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Provider Update Newsletter

March 2008, Volume 185
 

All Providers

Attention All Medical Assistance Providers
National Drug Code Requirement on Claims Billed for Covered Outpatient Drugs
Provider Electronic Solutions (PES) Software Users

Vision Providers

Refraction Testing

Hospital Providers

Billing Guidelines
 

Attention All Medical Assistance Providers

EDS continues outreach efforts to obtain your National Provider Identifier (NPI). Currently we have received NPIs from 89% of the participating Rhode Island Medical Assistance Providers. If you have not submitted your NPI along with your Taxonomy and Provider Legacy ID, please do so as soon as possible. In order to process your claims, this information is necessary.

EDS along with The Department of Human Services (DHS) urges you to forward your CMS approved e-mail, to Provider Enrollment by faxing a hard copy to 401-467-9581 or send by e-mail to RI-CSHelpDesk. Please be sure to include your taxonomy information and your current RI Medical Assistance Provider ID on the correspondence.

In order to process your claims, this information is necessary. Providers should begin using both the NPI and Taxonomy numbers on future claims submissions. Please notify your billing company or vendor to submit test claims.

Previously we were urging you to use your Legacy ID when there were issues regarding billing with NPI and Taxonomy, however your current legacy number will soon no longer be accepted. Please refer to previous provider updates for the cut off legacy use schedule.

If you would like more information about NPI, please visit the DHS website by clicking here and click on the link for the What’s NEW section. You will find helpful information regarding these changes.

The Department of Human Services and EDS appreciates your assistance and support with this project.
 

Date NPI Required	Provider Type Description
	Home Health Agency
	Nursing Home
	Severely Disabled Children
	Personal Care Aide / Assistant
2/11/2008	Home / Center Based Therapeutic Svcs
	Assisted Living Facility
	MR Rehab
	Early Intervention
	MR Waiver - Private
	Freestanding Dialysis
	Case Manage / Social Worker
	Substance Abuse Rehab
	CMHC / Rehab Option
2/25/2008	Other Therapies / PT, OT, SHL
	Psychologist
	Hospice
	Chiropractor
	Group Practice
	Ambulance

 

National Drug Code Requirement on Claims Billed for Covered Outpatient Drugs

Effective January 1, 2008 The Rhode Island Department of Human Services, in accordance with the Deficit Reduction Act of 2005, will require that Providers, when billing a CPT/HCPC code for a covered outpatient drug, must also submit the appropriate National Drug Code (NDC).

Outpatient Hospital claims and Outpatient Crossover claims are excluded from this requirement.

In accordance with this new requirement, we have created new edits and EOB’s that you may see on your claims if you do not bill as required by the mandate.

Edit 345 – Duplicate NDC number submitted for Same Claim Detail
This edit will verify that when an NDC number is submitted with a procedure code on a claim, there is only one instance of the NDC number per detail line. This will result in the EOB of 358 - Duplicate NDC number submitted for Same Claim Detail

Edit 346 – Non-Covered NDC
This edit will verify that NDC numbers submitted on claims are covered NDC numbers that the Rhode Island Medical Assistance pays for. If the NDC is not covered, this edit will set. This will result in the EOB of 346 – Non-covered NDC

Edit 347 – NDC Missing/Invalid for HCPCS billed
This edit will verify that NDC numbers submitted on claims are properly associated with the procedure code billed. The edit will also verify that a claim billed with a drug related procedure code has an NDC number(s) on that detail. This will result in the EOB of 347 – NDC Missing/Invalid for HCPCS billed

Edit 348 – NDC Quantity or Units Missing or equal to zero
This edit will verify that the drug quantity units submitted with NDCs on a claim are not missing. The edit will also verify that the units are greater than zero. This will result in the EOB of 351 – NDC Quantity or Units Missing or equal to zero

If you have any questions on this, please contact your Provider Representative.

