Provider Update Newsletter
March 2007, Volume 173
All Providers
National Provider Identifier/Do You Have Your NPI?
NPI and Electronic Billing Readiness
Payment Error Rate Measurement (PERM)
Dental Providers
Dental Policy
New Dental Program for Young Children
Do You Have Your NPI?
The Deadline for having a new National Provider
Identifier (NPI) is May 23, 2007. As the Department of Human Services
(DHS) along with EDS prepares for this national change within our
system, it is necessary to convert current provider numbers to the new
NPI’s which are issued by the Centers for Medicare and Medicaid (CMS).
DHS is requesting Rhode Island Medical Assistance (RIMA) providers to
forward their NPI, taxonomy(ies) and current provider number(s) to EDS
by March 14, 2007. This will allow enough time for processing your NPI
which includes testing new system changes. Thank you for being proactive
with this national regulation.
Fox Systems is the CMS contractor for NPI enumeration applications. An
NPI application can be located by clicking
here or by calling
1-800-465-3203 to request a paper copy of the application. Please allow
30 days for your application to be processed.
Having all this information by the above date will decrease the chance
of any delay in claims adjudication. If you would like further
information regarding NPI please visit the DHS website under the What’s
NEW section by clicking here. You
will find helpful information, which will prepare you on the upcoming
changes.
Once you have obtained your NPI please forward the approval by email by
clicking here or fax a hard
copy to 401-467-9581. Questions can be directed to EDS by calling
401-784-8877 to leave a voice message. Please include your name, contact
phone number, and a brief message. All calls will be responded to within
48 hours/2 business days.
NOTE:
If you are billing electronically, please complete the survey for NPI
readiness on May 23, 2007.
Who needs an NPI? Who should apply for a National
Provider Identifier (NPI)?
To confirm these questions, here’s a tip: If you bill Medicare and other
health insurance plans it is likely you are eligible to obtain a
National Provider Identifier for billing Medical Assistance health
insurance claims.
Why do I need to get an NPI?
All healthcare providers, who are Health Insurance Portability
Accountability Act (HIPAA) covered entities will need to get an NPI to
file standard electronic transactions after May 23, 2007.
When should I get my NPI?
It is recommended that you apply as soon as possible. Failure to obtain
your NPI by May 23, 2007 could result in delay in the adjudication of
your claims.
For more information visit the Department of Human Services website by
clicking here or
obtain an application through Fox Systems by click
here.
Provider Electronic Solutions (PES) Software Users
Do you use EDS’s Provider Electronics Solutions (PES) Software? If so,
are you running on the most current version of the software? We are
currently running version 2.02.
If you are running version 2.00, you must do two upgrades. You must
first upgrade to version 2.01 and then upgrade to version 2.02.
Performing the upgrades out of order will create issues for your
database and may result in loss of data.
If you are running version 2.01, you will only have to do one upgrade to
version 2.02. The upgrades can be found on the DHS website at
http://www.dhs.ri.gov/dhs/hipaa/hPES.htm.
If you are unsure of the version you are running, please follow the
steps below to determine the version. Log on to the PES software. Once
you have accessed the software:
A window will open displaying the version. If you
are not currently running version 2.02 you should upgrade your software
as soon as possible. Please print the directions down prior to starting
the upgrades, if you need assistance please contact the EDI Coordinator,
Dawn Durocher at 401-784-3813.
Once you upgrade to the 2.02 version, an additional upgrade will be
necessary in order to accommodate the new National Provider Identifier
and Taxonomy. More information will follow in future Provider Updates.
Please be sure to fill out the enclosed questionnaire on page 3 if you
are using PES.
NPI and Electronic Billing Readiness
In order to ensure provider readiness on May 23,
2007, we are asking providers to complete the following survey.
If you have any questions please contact the EDI Coordinator at
784-3813.
Return to EDS at Fax Number 467-9581 to ATTN:
Dawn Durocher
Payment Error Rate Measurement (PERM)
The Improper Payments Information Act of 2002
directs Federal agency heads, in accordance with the Office of
Management and Budget (OMB) guidance, to annually review its programs
that are susceptible to significant erroneous payments and report the
improper payment estimates to Congress. OMB identified the Medicaid and
the State Children's Health Insurance Program (SCHIP) as programs at
risk for significant erroneous payments.
The Centers for Medicare and Medicaid Services (CMS) will measure the
accuracy of Medicaid and SCHIP payments made by States for services
rendered to recipients through the Payment Error Rate Measurement (PERM)
program. Under the PERM program, CMS will use national contractors to
measure improper payments in Medicaid and SCHIP. The Lewin Group will
provide statistical support to the program by producing the claims to be
reviewed and by calculating Rhode Island’s error rate. Livanta LLC will
provide the documentation/database support by collecting medical
policies from the State and by collecting medical records from
providers. HealthDataInsights Inc., and their subcontractor Health
Services Advisory Group will be performing the medical reviews.
Medical records are needed to support medical reviews that the review
contractor will conduct on the fee-for-service Medicaid and SCHIP claims
to determine if the claims were correctly paid. If a claim is selected
in the sample for a service that you rendered to either a Medicaid or
SCHIP recipient, Livanta LLC will contact you for a copy of your medical
records to support the medical review of the claim.
