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Provider Update Newsletter

July 2005, Volume 153
 

All Providers

National Provider Identifier Activities Begin In 2005
Claims Submission and Payment Schedule
Provider Electronic Solutions Upgrade
Electronic Replacements and Voids
General Public Assistance (GPA) Covered Services
We're On The Move!

Pharmacy Providers

POS Scheduled Database Enhancements

Orthodontic Providers

  New Orthodontic Index is Implemented for Prior Authorizations

National Provider Identifier Activities Begin In 2005

The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the
availability of a new identifier for use in the standard electronic health care transactions.
The National Provider Identifier (NPI) will be the single provider identifier, replacing the
different provider identifiers you currently use for each health plan with which you do
business. This identifier, which implements a requirement of the Health Insurance Portability
and Accountability Act of 1996 (HIPAA), must be used by most HIPAA covered entities,
which are health plans, health care clearinghouses, and health care providers that conduct
electronic transactions for which the Secretary has adopted a standard (i.e., standard
transactions).

The NPI is one of the steps that CMS is taking to improve electronic transactions for health
care. National standards for electronic health care transactions encourage electronic commerce
in the health care industry and simplify the processes involved to reduce the administrative
burdens on health care providers. With national standards and identifiers in place for electronic
claims and other transactions, health care providers will be able to submit transactions to any
health plan in the United States. Health plans will be able to send standard transactions such as
remittance advices and referral authorizations to health care providers. These national standards
will make electronic data interchange a viable and preferable alternative to paper processing for
health care providers and health plans alike.

To date, CMS has adopted and implemented the following HIPAA standards: electronic health
care transactions and code sets, privacy, security, and the national employer identifier.

CMS is now beginning to implement the NPI. On January 23, 2004, the Secretary published a
Final Rule that adopted the NPI as this identifier. As of the compliance dates listed on the next
page, HIPAA covered entities must use NPIs to identify health care providers in standard
transactions. These transactions include claims, eligibility inquiries and responses, claim status
inquiries and responses, referrals, and remittance advices

Health care providers include individuals, such as physicians, dentists, and pharmacists, and
organizations, such as hospitals, nursing homes, pharmacies, and group practices. Health care
providers who transmit health information electronically in connection with any of the standard
transactions are required by the NPI Final Rule to obtain NPIs, even if they use business
associates, such as billing agencies, to prepare the transactions.

The NPI will replace health care provider identifiers that are in use today in standard transactions. Implementation of the NPI will eliminate the need for health care providers to use different
identification numbers to identify themselves when conducting standard transactions with multiple
health plans. Many health plans, including Medicare, Medicaid, and private health insurance issuers,
and all health care clearinghouses must accept and use NPIs in standard transactions by May 23, 2007.
Small health plans have until May 23, 2008. After those compliance dates, health care providers
may use only their NPIs to identify themselves in standard transactions, where the NPI is called for.

You will be able to apply for your NPI in one of three ways:

• You may apply through an easy web-based application process, which began
  May 23, 2005 by clicking here.
   

• You may prepare a paper application and send it to the entity that will be assigning
  the NPI (the Enumerator) on behalf of the Secretary, beginning July 1, 2005. A
  copy of the application, including the Enumerator’s mailing address, is available by
  clicking here. will be available. You may also call the Enumerator for a copy. The
   phone number is 1-800-465-3203 or TTY 1-800-692-2326.
   

• With your permission, an organization may submit your application in an electronic
  file. This could mean that a professional association or perhaps a health care
  provider who is your employer could submit an electronic file containing your
  information and the information of other health care providers. This process will
  be available in the fall of 2005.

Remember, you may apply for an NPI using only one of the ways described above. When
gathering information for your application, be sure that all of your information, such as your social
security number and Federal employer identification number, are correct. Once you receive your
NPI, safeguard its use. The application form contains a Privacy Act Statement, which explains
how we may disseminate the information collected in the application.

You may receive notices about the NPI from many of the health plans with which you do business.
Remember that you need apply only once for an NPI. The same NPI is used for every health plan.

The transition from existing health care provider identifiers to NPIs in standard transactions will
occur over the next couple of years. CMS urges health care providers to apply for an NPI
immediately. While the NPI must be used on standard transactions with health plans, other than
small health plans, no later than May 23, 2007, health care providers should not begin using the
NPI in standard transactions on or before the compliance dates until health plans have issued
specific instructions on accepting the NPI. Health plans will notify you when you can begin using
NPIs in standard transactions. You should be aware that health plans might request that you begin
using your NPI prior to the compliance dates. Applying for an NPI does not replace any enrollment
or credentialing processes with any health plan, including Medicare.

You may obtain information about the NPI by clicking here. This site contains Frequently Asked
Questions and other information related to the NPI and other HIPAA standards.


