Provider Update Newsletter
May 2007, Volume 175
All Providers
Attention All Medical Assistance Providers
Provider Electronic Solutions
Citizenship and Identity Requirements
Remittance Advice (RA)
DME Providers
Reminders to Suppliers of Durable Medical Equipment
Attention All Medical Assistance Providers
On May 23rd the implementation of the National
Provider Identifier (NPI) will take place for covered healthcare
entities. Included within this implementation, comes a change for all
paper claims. Since the State of Rhode Island’s Medical Assistance
Program may require that NPI and Taxonomy be on all claim forms in the
future, it is strongly recommended that you take appropriate
action to include NPI and Taxonomy on your claim forms submitted
after May 23rd 2007. This directive will encompass all provider numbers
such as billing, rendering, performing, and referring.
The CMS-1500 claim form was updated to accommodate the mandated National
Provider Identifiers and Taxonomy. The previous CMS-1500 (12-90) form
did not have the fields for reporting of NPIs. Further information on
the CMS-1500 form is available through the NUCC web site by clicking
here.
The National Uniform Billing Committee (NUBC) is responsible for
updating the UB-92; it has been replaced by the UB-04 paper claim form.
You may obtain copies of the CMS-1450 form, which is also known as the
UB-04, from the Standard Register Company, Forms Division. Instructions
for the UB-04 can be obtained from the National Uniform Billing
Committee web site by click here.
HIPAA requires submission of National Provider Identifiers and Taxonomy
on claims effective May 23, 2007.
The American Dental Association has updated the ADA claim form to
accommodate the mandated National Provider Identifiers and Taxonomy when
needed. The form and further details of all changed fields is available
through the American Dental Associations website located at by clicking
here.
Specific instructions for billing Rhode Island
Department of Human Services (DHS) can be obtained from the
DHS website, by selecting Medical
Assistance Provider Services, then Provider Manuals, your provider type,
then Claim Preparation instructions. If you do not have access to the
internet please contact the Customer Service Help Desk at 401-784-8100
for instate toll callers or 1-800-964-6211 for long distance calling.
Provider Electronic Solutions
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 by clicking
here.
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. This version is being tested
and will soon be available. More information will follow in future
Provider Updates.
Citizenship and Identity Requirements
There is an important new requirement that may
affect some of your clients or patients. Federal law now requires
that U.S. Citizens who apply for or receive Medical Assistance, RIte
Care or RIte Share (except those receiving SSI or Medicare) to show
proof of their citizenship and identity. Documentation of
citizenship and identity is required for all new applicants, and current
recipients upon their recertification.
How You Can Help
Applicants and recipients will be required to submit original documents
to a local DHS office or to an “authorized representative.” Authorized
representatives include Family Resource Counselors, hospitals, health
centers, and RIte Care health plans. Medical Assistance Providers can
also become authorized representatives. If you wish to become an
authorized representative, email Amy Lapierre by clicking
here. For more information
on the Citizenship and Identity requirements, please visit the DHS
Website by clicking here.
Remittance Advice
The paper Remittance Advice (RA) which is a summary
of the status of claims, is being modified by EDS by making two minor
modifications.
First, the current report title of “Rhode Island Medical Assistance
Program Remittance Advice” will be modified to say “Rhode Island Medical
Assistance and Other Programs Remittance Advice”. The intent of the
change is to make the report name more general to allow for inclusion of
other state programs.
Secondly, a new column called “Payer” will be added to the existing
Remittance Advice. This feature enables the Providers to easily identify
who the payer of the claim is. At this time, valid payers are Medicaid
(M), Rhode Island Pharmaceutical Assistance to the
Elderly (R), and the Department of Health (H).
Reminders to Suppliers of Durable Medical Equipment
Please take a few minutes to review the guidelines
for billing rental fees for durable medical equipment, particularly
Apnea Monitors. RIMA policy states “In no instance may the total cost of
the rental exceed the total value of the item.” Please refer to the DHS
Webste by clicking here for the
complete DHS DME policy.
Durable Medical Equipment Reimbursement
Durable Medical Equipment (DME) may be rented or purchased based upon
the patient's condition and the period of time the equipment will be
required. Durable Medical Equipment that is rented on a monthly basis
will be specified as to the length of time to be rented. In no instance
may the total cost of the rental exceed the total value of the item. In
such cases, no further payment of deductible or co-insurance will be
made by DHS.
Maximum Allowable
The maximum allowable amount for Durable Medical Equipment will be based
on the current Fee Schedule or usual and customary charge, whichever is
lower. This policy is predicated upon the prudent buyer concept; i.e.,
not paying more for an item when it can generally be obtained at a
lesser cost.
Service and Repair
Service and repair charges are included in the equipment rental fee. If
the equipment is patient-owned and it is not under warranty, Medical
Assistance will cover the charge for service and repair. If the
equipment is under a capped rental, the provider can bill for service
and maintenance.
Apnea Monitor
Indications: Apnea Monitors are covered for those EPSDT recipients who
are at risk of life threatening cessation of breathing. Such conditions
include SIDS siblings, apnea in a newborn, severe bronchopulmonary
displasia, gastroesophogeal reflux, etc. Consideration will be given to
older children who are at risk of apnea due to other respiratory
conditions i.e., tracheostomy.
Coverage and Payment Policy
Apnea monitors will be covered with prior authorization if any of the
above conditions are met. Rental of the monitor will be covered until
the child reaches ten months of age. Approval will continue in three
month intervals until the physician feels that the equipment is no
longer needed. Approval for six months will be considered for older
children when the condition is long term. All supplies used with Apnea
monitors are covered in the rental price.
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