporting Medical documentation
Attention
In accordance with Rhode Island Medicaid Pharmacy Services Policy page
300-60-17 for POS claims and page 400-10-3 for paper claims the correct location code
(LOC) is a required field when billing for pharmacy claims. The LOC code is used as part
of the methodology to determine the dispensing fee as well as an important identifier
during the Surveillance Utilization Review (SUR) process.
Please use the following NCPDP location codes when submitting a POS claim:
00 – Not Specified
01 – Home
02 – Intermediate Care
03 – Nursing Home
Please use the following location codes when submitting paper claims:
1 – Walk-In
2 – Nursing Facility
3 – ICF/MR
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”
Billing Cut Off Dates and Time Updates
When billing your Long Term Care Claims ELECTRONICALLY, please bill your claims ON or
BEFORE the following cut off dates and times.
| DAY |
DATE |
BEFORE |
| Thursday |
May 9, 2002 |
12:00 PM |
Thursday |
June 6, 2002 |
12:00 PM |
When billing your Long Term Care Claims on PAPER please
bill your claims ON or BEFORE the following cut off dates and times.
| DAY |
DATE |
BEFORE |
| Monday |
May 6, 2002 |
3:00 PM |
| Wednesday |
June 5, 2002 |
3:00 PM |
Procudure Code X0088
Skilled Pediatric Home Health Nursing Provider
Rates Effective 7/1/01 for Procedure Code X0088
| DS (RN-days) |
$32.95 |
DL (LPN-days) |
$30.89 |
| ES (RN-eves) |
$35.00 |
EL (LPN-days) |
$32.95 |
| NS (RN-nts) |
$38.10 |
NL (LPN-nts) |
$33.98 |
| WS (RN-w/e) |
$38.10 |
WL (LPN-w/e) |
$33.98 |
| HS (RN-hol) |
$51.48 |
HL (LPN-hol) |
$46.33 |
Mimium Data Set
Personal Care/ Combine Providers Participating in Enhanced Payment Program
Minimum Data Set (MDS) Modified for client acuity.
ALL clients must be assessed every SIX MONTHS.
Fax Cover Sheet MUST include the following information
· First and Last Name of the Client
· Client’s Social Security Number
· Return Fax Number
· Name of contact the Fax is returned back to
· Both MDS forms must have client’s name and SS#
LOW ACUITY CLIENTS
· ONLY the INITIAL MDS form should be faxed to EDS
· CHANGE in the clients level of care ( making them
high acuity) should be faxed to EDS
HIGH ACUITY CLIENTS
· High Acuity Effective date begins on the date the fax or mail form
is received by EDS
· Update MDS must be received prior to the end date of Acuity
Fax Number (401-941-7712)
Attention: Prior Authorization Department
Mail to: EDS
PO Box 2006
Warwick, RI 02886
Attention Prior Authorization Department
Note: When billing with a
SHIFT DIFFERENTIAL
With HIGH ACUITY
The Shift Differential Modifier is always in the FIRST MODIFIER FIELD on the claim
HIGH ACUITY and no SHIFT
DIFFERENTIAL,
The HIGH ACUITY MODIFIER is always
in the first modifier field.
|