Understandably, providers are concerned with maintaining the privacy of
patient information. However, providers are required by Section
1902(a)(27) of the Social Security Act to retain records necessary to
disclose the extent of services provided to individuals receiving
assistance and furnish CMS with information regarding any payments
claimed by the provider for rendering services. The furnishing of
information includes medical records. In addition, the collection and
review of protected health information contained in individual-level
medical records for payment review purposes is permissible by the Health
Insurance Portability and Accountability Act of 1996 and implementing
regulations at 45 Code of Federal Regulations, parts 160 and 164.
Generally, to obtain medical records for a claim sampled for review,
Livanta LLC will contact the provider to verify the correct name and
address information and to determine how the provider wants to receive
the request(s) (facsimile or US mail) for medical records. Once the
provider receives the request for medical records, s/he must submit the
information electronically or in hard copy within 90 days. Livanta LLC
and possibly State officials will follow up to ensure that providers
submit the documentation before the 90-day timeframe has expired.
It is important that providers cooperate with sending in all requested
documentation because no response or insufficient documentation will
count against the State as an error. Past studies have shown that the
largest causes of errors in the medical reviews is no documentation or
insufficient documentation. Therefore, information should be sent in
time and should be complete. If Livanta LLC requests medical records
from you and you have questions, call Robin Reed at Livanta LLC at (301)
957-2380.
Dental Policy
Reminder: Rhode Island Medicaid Dental Policy is in
effect for all dental claims. Recent reviews of dental claims have shown
that not all dental providers are adhering to the dental policy for
fixed prosthodontics and crowns included below.
The RI Medical Assistance Dental Policy may be referenced on the DHS
Website by clicking
here.
Any claims billed inappropriately will be recouped. Dental providers who
bill for permanent bridges or resin crowns to posterior teeth (Tooth
numbers 1-5, 12-16, 17-21, or 28-32) will have those claims recouped.
FIXED PROSTHODONTICS
Permanent bridges will be approved for anterior permanent teeth only.
Recipients must be less than 21 years of age. Permanent bridges will
be approved for a maximum of four (4) units. If greater than four units,
a partial denture should be provided and billed.
If anterior and posterior teeth are missing, a partial denture should be
provided and billed.
Prosthodontics, fixed – each abutment and each pontic constitutes a
unit in a fixed partial denture.
Local anesthesia is considered to be part of Fixed Prosthodontic
procedures
INDIVIDUAL CROWNS
Payment for crowns for anterior teeth, permanent or primary, is limited
to prefabricated resin crowns.
Payment for crowns for posterior teeth, permanent or primary, is limited
to stainless steel crowns.
Retention pins are limited to two per tooth in addition to restoration
during a 365 day period.
The Medical Assistance Program will only pay once per tooth per calendar
year for recementation of inlays and crowns (D2910 & D2920).
New Dental Program for Young Children
We are happy to report that the RIte Smiles Program
began on September 1, 2006. The new RIte Smiles dental plan is called
UnitedHealthcare Dental. United Healthcare and its dental
subsidiary, Dental Benefit Providers, has been administering the new
dental plan for Rhode Island. Dental Benefit Providers has considerable
expertise in administering dental benefits and currently administers
dental benefits for 1.3 million members in 8 states. DHS is working
closely with UnitedHealthcare Dental to assure a smooth transition for
all families as their children switch from Medical Assistance
Fee-For-Service Dental to UnitedHealthcare Dental.
Approximately 30,000 children who have Medical Assistance coverage are
eligible for RIte Smiles and will continue to be enrolled in
UnitedHealthcare Dental. We will continue to update you on the
enrollment schedule over the next several months.
IMPORTANT BILLING INFORMATION beginning September 1, 2006
Be sure to have your office staff check patient’s dental insurance ID
Cards
When to bill UHC Dental
-
RIte Smiles members will have a UnitedHealthcare
Dental card. UnitedHealthcare Dental should be billed even if you
haven’t signed up as a contracted provider in the UHC Dental Plan.
If you bill Medical Assistance for services rendered on or after
September 1 for a patient enrolled in RIte Smiles, the claim will
not be paid because the child no longer has Medical Assistance
Fee-For-Service Dental coverage. Providers not in the UHC Dental
Plan network will be reimbursed for dental services at the Medical
Assistance rates. UnitedHealthcare Dental is actively recruiting
dentists throughout the State to be part of its dental network. For
more information on becoming a participating provider, please call
UnitedHealthcare Dental’s recruitment line at: 1-888-679-8923.
-
For children with Medical Assistance ID cards
who are in the Rite Smiles Program, but haven’t received their UHC
Dental ID card yet, call UnitedHealthcare Dental’s Provider Service
number at 1-888-679-5353 to confirm eligibility.
When to bill EDS (for Medical Assistance
Claims)
For EDS’ Provider Customer Service Help Desk, please
call: 401-784-8100 for long distance callers or 1-800-964-6211
for in-state toll calls.
If you haven’t already signed up to become a part of
the RIte Smiles dental plan network, we hope you will do so.
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