RI MEDICAID
PROVIDER MANUAL
INDEPENDENT CLINICAL LABORATORY
Version 1.2
RI Medicaid Provider Manual – Independent Clinical Laboratory
Revision History
Version
1.0
1.1
1.2
Date
November, 2013
March, 2014
April, 2014
PR0008 V1.2 04/30/14
Reason for Revisions
New manual format
Remove CMS 1500 Interactive Instructions
NPI Enhancement Project
Completed by
HP Provider Services
HP Provider Services
HP Provider Services
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RI Medicaid Provider Manual – Independent Clinical Laboratory
Table of Contents
INTRODUCTION ............................................................................................................................................. 5
Provider Participation Guidelines ............................................................................................................. 5
Provider Enrollment .................................................................................................................................. 6
Recertification ........................................................................................................................................... 6
Electronic Data Interchange Trading Partner ........................................................................................... 6
Reimbursement of Claims ............................................................................................................................. 6
Claims Billing Guidelines ........................................................................................................................... 6
Eligibility Verification ................................................................................................................................ 7
Medicare/Medicaid Crossover.................................................................................................................. 7
Patient Liability ......................................................................................................................................... 7
Reimbursement Guidelines....................................................................................................................... 7
Covered and Non-Covered Services.............................................................................................................. 8
Covered Services ....................................................................................................................................... 8
Individual and Panel Test Billing ............................................................................................................... 8
Unlisted Procedures .................................................................................................................................. 8
Reference Laboratory ............................................................................................................................... 8
Non-Covered Services ............................................................................................................................... 8
Handling Fee ............................................................................................................................................. 8
Venipuncture ............................................................................................................................................ 9
Interpretation ........................................................................................................................................... 9
Appendix ..................................................................................................................................................... 10
Claims Preparation Instructions .............................................................................................................. 10
Clinical Lab Services – CMS 1500 Claim Form ..................................................................................... 10
CMS1500 Claim Form Instructions...................................................................................................... 10
Error Status Codes .................................................................................................................................. 10
ESC Code List (English) ........................................................................................................................ 10
Explanation of Benefits (EOB) Codes ...................................................................................................... 10
EOB Codes and Messages List (English) .............................................................................................. 10
EOB Codes and Messages List (Spanish) ............................................................................................. 10
Third Party Liability Carrier and Coverage Codes ................................................................................... 10
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RI Medicaid Provider Manual – Independent Clinical Laboratory
Third Party Liability (TPL) Carrier Codes.............................................................................................. 10
Third Party Liability (TPL) Coverage Codes ......................................................................................... 10
Billing Quick Reference ........................................................................................................................... 10
Recipient Eligibility Chart ........................................................................................................................ 10
Independent Laboratory Billing Quick Reference ................................................................................... 11
Paper Claims........................................................................................................................................ 11
Multiple Units ..................................................................................................................................... 11
Multi-page Claims ............................................................................................................................... 11
Rhode Island Medicaid as Secondary Payer-Commercial Payers ....................................................... 11
RIte Share-Paper Submission .............................................................................................................. 11
RIte Share-Electronic Submission ....................................................................................................... 11
Medicare Crossover Claims ................................................................................................................. 12
Timely Filing Guidelines ...................................................................................................................... 12
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RI Medicaid Provider Manual – Independent Clinical Laboratory
INTRODUCTION
HP Enterprise Services (HP), in conjunction with the Rhode Island Executive Office of
Health and Human Services (EOHHS), developed provider manuals for all Medicaid
Providers. The purpose of this guide is to assist Medicaid providers with general
Medicaid policy, coverage information and claim reimbursement. In addition the HP
Customer Service Help Desk is available to answer questions not covered in this
manual.
HP ENTERPRISE SERVICES can be reached by calling:

