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Provider Update Newsletter

July 2002, Volume 117
 

All Providers

HIPAA Happenings
Provider Search Added to the DHS Website
Cost Sharing and Premium Assistance
Covered Services
Extended Family Planning Services

Physician Providers

Botulinum Toxin Type A

Home Health Providers

Nursing Home, Hospice and EPSDT

HIPAA Happenings

The Centers for Medicare & Medicaid Services (CMS) today announced the adoption of the
Employer Identification Number (EIN) as the standard unique identifier for employers in the
filing and processing of health care claims and other transactions. The standard unique identifier,
mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), will help
eliminate paperwork, simplify activities such as enrollment in health plans and payment of health
insurance premiums and save money overall. The final rule establishing the EIN as a standard
identifier is published in the May 31, 2002 Federal Register. The effective date of this final rule is
July 30, 2002. The EIN is issued and maintained by the Internal Revenue Service (IRS). Businesses
that pay wages to employees already have EINs.

As a result of today’s announcement, the EIN will be used in certain transactions for which the
Department of Health and Human Services (HHS) has adopted standards under HIPAA. For
example, the EIN would be used to enroll an employee in a health plan. Health plans, health care
clearinghouses, and health care providers that conduct standard electronic transactions will be
required to use the EIN if the employer needs to be identified in the transaction. Until now, health
plans, health care clearinghouses, and health care providers may have used different identification
numbers to identify the same employer when they conduct business. Having multiple identifiers for
a single employer slows activities such as health plan enrollment and premium payment.

CMS also announced today two Notices of Proposed Rulemaking (NPRM) that would modify
a number of the standards for electronic transactions adopted in 2000.

One NPRM would adopt two technical implementation specifications for electronic retail
pharmacy drug claims. The first set of specifications would adopt the National Council for
Prescription Drug Programs (NCPDP) Batch Standard Batch Implementation Guide, Version 1,
Release 1, which supports the second set of specifications, the Telecommunication Version 5.1 for
the NCPDP Data Record in the Detail Data Record. It also proposes to repeal the adoption of
National Drug Codes as the standard medical data code set for reporting drugs and biologics in
all standard electronic transactions except for retail pharmacy transactions.

The second NPRM relates to the ongoing activities of Designated Standard Maintenance
Organizations (DMSOs) to update and maintain HIPAA electronic transactions. The NPRM
proposes to adopt modifications to certain adopted standards that resulted from the (DSMO)
process. Drafts for these modifications have been published as addenda to the technical
simplification implementation guides. A full text of the draft addenda is available.

Each of these NPRMs has a 30-day comment period from the date of publication. Final rules will
be published after comments have been received and considered. More information about the
HIPAA standards is available by clicking on the following links:

Health and Human Services- Administrative Simplification

Centers for Medicare and Medicaid Services

- Medicare News, May 28, 2002.

Provider Search

Medical Assistance clients, providers, and community groups will now be able to locate a
provider supporting the MA program through a Provider Search function on the Department
of Human Services Website. People accessing the Website Provider Directory will be able to
search for a doctor by specialty and address. The Website Directory will help families to more
easily access care and benefit from medical and dental services. Since you are enrolled in our
program, we will include your name as an available provider; the listing will show your name,
specialty, address, and phone number.

We appreciate your participation in this initiative to help Rhode Island families access routine
and preventive care. However, if you do not wish to be included in the Website Provider
Directory, you must complete the section below and return it to:

EDS at 1471 Elmwood Ave. Cranston, R.I., 02857 or fax it to 401-467-9581.
Providers who do not return the statement below by July 1 , 2002 will be included in the
Website Provider Directory.

Thank you for your support of our program and for the services you provide Rhode Island
Medical Assistance families.

( ) I do not wish to have my name, service address and telephone number included in the
DHS Website Provider Directory.

