Provider Update Newsletter
December 2003, Volume 134
All Providers
HIPAA Happenings
DHS Holiday Observations for 2004
Need Status of a Claim or Eligibility for a Recipient?
Surveillance Utilization Review Reminders
EDS Holiday Policy
Pharmacy Providers
RI Medical Assistance/RIte Care/RIte Share Families Re-certification Process
POS Reminder
Vision Providers
Reimbursement
for Refraction Testing
HIPAA Happenings
HIPAA Required Trading Partner Agreements (TPAs)
The provider community has been very responsive in the submission of completed Trading Partner Agreements (TPAs). As you know, a signed Trading Partner Agreement (TPA) is required for each billing provider, clearinghouse, or billing service that will directly exchange electronic data with EDS. Before HIPAA compliant claims can be submitted, TPAs are required from providers who use Provider Electronic Solutions (PES) Software, providers who submit electronic claims directly, and from billing agencies that submit claims for providers. The Rhode Island Medical Assistance Program has received signed TPAs from over 94% of the providers and agencies who must complete a TPA for claim submission. These providers have Trading Partner Identification Numbers and Passwords for claim submission and for use of the new functionality that is available through the RI Medicaid Web Portal.
If you do not submit electronic claims directly, you will want to submit a TPA so you, too, can access the RI Medicaid Web Portal. The web interface will allow for uploading of claims, downloading of remittances, interactive claim status and eligibility verification, NDC look up, and prior authorization status.
If your TPA is outstanding, please call 784-3884 for assistance from the EDS EDI support team.
PROVIDER ELECTRONIC SOLUTIONS UPGRADE
The Provider Electronic Solutions Upgrade Version 2.1 is available. This upgrade contains:
Ř A Password re-set feature
Ř The convenience of sorting your clients in alphabetical order in reports and claims
Ř Billed amount calculation for Waiver claims
This upgrade is mandatory and can be obtained through
the DHS Website. Select HIPAA, EDI, Provider Electronic Solutions.
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Select Version 2.1 Upgrade
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Select Save from the Save As Box
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Select your C Drive from the Drop Down Box
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Double Click on RIHIPAA
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Double Click on Upgrade
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Select Save
You have now saved Version 2.1 Upgrade. Click on Provider Electronic Solutions (HIPAA version). Double click on Upgrade. You will be prompted through the upgrade process.
We at DHS and EDS are grateful for the effort and attention you have given to this major transition to national HIPAA standards. Our first HIPAA financial cycle processed approximately 10% of electronic claim submissions in the new X12N format and we expect this number to grow quickly as Nursing Facilities transition in November. Again thank you all for your wonderful assistance with this major undertaking.
DHS Holiday Observations for 2004
The DHS will be closed on the following days.
| Thursday, January 1 |
New Years Day |
| Monday, January 19 |
Dr. Martin Luther King Jr. Day |
| Monday, May 31 |
Memorial Day |
| Monday, July 5 |
Observation of Independence Day |
| Monday, August 9 |
Victory Day |
| Monday, September 6 |
Labor Day |
| Monday, October 11 |
Columbus Day |
| Tuesday, November 2 |
Election Day |
| Tuesday, November 11 |
Veteran's Day |
| Thursday, November 25 |
Thanksgiving Day |
| Monday, December 27 |
Observance of Christmas Day |
Need Status of a Claim or Eligibility of
a Recipient
Check out our New Functionality Available through the
DHS web-site.
The web-site will be an avenue for 24-hour access to information critical to your services:
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Eligibility Verification – Verify recipient eligibility, print the information for file documentation
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Prior Authorization Status – Check the status of a Prior Authorization request
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Remittance Advice Payment Amount – Confirm your last 12 months of Medicaid Payment History
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National Drug Code (NDC) Search – Pharmacies will be able to search for an NDC reimbursable by RI Medicaid
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Message Center – Receive Notification or Alerts from Medicaid quicker than before
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Claim Status – Check the status of a submitted claim
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On line Application for Provider Enrollment
For questions about any of these services please contact our Customer Service Help Desk at 401-784-8100 for long distance callers and at 1-800-964-6211 for instate toll calls and bordering communities.
