Provider Update Newsletter
September 2007, Volume 179
All Providers
Attention All Medical Assistance Providers
Citizenship and Identity Requirements for Medical
Assistance Recipients
Medicare Recoveries
SFY 2008 medical Assistance Financial Calendar
Payment Error Rate measurement (PERM)
Dental Providers
Reminder to Dental Providers
Submitting Surgical/Consultation Claims for Reimbursement
Nursing Home Providers
Hospice Billing Reminder
Attention All Medical Assistance Providers
On May 23rd the implementation of the National
Provider Identifier (NPI) took place for covered healthcare entities.
Included within this, 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 necessary 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.
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updating the UB-92; it has been replaced by the UB-04 paper claim form.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 clicking here.
HIPAA requires submission of National Provider Identifiers and Taxonomy
on claims effective May 23, 2007. Effective September 30, 2007 RI
Medical Assistance will no longer accept the "old" CMS 1500 (12/90
Version) or the UB-92. Please submit paper claims after September 28th
utilizing the CMS-1500 (08-05 Version) and the UB-04.
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 by clicking
here.
Specific instructions for billing Rhode Island
Department of Human Services (DHS) can be obtained from the DHS website,
by clicking
here.
Select 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.
Citizenship and Identity Requirements for
Medical Assistance Recipients
Federal law now requires that U.S. Citizens who
apply for or currently receive Medical Assistance, RIte Care or RIte
Share (except those receiving SSI or Medicare) must provide proof of
citizenship and identity in order to obtain or maintain their health
coverage.
Documentation of citizenship and identity is required for all new
applicants upon initial application and current recipients upon
recertification. Without this documentation, Medical Assistance
eligibility will be denied.
If your patients have questions about this requirement, they can log on
to DHS Website by clicking here, or
contact their RIte Care Health Plan, the DHS Infoline or their Medical
Assistance worker.
Medicare Recoveries
Due to the implementation of the National Provider
Identifier, RI Medical Assistance is no longer able to recover payment
from Medicare when claims are paid as primary by Medical Assistance.
Effective immediately you will be notified via mail of clients and
claims that were reimbursed by RI Medical Assistance but, should be
submitted to Medicare as the primary payer for reimbursement.
EDS will mail a letter requesting that you bill Medicare for those
clients identified and submit a refund or recoupment request within
sixty days of receipt. Information included in the letter are the
clients first and last name, Medicare number, start date of their
Medicare coverage. EDS will also include the patient account number,
date of service, internal control numbers of the claims and paid amount
to assist in identifying those claims.
If you disagree with the information provided, you can dispute the claim
to the address and/or telephone numbers provided in the mailing. If a
refund is not received within 60 days, EDS will perform the recoupments.
Coinsurance and deductible amounts will continue to be paid through
normal billing procedures.
If you receive a notification letter, contact name and numbers will be
provided for questions.
SFY 2007 Medical Financial Calendar
|
Month |
LTC Due |
EMC Claims Due |
Cycle Date |
EFT
Payment |
3 wk cycle |
|
|
|
|
|
|
|
|
June |
6/7/2007 |
6/8/2007 |
6/9/2007 |
6/15/2007 |
|
|
|
|
6/22/2007 |
6/23/2007 |
6/29/2007 |
|
|
July |
7/12/2007 |
7/13/2007 |
7/14/2007 |
7/20/2007 |
1 |
|
|
|
7/27/2007 |
7/28/2007 |
8/3/2007 |
|
|
August |
8/9/2007 |
8/10/2007 |
8/11/2007 |
8/17/2007 |
|
|
|
|
8/24/2007 |
8/25/2007 |
8/31/2007 |
|
|
September |
9/13/2007 |
9/14/2007 |
9/15/2007 |
9/20/2007 |
1 |
|
|
|
9/28/2007 |
9/29/2007 |
10/5/2007 |
|
|
October |
10/11/2007 |
10/12/2007 |
10/13/2007 |
10/19/2007 |
|
|
|
|
10/26/2007 |
10/27/2007 |
11/2/2007 |
|
|
November |
11/8/2007 |
11/9/2007 |
11/10/2007 |
11/16/2007 |
|
|
|
|
11/23/2007 |
11/24/2007 |
11/30/2007 |
|
|
December |
12/13/2007 |
12/14/2007 |
12/15/2007 |
12/20/2007 |
1 |
|
|
|
12/28/2007 |
12/29/2007 |
1/4/2008 |
|
|
January |
1/10/2008 |
1/11/2008 |
1/12/2008 |
1/18/2008 |
|
|
|
|
1/25/2008 |
1/26/2008 |
2/1/2008 |
|
|
February |
2/7/2008 |
2/8/2008 |
2/9/2008 |
2/15/2008 |
|
|
|
|
2/22/2008 |
2/23/2008 |
2/29/2008 |
|
|
March |
3/13/2008 |
3/14/2008 |
3/15/2008 |
3/20/2008 |
1 |
|
|
|
3/28/2008 |
3/29/2008 |
4/4/2008 |
|
|
April |
4/10/2008 |
4/11/2008 |
4/12/2008 |
4/18/2008 |
|
|
|
|
4/25/2008 |
4/26/2008 |
5/2/2008 |
|
|
May |
5/8/2008 |
5/9/2008 |
5/10/2008 |
5/16/2008 |
|
|
|
|
5/23/2008 |
5/24/2008 |
5/30/2008 |
|
|
June |
6/5/2008 |
6/6/2008 |
6/7/2008 |
6/13/2008 |
|
|
|
|
6/20/2008 |
6/21/2008 |
6/27/2008 |
|
|
July |
7/10/2008 |
7/11/2008 |
7/12/2008 |
7/18/2008 |
1 |
|
|
|
7/25/2008 |
7/26/2008 |
|
|
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. RHODE
ISLAND IS A PERM 2007 STATE AND IS CURRENTLY UNDER REVIEW.
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.
Reminder to Dental Providers Submitting
Surgical/Consultation Claims for Reimbursement
Reminder to Dental 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.
Reminder to Dental Providers submitting Consultation claims for
reimbursement:
Procedure Code D9310 - Consultation (diagnostic service provided by
dentist or physician other than practitioner providing treatment)
Type of service provided by a dentist or dental specialist 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 may initiate diagnostic and/or therapeutic services.
Hospice Billing Reminder
If you have a recipient that elects Hospice care,
you are responsible to bill Hospice for the Room and Board charges for
the time period that the recipient has elected Hospice care. The Nursing
Home is not eligible to receive reimbursement directly from Medical
Assistance for the time period that the recipient has elected to receive
Hospice care.
The Hospice provider will bill Medical Assistance directly and reimburse
you once they have received payment from Medical Assistance. If you bill
Medical Assistance in error and you are paid, this will delay payment to
the Hospice provider which, in turn will delay their payment to you. It
is your responsibility to recoup any claim that you should not have
billed to Medical Assistance due to the recipient electing Hospice.
Once the Nursing Home claim has been recouped, then the Hospice provider
can bill Medical Assistance and receive payment as appropriate. If you
have any questions regarding this policy, please contact Kelly Leighton
by clicking here or
401-784-3823.
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