Provider Update Newsletter
July 2007, Volume 177
All Providers
Provider Electronic Solutions (PES) Software Users
Prior Authorization
Program of All-Inclusive Care for the Elderly (PACE)
Speed Up the Time in Which Your Paper Claims Process!!!
Dental Providers
Reminder to Providers Submitting
Surgical Claims for Reimbursement
Provider Electronic Solutions (PES) Software
Users
Do you use EDS’ Provider Electronics Solutions (PES)
Software?
If so, are you running on the most current version of the software? We
are currently running version 2.03. This version is necessary to use
for billing, as it includes a location for your NPI and taxonomy code.
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 2.03, you should upgrade your software
as soon as possible. If you are running version 2.00, you must do three
upgrades. You must first upgrade to version 2.01 then version 2.02, then
to version 2.03. Performing the upgrades out of order will create issues
for your database and may result in loss of data.
If you are running version 2.02, you will only have to do one upgrade to
version 2.03
The upgrades can be found on the DHS website by clicking
here.
It is imperative that you choose the upgrades from
the UPGRADE column on this website. If you choose to do a full
installation, you will lose all of you data and it will be necessary to
key in all your client and provider data. Please print the directions
down prior to starting the upgrades, if you need assistance please
contact the EDI Coordinator at 401-784-3813.
After you have upgraded, you must update your provider list to include
your NPI and Taxonomy. The instructions on how to change your Provider
lists are called: Creating Provider and Client List. These instructions
can be located by clicking here.
Once you have added your NPI and Taxonomy to the
provider list, please remember to change your provider ID on your claim
to your NPI and Taxonomy, as NPI and taxonomy are now required on all
electronic claims.
Prior Authorization
The Department of Human Services has modified the
Prior Authorization Request From. Please begin using the updated Prior
Authorization Request form immediately to facilitate the billing
processes. The new PA form can be obtained on the DHS website by
clicking here.
Please discontinue use of previous version of PA form.
Program of All-Inclusive Care for the
Elderly (PACE)
PACE began providing care to RI recipients in late
2005. If a recipient is eligible for PACE, they have elected to receive
all of their care from a PACE provider. PACE arranges for all of the
recipients’ care and reimburses their providers directly.
If you are checking eligibility, and you hear under other insurance
“Program for All-Inclusive Care for the Elderly,” this means that if you
provide care to the recipient you will not be reimbursed by Medical
Assistance. The recipient should be referred to PACE, and they will
arrange for any treatment that is required.
If you do provide service to a PACE recipient and you bill RI Medical
Assistance your claim will be denied.
If you have further questions, please contact the Customer Service Help
Desk at 401-784-8100 or 1-800-964-6211 for in-state toll calls.
Speed Up the Time in Which Your Paper Claims
Process!!!
To facilitate processing of your paper claims please
be sure to adhere to the following guidelines:
-
Ensure that your claims are properly aligned and
that pertinent information such as billing provider information and
insured ID number are legible
-
Typed written claims process more rapidly and
reduce the chance of errors
-
If billing with an NPI (National Provider
Identifier) ensure that you include a Taxonomy in the appropriate
area of the claim, Taxonomy is required with billing
-
If billing with a legacy provider ID be sure to
include the qualifier 1D
-
Do not staple, paper clip or tape claims
together
-
Do not mark up EOB’s by highlighting, starring,
check marks, etc, this may cause your claim to be processed
incorrectly
Please allow 4 - 6 weeks for Medicare secondary claims to process
before submitting on paper.
Reminders to Providers Submitting Surgical
Claims for Reimbursement
Pre-operative and Post-operative Days
All CPT codes within the surgical range (10000 thru 69999) cover
one (1) pre-operative day and thirty (30) post-operative
days. All office visits and subsequent hospital care days within this
range of days that are provided by a physician of the same specialty as
the surgeon will be denied as included in the post-operative period of
days. The post-operative days are counted starting the first day after
surgery.
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