Surveillance Utilization Review
Reminders
Do keep your documentation compliant with CMS and Medicaid standards by:
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Initializing all erasures/cross outs/mistakes.
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Having legible writing or printing.
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Dating all entries.
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Signing all entries. A signature includes full name and
title.
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Having the full name with initials identified somewhere in the record when the practice
is to initial documentation.
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Having full date, start time and finish time on documentation when using a code for
which units of time are being billed.
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Being sure to check the appropriate choices when using a checklist for activities or
services provided to a recipient ,E.g.. Home Care. A date and signature without any
checked activity is insufficient for documentation purposes.
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Making sure you are using the correct diagnosis code for the procedure code being
billed.
EDS Holiday 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.
RI Medical Assistance/RIte Care/RIte Share Families Re-certification Process
Recently, the implementation of an auto-close feature has been added to the automatic re-certification process of RI Medical Assistance/RIte Care/RIte Share families.
This new process generates a re-certification form, which contains current family information known to the Department of Human Services (DHS). The families are asked to review the form, make any changes, sign and return the form to DHS. Any family not returning the form in a timely manner is closed effective the last day of the month. Cases closed, for failing to return the form, are now done so through an automatic/systematic same day process.
Families who subsequently return the forms, are reopened on Medical Assistance effective on the date the form is received. Since enrollment in a RIte Care HMO is done on a prospective basis, members will be on Medicaid fee-for-service for a short period of time prior to being re-enrolled into the HMO. Although members are informed of this process, they may not identify as being on “Medical Assistance” unless specifically asked. All services rendered during this time should be billed and submitted directly to EDS.
Recipients should not be charged for services rendered nor turned away as being
ineligible. Instead providers are asked to verify eligibility through the Recipient Eligibility Verification System (REVS) at 401-784-8100 and bill EDS directly for those who are Medical Assistance eligible.
Any questions or concerns regarding eligibility should be directed to the EDS Customer Service Help Desk.
POS Reminder
Reminder: As of October 14, 2003 the processing of POS RIte Share claims had been made identical to that of the processing of POS Third Party Liability claims (TPL), where Medicaid is secondary to another primary insurance. This change is necessary in order to comply with the HIPAA mandated NCPDP 5.1 format.
Please note, the recipient’s primary insurance co-payment amount is no longer required in the processing of POS RIte Share claims. Instead, fields 308-C8 (Other Coverage Code) and 431-DV (Other Payer Amount Paid) are required just as in the processing of all other secondary claims.
RIte Share members just as any Medical Assistance eligible should not be
billed for pharmacy copays.
RIte Share members are still issued two cards, a commercial identification card and a Rhode Island Medical Assistance identification card. A provider may determine if a recipient is RIte Share eligible through the use of the Recipient Eligibility Verification System (REVS) at 401-784-8100 for long distance callers and at 1-800-964-6211 for instate toll calls and bordering communities.
Questions regarding the above mentioned billing procedure changes to the RIte Share claims process, please contact Ingelcia G. S. Jiran at (401) 784-3818.
Reimbursement for Refraction
Testing
Effective October 1, 2003 the Medical Assistance Program will reimburse for Refraction testing, procedure 92015, when Medicare reimburses for the routine eye exam (procedures 92002, 92004, 92012 and 92014). To process these claims a paper HCFA 1500 claim form will need to be sent in with the procedure 92015 with the Medicare EOMB reflecting payment for the routine eye exam. The fee for procedure 92015 is $20.00.
All paper claims must be sent to
P.O. Box 2009
Warwick, RI 02887
ATT: Dawn Durocher
If you have any question please call Dawn at 401-784-3813.
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