_______________        _______________________         _______________
Name/Provider Number          Phone Number                         Date

 

Cost Sharing and Premium Assistance

Premium Collection/Cost Sharing

As of January 2002, families on RIte Care or RIte Share with incomes over 150% FPL ($27,150
for a family of four) have been required to pay a monthly premium for their RIte Care/RIte Share
(Medical Assistance) health coverage. The premium amounts range from $43 to $58 per month
depending upon their income. Cost sharing impacts approximately 10% of the RIte Care/RIte
Share population. Families with income below 150% FPL are eligible to receive RIte Care or
RIte Share at no cost.

Failure to pay two months of premium will result in disenrollment of that family from Medical Assistance
for a period of four months (pregnant women and children will not be discontinued for failure to pay).
Although 80-90% of our clients are current with their payments, there are a number of families who
have been disenrolled as a result of failure to pay. A number of those families have relayed to us that
they have other affordable coverage.

We have and continue to educate our members on this new responsibility and the importance of paying
on time. We ask that should you have the opportunity to discuss this issue with your patient, you stress
the same message. If you are interested in having written information on RIte Care/RIte Share Cost
Sharing, available to your patients, please contact DHS at (401) 462-3113 or fax your request to
(401) 462-6353, attention Premium Collection Unit.

RIte Share Premium Assistance Program

DHS presently has enrolled over 1500 members in RIte Share and this number continues to grow.
For these members, we are subsidizing their employer-sponsored health insurance instead of paying
100% of the cost under the RIte Care program. As we continue to identify RIte Care members who
work for employers who offer “DHS-approved” coverage, we will transition those members into their employer-sponsored insurance, providing them with additional benefits through the use of their Medical
Assistance card.

Just a reminder, RIte Share members will have two member ID cards---a commercial insurance
card and a white Medical Assistance card. Providers should bill the commercial carrier for the
reimbursement of the allowable charge for the service. For member co-payments, providers should
bill the RIte Share Premium Assistance Program through EDS using the following codes:

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: Via POS use the NDC dispensed and bill commercial co-pay in field 433 (patient paid amount)
or On paper with the mock NDC 99999-1111-11 and bill the commer cial co-pay in charge field

Click on the RIte Care and RIte Share Programs link for more information.  For specific information
on billing procedures for RIte Share members, contact the EDS Customer Service Help Desk
at 784-8100 (local and long distance) or (800) 964-6211 (border communities and in-state toll).

Covered Services

Persons eligible for the Rhode Island Medical Assistance Program are entitled to free choice
of participating physician (doctor of medicine or osteopathy) and other providers of medical
services and supplies within the scope of benefits, unless otherwise restricted.

Note: Inpatient hospital services are subject to admission screening and hospital utilization
review procedures. Outpatient hospital services are subject to hospital utilization review procedures.

1. The cost of abortion services is paid only when it is necessary to preserve the life of
the woman or when pregnancy is the result of rape or incest.

2. Organ transplant operations for kidney, liver, cornea, pancreas, bone marrow, lung,
heart and heart/lung are Medical Assistance services subject to DHS Medical Necessity
guidelines.

3. Hearing Aids and Molded shoes are excluded.

4. Substance abuse services are Limited to counseling and Methadone maintenance
services provided by centers licensed and funded by Division of Substance Abuse of MHRH.

5. For recipients age 21 and older, the following optometry services are limited to once
every two years: one refractive eye care exam; one pair of eyeglasses (frames, lenses,
dispensing fees).

6. For recipients age 21 and older, payment will be made for one fractive
eye exam in a two year period. Payment is not made for eyeglasses (frames, lenses,
dispensing fees).

