Search

Provider Update Newsletter

October 2003, Volume 132
 

All Providers

HIPAA Happenings
Affected Providers

Nursing Home Care & Home Care Providers

Prior Authorization Reminder

HIPAA Happenings

HIPAA Compliance Date is October 16, 2003. Are you ready?

Are you ready? Well start here by asking yourself…

1. If a bill through Provider Electronic Services (PES) software;

   a. I filled out a Trading Partner Agreement and returned it to EDS?

   b. Do I know how to obtain a copy of the new HIPAA compliant PES software?
   

2. If I bill through a billing service, agent, or use a proprietary 3rd party software is my vendor or group prepared to submit HIPAA compliant transactions?

   a. Have I filled out, signed, and returned a Trading Partner Agreement?

   b. Has my billing service, agent, or group filled out, signed, and returned a Trading Partner Agreement?

   c. Does my software/system meet the EDI requirements and certification standards so I can submit HIPAA compliant transactions?

   Your readiness is your responsibility.
   Please remember we are here to help!
   
   

Affected Providers

Are all types of providers affected?

All electronic billing providers are affected by the administrative simplification requirements that HIPAA mandates beginning October 16, 2003. Every provider must be able to submit claims in the HIPAA compliant format (ANSI ASC X12N 4010 addenda).

What changes will be taking place?

There are numerous changes under HIPAA for all provider types. The table below outlines those changes by provider type.

Provider Type	Changes
All Providers	All other insurance primary claims may be billed electronically Medicare A, B, and DMERC claims will cross over electronically Voids and Replacements (a.k.a. adjustments and recoups) may be billed electronically Patient account numbers are required Attending provider number must also include Social Security # or Tax Id
Professional	Place of Service codes are required on Professional claims Adjustments may be billed electronically   Bill Frequency Codes are required:                           1 = Original Claim                           7 = Replacement of Previous Claim                           8 = Void of Previous Claim
Ambulance	Transportation Reason Codes required:                           A = Patient was transported to nearest facility                           B = Patient was transported for the benefit of physician                           C = Patient was transported for nearness of relatives                           D = Patient was transported for nearness of specialist                           E = Patient was transported to Rehab Transport Reason Codes required                           I = Initial                           R = Return                           T = Transfer                           X = Round Trip
Institutional	Occurrence Span Codes accepted All Valid Value Codes and Condition Codes accepted Attending provider requires social security # or tax id Revenue Code is now 4 characters (zero filled, right justified)
Dental	Quadrants are required:                           00 = Entire Oral Cavity                           01 = Maxillary Area                           02 = Mandibular Area                           09 = Other Area of Oral Cavity                           10 = Upper Right Quadrant                           20 = Upper Left Quadrant                           30 = Lower Left Quadrant                           40 = Lower Right Quadrant                           L = Left                           R = Right List of Surface Codes                           B = Buccal                           D = Distal                           F = Facial                           I = Incisal                           L = Lingual                           M = Mesial                           O = Occlusal Place of Service codes are required on Dental Claims
Long Term Care	Revenue Code is 0100 (all inclusive rate) Bill Types for all original claims                           PRL 001 (Medicare Co Ins Days) will be bill type 253                           RPL 002 (Medicaid Per Diem) will be bill type 263                           RPL 005 (Medicare/other insurance days) will be bill type 210 Bill Types for Replacements Claims (Adjustments)                           RPL 001 will be bill type 257                           RPL 002 will be bill type 267                           RPL 005 will be bill type 217 Bill Types for Voids (Recoups)                           RPL 001 will be bill type 258                           RPL 002 will be bill type 268                           RPL 005 will be bill type 218

The following table describes claim submission changes and modifications

Field	Electronic Billing
Patient Account	38 characters
Medical Record Number	30 characters
Revenue Code	4 characters, right justified, zero fill
Diagnosis Code	15 occurrences
Modifiers	4 occurrences

What do I do if I am not ready to submit HIPAA compliant claims on October 16, 2003?

Obtain a copy of Provider Electronic Solutions (PES) Software for your billing requirements, which can be downloaded free of charge from the DHS Web Site

What can I do after the DHS Web Portal enhancements?

The HIPAA Implementation will bring with it expanded provider services through the web. Logging onto the DHS Web Portal  will be an avenue for 24 hour access to information critical to your services. With web enhancements you will be able to:

• Verify Recipient Eligibility and print the information for files
• Check the status of a Prior Authorization request
• Confirm your last 12 months of Medicaid Payment History by receiving your Remittance Advice Payment Amount
• Pharmacies will be able to do search for a National Drug Code (NDC) reimbursable by RI Medicaid
• Receive Notification or Alerts from Medicaid quicker than before through the message center
• Check on Claims Status for a submitted claim
• On line Application for Provider Enrollment

 

All Providers

Certification Standards for Children’s Intensive Services (CIS) Program

The Departments of Human Services and Children, Youth and Families have announced that they will jointly issue certification standards for Children’s Intensive Services (CIS) Program. The CIS program provides intensive community based services to children at risk of institutionalization due to serious behavioral disorders.

Standards were released in early September. All providers must be certified to provide CIS services.

To obtain a copy of the certification standards, please contact:

George McCahey, MSW
Division of Children’s Behavioral Health and Education
101 Friendship Street
Providence, Rhode Island 02903
(401) 528-3763

 

Timely Filing

Federal Regulations and Rhodes Island General Law require that claims be submitted to the Rhode Island Medical Assistance Program within 365 days form the date of service. Failure to do may result in denial of payment. If you have any questions please call the Customer Service Help Desk at (401) 784-8100.

Prior Authorization Reminder

When Certified Nursing Assistant Services (CAN) are provided to children through the EPSDT benefit (procedure code X0087), prior authorization is not required. To verify the level of service available for the recipient, please contact Gail Davis, RN at EDS at (401) 784-3873.