PLEASE FILE ADJUSTMENTS FOR CLAIMS WHICH MAY HAVE BEEN INCORRECTLY PAID

ATTENTION ALL EPSDT DENTAL PROGRAM PROVIDERS

A REIMBURSEMENT RATE INCREASE FOR CERTAIN DESIGNATED DENTAL PROCEDURE CODES REIMBURSED UNDER THE EPSDT DENTAL PROGRAM WILL BECOME EFFECTIVE JULY 6, 2002 UPON THE APPROVAL OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES, CENTER FOR MEDICARE AND MEDICAID SERVICES (CMS). ADDITIONAL INFORMATION, INCLUDING THE NEW RATES, WILL BE SENT TO YOU ONCE APPROVAL IS GRANTED. 

CLAIMS SUBMITTED FOR PAYMENT PRIOR TO CMS APPROVAL WILL CONTINUE TO BE REIMBURSED AT THE CURRENT REIMBURSEMENT RATE (REFER TO FEE SCHEDULE DATED JANUARY 21, 2001) OR THE AMOUNT BILLED IF LOWER THAN THE ESTABLISHED FEE. 

AFTER APPROVAL BY CMS, CLAIMS SUBMITTED FOR PAYMENT FOR DATES OF SERVICE BEGINNING JULY 6, 2002, UNTIL THE DATE OF PROVIDER NOTIFICATION OF THE NEW RATES, WILL BE AUTOMATICALLY RECYCLED BY MEDICAID. UPON RECYCLING, THE REIMBURSEMENT RATE WILL BE DETERMINED BY THE LESSER OF THE MEDICAID-ESTABLISHED FEE (THE RATE EFFECTIVE JULY 6, 2002) OR THE BILLED CHARGE. AS INSTRUCTED IN THE MEDICAID DENTAL SERVICES MANUAL, YOU SHOULD ALWAYS BILL YOUR USUAL AND CUSTOMARY FEE. ANY ADDITIONAL CLAIM ADJUSTMENTS REQUIRED AFTER THE INITIAL CLAIM RECYCLING WILL BE THE RESPONSIBILITY OF THE PROVIDER. 

REIMBURSEMENT FOR THESE SERVICES IS A FLAT FEE ESTABLISHED BY THE BUREAU MINUS THE AMOUNT THAT ANY THIRD PARTY COVERAGE WOULD PAY.  SHOULD YOU HAVE ANY QUESTIONS, YOU MAY CONTACT UNISYS PROVIDER RELATIONS BY CALLING 1-800-473-2783.

NOTICE TO ALL PROVIDERS

IN REGARDS TO THE FOLLOWING MESSAGE RELATED TO BILLING FOR EMERGENCY ROOM SERVICES, SENT FOR THE WEEK OF 8/6/02 AND 8/13/02, THE PROGRAMMING FOR EMC WAS NOT COMPLETED WHEN THIS MESSAGE WAS SENT AND DATA PLACED IN FORM LOCATOR 11 OF THE UB92 WAS NOT RECOGNIZED BY THE SYSTEM IF BILLED ELECTRONICALLY. THIS PROGRAMMING IS COMPLETED AND THE EMC PROVIDERS ARE BEING NOTIFIED OF APPROPRIATE SOFTWARE BILLING CHANGES. PROVIDERS ARE RESPONSIBLE FOR RESUBMITTING FOR ANY CLAIMS THAT WERE NOT PROCESSED CORRECTLY. 

EFFECTIVE JULY 1, 2002,EMERGENCY DEPARTMENT PHYSICIAN VISITS OF MODERATE TO HIGH COMPLEXITY (CPT 99283, 99284, AND 99285,99291, 99292, 99243, 99244, 99245), AND ASSOCIATED HOSPITAL SERVICES WILL BE EXEMPT FROM THE COMMUNITYCARE POST-AUTHORIZATION PROCESS. 

HOSPITALS BILLING FOR SERVICES ASSOCIATED WITH MODERATE TO HIGH LEVEL EMERGENCY PHYSICIAN CARE, SHOULD PLACE A "3" IN FORM LOCATOR 11 ON THE UB92. MODERATE TO HIGH LEVEL COMPLEXITY SHOULD CORRESPOND TO THE LEVEL OF CARE NOTED IN THE DEFINITION OF EVALUATION AND MANAGEMENT CPT CODES 99283, 99284, 99285. PROVIDERS ARE RESPONSIBLE FOR SUBMITTING ADJUSTMENTS FOR ANY CLAIMS PAID INCORRECTLY. 

HOSPITALS BILLING FOR SERVICES ASSOCIATED WITH LOW LEVEL EMERGENCY PHYSICIAN CARE, SHOULD PLACE A "1" IN FORM LOCATOR 11 ON THE UB92. LOW LEVEL COMPLEXITY SHOULD CORRESPOND TO THE LEVEL OF CARE NOTED IN THE DEFINITION OF EVALUATION AND MANAGEMENT CPT CODES 99281, 99282. WHEN AN ENROLLEE IS HOSPITALIZED OR RECEIVES SERVICES IN THE ER, IT IS THE HOSPITAL'S RESPONSIBILITY TO ENSURE THAT THE PCP'S AUTHORIZATION NUMBER IS AVAILABLE FOR ANY OTHER PROVIDERS THAT WILL BILL MEDICAID FOR SERVICES RELATED TO THE HOSPITAL ADMISSION OR ER VISIT.