Provider Update Newsletter
December 2007, Volume 182
All Providers
Attention All Medical Assistance Providers
Referring Providers
Third Party Recoveries
Program of All-Inclusive Care for the Elderly (PACE)
RIte Share Premium Assistance Program
Payment Error Rate Measurement (PERM)
Hospice Providers
Rate Changes
Attention All Medical Assistance Providers
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updating the UB-92; it has been replaced by the UB-04 paper claim form.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 bu clicking here.
HIPAA requires submission of National Provider Identifiers and Taxonomy
on claims effective May 23, 2007.
Effective September 30, 2007 RI Medical Assistance no longer accepts
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. 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.
Referring Providers
RI Department of Human Services continues to
implement quality initiatives to support your patient care efforts and
improve our service. In line with this goal we have chosen MedSolutions,
Inc. to provide prior authorization services for outpatient radiology
for Medical Assistance Recipients. MedSolutions is a radiology services
organization specializing in the management of quality, cost-effective
diagnostic services. The new radiology requirements will become
effective January 1, 2008.
For all outpatient, elective MRI, CT and PET imaging studies performed
on or after January 1, 2008 the referring provider will be required to
obtain prior authorization of coverage directly from MedSolutions by
submission of your request via the web, toll-free telephone, or
toll-free fax prior to scheduling the procedure.
Imaging studies performed in conjunction with an inpatient stay or
emergency room visit are not subject to prior authorization by
MedSolutions.
Over the next few weeks, more information will be provided concerning
the details of the prior authorization program. Please note that
implementation of this program allows RI Medical Assistance to assist
our providers and beneficiaries to obtain the most appropriate imaging
study available.
Your cooperation with these changes is appreciated. If you have any
questions, please contact your Provider Representative, Paul Mulamba at
401-784-3879.
Third Party Recoveries
RI Medical Assistance is no longer able to recover
payment from Blue Cross Blue Shield of Rhode Island, out of State Blue
Cross plans and their pharmacy benefit plans 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 Blue Cross as the primary
payer for reimbursement. Blue Cross Blue Shield of Rhode Island has
agreed to waive the timely filing limit for these claims.
EDS will mail a letter requesting that you bill Blue Cross Blue Shield
for those clients identified and submit a refund or recoupment request
to EDS within sixty days of receipt. Information included in the letter
is the clients first and last name, policy number, and start date of
their 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
by contacting EDS at the address and/or telephone numbers provided in
the mailing. If payment is not received within 60 days, EDS will perform
the recoupments. Once the recoupment is processed by EDS and the claim
(s) are reimbursed by Blue Cross Blue Shield then please submit any
outstanding balance to RI Medical Assistance as the secondary payer. The
claim may be submitted either electronically with other insurance
payment information included or on paper with the appropriate
explanation of benefits.
Program of All-Inclusive Care for the
Elderly (PACE)
PACE began providing care to RI Medical Assistance
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 a recipient is on PACE, the recipient is no longer eligible to
receive services under Medical Assistance Fee For Service (Medicaid).
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 any questions
regarding eligibility, please log onto the DHS website to obtain
eligibility by clicking here, and
sleecting MMIS Web Transactions or contact the Customer Service Help
Desk at 401-784-8100 or 1-800-964-6211 for in-state toll calls.
RIte Share Premium Assistance Program
Membership in RIte Share. The health insurance
premium assistance program with the Rhode Island Department of Human
Services (DHS) Medical Assistance (MA) program continues to grow. The
Rite Share program subsidizes employer-sponsored health insurance for
health insurance members and their families.
RIte Share members actually receive health coverage through their
employer-sponsored health plan such as Blue Cross Blue Shield of Rhode
Island, BlueCHIP/Coordinated Health Partners, and United Healthcare,
Inc. The RIte Share benefit package is identical to the RIte Care
benefit package. Services and member co-payments, which are not covered
by the commercial carriers are billed directly to the RIte Share
Program. Member co-payments are reimbursed through the Medical
Assistance Program using the state only codes listed below.
Remember: At no time should Providers collect the co-payments directly
from a client. This is against Medical Assistance regulations.
Providers can bill RIte Share for member co-payments or co-insurance
and/or deductible amounts using the following codes.
|
Provider Category |
Member Co-Payment Reimbursement Billing |
|
Physicians and other medical professionals: |
State
Local Code X0700 for reimbursement of co-payments:
The provider can bill the
member co-payments without obtaining an EOB from the primary or
RIte Share insurance carrier. Indicate no to other insurance.
State
Local Code X0701 for billing coinsurance and/or deductible
amounts.
Submit Explanation of Benefits (EOB)/Remittance Advice (RA) from
the primary carrier.
These claims will be
manually priced according to the coinsurance and or deductible
amount posted on the EOB from the RIte Share primary carrier.
|
|
Pharmacies |
POS Claim: Use the NDC
dispensed and bill commercial co-payments in field 433 (patient
paid amount).
Paper Claim: Use the mock
NDC 99999-1111-11 for billing the commercial co-pay in the
charge field. |
When checking eligibility either on the web or thru
REVS we will state the client is in the Rite Share Program. Only RIte
Share members are eligible for the X0700 and X0701 codes.
For additional information on the Rite Share and RIte Care programs,
reference the DHS web by clicking here.
For specific information in billing procedures for RIte Share members,
contact EDS’ Customer Service Help Desk at 401-784-8100 for local and
long distance or 800-964-6211 for bordering communities and instate toll
calls.
Payment Error Rate Measurement (PERM)
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.
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. The
request for medical records to support the sampled claims is expected to
commence the first week of December 2007.
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 60 days. Livanta LLC
and possibly State officials will follow up to ensure that providers
submit the documents before the 6O day time frame 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. If Livanta LLC requests medical
records from you and you have questions, call Robin Reed at Livanta LLC
at (301) 957-2380.
Rate Changes
Effective October 1, 2007, the
rates for Hospice Care are as follows:
|
Code |
Description |
Rate |
| T2042 |
Hospice Routine Home Care: Per
Diem |
$135.29 |
| T2043 |
Hospice Care – Continuous Home
Care: Per Hour |
$32.87 |
| T2044 |
Hospice Inpatient Respite Care:
Per Diem |
$147.12 |
| T2045 |
Hospice General Inpatient Care:
Per Diem |
$601.02 |
If you have any questions or
concerns, please contact Kelly Leighton at 401-784-3823 or by email by
clicking here.
|
