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Provider Update Newsletter

November 2003, Volume 133
 

All Providers

HIPAA Happenings
Affected Providers

HIPAA Happenings

You should be ready?

Effective October 16, 2003 , the Rhode Island Medical Assistance Program will implement HIPAA compliant electronic transactions, including

• ASC X12N 837 Health Care Claims (Professional, Institutional and Dental)

• ASC X12N 835 Health Care Claim – Payment/Advice

• ASC X12N 270/271 Health Care Eligibility Inquiry and Response

You or your billing agency should now be prepared to bill for the new HIPAA compliant billing transactions. Nursing Home billing submitted at the beginning of November 2003 for October 2003 services must use the new formats 

The final non-compliant, non-HIPAA financial was completed as of THURSDAY, October 9, 2003. This was the last Financial Cycle, which ran in the old format (non-compliant), pre HIPAA. All claims that were received prior to 5:01 PM on Thursday, October 9, 2003 will have been included in the old format and will be reported on the October 31, 2003 Remittance Advice.

HIPAA compliant transactions cannot be submitted through the EDS Bulletin Board (BBS). Your HIPAA compliant transactions must be submitted via the Department of Human Services (DHS) website or through the EDS dial up RAS connection. Connectivity information is provided in the Companion Guides and also in the PES billing software installation instructions.

Taking Steps to ensure HIPAA readiness

• Confirm your Billing Agent has tested with EDS and is ready to submit HIPAA compliant transactions, OR

• Confirm your software is compliant, tested, and meets the EDI requirements and certification standards, OR

• Complete the installation of EDS Provider Electronic Solutions (PES) software and return your signed Trading Partner Agreement (TPA)

• Return your signed TPA if required. A signed TPA is required if you use PES, submit claims directly to EDS, or wish to use the new functionality that will be available through the DHS website.

EDS’ proprietary software, Provider Electronic Solutions (PES), is available to support your HIPAA compliant electronic billing needs. PES can be accessed to download from the Department of Human Service (DHS) website. You will also find download and installation instructions at the DHS website. Call the EDI Help Desk at (401) 784-3884 to request a CD version of PES, ask questions, get help with the software or the installation.

Medicaid Electronic Contingency Plan

The RI Medical Assistance Program will implement a contingency plan to accept noncompliant electronic transactions after the October 16, 2003 compliance deadline. Providers who use PES, must use the new version of HIPAA compliant PES. For providers who submit claims in a format other than PES, (vendor software, billing agent, clearinghouse), Rhode Island Medical Assistance will accept both HIPAA compliant claims and non-HIPAA compliant claims for several months after October 16, 2003. You may submit claims in the current format while you are finalizing your method of submitting HIPAA compliant electronic transactions. If your HIPAA compliant testing is not complete, please continue to bill electronically using the current format. 

Please note that: Claims from Nursing Homes and Medicare must meet HIPAA compliant standards October 16, 2003.

Important to Remember…..

• When using PES, please select your unique password. EDS will provide you with a temporary password, which will need to be changed. Once your unique password is established the Options tab requires changes…refer to the Installation Instructions on the DHS website on pages 4 – 5 
  

• Please call the EDI Help Desk at (401) 784-3884 if you have a question concerning your Trading Partner Agreement, Provider Electronic Solutions (PES) software, electronic transaction testing, or the readiness of your billing agency. We are here to help you transition successfully to HIPAA compliant electronic transactions.
  

Affected Providers

Thank you all the efforts you have made to prepare and transition to HIPAA compliant electronic transactions. 

If you have any questions or suggestions at any time about the service we provide you, please call us through the EDS Customer Service Help Desk at (401) 784-8100 between Monday through Fridays from 8:00am to 5:00pm or contact or leave a message with our EDI Help Desk at (401) 784-3884. Calls to the EDI Help Desk will be returned within 24 hours

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