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Provider Update Newsletter

November 2002, Volume 121 

All Providers

HIPAA Happenings
EMC Trouble Shooting
Electronic Transfer Form
RIte Share

Dental Providers

Services Performed in an Outpatient Hospital

Pharmacy Providers

DUR and Therapeutic Alerts

HIPAA Happenings

Local Codes - DHS and EDS have been crosswalking our Local Codes to
National Code Sets (HCPCS, CPT, ADA, etc.) over the past few months
and we expect to be able to publish these results by the end of February 2003.
We will post the results to the DHS Web site – www.dhs.state.ri.us/hipaa –
and in the monthly Provider Update. We will also offer training sessions on
new Code utilization during late Spring 2003.

Privacy Rule - HIPAA covered entities must comply with the HIPAA Privacy
Rule by April 14, 2003. The US Dept. of Health & Human Services/CMS has
designated oversight of Privacy Rule enforcement to the US Office of Civil Rights.
The DHS Privacy Workgroup has drafted a Notice of Privacy Practice, which is
now being finalized. We expect to send this NPP to our beneficiaries and Business
Partners over the next several months – the NPP will also be posted to our Web site.

In order to become compliant with the HIPAA Privacy Rule, your business will
need to perform several activities by April 14, 2003, including:

· appoint a Privacy Officer

· develop a Notice of Privacy Practice

· development of Minimum Necessary information release policies

· amend Business Associate contracts to include Privacy Rule considerations

· develop verification/authorization/access to healthcare information procedures

· develop method to track authorized (vs. normal TPO) releases

· develop complaint procedure

· develop anti-retaliation policy

· train workforce

· develop Privacy Policy Manual

Please visit the CMS Web site for more information.We will also be holding training
sessions this winter and will notify you of the details via the Provider Update, DHS
Web site, and RA messages, and special notification.

EMC Trouble Shooting

EMC troubleshooting issues should be directed to the Customer Service Help Desk
at 401-784-8100 or in state toll calls 1-800-964-6211. The representatives will assist
you but should they be unable to resolve your issue they will then refer the issue to
your Provider Representative.

Electronic Transfer Form

Expedites Access to Cash by 3-7 Days!

Deposits Are Made the Day the Paper Checks Are Mailed!

Timely and Cost Effective!

If you are intrested in receiving you payments electronically, please fill out the
Direct Deposit Form and return it to EDS.

RIte Share

RIte Share

RIte Share, Rhode Island’s Premium Assistance Program, currently has over 2,000
members who get their health insurance coverage through their employer with the state
subsidizing a portion of the premium cost. For qualifying families, the state pays for the
employee’s cost for that health insurance.

RIte Share also pays for 100% of a member’s co-payments. Providers can bill the
Medicaid Program for those co-payments, if they are either a Medical Assistance
provider or a RIte Share, “co-pay only Provider.” For information on billing, please
call EDS at 401-784-8100. In addition to the information they received upon initial
enrollment in September, Rite Share members were sent a comprehensive mailing
on the Rite Share Program.

Cost Sharing (RIte Care and RIte Share Members)

RIte Care and RIte Share members whose income is above 150% of the federal
poverty level are required to pay a monthly premium to obtain or maintain their
health insurance coverage. Approximately 10% of the RIte Care and RIte Share
members pay a monthly premium to the state.  In August 2002, the state increased
the premium amounts that families are required to pay. Families that fail to pay two
months of premium will lose their health insurance coverage for a four month period.

Providers should always check eligibility for Medical Assistance since members can
lose eligibility for a number of reasons. Examples include: forgetting to recertify for
Medical Assistance annually, failure to pay premiums, or having a change in income
or family size that may affect their eligibility.

Children with Special Needs Enroll in RIte Care

The State will be enrolling several thousand RI children who currently have Medicaid
fee-for-service into a RIte Care health plan in 2002 and 2003. Enrollment will occur
over several months beginning in late 2002. The children who will be enrolled include
children with Medicaid coverage because of eligibility for: SSI, Katie Beckett or
Adoption Subsidy. Children who have other health insurance in addition to Medicaid,
children in long term care facilities, and those who reside out-of-state will not be enrolled
in RIte Care. For more updated information on this enrollment please click on the following
link Children with Special Needs or call Family Voices at 401-727-4144 ext. 62 (English)
or ext. 41 (Spanish).

Dental Services Performed in an Outpatient Hospital

Dental Services performed in an outpatient hospital setting require prior authorization.

Prior authorizations for children and their families should be sent to Sharon Penkala

Prior authorizations for adults with disabilities and the elderly should be sent to Paula Avarista

mail to:

The Department of Human Services, 600 New London Ave., Cranston, RI 02920

DUR and Therapeutic 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 (Please note that 1B has been added to the list
of accepted codes):

Intervention Codes	Outcome Codes
MO- Prescriber Consulted	1C- Filled, With Different Dose
MR- Medication Review	1B- Prescription Filled As Is
PO- Patient Consulted	1D- Filled, With Different Directions
PM- Patient Monitoring	1G- Filled, With Prescriber Approval
PH- Patient Medication History	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

Should you have any questions or concerns please feel free to contact
Ingelcia G. S. Jiran at (401) 784-3818