1-401-784-8100 for local and long distance calls

1-800-964-6211 for in-state toll calls or border community calls
Provider Participation Guidelines
An independent clinical laboratory may be free-standing, operated by and within a
hospital or physician’s office if the laboratory otherwise meets the criteria of an
independent clinical laboratory, is certified to participate in Medicare and is licensed to
provide services in the State of Rhode Island. Also, to be reimbursed by the Medicaid
Program, all providers performing laboratory tests must have a Clinical Laboratory
Improvement Act (CLIA) certification or registration number issued by the Centers for
Medicare and Medicaid (CMS).
To participate in the Medicaid Program, providers must be located and performing
services in Rhode Island or in a border community. Consideration will be given to out-ofstate providers only if the covered service is not available in Rhode Island, the recipient
is currently residing in another state or if the covered service was performed as an
emergency service while the recipient was traveling through another state. Out of state
providers must enroll with RI Medicaid and received authorization before a claim can be
submitted.
The public health laboratory in Rhode Island is a licensed provider of Medicaid Program
services.
To participate in the Medicaid Program, a clinical lab must have the ability to perform
testing on-site at their Rhode Island facility. A clinical lab must be more than a “drawing
station” for the purposes of the Medicaid Program.
Any licensed provider may bill for laboratory procedures based on what their license
permits under Rhode Island law.
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RI Medicaid Provider Manual – Independent Clinical Laboratory
Provider Enrollment
HP Enterprise Services is the fiscal agent for EOHHS and the Medicaid Program, and
as the fiscal agent is responsible for the enrollment, claims processing and
reconciliation.
Providers must complete the enrollment process before claims are accepted.
Information on enrollment is found on the Forms and Applications tab of the EOHHS
website (www.eohhs.ri.gov). Select Provider Enrollment Application and Related forms
to access the appropriate enrollment form and instructions for completion.
As a rule, RI Medicaid does not enroll out of state laboratories. The exceptions to this
are noted above.
Recertification
Clinical Laboratories are annually recertified by the RI Department of Health (DOH). The
license expiration date for Clinical Laboratories is June 30. Providers obtain license
renewal through DOH. Out of state providers must forward a copy of the renewal
documentation to HP Enterprise Services. HP Enterprise Services should receive this
information as soon as possible to prevent suspension from the program.
Electronic Data Interchange Trading Partner
Effective October, 2003, all Medicaid providers must utilize HIPAA compliant software to
submit claims electronically. Providers in Rhode Island may use HP Enterprise
Services’ free software, Provider Electronic Solutions (PES), or software that has
completed HIPAA compliance testing with HP Enterprise Services. To submit claims
electronically, providers must complete an Electronic Data Interchange (EDI) Trading
Partner Agreement (TPA).
A Trading Partner Agreement is also required to access the secured portion of the
EOHHS website. This portion of the website allows you to check eligibility, claim status,
Remittance Advice, and other necessary information. New providers should submit a
Trading Partner Agreement with their enrollment application.
This agreement is found on the EOHHS website (www.eohhs.ri.gov) on the Forms and
Application Tab /Forms A-Z, titled Trading Partner Agreement. This completed form will
generate an identification number and a password to access the EOHHS portal. For
questions about completing the TPA, contact the EDI coordinator at (401) 784-8014.
Reimbursement of Claims
Claims Billing Guidelines
It is important that the proper diagnosis code(s) be indicated on the claim form when
billing for laboratory services. Inconsistency between a billed test and the diagnosis for
which it is performed may cause the claim to deny. Instructions for completing the CMS
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RI Medicaid Provider Manual – Independent Clinical Laboratory
1500 claim form are located at Claims Processing. See appendix xx for completed claim
examples and instructions.
Eligibility Verification
Providers are required to verify a recipients eligibility prior performing services. This is
required for all visits. Recipient eligibility can be verified on the EOHHS web portal. To
access the portal, providers need to have completed a Trading Partner Agreement and
will use their assigned identification number and password. Providers must have the
recipient’s Medicaid ID number (MID). The recipient MID is present on all RI Medicaid
identification cards. The web portal is found at
https://www.eohhs.ri.gov/secure/logon.do.
Medicare/Medicaid Crossover
The Medicaid Program reimbursement for crossover claims is always capped by the
established Medicaid Program allowed amount, regardless of coinsurance or deductible
amounts. The standard calculation for crossover payments is as follows:
RI Medicaid reimburses Medicare Crossover Claims using the following logic;
a.
b.
c.
RI Medical Assistance Allowed Amount (–) Medicare Payment = $X.XX
Medicare Coinsurance (+) Deductible = $X.XX
RI Medical Assistance Payment = Lesser of #1 and #2
Patient Liability
The Medicaid Program reimbursement is considered payment in full. The provider is
not permitted to seek further payment from the recipient in excess of the Medicaid
Program rate.
Reimbursement Guidelines
The reimbursement rates for Clinical Laboratories are listed in the Fee Schedule.
Clinical Laboratories cannot, by law, be paid more than the amount allowed in the
published fee schedule or the amount reimbursed by Medicare, whichever is less.
Providers must bill the Medicaid Program at the same usual and customary rate as
charged to the general public and not at the published fee schedule rate. Rates
discounted to specific groups (such as Senior Citizens) must be billed at the same
discounted rate to the Medicaid Program. Payments to providers will not exceed the
maximum reimbursement rate of the Medicaid Program.
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RI Medicaid Provider Manual – Independent Clinical Laboratory
Covered and Non-Covered Services
Covered Services
The Medicaid Program covers the clinical laboratory services listed on the fee schedule.
This list is reviewed and updated periodically. New procedures are added and old
procedures removed based on criteria determining the validity and medical necessity of
each procedure.
Requests to review coverage of procedure codes will be considered by the Department
