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Provider Update Newsletter

February 2006, Volume 160
 

All Providers

HIPAA Code Sets Conversion
Prior Authorization Guidelines

Pharmacy Providers

Medicare Part D & Benefit Coverage for Optional Drug Classes Effective January 1, 2006

HIPAA Code Sets Converstion

HIPAA (Health Insurance Portability & Accountability Act) mandates that all states eliminate
the use of their local procedure codes and local modifiers except as specifically provided
within 42 CFR (Code of Federal Regulations).

The purpose of local procedure code mapping is to attempt to crosswalk the RI local codes
to any existing or new National HCPCS, CPT, ADA or other National Code Sets. There
are some local codes that will remain due to the code being non-medical or no appropriate
national code crosswalk.

DHS and EDS have completed the crosswalk of our Local Codes/Modifiers to National
Code Sets. We have performed financial analyses to ensure that provider reimbursements
reflect current Medicaid policy and budget allotments.

EDS is moving toward a May 2006 implementation date and expects a smooth transition.
To keep providers informed we will be utilizing the following forms of communication
which include the monthly Provider Updates, the DHS website, the Banner Page of the
Remittance Advice and mailings direct to your office.

Provider specific mailings to watch for will be the code crosswalks and workshop information
in February/March 2006. Educational workshops will be held in April 2006.

If you have recently moved or will be moving within the next 6 months, please notify our
Provider Enrollment Department with your current address to ensure you receive all the
appropriate mailings. To change or update your address please print a Change of Address
form from the DHS website by clicking here and mailing it to:

Electronic Data Systems
Provider Enrollment Unit
PO Box 2010
Warwick, RI 02887-2010
 

Prior Authorization Guidelines

A significant number of Prior Authorization (PA) requests received fail to include the
necessary documentation 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 and/or nutrition, a complete Medicare approved CMN must be used. For
  all other Durable Equipment please use the Rhode Island Department of Human
  Services Medical Assistance CMN found in your provider manual.

• Rhode Island Medicaid 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, be sure to include related price lists.

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

Medicare Part D & Benefit Coverage for Optional
Drug Classes Effective January 1, 2006

Effective January 1, 2006 the new Medicare Part D Prescription Drug Plans (PDP) coverage,
Part D, begins for all Medicare beneficiaries, including those beneficiaries eligible for both
Medicare and Medicaid. State Medicaid coverage for prescription medications for dually
ligible beneficiaries ends on December 31, 2005, with limited exceptions.

At this time the Rhode Island Department of Human Services Medicaid Program will continue
coverage of medications in the following classes of Optional Drugs:

Benzodiazepines
Barbiturates
Cough & Cold medications
Prescription vitamins & mineral products, except prenatal vitamins and fluoride prepartions
Over-the-Counter Medications
Weight Loss / Anti-Obesity Agents*

Please note that coverage in these drug classes is limited to those medications currently
covered by the Rhode Island Department of Human Services Medical Assistance Program.

* These medications will continue to be covered through the Pharmacy Prior Authorization
(PA) Program; PA forms are available on the DHS Website by clicking here.