Recent Web Enhancements

Are you aware that you can check claim status and eligibility on the DHS website? If so you will notice some changes. DHS and EDS have provided enhancements to both Eligibility Verification and Claim Status transactions to allow for simple interpretation and use. If you have not utilized this valuable resource before, this is the best time to start. You will find that the DHS website is an avenue for quick and easy access to critical eligibility, claims, financial information and much more. Here is some of what you will find:

• Eligibility Verification – Verify recipient eligibility and print the information for file documentation

• Prior Authorization Status – Check the status of a prior authorization request

• Remittance Advice Payment Amount – Confirm your medical assistance payment history for the last 12 months

• NDC Search – Pharmacies will be able to search for a National Drug Code reimbursable by RI Medical Assistance

• Message Center – Receive notification or alerts from RI Medical Assistance more quickly than ever before

• Claim Status – Check the status of a submitted claim

• Online Provider Enrollment – Complete information on your application form online and print for submission (Application form must still be signed and mailed to EDS)

To access the web site you must first complete a Trading Partner Agreement (TPA). You may download the TPA from the DHS website.

Trading Partner Password Notice

For security reasons your Trading Partner password will expire every 90 days. Please follow these instructions in order to successfully change your password.


Step 1: Changing your password online

• Go to DHS Website and access MMIS Web Transactions

• Enter your Trading Partner ID and your current password

• On the next screen, enter your new password twice

• If you do not have access to the internet, please contact your provider representative for assistance

Step 2: Changing your password in the software

• If you are using Provider Electronic Solutions (PES), go to Tools, Options, and on the Batch tab update your web password

• If you are using your own software, change your password in the appropriate field
  

Introduction to Medicaid Billing

Does the idea of Medical Assistance billing challenge you? 
Are you questioning which fields need to be completed on the claim form or in your software? 
Do you have new staff? 

If you answered yes to any of these questions, we have the workshop designed especially for you! Come and learn all you need to know about billing RI Medical Assistance. You will see how easy it is to verify eligibility by phone or computer, to submit a claim on paper or electronically, and to interpret a remittance advice.

If this sounds like it would interest you, please join the EDS Provider Representatives for our Monthly Billing Workshop. The next sessions will be held on: 

September 21, 2004

October 19, 2004

November 16, 2004

December 14, 2004

For your convenience there will be two sessions, a morning session from 10am to 12pm and an afternoon session from 2pm to 4pm. Both will be held at 1471 Elmwood Ave., Cranston, RI.

Please notify us by telephone at 401-784-3823 if you would like to attend. Also, if there is a particular topic that you would like us to cover in the training, please let the representative know when you call. 

Surveillance Utilization Review (SUR) Reminders

In order to keep your documentation compliant with CMS and Medicaid standards please ensure that the following steps are taken:

1. Initial all erasures/cross outs/mistakes

2. Write or print legibly

3. Date all entries

4. Sign all entries (A signature includes full name and title)

5. List the full name with initials somewhere in the record when corrections are being initialed.

6. List the full date, start time and finish time on the documentation when using a code for which units of time are being billed

7. 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 processing.

8. Ensure that you are using the correct diagnosis code for the procedure code being billed
   

Pharmacy Prior Authorization Program

Requests for prior authorization are automatically approved or denied by the Rhode Island Medical Assistance Pharmacy Prior Authorization (PA) Program at point of service (POS). 

• If approved, the pharmacist is sent a message that the claim is paid

• If denied, a message is returned to the pharmacist stating, “Prior Authorization Required, Have prescriber call (866) 420-3874

• The pharmacist is responsible for calling the prescriber and instructing the prescriber to contact the call center by phone at (866) 420-3874 or by fax at (800) 390-0109. Calls should not be directed to DHS or EDS

• Patients should not be told that the claim is denied, but rather that the medication requires a Prior Authorization

• The PA process is a collaborative effort between the pharmacist and the prescriber ensuring an “invisible” process for the client
  

Medicare Prescription Drug Discount Card

On December 8, 2003, President George W. Bush signed into law the Medicare Prescription Drug Improvement and Modernization Act of 2003. This Act establishes a prescription drug benefit for Medicare beneficiaries and implements many changes to the Medicare program overall. 

A temporary drug discount card was created in June 2004 to expire at the end of 2005. This card is expected to save participants 10 to 15 percent on medication. The legislation also establishes a permanent prescription drug benefit for Medicare beneficiaries, which will go into effect on January 1, 2006. Both the temporary and permanent discount cards are voluntary and will provide additional subsidies for low-income beneficiaries. There are 28 Medicare-approved card sponsors, 24 of which will operate in Rhode Island. Individuals will need to apply through the card sponsor and pay a small annual enrollment fee. They may only be enrolled with one card sponsor. 

Individuals who have both Medicare and Rhode Island Medical Assistance are not eligible for the Temporary Prescription Drug Discount Card. The discount card is intended for Medicare participants who do not have prescription drug benefits. If a participant has Rhode Island Medical Assistance, prescription drug coverage is included. In January 2006, participants that have both Medicare and Rhode Island Medical Assistance will have their prescription drugs covered by Medicare Part D. 

For more information you may access the Medicare Website or call 1-800-Medicare. Recipients may also call the Department of Elderly Affairs’ Customer Information and Referral Assistance Center at 401-462-4000 for more information. 

Refunds or Recoupments of Paid Claims

There may be occasions when it is necessary for you to refund all or part of the amount paid by DHS. In these situations you may choose to refund the overpayment or to have it recouped.

Refund – Refunds can be made either by sending in a check or money order payable to the State of Rhode Island or by returning the original check received from the Medical Assistance Program. A copy of the Remittance Advice (RA) containing the appropriate claim(s) must be included with the check or money order. On the RA, circle or highlight the claim(s) corresponding to the refund and indicate the reason for the refund. 

If the refund is for more than one claim, indicate the amount to be applied to each claim and the reason for each refund.

Recoupment – The Adjustment Request Form can be used to recoup an overpayment by DHS. If a whole claim must be recouped, complete the Adjustment Request Form and enter "Please recoup this claim" in the Reason for Adjustment box. If only part of a claim will be recouped, enter the amount of the recoupment in the Reason for Adjustment box. In either case be sure to explain why the recoupment must be made in the Reason for Adjustment box. The amount indicated will be recouped automatically. 

All refunds, whether processed with an Adjustment Request Form for a recoupment or with a refund check, should be mailed to: 

EDS 
Adjustments Unit 
P.O. Box 2010 
Warwick, RI 02887-2010

Further information on this topic can be retrieved on the DHS Website by clicking here

Refunds Resulting From Other Insurance

If a refund or recoupment is requested because a third party has made a payment for the same service that was paid by Medical Assistance, you must identify the other insurer and provide a policy number if available.

You must refund the full amount received from other insurance up to 100% of the Medical Assistance payment. The refund should be sent within 30 days. 

RI Medical Assistance providers must accept Medical Assistance payments as payment in full for covered services and may not use payment by a third party to make up the difference between the amount billed and the amount of the Medical Assistance payment. 

Refund checks should be made payable to the State of Rhode Island and mailed to: 

EDS 
Adjustments Unit
P.O. Box 2010 
Warwick, RI 02887-2010