of Human Services on a case by case basis. Refer to the Prior Authorization section.
Individual and Panel Test Billing
Clinical laboratories should bill lab tests individually when the rate for individual tests is
less than the rate for billing an equivalent panel; however, if the rate for a panel is less
than the rate for the individual tests billed separately, then a panel should be billed. In
summary, when billing the usual and customary charge for a panel or the tests billed
individually, always bill the procedure with the lower reimbursement rate.
Unlisted Procedures
Providers must request prior authorization for any procedure not listed in the fee
schedule. Approved procedures will be billed using one of the “unlisted” (99) codes.
Prior authorization requests may be made in writing and mailed to HP Enterprise
Services, PO Box 2010, Warwick, RI 02887.
Reference Laboratory
The Medicaid Program will reimburse for testing performed within the laboratory billing
for the service. Services are considered performed by the provider when either an
employee. the individual provider, or reference laboratory performs the service.
Payment is made to the billing laboratory and not the reference laboratory.
Non-Covered Services
Generally, procedures not listed in the fee schedule are not covered services. Services
or procedures that are unproved, experimental or research in nature are not covered
benefits of the Medicaid Program.
Services which are not medically necessary to treat the patient’s condition, or are not
directly related to the patient’s diagnosis, symptoms, or medical history are not
reimbursable under the Medicaid Program.
Handling Fee
The Medicaid Program does not reimburse clinical laboratories separately for handling
test samples. Handling fees are included in the reimbursement rate for the service
billed.
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RI Medicaid Provider Manual – Independent Clinical Laboratory
Venipuncture
The Medicaid Program does not reimburse clinical laboratories separately for
venipuncture. This procedure is included in the reimbursement rate for the service
billed.
Interpretation
The interpretation (reading) of lab results can be billed by hospital providers only;
therefore, clinical laboratories will not be reimbursed for services billed with a “26”
modifier.
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RI Medicaid Provider Manual – Independent Clinical Laboratory
Appendix
Claims Preparation Instructions
Clinical Lab Services – CMS 1500 Claim Form
CMS1500 Claim Form Instructions
Error Status Codes
ESC Code List (English)
Explanation of Benefits (EOB) Codes
EOB Codes and Messages List (English)
EOB Codes and Messages List (Spanish)
Third Party Liability Carrier and Coverage Codes
Third Party Liability (TPL) Carrier Codes
Third Party Liability (TPL) Coverage Codes
Billing Quick Reference
Recipient Eligibility Chart
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RI Medicaid Provider Manual – Independent Clinical Laboratory
Independent Laboratory Billing Quick Reference
Paper Claims
Paper claims for laboratory services must be submitted using the CMS-1500 (version 02/12)
claim form.
Multiple Units
The total amount of units must be billed on one detail when billing for multiple units of a
procedure code. When the units billed exceed the allowable daily units under Medicaid policy,
the claim must be submitted on paper and must include lab reports clearly indicating
(highlighted and noted with corresponding procedure code) repetitive results. Note: some
procedures are subject to Claim Check and National Correct Coding Initiative guidelines and
edits. For a list of affected codes, please see the EOHHS website.
Multi-page Claims
Paper claims cannot be longer than 2 pages (12 details). If more than 12 details are needed,
they must be submitted on separate claims. If applicable, complete EOB copies from primary
payers must be attached to each claim.
Rhode Island Medicaid as Secondary Payer-Commercial Payers
When there is other insurance to consider, RI Medicaid will usually pay the difference between
the total primary payment and the Medicaid allowable reimbursement. In most cases, you must
send the primary EOB with your claim when submitting on paper. When billing electronically
indicate yes to other insurance, enter Adjustment Codes, Group/Reason Codes and
amounts…standard when billing RI Medicaid as the secondary payer. These codes should be
entered as reported on the primary payers EOB. Secondary payment/non-payment is based on
the total claim and is not calculated by procedure code. Note: A denials on primary EOB
indicating non-compliance with policy are considered invalid and Medicaid will not consider
the claim for payment.
RIte Share-Paper Submission
RI Medicaid will usually pay the patient responsibility (coinsurance and/or deductible) portion
of claims for recipients enrolled in the Rite Share program. These should be billed using
procedure code X0701. The amount billed should equal the total of the coinsurance and
deductible. The primary EOB indicating the amount(s) must be submitted with the claim. Note:
RI Medicaid no longer reimburses copays for Rite Share recipients. Providers are not allowed
to collect the copays from recipients.
RIte Share-Electronic Submission
Patient Responsibility (coinsurance and/or deductible) should be submitted using the actual
procedure code for the services performed. Indicate yes to other insurance and enter
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RI Medicaid Provider Manual – Independent Clinical Laboratory
Adjustment Codes, Group/Reason Codes as reported on the primary payers EOB. The PR codes
will indicate the amount of the coinsurance and/or deductible. Note: RI Medicaid no longer
reimburses copays for Rite Share recipients. Providers are not allowed to collect the copays
from recipients.
Medicare Crossover Claims
RI Medicaid reimburses Medicare Crossover Claims using the following logic;
a.
b.
c.
RI Medical Assistance Allowed Amount (–) Medicare Payment = $X.XX
Medicare Coinsurance (+) Deductible = $X.XX
RI Medical Assistance Payment = Lesser of #1 and #2
Timely Filing Guidelines
The Rhode Executive Office of Health and Human Services has a claim submission restriction of
twelve (12) months from the date of service provided to Medicaid clients. HP must receive a
claim for services for Medicaid clients, with no other health insurance within 12 months of the
date-of-service in order to process claims for adjudication. Any claim submitted with a date
greater than twelve months from date of service will deny for timely filing. Adjustments and
recoups are also subject to these guidelines unless they result in lesser reimbursement.
Claims received more than 12 months after the date of service must meet one or more of the
following qualifications to bypass the timely filing time limit:

Retroactive recipient eligibility claims must be submitted within ninety days (90) of the
eligibility update.

Claims with a date of service over one year with an involved third party payer
(insurance), must be submitted within ninety days (90) of the payers (insurance) valid
Explanation of Benefits (EOB) date. Denials for timely filing or failure to comply with the
primary payer rules are not included in this exception.

Claims with a date of service over one year that had denied (other than timely filing)
previously by HP must be submitted within ninety (90) days from the process date on
the remittance advice. (This includes denials resulting from processing and/or recoupment errors.)

Any claim with a service date over one year and a EOB date from another payer or a
remittance advice from HP over (90) days will be denied for timely filing.

Provider eligibility updates within ninety days (90) from the approval date

Provider computer printouts are not considered acceptable proofs of timely filing.
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RI Medicaid Provider Manual – Independent Clinical Laboratory
Claims that meet any of the timely filing exceptions must be submitted on paper with the
supporting documentation to your Provider Representative.
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Recipient Eligibility Information – Recipient should present all active ID cards at all appointments.
Medicaid
• Each recipient is
issued a Medicaid
ID card, also known
as the "Anchor
Card".
RIteSmiles
• Recipients will also
have an ID card
issued by United
Healthcare.
RIteCare
RIteShare
• Recipients will also
have a "Plan" ID
card, issued by
United Healthcare
or Neighborhood
Health.
• Recipients will also
have a primary
insurer commercial
carrier ID card.
Rhody Health
Partners
Rhody Health
Options
• Recipients will also
have an ID card
issued by United
Healthcare or
Neighborhood
Health.
• Recipients will also
have an ID card
issued by
Neighborhood
Health.
Connect Care
Choice
• Each recipient is
issued a Medicaid
ID card, also known
as the "Anchor
Card".
Connect Care Choice
Community Partners
•Each recipient is issued
a Medicaid ID card,
also known as the
"Anchor Card".