Rhode Island Executive Office of Health and Human Rhode Island Executive Office of Health and Human Services Medical Assistance ProgramServices Medical Assistance Program

New Provider Introduction to New Provider Introduction to The Rhode Island Medical Assistance ProgramThe Rhode Island Medical Assistance Program

What’s InsideWhat’s Inside

Welcome………………………………………………..….……..3Welcome………………………………………………..….……..3

Commonly Used Terms and Abbreviations……………...……..5Commonly Used Terms and Abbreviations……………...……..5

Now That You Are A Provider.…………………………....…....6Now That You Are A Provider.…………………………....…....6

EOHHS Website.………………...……………………..…….....9EOHHS Website.………………...……………………..…….....9

Provider Reference Guides……………………………..……...21Provider Reference Guides……………………………..……...21

Billing Rhode Island Medical Assistance ProgramBilling Rhode Island Medical Assistance Program…….……..23…….……..23

Timely Filing………………………………………….….………25Timely Filing………………………………………….….………25

Claim Payment………………………………….……….….…..28Claim Payment………………………………….……….….…..28

Recipient Identification and Eligibility…………………………29Recipient Identification and Eligibility…………………………29

Identification Cards……………………………………………..30Identification Cards……………………………………………..30

Your Role As a Medical Assistance Provider..Your Role As a Medical Assistance Provider........................32......................32

The Medical Assistance Program recently transferred from the Department of Human Services (DHS) to the Executive Office of The Medical Assistance Program recently transferred from the Department of Human Services (DHS) to the Executive Office of

HealthHealth

and Human Services (EOHHS). For this reason, we will refer to both DHS and EOHHS in this presentation.and Human Services (EOHHS). For this reason, we will refer to both DHS and EOHHS in this presentation.

Welcome to the Rhode Island Medical Assistance Program

•We appreciate your participation and support. We are committed to helping you every step of the way.

•As a dedicated medical professional, you are an integral part in our quest to ensure all Rhode Islanders have access to quality, affordable health care.

Commonly Used Terms and Commonly Used Terms and AbbreviationsAbbreviations

• ADA –American Dental Association• AMA –American Medical Association• CMS –Centers for Medicare and

Medicaid Services Formerly HCFA• CPT –Physician’s Current Procedural

Terminology• DCYF –Department for Children, Youth

and Families• DHS –Department of Human Services• DME –Durable Medical Equipment• DOB –Date of Birth• DOS –Date of Service• EDI – Electronic Data Interchange• EFT –Electronic Funds Transfer• EOB –Explanation of Benefits• EOHHS – Executive Office of Health

and Human Services• EOMB –Explanation of Medicare

Benefits• EPSDT –Early and Periodic Screening,

Diagnosis and Treatment• FA –Fiscal Agent• FFS –Fee–for–Service

• HCPCS –Common Procedure Coding System

• HP –HP Enterprise Services• ICD-9-CM –International

Classification of Disease–9th Edition• ICN –Internal Control Number• ID –Identification• MA – Medical Assistance• MC –Medicare• MID – Recipient Medicaid Identification • NDC –National Drug Code• NPI – National Provider Identifier• PA –Prior Authorization• POS –Place of Service• QMB –Qualified Medicare Beneficiary• RA –Remittance Advice• SLMB –Specified Low–Income Medicare

Beneficiary• TPA – Trading Partner Agreement• TPL –Third Party Liability• UCR –Usual and Customary Rate• YTD –Year to Date

Now That You Are a ProviderNow That You Are a Provider

Rhode Island Medical Assistance Provider ID

•As a new provider, you have received a unique seven-character Rhode Island Medical Assistance Provider ID.

•The Rhode Island Medical Assistance Provider ID is not used for billing.

•The Medical Assistance Provider ID is used when accessing the Interactive Services portion of the Executive Office of Health and Human Services (EOHHS) website listed below.

•Providers must use their NPI and chosen taxonomy code on all claim submissions.

EOHHS Website: www.dhs.ri.gov

Now That You Are a ProviderNow That You Are a Provider

Trading Partner Agreement

•Immediately upon receiving your approval letter, please complete a Trading Partner Agreement (TPA).