 

Claims Submission and Payment Schedule

Please see below for the Medical Assistance Program Claim Submission and Payment
Schedule for State Fiscal Year 2006:

Month	LTC Claims due by Noon	Electronic Claims Due by 5:00 PM	Cycle Date	EFT Payment Date
July	7/7/2005	7/8/2005	7/9/2005	7/15/2005
		7/22/2005	7/23/2005	7/29/2005
August	8/11/2005	8/12/2005	8/13/2005	8/19/2005
		8/26/2005	8/27/2005	9/2/2005
September	9/8/2005	9/9/2005	9/10/2005	9/16/2005
		9/23/2005	9/24/2005	9/30/2005
October	10/6/2005	10/7/2005	10/8/2005	10/14/2005
		10/21/2005	10/22/2005	10/28/2005
November	11/9/2005	11/11/2005**	11/12/2005	11/18/2005
		11/25/2005	11/26/2005	12/2/2005
December	12/8/2005	12/9/2005	12/10/2005	12/16/2005
		12/23/2005	12/24/2005	12/30/2005
January	1/12/2006	1/13/2006	1/14/2006	1/20/2006
		1/27/2006	1/28/2006	2/3/2006
February	2/9/2006	2/10/2006	2/11/2006	2/17/2006
		2/24/2006	2/25/2006	3/3/2006
March	3/9/2006	3/10/2006	3/11/2006	3/17/2006
		3/24/2006	3/25/2006	3/31/2006
April	4/6/2006	4/7/2006	4/8/2006	4/14/2006
		4/21/2006	4/22/2006	4/28/2006
May	5/11/2006	5/12/2006	5/13/2006	5/19/2006
		5/26/2006	5/27/2006	6/3/2006
June	6/8/2006	6/9/2006	6/10/2006	6/16/2006
		6/23/2006	6/24/2006	6/30/2006
July	7/6/2006	7/7/2006	7/8/2006	7/14/2006
		7/21/2006	7/22/2006	7/28/2006

**Please note that EDS will be closed on Friday, November 11th due to the Veterans’ Day
Holiday. While electronic claims may still be submitted on that date, staff will not be available
to assist you with billing issues. If this is a concern, please submit by Thursday, November 10th.

Provider Electronic Solutions Upgrade

The Provider Electronic Solutions (PES) Upgrade Version 2.02 is now available. The update
includes enhancements for the following claim types:

All Claim Types:

• Totals on the detail and summary report – Number of claims and the total amount
  billed will be displayed
   

• Simplified billing of coordination of benefits claims – Client information will auto-populate,
  based on information from the client list, eliminating double entry
   

• Client list – Expanded to hold more recipients

Waiver Claims – An “Edit All” button has been added to allow you to change dates of service
globally on all claims in a ready status

Nursing Home Claims – The dates of service that are keyed on Header 1 will automatically
populate the dates of service fields on Service 1

Nursing Home Claims – “Edit all” will now work prior to the last day of the month. For example,
if today is June 23rd, you can copy your claims and edit all for dates June 1st - June 30th. Please
note that you still cannot submit prior to the last date of the month you are billing.

This upgrade is mandatory and can be obtained on the Department of Human Services Web site
by clicking here. Once on the home page, please follow the steps below to complete the update

• Select HIPAA from the blue menu bar

• Select Electronic Data Interchange (EDI)

• Select Provider Electronic Solutions

• Select Version 2.02 Upgrade***

• Select Save from the Save As box

• Select the C drive from drop down box

• Double Click on RIHIPAA

• Double Click on Upgrade

• Select Save

      Select HIPAA from the blue menu barOnce you have saved the Version 2.02 upgrade,
click on the PES software. Double click on the upgrade button. You will now be
prompted through the upgrade process

***Note – If you have not upgraded to version 2.01, you will need to install that upgrade
first, and then you can install the version 2.02 upgrade. Version 2.01 is also available
in the same location on the Department of Human Services Web site.

If you do not have access to the Internet and would like to obtain a copy on CD, please
contact the Customer Service Help Desk at 401-784-8100 for long distance callers or
1-800-964-6211 for instate toll calls and bordering communities.
 

Electronic Replacements and Voids

Rhode Island Medical Assistance can now process electronic replacements and voids. With a
replacement, you can make changes to a paid claim, as in an adjustment. With a void, you may
remit the entire payment on a claim, as in a recoup.

Please follow the process specific to your claim type as listed below:

Professional, Dental and Waiver Claims:
Identify a replacement or void by the claim frequency code.

7 = Replacement
8 = Void

Institutional Claims:
Identify a replacement or void by the third position of the bill type.

7 = Replacement
8 = Void

The original Internal Control Number (ICN) is required for the claim that you would like to
replace or void. The ICN can be found on your remittance advice. It is a 15-digit number.

How will replacements be displayed on the Remittance Advice?

• The original claim will be voided and be reported in the “Financial Items” section as a
  void with reason code “147” (electronic replacement)
   

• The original claim will be voided and be reported in the “Financial Items” section as a
  void with reason code “147” (electronic replacement)
   

• The electronic replacement will not report in the “Adjusted Claims” section

How will voids be displayed on the Remittance Advice?

