Provider Update Newsletter

June 2000, Volume 92

Electronic Funds Transfer (EFT) Reminder and FYI to Sovereign Customers
HIPAA Happenings
DHS Web Site
Provider Suggestions for Future Articles
Provider Payment Schedule

GPA Claims Processing

EMC Helpful Hints

Nursing Schedules

REVS for Recipient Eligibility

Rate Increases

Billing Reminder

Prescribing Provider Number

 

EFT is a free, cost-effective, electronic alternative to receiving paper checks for Medical Assistance reimbursement by automatically depositing reimbursement into your bank account on the day paper checks are mailed. This expedites access to cash by 3-7 days. To enroll: Complete the form provided: RI Medical Assistance Program’s Authorization For Direct Deposit Form, attach a copy of a voided check and mail it to: EDS, Financial Department, P.O. Box 2010, Warwick, RI 02887-2010.

Many providers have been calling the CSHD regarding changing their direct deposit accounts from Bank Boston to Sovereign. The RI Medical Assistance Program’s Authorization for Direct Deposit Form should be completed and mailed to: EDS, Financial Department, P.O. Box 2010, Warwick, RI 02887-2010. Thank you!

This month, the Health Care Financing Administration (HCFA) - Boston Regional Office, will be holding technical training seminars for State and Fiscal Intermediary Contractor staffs concerning the new provisions of HIPAA (Health Insurance Portability and Accountability Act) Administrative Simplification (AS). These sessions will cover such topics as new standardized data transaction sets, national Coding sets, patient and provider identifiers, claim attachments, and security and privacy issues. HCFA will be providing guidance and assistance to the States throughout the HIPAA-AS implementation process.

DHS and EDS will also be hosting several informational seminars over the next few months to familiarize State and Provider staffs about some of HIPAA’s new rules and protocols. We will continue to publish HIPAA requirements, as they become known. For additional information on HIPAA, visit the following Web sites.

www.hcfa.gov – HCFA’s home site; HIPAA page
www.wpc-edi.com – Washington Publishing Company – data transaction set standards and protocols; Code messaging
www.ehnac.org – Electronic Healthcare Network Accreditation Commission www.ps-tag.org – Private Sector Technical Assistance Group – white papers on HIPAA financial considerations
www.rx2000hipaa@rx2000.org – listserv group featuring daily discussions about HIPAA policy and implementation

We’ve added an interactive City/Town and DHS Office listing page that will assist in client referrals to DHS programs. There are also DHS program descriptions and contacts that we hope will make our services more accessible to those who need them.

We will continue to add interactive formats and design changes over the next few months and encourage your comments and suggestions as to how we can make this a better resource for you.

Provider Suggestions for Future Articles

Is there an article you would like to see? If so, please send your suggestions on your company stationery to: EDS, Provider Update, P.O. Box 2010, Warwick, RI 02887-2010. Our staff will research your article suggestion and possibly publish your requested article. Thanks for helping us help you!

The claims processing and payment cycles schedule for the July 2000 through January 2001 period is provided for your convenience.

Beginning May 1, 2000, all claims for services provided to General Public Assistance (GPA) Recipients with dates of service on or after May 1, 2000 should be billed to EDS using your Medical Assistance Provider ID. The address for paper claims submissions beginning May 1, 2000 can be found in your Provider Reference Manual. All electronic claims submitters will be able to submit GPA claims along with claims for Medicaid Recipients. Pharmacy providers may submit those claims through POS beginning May 1, 2000. All other providers submitting electronically may bill through their current electronic claims submission method, including Provider Electronic Solutions software.

For dates of service through April 30, 2000, all providers for GPA Recipients should continue to submit claims to the Department of Human Services for processing. If you have questions regarding claims submissions for GPA services through April 30, 2000 please contact the Department of Human Services at (401) 462-1891. The change only effects claims processing, it does not impact reimbursement.

1. When submitting by diskette please use a new formatted blank diskette. If you are reusing a diskette from a previous submission, please reformat the diskette before saving claims to it.

