Provider Update Newsletter
April 2008, Volume 186
All Providers
Attention All Medical Assistance Providers
Claims Filing/Processing Tips
Radiology/Imaging Procedures
Physician Providers
Professional Crossover Payments
DME Providers
Nutritional Supplements
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.
Please be aware that any claim submitted
electronically to RI Medical Assistance after 5:00 PM on the compliance
date must contain a NPI and Taxonomy. RI Medical Assistance will no
longer accept your legacy number (Provider ID). Any claims submitted
electronically, after this deadline without an NPI and Taxonomy will be
denied.
|
Date NPI
Required
|
Provider
Type Description
|
|
|
Licensed
Therapist |
|
|
Independent Labs |
|
|
Optometrist |
|
|
LEA
- Performing Provider |
|
3/17/2008
|
Local
Education Association (Special) |
|
|
Free Standing Ambulatory Surgical
Center |
|
|
Inpatient Facility |
|
|
Outpatient
Facility |
|
|
Federally
Qualified Health Center |
|
|
Audiologist |
|
|
Children's Services |
|
|
Podiatrist |
|
|
|
|
3/31/2008 |
Dentist |
|
DME
Supplier/Prosthetics/Orthotics |
|
|
|
|
4/14/2008
|
Physician |
|
Physician's
Assistant |
|
Nurse
Practitioner |
|
Nurse
Practitioner - Billing |
Claims Filing/Processing Tips
Claims Filing
The Rhode Island Medical Assistance Program requires
that a provider fully utilize a recipient’s third party resources before
billing the Medical Assistance Program.
When a Medical Assistance recipient has other health insurance the
provider must bill that health insurer prior to billing the Medical
Assistance Program, as Medicaid is the payer of last resort.
A copy of the Explanation of Benefits (EOB) from the other insurance
carrier must be included with the Medical Assistance Program claim for
recipients with other insurance. The Primary Insurances should be able
to provide you with the ability to print an EOB (Explanation of
Benefits) from their web site.
Please note we must have the following information to process your
claims requests:
The following information must be visible on the EOB:
-
Name of the Primary Insurance
-
Date that the Primary Insurance paid or denied
the claim
-
Patient’s name and ID#
-
Date of Service
-
Appropriate procedure Codes according to your
Provider Type
-
Total charges/ deductible and co-ins/ allowed
amounts/ and paid amounts must be visible
-
Explanation of Primary Insurance denial codes
Due to optical scanning, please do not
highlight or mark up the EOB.
Claims Processing Tips
When claims are RTP (returned to provider) please ensure proper
corrections are made before re-submitting the claim.
Please do not staple, paper clip, tape, etc. claims together.
Before dropping a Medicare crossover claim to paper, please wait at
least 3 payment cycles to see if it has crossed over electronically.
Please do not mark-up the EOB’s with check marks etc. All names and
information other than the
recipient you are billing for
should be blacked out.
Please ensure proper alignment of
information on claim for accurate processing.
Radiology/Imaging Procedures
For all outpatient, elective MRI, CT and PET imaging
studies performed on or after January 1, 2008 referring provider’s will
be required to obtain prior authorization of coverage directly from
MedSolutions. You may make these requests via: toll-free telephone at
(888) 693-3211, the web by clicking
here, or toll-free
by fax at (888) 693-3210 prior to scheduling the procedure.
Please note, prior authorization is not required for those beneficiaries
who have a primary insurance that has approved and paid the claim. In
those instances, you are billing for the copay only.
Medicaid clients who have a primary commercial or Medicare coverage Do
Not require authorization
For any issues that cannot be resolved with MedSolutions, please contact
EDS at (401) 784-8100 or in-state toll free at (800) 964-6211.
Professional Crossover Payments
The standard calculation for a crossover payment is the lesser of:
The difference between the Medical Assistance (MA) allowed and the
Medicare payment (MA allowed minus Medicare paid): or
-
The Medicare coinsurance and deductible up to
the MA allowed amout
-
If another insurance has paid for the service,
the Medical Assistance Program will pay any co-insurance,
deductible, and co-payment amount, as long as the total amount paid
by the other insurance does not exceed the Medical Assistance
Program allowed amount for the service billed. If the other
insurance amount exceeds the MA allowable, Medical Assistance will
reflect a zero paid amount.
Nutritional Supplements
Access to Nutritional Supplements is a two-part
process involving both the provider of the nutritional supplement and
the prescriber.
-
The prior authorization (PA) form must be
completed by either one of the following two entities that will be
supplying the nutritional supplement;
a.) The DME
Provider
b.) the pharmacy, who is also a billing DME
provider
Please note that PA’s requested by prescribers will not be
considered as they are not the “provider” of the nutritional
supplement itself.
-
The prescriber is responsible for completing the
Certificate of Medical Necessity. The CMN must include a statement
indicating;
a.) that the
nutritional supplement is the only source of nutrition for the
beneficiary
b.) the amount of calories used per day
Both the PA form and the CMN can be downloaded from
the DHS web site by clicking
here.
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