• The void will display in the “Financial Items” section as a void with reason code
  “148” (electronic void)

Important Reminder

• Timely filing guidelines still apply if the date of service is older than 365 days. If you have
  a claim with a date of service older than 365 days and an EOB that is within 365 days,
  you will need to send your adjustment to EDS on the Single Claim Adjustment Request
  Form. If you try to submit a replacement on a date of service older than 365 days, your
  original claim will be recouped and your replaced claim will deny for timely filing.
   

• You cannot adjust a denied claim. Denied claims will need to be corrected and
  resubmitted.
   

• You cannot adjust late payments (Type of bill 115 or 135).

If you use Provider Electronic Solutions for electronic billing please log on to the DHS Website
by clicking here for a complete set of instructions for submitting electronic replacements or voids.

If you utilize another software for electronic billing, you must verify with your vendor that
you can bill electronic replacements or voids using that software.

If you have further questions please call the Customer Service Help Desk at 401-784-8100
for long distance callers or 1-800-964-6211 for instate toll calls and boarding communities.

General Public Assistance (GPA) Covered Services

The Department of Human Services (DHS) General Public Assistance Program (GPA) provides
qualifying individuals with assistance for a limited scope of services, including physician office
visits and some prescription medications. Please see the chart below for a summary of GPA
covered HCPCS codes. Please note that an additional code, A4413, has been recently added.

GPA Covered Procedure Codes
Office/Emergency Room Visits
(Reimbursed at 50% of Medicaid Rate)
Procedure Code	Description
99201 - 99205	Office Visit - Medical
99211 - 99215	Office Visit - Medical
99217	Office Visit - Medical
92002	Office Visit - Vision/Opthalmic
92004	Office Visit - Vision/Opthalmic
92012	Office Visit - Vision/Opthalmic
92014	Office Visit - Vision/Opthalmic
99281 - 99285	Emergency Department Visit
Durable Medical Equipment
(Reimbursed at 100% of Medicaid Rate)
Procedure Code	Description	Procedure Code	Description
A4253	Diabetic Supply	A5051 - A5055	Ostomy Supply
A4255	Diabetic Supply	A5061 - A5065	Ostomy Supply
A4258	Diabetic Supply	A5071 - A5075	Ostomy Supply
A4259	Diabetic Supply	A5081 - A5082	Ostomy Supply
A4310 - A4316	Ostomy Supply	A5093	Ostomy Supply
A4320 - A4323	Ostomy Supply	A5102	Ostomy Supply
A4326 - A4330	Ostomy Supply	A5112 - A5114	Ostomy Supply
A4335	Ostomy Supply	A5119	Ostomy Supply
A4338	Ostomy Supply	A5121 - A5123	Ostomy Supply
A4340	Ostomy Supply	A5126	Ostomy Supply
A4344	Ostomy Supply	A5131	Ostomy Supply
A4346 - A4347	Ostomy Supply	A5149	Ostomy Supply
A4351 - A4359	Ostomy Supply	E0607	Diabetic Supply
A4361 - A4400	Ostomy Supply	E0609	Diabetic Supply
A4402	Ostomy Supply	K0277 - K0281	Ostomy Supply
A4404 - A4410	Ostomy Supply	K0407 - K0411	Ostomy Supply
A4413 - A4434	Ostomy Supply

We're  On The Move

EDS will be moving to a new office location over the weekend of June 24, 2005. Our updated
address will be:

Electronic Data Systems
171 Service Avenue (Off of Jefferson Boulevard)
Building 1, Suite 100
Warwick, RI 02886

Please make a note of the change.

POS Scheduled Database Enhancements

Database enhancements are scheduled each morning for 15 minutes between 5:30 AM and
6:00 AM and 12 times yearly, on Sunday evenings, from 10:00 PM – 1:00 AM. During these
scheduled times, POS runs in Claims Capture mode, which allows claims to be submitted but
does not automatically pay or deny claims. For your convenience, listed below are the 2006
State Fiscal Year 12 pre-scheduled Sunday dates in which POS will be in Capture Mode.

07/03/05	01/01/06
07/31/05	01/22/06
08/21/05	02/19/06
10/02/05	04/02/06
10/30/05	05/21/06
11/20/05	07/02/06

New Orthodontic Index is Implemented for Prior Authorizations

The Department of Human Services has adapted a standardized set of review criteria to
evaluate Medicaid orthodontic cases and will implement the new evaluation tool beginning
July 1, 2005. This will affect only those cases reviewed on or after July 1, 2005, and not
those cases previously approved.

The new index, called the HLDI (RI Mod) (Handicapping Labio-lingual Deviation Index) is
applied to each individual case by Board qualified orthodontists to identify those cases that
clearly demonstrate medical necessity by determining the degree of handicapping malocclusion.
The HLD Index has proven successful in several other states at identifying a large range of
very disfiguring malocclusions.

The new criteria will not change either the prior authorization process or the support materials
that accompany the prior authorization. As a reminder, prior authorization submission requirements
include: the diagnosis, the length and type of treatment, and records of diagnostic quality, which
include: diagnostic photographs (for full orthodontic treatment), a cephalometric radiograph,
either a panoramic radiograph or a complete series of intraoral radiographs.

If you have any questions or concerns please contact Ashley Cunningham at 401-784-3832
or email Ashley by clicking here.