Type of Service	Categorically Needy	Medically Needy
Inpatient Hospital Services (see note above)	Yes 1,2	Yes 1,2
Inpatient Psychiatric Hospital Services for those Age 65 and over or under 21	Yes	Yes
Outpatient Hospital Service (see note above) Clinic and Emergency Room	Yes 1,3	No
Laboratory and X-rays	Yes	Yes
Pharmacy	Yes	Yes
Physician Services	Yes 1, 2	Yes 1, 2
Pharmacy Services	Yes	Yes
Dental Services	Yes	Yes
Clinical Laboratory Services	Yes	Yes
Durable Medical Equipment,Surgical Appliances, And Prosthetic Devices	Yes	Yes 3
Certified Home Health Agency Services	Yes	Yes
Podiatry Services	Yes	No
Ambulance Services	Yes	Yes
Community Mental Health Center Services	Yes	Yes
Substance Abuse Services	Yes 4	Yes 4
Nursing Facility Services	Yes	Yes
Optometric Services	Yes 5	Yes 6
Intermediate Care Facility and Day Treatment Services for the Mentally Retarded	Yes	Yes

Extended Family Planning Services

Covered benefits for Extended Family Planning :

Gynecological Services	* Limited to no more than four office visits annually, one comprehensive Gynecological “annual Exam” and up to three additional family planning Method-related office visits, if indicated. * Pregnancy Testing
Laboratory	* Annual pap smear * STD screening if indicated * Anemia testing, dipstick urinalysis and urine culture, if indicated
Procedures	Covered benefit is limited to the following office/clinic/outpatient,If indicated: * Colposcopy, and cryosurgery or other cauterization of the cervix * Tubal ligation * Treatment for genital warts * Norplant insertion and removal * IUD insertion and removal * Incision and drainage of a Bartholin’s gland Cyst or abscess
Immunizations	Limited to postpartum rubella immunization, if indicated
Prescription and Non-prescription Family Planning Methods	Limited to 12-30 day supplies per year. Covered contraceptives include oral contraceptives, IUD, Norplant, cervical cap, diaphragm, and DepoProvera. Covered non-prescription methods include foam, condoms, spermicidal cream/jelly, and sponges. Emergency contraceptive pills, as necessary.
Referrals	Referral for other medically necessary services as appropriate/indicated, including but not limited to: * Referral to state STD clinic treatment, if indicated * Referral to state anonymous HIV testing and counseling sites, if indicated.
Follow – Up treatment	Gynecological services, laboratory testing procedures and pharmaceutical supplies needed due to complications from provision of a covered procedure or service. * Interpreter Services as necessary

NOTE: Services are covered on an outpatient basis only. In patient services
are not a covered benefit for the Extended Family Planning population.

Botulinum Toxin Type A

Please note the following change in billing restriction for procedure J0585

* Procedure code J0585- Botulinum Toxin Type A, per unit now requires prior authorization.

Nursing Home, Hospice and EPSDT

Nursing Home /Hospice Care Providers

When a recipient is in a Long-Term Care facility and receiving services from a Hospice agency,
the recipient status should be listed as a “05” (discharged to Hospice) on the monthly long-term care
claim. During the period the patient is receiving Hospice care and residing in the Nursing Home,
Rhode Island Medicaid should NOT be billed by Long-Term Care facilities. The Nursing Home
should bill the Hospice provider and the Hospice provider will bill Rhode Island Medicaid. Should
you have further questions, please contact Dana Ciampanelli at (401) 784-3889.

Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Nursing Schedules are required only when MULTIPLE nursing agencies are involved with a child.

In order to process Prior Authorizations more efficiently, in particular for those clients utilizing
more than one agency, please forward copies of your agency’s nursing schedules to Anne Roach
at DHS.

This process should be used when requesting approval for procedure codes:

X0088 (EPSDT NURSING SERVICES - PEDIATRIC PRIVATE DUTY NURSE)
X0987 (EPSDT NURSING SERVICES - PEDIATRIC PRIVATE DUTY - 2ND CHILD)
X0988 (EPSDT NURSING SERVICES - PEDIATRIC PRIVATE DUTY - 3RD CHILD)

and only when multiple nursing agencies are involved with a child. It is understood that nursing
schedules may be incomplete when you are sending the authorization request. However, this
process will offer further structure to the authorization process. This change became effective
05/01/2000. Should you have questions, you may contact Anne Roach at (401) 462-6370.