RI Medical Assistance Website & Electronic Replacements/Voids

Would you like more information regarding RI Medical Assistance web transactions or how to bill an 
electronic adjustment? EDS staff will be offering a demonstration and hands-on training for processing 
RI Medical Assistance web-based transactions, such as eligibility and claims status, and billing 
electronic claim voids/replacements. Please bring along a few claim examples and patient identification
 numbers for your use.

Training sessions will be held on September 28, 2004. There will be multiple1-hour sessions held 
at New England Institute of Technology located at 2500 Post Road Warwick, Rhode Island. Please 
contact Kelly Leighton at 401-784-3823 for specific times and to reserve your spot.

Introduction to Medicaid Billing Reminder

Don’t forget to 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 Workshops. 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. All sessions 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. 

A Message From The Claims Department

 The EDS claims processing department would like to thank all RI Medical Assistance Providers who 
have eliminated the use of staples, paper clips and tape on their paper claims, which has proven to enhance 
efficiency in processing. Your continued efforts are appreciated. 

In addition, the members of the claims team would also like to offer a reminder to further improve the 
accuracy and timeliness of paper claims processing. When billing RI Medical Assistance as a secondary 
coverage, please remember to list the three character or numeric carrier code of the primary 
insurer in Box  9D of the HCFA Claim Form. A list of these codes can be found in every provider manual 
or at the DHS website under “Healthcare”. Please note that carrier codes are only required when there is a primary 
insurer indicated in Box 11D. If there is not a primary insurer indicated in Box 11D, Box 9D should be 
left blank.

HIPAA Happenings

The HIPAA National Provider Identifier (NPI) Rule was finalized earlier this year and allows providers to 
begin requesting the new national standard format Provider Number and related taxonomy beginning in April 
of 2005. In order to ensure successful compliance with the Rule by April 2007, providers must become familiar 
with their business practices and claims software that will require assessment and modification in order to 
become compliant with this latest HIPAA Rule.

Although compliance is some two years away, preliminary assessment of the RI MMIS points to the fact that 
this will be a major system change. It will easily be as complex and consuming as preparing for some of the 
HIPAA Transactions implemented in 2003. We urge you to begin discussions with your software staff and 
vendors to ensure they are aware of this new Rule. RI DHS and EDS will hold information and training sessions 
as we develop solutions and procedures relating to implementation of this new Provider Identifier/Number.

For further detail and a copy of the Rule, please visit the CMS Website

Pharmacy Program Enhancements

Drug-Drug Interaction Alert: Denial of the Drug-Drug Interaction DUR Alert began on Tuesday, 
July 27, 2004. As with the Early Refill and Therapeutic Duplication Alerts this Drug-Drug Interaction 
Alert 
was designed to recognize and utilize the professional judgment and intervention skills of pharmacists.

If a claim is submitted for a recipient whose claim history includes an interacting drug and the date of 
service of the current claim is within the interaction time of the earlier drug (determined by the date of 
service and the days supply times the drug interaction percentage of 115%), the claim will deny 
with the denial message, “645 Claim Denied DUR Drug to Drug Interaction Alert”. To override this 
denial, the pharmacist submitting a claim through POS must initiate a DUR Alert Override using valid 
intervention and outcome response codes.

Valid intervention and outcome codes must be entered in order for the claim to be paid. These 
codes are selected based on the pharmacist’s professional judgment and assessment, and may involve 
contacting the prescriber to obtain more information before a code is used.

Current valid intervention and outcome codes:

INTERVENTION CODES		OUTCOME CODES
M0	Prescriber Consulted	1B	Prescription Filled As is
MR	Medication Review	1C	Filled, With Different Dose
P0	Patient Consulted	1D	Filled, With Different Directions
PM	Patient monitoring	1E	Filled, With Different Drug
PH	Patient Medication History	1G	Filled, With Prescriber Approval
		3C	Discontinued Drug
		3D	Regimen Changed
		3E	Therapy Changed
		3H	Follow-Up/Report

If no code has been entered, or if an invalid outcome and intervention code is used, the claims will remain 
denied and no payment will be made.

Please note that those wishing to override an alert must do so within 3 days of receipt of the denial. 
Providers attempting to override an alert beyond the 3 day time period will receive a message of “no 
corresponding claim; please resubmit.”

POS Reversals: Effective July 27, 2004 the window of time in which a POS claim can be reversed was 
increased from one week to 365 days. Claims submitted and adjudicated can now be reversed/rebilled 
up to 365 days from the date of service (DOS).

New Edit/Denial Code for Recipients Residing in Long Term Care Facilities: Effective
August 24, 2004 a new edit, “529 Suspect Duplicate Drug Claim for Nursing Home Recipient” and 
corresponding denial code “551 Suspect Duplicate Drug Claim for Nursing Home Recipient” were 
implemented.

Current policy states that pharmacy claims for recipients residing in Long Term Care facilities should only 
be billed once a month and that only one dispensing fee per recipient per drug per calendar month is 
reimbursable.

The implementation of this edit will ensure that the current policy is upheld. The edit will set when a 
pharmacy claim for a nursing home recipient is billed having the same generic code as that billed on a 
previous claim by the same pharmacy provider and paid within the same calendar month.

Over-the-Counter Products: The State of Rhode Island Medical Assistance Pharmacy Program has 
revised its list of covered over-the-counter products. The product listing is part of the Pharmacy Services 
Provider Reference Manual (300-60-2). The revised listing was mailed out to all pharmacy locations on 
July 9, 2004 and can also be found on the DHS website.

Should you have questions or concerns regarding any of these issues, please feel free to contact the Customer 
Service Help Desk at 401-784-8100 or 1-800-964-6211 or contact your Pharmacy Coordinator, Ingelcia G. 
Simas at 401-784-3818 or by email.

Local Education Agency (LEA) Data Match

The LEA Data Match process will be executed 3 times per year, in March, July, and November. 
Any LEA interested in participating in the data match will be required to submit files prior to the pre-defined 
deadline, which is the 15th of each execution month. EDS will then process and return the information to 
the LEA by the end of that same month. If the given submission deadline is missed for any month, the LEA will 
be required to wait until the next month’s submission deadline to forward files to EDS.

The Data Match will be used to provide the LEA with RI Medical Assistance identification numbers for LEA 
clients. However, please note that the provision of an identification number is not a guarantee of recipient eligibility. Consequently, it is still the responsibility of the provider to ensure that clients are eligible for the 
services being rendered. Eligibility can be verified using either the Recipient Eligibility Voice System (REVS) or 
the new Web Eligibility Inquiry System accessible through the DHS website.

If you have questions or concerns regarding this process, please contact Karen Richard, EDS Provider 
Representative, at 401-784-3888 or by email