Paper Claim Submitters

As you are likely aware, CMS has recently issued a policy stating they will now hold paper Medicare 
claims for 30 days before payment will be made. The goal of this effort is to attain a higher level of 
HIPAA-compliant electronic claim submissions.

RI DHS Medical Assistance will continue to process paper claims as received, however, we also wish 
to attain higher electronic claim submission rates and remind you that free PES claim submission software 
is available from DHS/EDS.

If you currently bill on paper, we strongly urge you to consider using the HIPAA-compliant PES billing 
software to submit Medical Assistance claims. EDS will provide online or in-person assistance with your 
installation and setup. Please call Paula Giocastro at 401-784-3817 or your provider representative at 
401-467-1837 for further assistance.

Electronic Remittance 835 Enhancements

Enhancements have been completed for the 835 Electronic Remittance. These changes affect providers 
billing institutional claims only. 

Detail lines for institutional claims will now display in your Electronic Remittance along with any applicable 
explanation of benefits. This change has resulted in the explanation of benefits 794 displaying on detail lines. 

The description for explanation 794 is: “PAYMENT ADJUSTMENT DUE TO PROVIDER ACCOMMODATION RATE REDUCTION” 

and is equivalent to 093: “PAYMENT AMOUNT REDUCED TO MAXIMUM ALLOWABLE AMOUNT”. 

Common Third Part Liability (TPL) Enhancements

As mentioned in the September Provider Update, when a claim is billed for a recipient who has other insurance, 
the three digit carrier code for the coverage must be listed in Box 9D of the HCFA 1500. A full listing of 
these codes can be found in the provider manuals on the Department of Human Services (DHS) website. 
However, because some providers have not yet gained access to the Internet, a list of the most common codes
is shown below.

001 Blue Cross/Blue Shield of Rhode Island	045 Cigna Health Care
004 Healthmate	058 Federal Employee Plan/BC
006 United Health Care of New England	06A United Senior Care
009 HMO Blue of Massachesetts	12A Blue Chip Medicare HMO
010 Delta Dental of Rhode Island	MDA Medicare Part A
012 Blue Chip Coordinated Health Partners	MDB Medicare Part B
014 Delta Dental of Massachusetts	089 Tufts Total Health Plan
028 AARP

Recipient Eligibility Verification System (REVS) Reminders

• The REVS line may be reached by calling 401-784-8100 or 1-800-964-6211, which is toll free for 
  in-state callers. 
  

• If you are inquiring on a recipient’s eligibility by telephone for dates of service (DOS) within the last year,
   you must always use REVS. On REVS you can enter a specific DOS or span dates to retrieve information. 
  

• If the DOS is over one year in the past, it is necessary to speak with a representative for assistance by 
  pressing “0” when prompted. 
  

• Please be sure to listen carefully to all recipient eligibility and benefit information when calling REVS. 
  If the call is disconnected before relevant segments are heard, confusion on eligibility may result. 
  

• REVS will provide a verification number after all relevant eligibility information is announced. Please 
  note that the verification number does not guarantee recipient eligibility and will be given even if the 
  recipient is not eligible.
  

• Providers who have a Medical Assistance Provider Number that includes letters must enter them as a
  number code when dialing into REVS.  The asterisk (*) is pressed   followed by two numbers representing 
  a specific letter. The first number corresponds to the number on the key that contains the letter. The second 
  number corresponds to the position of the letter on the key.  For example, letter "A" would be entered as *21 
  because letter "A" appears in the first position of the second key on the telephone   keypad.  Since "Q" and 
  "Z" do not appear on the telephone keypad, these two letters are treated as if they are the first and second 
  characters of key number 1.  See below for a quick reference guide for converting letters to numbers for REVS:

A=*21	N=*62
B=*22	O=*63
C=*23	P=*71
D=*31	Q=*11
E=*32	R=*72
F=*33	S=*73
G=*41	T=*81
H=*42	U=*82
I=*43	V=*83
J=*51	W=*91
K=*52	X=*92
L=*53	Y=*93
M=*61	Z=*12

Surveillance Utilization Review (SUR) Reminder

According to Medicaid policy, Durable Medical Equipment (DME) may be either rented or purchased 
based upon the patient’s condition and the period of time the equipment will be required. In no instance 
may the total rental amount reimbursed by DHS exceed the total value of the item. In such cases, no further 
payment of deductible or co-insurance payment will be made by the Department of Human Services (DHS).

The maximum allowable amount for DME will be based on the current fee schedule or usual and customary 
charge, whichever is lower. This policy is predicated on the prudent buyer concept; i.e., not paying more for 
an item when it can generally be obtained at a lesser cost.

Please refer to your Provider Manual for additional information as needed.

Filing Limit Change

All unpaid claims and adjustments to previously paid claims with dates of service over 365 days must
be submitted to Kelly Leighton no later than September 30, 2004.  This information must be sent on the
spreadsheet provided by the Department of Elderly Affairs (DEA).  Claims and adjustments received by
the deadline will be processed if sufficient proof of timely filing is   included.  After this date, claims and
adjustments over 1 year old will be returned for timely filing and will not be processed.

 If you need a copy of the spreadsheet or have any questions, please call Kelly Leighton at 401-784-3823.