Provider Update Newsletter
October 2005, Volume 156
All Providers
RIte Share Electronic Billing
Additional Codes Requiring Prior Authorization
New Provider Representative
Early Intervention Providers
Billing Vision Services When Medicare
is Primary
RIte Share Electronic Billing
It is now possible to bill the RIte Share copay,
coinsurance and deductible electronically
for either the 837I or the 837P HIPAA compliant transaction.
Institutional Providers (837I):
Providers must bill a HIPAA compliant 837I using the
correct bill type and the appropriate
revenue and or procedures codes with the correct units and dollar amount
billed in order to
be reimbursed for the copay. Institutional providers can now bill using
the CAS (Claim
Adjustment Segment) segment at the header of the claim. Use adjustment
group code
equal to PR (Patient Responsibility). Adjustment reason codes may be 1
(deductible), 2
(coinsurance) and/or 3 (copay). The total dollar amount associated with
each adjustment
reason code should apply to the entire claim.
If the claim is billed with one or more of the same claim adjustment
reason codes the claim
will suspend with the new edit 686 (Adj Rsn for RIte Share recip billed
more than once).
If the claim is billed with only the SLA (Service Line Adjustment) and
does not have a
CAS segment, the claim will suspend with the new edit 684 (Claim billed
without header
claim adjustment segment) because the SLA will be disregarded for these
claims.
If the recipient is enrolled in RIte Share for the dates of service on
the claim, the claim will
reimburse the deductible, coinsurance and copay up to the maximum
allowed amount for
each reason code. The total dollar amount paid will be posted as the
allowed amount on
detail number one and it will equal the paid amount on the header of the
claim.
If the sum for the reason codes is greater than the billed amount on the
claim then EOB 688
(Claim allowable greater than billed due to copay) will be posted on the
first detail. The
remaining details will pay zero and will have EOB 689 (Claim payment
included in copay
payment) posted on the details.
Professional Providers (837P):
Providers must bill a HIPAA compliant 837P
transaction with the appropriate units, procedure
codes for services provided on the dates of service. The RIte Share
copay, coinsurance or
deductible can be billed using either the CAS (Claim Adjustment Segment)
at the header which
will be applied to the entire claim or the SLA (Service Line Adjustment)
and will be applied at each
detail. The adjustment group code should be PR (Patient Responsibility)
and adjustment reason
codes 1 (deductible), 2 (coinsurance) and/or 3 (copay).
If any detail of the claim is billed with more than one of the same
claim adjustment reason codes,
the detail of the claim will suspend with the new edit 687 (Adj Rsn for
RIte Share recip billed more
than once).
If the recipient is enrolled in RIte Share for the dates of service on
the claim, the claim will
reimburse the deductible, coinsurance and copay up to the maximum
allowed amount for each
reason code.
If the claim is submitted with only a CAS segment then the first detail
allowed amount will equal
the sum of the 3 adjustment reason codes up to the maximum allowed
amount for each adjustment
reason code. If however, the sum for the reason codes is greater than
the billed amount of all the
details on the claim then EOB 688 (Claim allowable greater than billed
due to copay) will be posted
on the first detail. If the sum of the reason codes is less than the sum
of the billed amount and less
than the maximum, EOB 093 (Payment amount reduced to maximum allowable
amount) will be
posted on the first detail.
All subsequent details will pay zero and EOB 689 (Claim payment included
in copay payment) will
be posted on the remaining details.
If the claim is submitted with a SLA and/or CAS segment, each detail
will be processed against the
SLA segment. Any detail with a SLA segment will have the allowed amount
equal to the sum of
all 3 adjustment group codes. If the sum for the reason codes is greater
than the billed amount on
the claim then EOB 688 (Claim allowable greater than billed due to copay)
will be posted on that
detail. If some details do not have SLA, the claim will process as
normal fee-for-service.
Additional Codes Requiring Prior
Authorization
The following procedure codes billed on claims
processed after August 24, 2005 require Prior Authorization:
67900- REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL
APPROACH)
67901- REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE
OR OTHER MATERIAL
67902- REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH FASCIAL
SLING (INCLUDES OBTAINING FASCIA)
67903- REPAIR OF BLEPHAROPTOSIS; (TARSO)LEVATOR RESECTION OR
ADVANCEMENT, INTERNAL APPROACH
67904- REPAIR OF BLEPHAROPTOSIS; (TARSO)LEVATOR RESECTION OR
ADVANCEMENT, EXTERNAL APPROACH
67906- REPAIR OF BLEPHAROPTOSIS; SUPERIOR RECTUS TECHNIQUE WITH FASCIAL
SLING (INCLUDES OBTAINING FASCIA)
67908- REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR
RESECTION (EG, FASANELLA-SERVAT TYPE)
67909- REDUCTION OF OVERCORRECTION OF PTOSIS
67911- CORRECTION OF LID RETRACTION
67912- CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID
LOAD
New Provider Representative
EDS is pleased to announce that Helen Vaughn has
joined the Provider Representative Team as the
Electronic Data Interchange (EDI) Coordinator. Please contact Helen for
EDI issues and questions,
or for individual EDI training. You can reach Helen at 401-784-3879 or
email Helen by clicking here.
Billing Vision Services When Medicare is primary
When billing Medicare Crossovers, providers should
“black out” the office visit code on the
Medicare Explanation of Benefits (EOB) and bill only the frames, lenses,
and dispensing fee
codes showing a zero payment. EDS can then process the frames, lenses,
and dispensing fee
codes as prime.
Please be aware that refractions (92015) are only covered if Medicare
has made a payment on an
eye exam. In order to process the claim, the Medicare EOB must be
attached and sent to the
attention of Ashley Cunningham for special handling at the following
address:
EDS
P.O. Box 2009
Warwick, RI 02887-2009
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