To reformat a diskette:

• Open Windows Explorer
• Put diskette into the A drive
• Use the right mouse button to click on the A drive
• Select the format option
• Click Start

2. When submitting a diskette to EDS please include a Transmittal Control and Certification form. This form should list all provider numbers and the number of claims for each provider number that is being submitted on the diskette.

In order to process Prior Authorizations more efficiently, in particular for those clients utilizing more than one agency, copies of your agency’s nursing schedules should be attached to the authorization when submitting to EDS. This process should be used when requesting approval for procedure codes X0088, X0987, X0988, and only when multiple nursing agencies are involved with a child.

It is understood that the nursing schedule may be incomplete when you are sending the authorization request, however, it will offer further structure to the authorization process. This change has become effective 05/01/2000. Should you have questions, you may contact Ann Roach at 462-6370.

REVS for Recipient Eligibility

When calling REVS for recipient eligibility, if the recipient is "categorically needy" or eligible only for "in-plan services" and is active with a Managed Care provider, please call the Managed Care provider to inquire whether limited vision service benefits have been exhausted.

Claims for vision benefits for recipients on Managed Care should be submitted to the Managed Care provider. EDS is not able to inform providers vision service benefit claim information for Managed Care recipients. If fee for service, questions can be directed to the Customer Service Help Desk (CSHD) at 1-401-784-8100 for local and long distance callers or at 1-800-964-6211 for long distance within Rhode Island and border communities.

DHS and EDS have implemented a rate increase for Substance Abuse Rehabilitation Centers (PT 060) providers per MHRH. Please begin to use the new rates effective April 2, 2000. Following is a list of the procedure codes that will be effected:

X0302 – Substance Abuse, Day Treatment: $85.00

X0303 – Adolescent Day Treatment: $70.00

X0305 – Methadone Detoxification – Outpatient: $65.00

X0316 – Substance Abuse Counseling Services – Initial Assessment 60 – 90 Minute Visit: $90.00

X0317 – Substance Abuse Counseling Services – Individual Minimum 40 – 50 Minute Visit: $50.00

X0321 – Methadone Maintenance, Assessment and Evaluation, Counseling, Medication,

Treatment and Review, and Lab: $65.00

X0322 – Substance Abuse Counseling Services, Significant Other – Assessment,

Minimum 1 ½ hour: $90.00

X0323 – Substance Abuse Counseling Services, Significant Other – Individual,

Minimum 40 – 50 Minute Visit: $50.00

X0326 – Individual Assessment – Residential: $90.00

X0327 – Individual Counseling – Residential: $50.00

Billing Reminder

Please note that you may bill for anesthesia services with the CPT surgical codes 10000 – 69999 with either an "AA" or "AB" modifier, but not both. "AA" is to be used if the anesthesiologist actually administers the anesthesia for the procedure, and "AB" is to be used if the anesthesiologist supervises another in the administration of the anesthesia for the procedure.

The practice of billing an anesthesia service with both modifiers will be recouped.

As previously noted, as of March 1, 2000, when submitting pharmacy claims with DOS on or after March 1, 2000, the Prescribing Provider’s Drug Enforcement Agency (DEA) number must be indicated in the Prescribing Physician ID field. The DEA number consists of 9 characters and is alpha numeric. The first 2 characters are letters followed by 7 numbers. Claims submitted with an incorrect DEA number or no DEA number will be denied.

In the event that a DEA number is entered and denied as invalid, the provider should do the following:

1. Verify with Physician that the DEA number is correct

2. Verify that the DEA number is being entered and NOT a license number

3. Verify that the DEA number is being entered into the correct field

If all the above steps have been taken and a denial message is still being received then feel free to contact the EDS Customer Service Help Desk at 401-784-8100 or the Pharmacy Coordinator, Ingelcia Simas, at 401-784-3818. Please have the Prescribing Physician’s name, DEA # and zip code readily available when calling to speak to a Representative.

Please Note: In the event that a Prescribing Physician does not have a DEA number and is prescribing a non-narcotic or the Prescribing Physician is outside the states of RI, CT or MA the Pharmacy is required to bill with their own DEA number.