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Provider Update Newsletter

August 2005, Volume 154
 

All Providers

ClaimCheck Review
Faxing Etiquette
EDS Has Moved!
 

Durable Medical Equipment (DME) Providers

Prior Authorization Guidelines

ClaimCheck Review

In September, 2004, the Rhode Island Department of Human Services (DHS) introduced
ClaimCheck® claims evaluation software for the Medical Assistance Program. ClaimCheck®
utilizes a national database and comprehensive clinical knowledge base that incorporates
American Medical Association (AMA) guidelines, CMS, specialty society guidelines, industry
standards, medical policy, and literature and academic affiliations. Some other Rhode Island
insurers also use ClaimCheck®. DHS’ decision to implement this widely used software means
providers benefit from greater standardization, minimal medical review, and faster, more
clinically precise and consistent adjudication of healthcare claims. Please see below for a
summary of the nonstandard billing practices that ClaimCheck® is able to identify:

Rebundling: Procedure unbundling occurs when two or more procedure codes are used to
report a service when a single, more comprehensive procedure code exists that more accurately
represents the service performed by a provider. The suggested more comprehensive code will
be added for payment and all panel components will be denied with an explanation of benefits
(EOB) of 560 which states: Separate components have been included in comprehensive panel.

Incidental: Certain procedure codes are commonly performed in conjunction with other
procedures as a component of the overall service provided. An incidental procedure is one that
is performed at the same time as a more complex primary procedure and is clinically integral to
the successful outcome of the primary procedure. The more complex primary procedure would
be reimbursed and the incidental procedure would be denied with an EOB of 333 which states:
Services denied as being same or as included in another on the same day.

Does Not Require Assistant Surgeon: Designations were developed on a procedure-by-procedure
basis using literature reviews, clinical expertise, and published guidelines by specialty organizations
and not strictly aligned with any single source. Based on input from the Code Auditing Advisory
Committee members, the Clinical Affairs Department and the American College of Surgeons
have identified clinical guidelines for procedure codes billed with an Assistant Surgeon. When
such a procedure is identified by ClaimCheck®, it is reviewed by a staff Registered Nurse for recommendation. If denial is recommended, the EOB will be 441 which states: An assistant
surgeon is not allowed with this procedure code

Modifier 25: Modifier 25 is used to report a significant, separately identifiable evaluation and
management service by the same physician on the same day of a procedure. The procedure would
be denied with EOB of 333 , which states: Services denied as being same or as included in another
on the same day.

Mutually Exclusive: Mutually Exclusive edits consist of combinations of procedures that differ in
technique or approach but lead to the same outcome. In some instances, the combination of
procedures may be anatomically impossible. Procedures that represent overlapping services or
accomplish the same result are considered mutually exclusive. In addition, reporting an initial
service and subsequent service is considered mutually exclusive. The overlapping procedure would
be denied with the EOB of 074 that states: Detail denied, Service included in Office Visit.

Not indicated for Separate Reimbursement: A reimbursement edit is developed based on Healthcare reimbursement policies for which no clinical rationale exists. If identified procedures would be denied
with the EOB of 333 that states: Services denied as being same or as included in another on the
same day.

Modifier 59: Submitting modifier 59 with a procedure indicates that a distinct procedural service
was performed separately from other services rendered on the same day by the same provider.
When such a procedure is identified by ClaimCheck® it is reviewed by a staff Registered Nurse
for recommendation. If denial is recommended, the EOB will be 799 which states: Detail Denied
As Included Within Or Identical To A Concurrently Billed Service.

Cosmetic: A number of surgical procedures may be performed without a medically indicated
purpose and are considered cosmetic in nature. When such a procedure is identified by
ClaimCheck® it is reviewed by a staff Registered Nurse for recommendation. If denial is
recommended the EOB will be 565, which states: Service denied, as considered Cosmetic.
 

Faxing Etiquette

Please consider the following guidelines when faxing documents to EDS:

- Please be sure to include a cover sheet. When documents are faxed without a cover sheet there is
   potential risk that the document will not be delivered to the intended party.

- The fax cover sheet should include the intended recipient’s name and phone number, the sender’s
  name and phone number, and the number of pages including the cover sheet.

 -When faxing a copy of a document, please ensure that it is clear and legible.

- Please limit faxes to 10 pages or less. Documents of more than 10 pages tie up the fax machine,
   making it difficult for other providers to fax
 

EDS Has Moved!

EDS relocated to a new office location as of June 27, 2005. PLEASE BE ADVISED THAT
OUR POST OFFICE BOXES AND TELEPHONE NUMBERS REMAIN THE SAME.
See below for current contact information.

Physical Address:
Electronic Data Systems (EDS)
171 Service Avenue
Building 1, Suite 100
Warwick, RI 02886-1020

Customer Service Help Desk/REVS Telephone Numbers:
Local and Out of State Long Distance: 401-784-8100
In State Long Distance: 1-800-964-6211
 

Mailing Addresses:
Home Health and Pharmacy Claims	EDS   P.O. Box 2005 Warwick, RI  02887-2005
Hospice, TPL and Waiver/Rehab Claims, Order Medical Assistance Forms, Prior Authorization (PA) Requests	EDS   P.O. Box 2006 Warwick, RI  02887-2009
Dental, Inpatient and Outpatient	EDS   P.O. Box 2007 Warwick, RI  02887-2007
Crossover Part A, Crossover Part B and Professional Claims	EDS   P.O. Box 2008                              Warwick, RI  02887-2009
Ambulance, Clinical Lab, DME, EMC, EPSDT, SOBRA  HCFA 1500, Long Term Care (TAD), Physician, Podiatry, Psychiatry, Radiology, Rehabilitation and Vision Claims	EDS   P.O. Box 2009                              Warwick, RI  02887-2009
All Correspondence and Adjustments	EDS   P.O. Box 20010 Warwick, RI  02887-2010

Prior Authorization Guidelines

A significant number of Prior Authorization (PA) requests for Durable Medical Equipment
(DME) that are received fail to include the necessary information for processing. As a result
these requests must be returned to the provider. Please review the following information to help
to expedite the
PA process and minimize the number of PA requests returned:

• Medical Assistance PA forms must be complete, including an original, dated signature.
   

• A complete Certificate of Medical Necessity (CMN), including the signature of the
  prescribing physician, must be submitted with the PA request. When submitting a PA
  for oxygen or nutrition, a complete Medicare approved CMN must be used. For all
  other Durable Medical Equipment, please use the Rhode Island Department of Human
  Services Medical Assistance CMN found in your provider manual and on the DHS Web
  site by clicking here.
   

• Rhode Island Medical Assistance timely filing guidelines do apply to all PA requests.
  Requests for dates of service more than 365 days in the past will be returned to the provider.
  If you wish to appeal the timely filing limit based on extenuating circumstances, the PA should
  be sent to the attention of your provider representative.
   

• For Wheelchairs, Ramps, Assistive Devices, and similar items, be sure to include related
  price lists.
   

• Submit any additional supporting medical documentation with the PA request.