Search

Provider Update Newsletter

September 2002, Volume 119 

All Providers

HIPAA Happenings
Provider Electronic Solutions
Timely Filing
Helpful Hints
Enrollment of Children with Special Needs
Payment and Processing Schedule

Pharmacy Providers

Drug Utilization Review (DUR) Alerts
Early Refill Override Form

Long Term Care Providers

EMC Schedule

Home Health Providers

Personal Care/ Combine Providers Participating
in Enhanced Payment Program

 

HIPAA Happenings

HIPAA Transaction and Code Set Extension Form

As you’re aware, the date for compliance with the HIPAA Transaction and Code
Set Final Rule is now October 17, 2003. However, CMS requires that all covered-
entities that will not be compliant with this Rule by October 17, 2002, that’s this year,
file an Extension Request with them by October 16, 2002. CMS also prefers that the
Extension Request Forms be filed electronically However, if you need to file a paper
Extension Form, please call us at (401) 462-6392 and we will mail one to you.
Please note that RI DHS Medicaid will be filing an Extension Request Form as we
will not have all HIPAA Transactions and Code Sets in place by October of this year.

HIPAA Joint Communication

Over the past several months, DHS and EDS have been working with the State’s
major insurers and Provider Associations on a joint effort aimed at coordinating
HIPAA Rule implementation and outreach. You will receive an initial communication
that details our upcoming training opportunities and a draft HIPAA Transaction Set
implementation schedule. Please contact us at (401) 462-6392 if you have any
questions or comments regarding this effort.

HIPAA and Local Codes

As we mentioned, RI DHS Medicaid will be filing a Transaction and Code Set
Extension Request Form. One of the reasons for this request concerns the
elimination of Local Codes from Medicaid (and other insurers) billing and reimbursement
procedures. DHS is currently crosswalking our Medicaid Local Codes to the national
Code Sets and will perform financial analyses to ensure that provider reimbursements
reflect current Medicaid policy and budget allotments. We anticipate that publication to
our provider communities of revised Medicaid “Local Code” billing standards and procedures
will occur in the spring of 2003. Until that time, Medicaid Local Codes will be accepted
for submission for payment.

HIPAA NCPDP 5.1 and 1.1 batch Pharmacy Transaction

DHS will be ready to implement the new HIPAA on-line (POS) pharmacy Transaction
Set on October 17, 2002. Surveys of our pharmacy providers have indicated that most
all will be ready for the new standard this year. If you anticipate that your organization will
not be ready this year, please call us at (401) 784-3818. You may also call us at this number
to set up testing of the new standards with your pharmacy.

HIPAA Privacy Final Rule at DHS

RI DHS has recently formed a Department-wide Privacy Workgroup for the purpose
of ensuring that all policies, protocols, and operations conform to Privacy Final Rule
regulation (compliance due April 14, 2003). Over the next several months, we will be
outlining Minimum Necessary definitions relating to the release of Protected Health
Information (PHI) to our various constituencies and Business Partners. We will also be
reviewing and standardizing our various legal contracts and Data User Agreements to make
sure our healthcare partners have policies and procedures in place to ensure the protection
of Medicaid Program enrollees’ PHI.

CMS HIPAA Outreach

CMS has recently published a schedule of HIPAA outreach visits in the New England region.
CMS will be on-site in Rhode Island on Monday, September 9, 2002, from 3:00 – 6:00 pm,
at the Arnold Conference Center in the Regan Building of the Eleanor Slater Hospital. The
session is free and open to any interested organization or individual.

Provider Electronic Solutions

Are you making an upgrade to your computer? If you are using Provider Electronic Solutions
to submit claims to Medicaid electronically please note the following:

When upgrading your computer be sure you have a copy of your Password and Logon ID
to re-enter if you should need to re-install PES software

Verify if dialing 9 is required to obtain an outside telephone line; if dialing 9 is not required
remove the 9 from the telephone number listed under Tools, Options and Carrier in your
software

You can copy your Data Base prior to deleting the software from your computer

To locate your database follow these steps:

   Click on My computer, C drive, RIPES 32,

    Locate the folder below
          rinewecs.mdb.

   Copy on a diskette or into another directory

    Archived data is stored in a compressed file in the archive folder,
    arch extension

   Copy on to a diskette or into another directory

If you should have any questions regarding Provider Electronic Solutions please contact
your Provider Representative at 401-784-8100.

Timely Filing

Criteria for overriding the timely filing edit are: retroactive client or provider eligibility
(within the year), previous denial or recoup within 12 months.

Claims that involve a third party payer must be submitted twelve months from the date
of payment of the other insurance payer. This will be verified by the other insurance
Explanation of Benefits (EOB). Any claim received with a date greater than the twelve
months from payment of the other insurer will be denied for timely filing.

Adjustments to a paid claim will be accepted up to twelve months from the remittance
advice date that the original claim payment was posted to.

If you have determined that your claim meets the criteria to override timely filing edit please
send your claim in on paper to your provider representative. When sending in these claims for
review please include a copy of the RI Medicaid remittance advice showing denial within a
year from the date of service or with an explanation. This will improve the turn around time
on processing of your timely filing claims.

Should you have further questions please call the CSHD at 401-784-8100 or for in state toll
calls and bordering communities 1-800-964-6211.

