RA Messages for April 27, 2004

---

ATTENTION DME, MENTAL HEALTH REHAB, AND WAIVER PROVIDERS

DURING THE MARCH 1, 2004 HIPAA IMPLEMENTATION FOR DME AND MENTAL HEALTH REHABILITATION, A PRIOR AUTHORIZATION FILE EDIT ERROR WAS DISCOVERED. THE ERROR WAS CORRECTED AND CLAIMS INVOLVED WERE RECYCLED. WHILE RESOLVING THE INITIAL PROBLEM, THE CLAIMS PROCESSED ON MARCH 11, 2004 INCURRED AN ADDITIONAL PROCESSING ERROR AND EITHER PAID WHEN THEY SHOULD HAVE DENIED OR PAID ERRONEOUS PAYMENTS. THIS ADDITIONAL PROCESSING ERROR AFFECTED DME, MENTAL HEALTH REHABILITATION AND WAIVER CLAIMS. THIS PROBLEM WAS CORRECTED AND ADJUSTMENTS OR VOIDS ARE PROCESSED AS APPROPRIATE ON THE APRIL 13, 2004 REMITTANCE ADVICE. 

---

ATTENTION ALL MEDICAID PROVIDERS

AS OF DECEMBER 1, 2003, THE COMMUNITYCARE PROGRAM HAS BEEN IMPLEMENTED STATEWIDE. APPROXIMATELY 80% OF ALL MEDICAID ELIGIBLES ARE ENROLLED IN COMMUNITYCARE AND ARE LINKED TO A COMMUNITYCARE PRIMARY CARE PHYSICIAN (PCP). THEREFORE, THE COMMUNITYCARE PROGRAM IMPACTS THE REIMBURSEMENT AND PRACTICE OF ALL MEDICAID PROVIDERS IN EVERY AREA OF THE STATE, NOT JUST COMMUNITYCARE-ENROLLED PCPS. ALL MEDICAID PROVIDERS SHOULD BECOME FAMILIAR WITH THE PROGRAM, AND READ ALL REMITTANCE MESSAGES AND PROVIDER UPDATE ARTICLES CONCERNING COMMUNITYCARE. 

PROVIDERS CAN FIND OUT WHICH PCP A PATIENT IS LINKED TO WHEN THEY CHECK THE PATIENT'S MEDICAID ELIGIBILITY USING ANY OF THE MEDICAID ELIGIBILITY VERIFICATION SYSTEMS, IE; REVS, MEVS AND THE WEB APPLICATION (EMEVS). THIS INFORMATION SHOULD ALWAYS BE CHECKED PRIOR TO PROVIDING NON- EMERGENT SERVICES TO ANY MEDICAID RECIPIENT. IF THERE IS NOT A PCP LISTED, THEN THE PATIENT IS NOT IN COMMUNITYCARE, AND A PCP REFERRAL IS NOT NEEDED.

---

ATTENTION COMMUNITYCARE/KIDMED PROVIDERS

AS WE HAVE MOVED FROM HARD COPY CP-0-92 AND RS-0-07 REPORTS TO ELECTRONIC ON-LINE REPORTS FOR PROVIDER RETRIEVAL, WE HAVE RECEIVED A NUMBER OF PROVIDER CALLS INDICATING THAT THE UNISYS WATERMARK ON EACH PAGE IS CAUSING EXTENDED PRINTING TIME AND CAUSING INFORMATION ON THE PAGE TO BE UN-READABLE BECAUSE THE WATERMARK PRINTS TOO DARK.  AS A RESULT OF YOUR CONCERNS, THE WATERMARK IS BEING REMOVED FROM THE REPORT PAGES.  THIS CHANGE WILL TAKE PLACE FOR THE MAY 2004 REPORT.

---

ATTENTION DME AND PHARMACY PROVIDERS

OUR PROGRAM INTEGRITY STAFF HAVE BEEN CONDUCTING FIELD AUDITS ON DURABLE MEDICAL EQUIPMENT PROVIDERS AND HAS FOUND IN SOME CASES, THE PROVIDER IS NOT MAINTAINING A COPY OF THE PRIMARY CARE PHYSICIAN'S REFERRAL. THIS IS A REQUIREMENT UNDER THE COMMUNITYCARE PROGRAM. FAILURE TO MAINTAIN A COPY OF A REFERRAL IS GROUNDS FOR RECOUPMENT OF MONEY PAID FOR SERVICES, EQUIPMENT AND SUPPLIES, AS WELL AS IMPOSITION OF OTHER SANCTIONS AS A RESULT OF THE PROVIDER NOT ADHERING TO MEDICAID POLICY. 

IT IS NOT NECESSARY TO HAVE A REFERRAL FROM THE PRIMARY CARE PHYSICIAN PRIOR TO SUBMITTING A REQUEST FOR AUTHORIZATION OF PAYMENT TO THE PRIOR AUTHORIZATION UNIT (PAU). HOWEVER, A REFERRAL MUST BE OBTAINED AND MAINTAINED ON FILE PRIOR TO BILLING, SINCE ALL CONDITIONS REQUIRED FOR PAYMENT MUST BE MET PRIOR TO BILLING.