For Physicians – Paul Mulamba – 784-3879
For Dialysis – Sandra Coles – 784-3832
For Hospitals – Kelly Leighton – 784-3823
 

 

Provider Electronic Solutions (PES) Software Users

Do you use the EDS Provider Electronics Solutions (PES) Software?
If so, are you running on the most current version of the software? We are currently running version 2.04, which has recently incorporated changes from the Deficit Reduction Act, requiring an NDC on the claim when billing a CPT/HCPC code for a covered outpatient drug. This change may not effect all providers but it is imperative that all providers complete the upgrade.

Providers should begin using the most current version of the PES software as soon as possible. New users should perform a full installation of version 2.04. It can be downloaded from the DHS Website by clicking here.

Existing users will need to apply the upgrade that is the next consecutive version of your current software. It is recommended to download and install each upgrade as it becomes available. If your software is Networked, please see note below.

To complete an Upgrade:
Under the upgrade section, choose the appropriate upgrade, either version 2.01, 2.02, 2.03 or 2.04:

• It is very important that you choose the appropriate upgrade, if you are running version 2.03, you can upgrade to 2.04

• If you are running version 2.02, you must FIRST upgrade to version 2.03 completely then do a second upgrade to version 2.04

• If you are running version 2.01, you must FIRST upgrade to version 2.02 completely, then do a second upgrade to version 2.03 and then do the final upgrade to version 2.04

• If you are running version 2.00, you must FIRST upgrade to version 2.01 completely, then do a second upgrade to 2.02, then a third upgrade to 2.03 and then do the final upgrade to version 2.04

Select Save

When the box comes up that says “Save As”

• Choose your “C” drive (or the drive which the software resides on)

• Choose the RIHIPAA folder

• Choose Upgrades

• Hit Save: It may take a few minutes to save the upgrade.
  
  Once this is done, you must perform this second step in order to complete the upgrade.
   

• Click on your start button

• Choose “All Programs”

• Choose “RI EDS Provider Electronic Solutions”

• Choose “Upgrade”

You will get a message that states: “Upgrades can not be applied while the EDS Provider Electronic Solutions software is running. Please exit all applications prior to continuing with the upgrade. Do you wish to apply the upgrades now?

• If the software is closed, choose “yes.”

• If the software is open, close the software and then choose “yes”

• Once you choose yes, you should get a message that there is “1 new upgrade”

• Do you wish to continue? Choose “yes”

Follow defaults through the next few screens. Once it is completed, select finish.

You’re software has been upgraded!

Network Installations
If your PES software is on a Network, you MUST apply the upgrades to the Network first following the same process as above. Once the Network has been upgraded, you may upgrade the individual workstations. Please note that the upgrades must be done consecutively on both the Network and the individual workstation.

For example: If you are running version 2.02, you must upgrade the Network to version 2.03, then upgrade the workstation to 2.03. Once that is completed, you may upgrade the Network to version 2.04, and then upgrade the workstation to 2.04.

For further assistance, please contact Mary Jane Nardone, the EDI Coordinator at 401-784-3813.

 

Refraction Testing

The Medical Assistance Program will reimburse for Refraction testing, procedure 92015,
when Medicare reimburses for the routine eye exam (procedures 92002, 92004, 92012
and 92014).

To process these claims a paper CMS 1500 claim form must be sent in with the procedure
92015 with the Medicare EOMB reflecting payment for the routine eye exam. The fee for procedure 92015 is $20.00.

All paper claims must be sent to:
EDS
P.O. Box 2009
Warwick, RI 02887
ATTN: Sandra Bates

If you have any questions, please call your EDS provider representative, Sandra at 401-784-3832.
 

Billing Guidelines

All Rite Share reimbursements for co-pays, co-insurances or deductibles should be processed on bill type 994.

The total Rite Share amount should be listed only on the first line in the Total Charges box.

All other line items on the claim should be crossed out. At the bottom of the claim, only the total Rite Share amount should appear as the Total Charge.

Any other insurance listed in the Payer Name box should be crossed out.

The total Rite Share amount should also be listed in the Est. Amount Due box.