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Provider Update Newsletter

January 2003, Volume 122
 

All Providers

HIPAA Happenings
EDS Gift Policy
Having Trouble Submitting a Claim?

Pharmacy Providers

HIPAA NCPDP POS 5.1

Home Health Providers

Minimum Data Sets (MDS)

Hospital Providers

Transportation Billing
Reminder

Physician Providers

Billing an office visit for established patient

HIPAA Happenings

These transactions are currently scheduled to cut over on March 22, 2003. DHS and EDS will be ready to begin testing in February 2003. Specific testing dates are forthcoming. Contact Ingelcia Jiran of EDS at (401) 784-3818 if you have questions.

HIPAA Transaction Implementation Guide Addenda

As you are probably aware X12 published implementation guides for transactions to be implemented under HIPAA in May 2000. The post publication review process identified items that could be considered impediments to implementation. These items were passed to the X12N Health Care Work Group that created the original Implementation Guide for their review.

Modifications based on those comments were reflected in draft versions of the Addenda for each of the X12N Implementation Guides adopted for use under HIPAA. Draft Addenda for each X12N Implementation Guide went through a Notice of Proposed Rule Making (NPRM) comment process that began on May 31, 2002. Changes based on comments received during the NPRM process and X12N's own review processes were made to each addenda document. All addenda were approved for publication by X12N on October 10, 2002.

A Final Rule adopting these Addenda for use under HIPAA has not been issued by the Department of Health and Human Services. Until a Final Rule adopting the Addenda is released, use of the Addenda must be made in compliance with the Final Rule adopting the May 2000 X12N Implementation Guides and the Administrative Simplification Compliance Act of 2001.

Please make sure that personnel responsible for implementing HIPAA standards in billing and other systems are aware of these documents. They can be accessed and downloaded from the Washington Publishing Company Website

EDS Gift Policy

Providers often acknowledge the services provided by the EDS Customer Service Help Desk and Provider Representatives. EDS appreciates your positive feedback as well as suggestions. Please call or email EDS at anytime. You will also help EDS by not sending gifts showing your appreciation. Our objective and purpose is to provide you effective customer service in navigating the Medical Assistance Program billing processes on behalf of the Rhode Island Department of Human Services. Responsive customer service is our mission; service is our responsibility. Thank you for understanding EDS’ position and corporate policy in this matter.

During this holiday season we also thank you, the Rhode Island Medical Assistance provider community, for the services you provide our clients. May you have safe and happy holidays. 

Having Trouble Submitting a Claim?

Having trouble submitting a claim and do not know who your provider representative is?

Here is a complete listing of the representatives and the providers they assist. For immediate assistance you can utilize the Customer Service Help Desk at 401-784-8100 for local and long distance calls or 1-800-964-6211 for instate toll calls and bordering communities. You call also e-mail the Customer Service Help Desk at ricshd@eds.com.

Contact us by e-mail

Kelly Leighton.........………..Kelly.Leighton@eds.com
Dawn Durocher…………….durocdm@eds.com
Karen Richard………………karen.richard@eds.com
Paula Giocastro……………..giocapa@eds.com

HIPAA NCPDP POS 5.1

As a result of the responses to the Pharmacy survey on NCPDP POS 5.1 and batch 1.1 standards readiness, DHS and EDS have delayed rollout of the new standards until March 22, 2003. This date will allow pharmacy providers to implement the new HIPAA related standards. 

Specifics regarding testing, certification and overall implementation have been provided to your vendors and are available on the DHS Web site on the HIPAA page. Please contact your support staff or vendors to confirm that they started the testing and certification process with WebMD & EDS. If you have any questions, please feel free to contact the EDS pharmacy coordinator, Ingelcia Jiran at (401) 784-3818 or at email address: ingelcia.jiran@eds.com.

Minimum Data Sets

All Minimum Data Sets (MDS) are faxed to: 
Attention: EDS Prior Authorization Department at (401) 941-7712 

Or mailed to: 

EDS  P.O. Box 2006
Warwick, RI 02887-2006 
Attention: Prior Authorization Department

If your Home Health client is receiving homemaker only services please enter HOMEMAKER
ONLY on the MDS forms.

Transportation Billing

Hospitals are authorized to direct bill for transportation, including wheelchair vans. Hospitals are required to use revenue code 542 to bill for these services utilizing either an outpatient or inpatient claims. 

REMINDER:

All Hospitals are to verify Medicaid Eligibility by calling the REVs line at EDS,
401-784-8100 or 1-800-964-6211 for instate toll calls.

To verify Medicaid Eligibility and to determine third party liability for Medicaid recipients for other insures, managed care for Rite Care members and Medicare part A. This should be done on all admissions prior to notifying the Medicaid Utilization Review Agent, Qualidigm.

Billing an office for an established patients

Code 99211 – evaluation and management of an established patient, that may not require
the presence of a physician. Usually the presenting problems are minimal.
Time: 5 minutes

Code 99212 – evaluation and management of an established patient which required at least 
two of these three key components:
Problem focused history of illness;
Problem focused exam;
Straightforward medical decision-making. 
Time: Usually the presenting problem (s) are self limited or minor with 
usual face-to-face time with MD about 10 minutes.

Code 99213 – evaluation and management of an established patient which required at least two
of these three key components:
An expanded problem focused history of illness; 
An expanded problem focused exam; 
Medical decision making of low complexity.
Time: Usually the presenting problem (s) are low to moderate severity with 
usual face-to-face time with MD about 15 minutes.

Code 99214 – evaluation and management of an established patient which required at least two 
of these three key components:
A detailed history;
A detailed examination;
Medical decision making of moderate complexity.
Time: Usually the presenting problem (s) are moderate to high severity with
usual face-to-face time with MD about 25 minutes.

Code 99215 – evaluation and management of an established patient which required at least two
of these three key components:
A comprehensive history;
A comprehensive examination;
Medical decision making of high complexity
Time: Usually the presenting problem (s) are moderate to high severity with 
usual face-to-face time with MD about 40 minutes

For a more detailed explanation of these codes please refer to the 2003 Physicians’ Current Procedural Terminology Manual (CPT Manual).

Look for advice on “ documentation requests ” from SUR (Surveillance & Utilization Review) in the next issue.