•A TPA is required to use the interactive portion of the EOHHS website. It is also required before you can begin submitting claims electronically.

•Please complete the TPA and return it as instructed on the last page of the Trading Partner Agreement.

•The TPA can be found on the EOHHS website by selecting Provider Services, then select HIPAA, then select EDI – Electronic Data Interchange and then Trading Partner Agreement.

Now That You Are a ProviderNow That You Are a Provider

Provider Representative

•Each provider type has been assigned a Provider Representative to assist with any extraordinary claims issues, unique policy questions, general provider education or to navigate the Medical Assistance Program.

•A listing of Provider Representatives can be found at www.dhs.ri.gov. From the home page, select the Provider Types link in the left margin, then select your provider type from the list.

EOHHS Website…Your Information EOHHS Website…Your Information GatewayGateway

www.dhs.ri.govThe EOHHS Website is your gateway for eligibility, claim status, prior authorization status, and your Remittance Advice. With Interactive Web Services,* you may log in to access information 24 hours per day, 7 days per week.

Interactive Web Services can be accessed by logging on to the web site listed above, then selecting the Interactive Web Services link in the left margin.

Business process forms can be found in one place, including applications, claim adjustment requests or a change of information form. These and more can be found on the EOHHS website. See the chart on the next page for an outline of all of the web site pages.

If you are unable to find an answer to your question by using Interactive Web Services or the EOHHS website, you may contact the Customer Service Help Desk at (401) 784-8100 for local and long distance calls or 1-800-964-6211 for in-state toll calls, Monday-Friday 8 am-5 pm.

*Trading Partner Agreement required to access Interactive Web Services

Available Information On Available Information On www.dhs.ri.gov

See website for complete listing.See website for complete listing.www.dhs.ri.gov

Interactive Web Services

(log in required)

Provider Enrollment

Provider Services

Provider Types Provider News and Updates

Provider Search

Pharmacy

Provider Enrollment

Portal (log in required)

Provider News and Updates

Links

Rhode Island Medicaid Electronic

Health Records Incentive Program

Eligibility Wizard for the Medicare HER Incentive Program

Provider Electronic Solutions Software

Provider Representatives

Provider Enrollment

Provider Update-Archive

HIPAA

Service for Elders and Adults with Disabilities

Child and Youth Services

Physician Services

Hospital Services

Electronic Data Interchange

Provider Types

News

Provider Updates

Provider Representati

ve

Program Information

Reference Guide

Updates

Recipient Eligibility

Verification

Service Limits for Vision and

Dental

Claims Processing

Prior Authorization

National Drug Code

(NDC) Search

Remittance Advice

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$10,000.00$10,000.00$10,000.00$10,000.00

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Remittance Advice (RA)Remittance Advice (RA)

It is the provider’s responsibility to retrieve the RA from the EOHHS website after every financial cycle.

The RA will provide you with the status of all the claims you submitted to RI Medical Assistance. It will provide information on paid, denied, and suspended claims.

You must save and or print it for your records.

There are only four historical RA’s available at a time.

As new RA’s are generated, the oldest RA is deleted.

Once the RA is deleted, it is not retrievable and will not be printed.

Provider Reference GuidesProvider Reference Guides

Reference Guides cover general Medical Assistance information in addition to provider specific information. Please refer to the Provider Guidelines when looking for information on:

•Provider Participation

•Covered and Non-Covered Services

•Medical Necessity

•Limitations and Special Requirements

•Reimbursement Guidelines

•Other Important Topics

* Please note that policy and procedures are subject to change. Please refer to your Provider Updates regularly for any changes regarding your provider type.

Billing Rhode Island Medical Assistance Billing Rhode Island Medical Assistance ProgramProgram

Electronic billing is always the preferred method of claimsubmission. When necessary, Rhode Island Medical

Assistance doesaccept the UB-04, CMS-1500,and the ADA 2006 standardizedclaim forms. Medical Assistance also utilizes it’s proprietaryWaiver/Rehab claim form. If circumstance requires the need

forpaper claim submission, please mail your claims to:

HP Enterprise Services P.O. Box 2010

Warwick, RI 02887-2010

Access the EOHHS website “Forms and Applications” section to print the Waiver/Rehab claim form and for claim instructions for all claim types.

