Provider Update Newsletter
June 2007, Volume 176
All Providers
Early Electronic Claims Submissions Cutoff
for 5/26/2007 Financial Cycle & NPI Submission
Dental Providers
Reminders For Dental Providers
Pharmacy Providers
Billing Co-Insurance for Part-B
Medications
Early Electronic Claims Submissions Cutoff
for 5/26/2007 Financial Cycle & NPI Submission
The claims submission deadline (cutoff) for payment
in the financial cycle dated
May 26, 2007 will be moved back one day.
All claims must be submitted to EDS no later than 5:00 pm on Thursday,
May 24, 2007, to be included in the RA dated June 1, 2007. In order to
avoid delays in claims processing, please submit claims through May 24th
using the current RI Medical Assistance Provider Number (legacy
number).
We are recommending that providers not submit claims between May 24th at
5:01pm and May 28th because we will be implementing the National
Provider Identifier (NPI) functionality. It will be necessary to have
the electronic claims translator capturing claims during this
implementation. Any claims received by EDS from May 24th at 5:01 pm
through May 28th will not generate any type of immediate electronic
notification (997 Functional Acknowledgement or Claim Accept/Reject
Report ).
As soon as the electronic claims translator becomes available, providers
will be able to access their Functional Acknowledgement. At that time,
the previously captured claims will be available for providers to check
claim status on the DHS website. Normal claim submissions can resume on
Tuesday, May 29, 2007. These claims will be processed for the next
financial cycle, June 8, 2007, which will pay on June 15, 2007.
Providers submitting claims after May 24, 2007 can begin using the NPI
and Taxonomy. We are recommending that providers initially submit
smaller claim batches with their NPI and Taxonomy to ensure accurate
claim adjudication.
We will maintain a dual processing system for those providers who are
still transitioning to NPI. Providers who have not yet received their
NPI or are still in the process of coding their systems may continue to
submit their RI Medical Assistance Provider (Legacy) Number on an
interim basis.
Please call the Customer Service Help Desk for further assistance at
800-964-6211 for bordering communities and in-state toll calling or
401-784-8100 for all long distance callers. More information will be
available on the DHS website, the
Remittance Advice Banner Page and in future Provider Updates.
Reminders for Dental Providers
ENDODONTICS
Therapeutic Pulpotomy (excluding final restoration)
Removal of pulp coronal to the dentinocemental junction and application
of medicament.
D3220 - Pulpotomy is the surgical removal of a portion of the
pulp with the aim of
maintaining the vitality of the remaining portion by means of an
adequate dressing.
When review of a dental claim finds that a
pulpotomy has been performed as the first stage of a root canal, payment
for the pulpotomy will be recouped.
Root Canal Therapy
Root canal therapy is limited to one (1) procedure per tooth, per
recipient, per lifetime.
Root canal therapy is limited to permanent teeth, and only if the
treatment will lead to a favorable prognosis. Root canals may be
performed on any permanent teeth for recipients under the age of 21, but
only on anterior teeth (#6-11 and #22-27) for recipients age 21 and
over.
Code D7912
This code is for complicated suturing greater than 5 cm and it is
for use with traumatic wounds and excludes closure of surgical
incisions. Some physicians are billing this code in addition to a
surgical extraction.
Code D7320
This code is an Alveoplasty not in conjunction with extractions-per
quadrant.
No extractions performed in an edentulous area. This is a surgical
preparation of ridge for dentures. Extractions may not be performed on
the same day of service.
Professional Consultation
Is a diagnostic service provided by a dentist or physician (other
than the practitioner providing treatment) whose opinion or advice
regarding evaluation and/or management of a specific problem may be
requested by another dentist, physician or appropriate source. The
dentist consulted may initiate diagnostic and or/therapeutic services.
Billing Co-Insurance for Part-B Medications
For those dual eligible beneficiaries receiving
medications covered through Part B Medicare (ie inhalations drugs,
anti-rejection drugs, etc.), pharmacies must first bill Part B Medicare
(or the Medicare Special Needs Plan) according to their policy and bill
Medicare as a secondary payer using the CMS 1500 form and appropriate J
code for the 20% coinsurance. Please indicate on the form the amount
paid by the primary insurer.
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