Helpful Hints

DHS Holiday Schedule for 2002

Labor Day	September 2, 2002
Columbus Day	October 14, 2002
Election Day	November 5, 2002
Veteran’s Day	November 11, 2002
Thanksgiving Day	November 28,2002
Christmas Day	December 25, 2002

When Calling the CSHD

To help service your call in a timely manner, please have the following information available
when calling the Customer Service Help Desk:

    Your Rhode Medical Assistance Provider Identification Number
    The client’s Medical Identification number
    The correct spelling of the client’s first and last name
    The dates of service of which you are billing

Enrollment of Children with Special Needs

Since 1998, the Department of Human Services has lead a concerted effort to improve
the health care delivery system of children with special needs who have Medicaid coverage.
CEDARR Family Centers are one outcome of this effort. Beginning this Fall 2002, another
major effort to improve services for these children is underway- enrollment into RIte Care,
Rhode Island’s Medicaid managed care program.

Children with special needs who have Medicaid (fee-for-service) coverage include:
children with SSI eligibility; children eligible for Medicaid through the Katie Beckett provision;
and children in DCYF’s adoption subsidy program. Approximately 6,000 children will be
enrolled into a RIte Care health plan. (Children with special needs who have other commercial
health insurance will continue with that coverage and will not be enrolled into RIte Care.)

Enrollment will occur gradually over a period of six months beginning this September.
Families will be able to select a health plan of their choice for their child. The Department
will provide enrollment information and assistance for families. Eligibility and benefits
will not change.

For more information on this enrollment and the Department’s CEDARR initiative,
please click on the following link Children with Special Needs. The Department has also
set up an email address: special@gw.dhs.state.ri.us

For more information, families can call: Family Voices at (401) 727-4144
ext. 62 (English) or ext. 41 (Spanish).

Payment and Processing Schedule

The claims processing and payment cycles for June 2002 - July 2003 can be viewed
on the Payment and Processing Page.

Drug Utilization Review (DUR) Alerts

Drug Utilization Review (DUR) Alert Claim Denial Program

The Rhode Island Department of Human Services has developed system modifications for
implementation of a DUR Alert Claim Denial Program. Denial of Early Refill and Therapeutic
Duplication DUR Alerts began on Monday, July 22, 2002. This program is designed to
recognize and utilize the professional judgment and intervention skills of pharmacists.

Early Refill DUR and Therapeutic Duplication Alerts

If a claim for a refill is submitted before 80% of the prior prescription is used that claim will
be denied (this is a decrease from the 85%). Drugs within therapeutic duplication alert categories
will also be denied. To override these denials, the pharmacist submitting a claim through POS
must initiate a DUR Alert Override using valid intervention and outcome response codes.

Valid intervention and outcome codes must be entered in order for the claim to be paid. These
codes are selected based on the pharmacist’s professional judgment and assessment, and may
involve contacting the prescriber to obtain more information before a code is used.

Current valid intervention and outcome codes:

INTERVENTION CODES
M0	Prescriber Consulted
MR	Medication Review
P0	Patient Consulted
PM	Patient Monitoring
PH	Patient Medication History

 

OUTCOME CODES
1C	Filled, With Different Dose
1D	Filled, With Different Directions
1G	Filled, With Prescriber Approval
3C	Discontinued Drug
3D	Regimen Changed
3E	Therapy Changed
3H	Follow-Up/Report

Please Note: The correct code for a lost or stolen prescription is 3H. The attached
form must be completed and kept on file. This form must be made available for
auditing purposes.  If no code has been entered, or if an invalid outcome and intervention
code is used, the claims will remain denied and no payment will be made.Please note that
those wishing to override an alert must do so within 3 days of receipt of the denial. Providers
trying to override an alert beyond the 3 day time period will receive a message of “no
corresponding claim; please resubmit”.

Therapeutic Classes exempt from hitting the Early Refill & Therapeutic Alerts are:

A7B	Vasodilators, Coronary		W5I	Antivirals, HIV- Specific, Nucleotide Ana
C4G	Insulins		W5J	Antivirals, HIV- Specific, Nucleoside Ana
JD5	Beta-Adrenerigic Agents		W5K	Antivirals, HIV- Specific, Non - Nucleoside
W5B	Antivirals, HIV- Specific		W5L	Antivirals, HIV- Specific, Nucleoside Alg
W5C	Antivirals, HIV- Specific, Protease Inhibit		W5M	Antivirals, HIV- Specific, Protease Inhibit

Early Refill Override Form

                   
Please click on the following link if you need to retreive a copy of the Early Refill
Override Form.

EMC Schedule

If you are using the Provider Electronic Solutions software please note the following
dates for submitting claims to meet the financial deadlines:

Month	TAD's Due Paper Claims	Nursing Home EMC*	Cycle Date	EDS Wire Transfer
August	08/05/02	08/08/02	08/10/02	08/16/02
September	09/05/02	09/12/02	09/14/02	09/20/02
October	10/07/02	10/10/02	10/12/02	10/18/02
November	11/05/02	11/07/02	11/09/02	11/15/02
December	12/05/02	12/12/02	12/14/02	12/20/02

*EMC Claims are due by 12:00 Noon

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 for 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.