Paper Claims vs. Electronic ClaimsPaper Claims vs. Electronic Claims

Paper Claims

• Higher Costs (postage, forms)• Longer reimbursement wait time• Requires Original Signature• Slower turnaround time due to manual data entry

Electronic Claims

•Cost Savings•Faster Turnaround Time•Free Software•No Original Signature Required•Quicker Corrections•Quicker reimbursement

(usually next scheduled financial cycle)

For additional information about electronic claims submission and our free software, please visit the EOHHS website and select the Provider Services link in the left margin and then select the Provider Electronic Solutions (PES) Software link. You may also contact the Electronic Data Interchange Coordinator via email at mary-jane.nardone@hp.com

Timely FilingTimely Filing

Important Timely Filing Information

In order for a claim to be processed for adjudication, the Medical Assistance claim must:

• be received within twelve months of the date of service (DOS) for services, or

• if the claim is over a year old, then within 90 days of the date of denial.

Any claim that does not meet these criteria will be denied for timely filing.

Adjustments to a paid claim, with a DOS over a year old, will be accepted up to 90 days from the remittance advice date for the original claim payment

Important Timely Filing Important Timely Filing InformationInformation

Claims, over a year old, that involve a third party payer must be submitted:

• within 90 days from the Explanation of Benefits (EOB) date from the other payer. The other insurance actual Explanation of Benefits must be attached to the claim.

Any claim with a DOS over 1 year old, received with a third party payer EOB date greater than the 90 days, will be denied for timely filing.

Important Timely Filing Important Timely Filing InformationInformation

The criteria for overriding the twelve month timely filing limit are:

• retroactive recipient or provider eligibility (within 90 days of claim submission),

• previous denial (other than timely filing, within 90 days of claim submission).

Provider computer printouts are not considered acceptable proofs of timely filing.

Claims submitted for DOS over 1 year must be submitted on paper to the appropriate Provider Representative and must include the necessary documentation.

Claim PaymentClaim Payment

•All providers are required to accept payment via Electronic Funds Transfer (EFT). Paper checks will not be issued.

•Each financial cycle is approximately 2 weeks. However, due to fiscal necessity, some cycles can be longer or shorter. For the complete claims processing and payment schedule, please see the current State Financial Calendar by logging onto www.dhs.ri.gov, then select Provider Services in the left margin, then select the Payment and Processing Schedules link in the left margin.

•Individual claim status is reported at the end of each financial cycle on the provider’s Remittance Advice (RA).

Recipient Identification and EligibilityRecipient Identification and Eligibility

Each recipient is issued a Medical Assistance ID card, also known as the “Anchor” card. In addition, the following cards can be issued:

• RIteCare - recipients will also have a “Plan” ID card issued by United Healthcare or Neighborhood Health

• RIteShare - recipients will also have a primary insurer commercial carrier ID card

• RIteSmiles - recipients will also have an ID card issued by United Healthcare

• Rhody Health Partners - recipients will also have an ID card issued by United Healthcare or Neighborhood Health

Recipients should present all active ID cards at each appointment

Identification CardsIdentification Cards

Identification CardsIdentification Cards

Provider ResponsibilityProvider Responsibility

Your Role As a Rhode Island Medical Assistance Provider is to check eligibility for every date of service prior to delivery:

•Recipient eligibility: Medical Assistance, Medical Assistance Long Term Care, RIteCare, RIteShare, RIteSmiles, Rhody Health Partners, Connect Care Choice

•Third Party Liability (TPL)

•Determine Prior Authorization (PA) service requirements

All information is available when checking Eligibility on Interactive Web Services. If you still have questions after checking the eligibility on the Interactive Web Services, you may contact our Customer Service Help Desk by calling 401-784-8100 for local and long distance calls or 1-800-964-6211 for in-state toll calls.

Thank you!