Home

eMedNY Subsystem User Manual

1. 28 3 3 Section One Surmmout Dese ELE 29 3 3 1 Summout No Payment Field Descriptions cccccccccssssseeccceeeseessseecccceeseesseeccceeeaueassececeeeeaaenseeeeeeseesuanseeeeeeesuangeeeeeeeeas 30 3 4 Section TWO drogue T m 31 3 4 1 Provider Notification Field Descriptions 32 3 5 SECTION Whee aa DSN a E E 33 3 5 1 Claim Detail Page Field 37 3 5 2 Explanation or Claim Detail COMUMING Sue 37 3 5 3 Subtotals Totals Grand 39 3 6 Section Four Financial Transactions and Accounts 41 3 6 1 41 a ACOA RR UU T m ET 43 3 7 Section Five Edit Error D SCTEIDLIOTI ssseessuxesamivm ve Um DIA
2. UIS ERIS RUM 45 POO Claim 46 INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 2 of 48 CLAIMS SUBMISSION For eMedNY Billing Guideline questions please contact the eMedNY Call Center 1 800 343 9000 INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 3 of 48 ees PURPOSE STATEMENT 1 Purpose Statement The purpose of this document is to assist the provider community in understanding and complying with the New York State Medicaid NYS Medicaid requirements and expectations for Billing and submitting claims Interpreting and using the information returned in the Medicaid Remittance Advice This document is customized for ICF DD providers and should be used by the provider as an instructional as well as a reference tool For providers new to NYS Medicaid it is required to read the All Providers General Billing Guideline Information available at www emedny org by clicking on the link to the webpage as follows Information for All Providers INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 4 of 48 CLAIMS SUBMISSION 2 Claims Submission ICF DD providers can submit their claims to NYS Medicaid in electronic or paper formats Providers ar
3. B ET TO ABC INTERMEDIATE CARE FACILITY INFORMATION SYSTEM MEDICAL ASSISTANCE TITLE XIX PROGRAM Ben eme REMITTANCE STATEMENT REMITTANCE NO 07080500001 REASON CODE DESCRIPTION CURR BAL RECOUP gun TOTAL AMOUNT DUE THE STATE XXX XX INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 43 of 48 REMITTANCE ADVICE 3 6 2 1 Explanation of Accounts Receivable Columns If a provider has negative balances of different types or negative balances created at different times each negative balance will be listed in a different line Reason Code Description This is the description of the Financial Reason Code For example Third Party Recovery Original Balance The original amount or starting balance for any particular financial reason Current Balance The current amount owed to Medicaid after the cycle recoupments if any were applied This balance may be equal to or less than the original balance Recoupment Amount The deduction recoupment scheduled for each cycle Total Amount Due the State This amount is the sum of all the Current Balances listed above INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 44 of 48 REMITTANCE ADVICE 3 7 Section Five Edit Error Description The last section of the Remi
4. Financial Transactions recoupments Accounts Receivable cumulative financial information Section Five Edit Error Description INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 23 of 48 REMITTANCE ADVICE 3 1 Section One Medicaid Check For providers who have selected to be paid by check a Medicaid check is issued when the provider has claims approved for the cycle and the approved amount is greater than the recoupments if any scheduled for the cycle This section contains the check stub and the actual Medicaid check payment INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 24 of 48 REMITTANCE ADVICE Exhibit 3 1 1 DICAID MANAGEMEN INFORM ATION SYSTEM TO ABC INTERMEDIATE CARE FACILITY 2010 05 31 REMITTANCE 07080600001 PROV ID 00123456 1 234567890 00123456 123456 890 2010 05 31 INTERMEDIATE CARE FACILITY 123 MAIN ST TOWN 11111 YOUR CHECK IS BELOW TO DETACH TEAR ALONG PERFORATED DASHED LINE REMITTANGE PROVIDER ID DOLLAR S CENTS NUMBER 2010 05 31 07080600001 00123456 1234567890 ABC INTERMEDIATE CARE FACILITY S 123 ST DIC AID ANY OWN NY 11111 NAGEM INF FORM ATION SYSTEM CHECKS DRAWN KEY BANK 80 STATE STREET ALBANY NEW YORX 12207 MEDICAL ASSISTANCE TITLE XIX PROGRAM
5. INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 21 of 48 CLAIMS SUBMISSION On the line below the ID numbers enter the last name and first name of the provider See the example in Exhibit 2 4 2 14 Exhibit 2 4 2 14 The referring provider is John Smith with an NPI number 123456 890 78 OTHER 1234557890 QUAL LAST SMITH FIRST JOHN INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 22 of 48 REMITTANCE ADVICE 3 Explanation of Paper Remittance Advice Sections This Section present a sample of each section of the remittance advice for ICF DD providers followed by an explanation of the elements contained in the section The information displayed in the remittance advice samples is for illustration purposes only The following information applies to a remittance advice with the default sort pattern General Remittance Advice Information is available in the All Providers General Billing Guideline Information section available at www emedny org by clicking on the link to the webpage as follows Information for All Providers The remittance advice is composed of five sections Section One may be one of the following Medicaid Check Notice of Electronic Funds Transfer Summout no claims paid Section Two Provider Notification special messages Section Three Claim Detail Section Four
6. New York State Electronic Medicaid System UB04 Billing Guidelines INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 TT TABLE OF CONTENTS TABLE OF CONTENTS TL Purpose E RUDI 4 Clamis eua MM 5 2 1 edes 5 2 2 NER 6 2 2 1 General Instructions for Completing Paper 6 2 3 a ESI 8 2 4 DD Services Billing SEY m 8 2 4 1 Instructions for the Submission of Medicare Crossover 8 242 UB 04 Claim Form Field nstrUctiOTIS Esa RUE Rua UE uS atas UMP SUM uuo UN CU eds 9 3 Explanation of Paper Remittance Advice 5 23 3 1 BECTON OME Medicaid CMM 24 31 1 Medicaid Check Stub Field DeSeHpEONS 26 3 1 2 Medicaid Check Field 26 3 2 METRE MT 27 3 2 1 EFT Notification Page Field
7. STATUS ERRORS PEND 00162 00571 0 00 387 51 0 00 PEND 01131 PREVIOUSLY PENDED CLAIM NEW PEND INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 Page 35 of 48 5 31 2010 REMITTANCE ADVICE Exhibit 3 5 4 D ICAID DATES a CYCLE 1710 IB FORMATION TE MEDICAL ASSISTANCE TITLE XIX PROGRAM ETIN TO ABC INTERMEDIATE CARE FACILITY MITTAN TEMEN ICF DD 123 MAIN STREET REMITTANCE STATEMENT GRAND TOTALS ANYTOWN NEW YORK 11111 PROV ID 00123456 1234567830 REMITTANCE NO 07080600001 REMITTANCE TOTALS GRAND TOTALS VOIDS ADJUSTS 83 04 NUMBER OF CLAIMS 1 TOTAL PENDS 75 62 NUMBER CLAIMS 2 TOTAL PAID 1551 24 NUMBER OF CLAIMS 5 TOTAL DENY 5 62 NUMBER CLAIMS 2 TOTAL PAID 1452 20 NUMBER OF CLAIMS 33 INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 36 of 48 REMITTANCE ADVICE 3 5 1 Claim Detail Page Field Descriptions Upper Left Corner Provider s Name Address Upper Right Corner Remittance page number Date The date on which the remittance advice was issued Cycle number The cycle number should be used when calling the eMedNY Call Center with questions about specific processed claims or payments ETIN not applicable Provider Service Classification ICF DD PROV ID This field will contain the Medicaid Provider ID and the NPI Remittance Number 3 5 2 Ex
8. Form Locator 4 Bill Classification category select the code that best describes the type of service being claimed Frequency Adjustment Void Code New York State Medicaid uses the third position of this field on y to identify whether the claim is an original a replacement adjustment or a void If submitting an original claim enter the value 0 in the third position of this field as in Exhibit 2 4 2 1 Exhibit 2 4 2 1 OF BILL If submitting an adjustment replacement to a previously paid claim enter the value 7 in the third position of this field as in Exhibit 2 4 2 2 Exhibit 2 4 2 2 d TYPE BILL If submitting a void to a previously paid claim enter the value 8 in the third position of this field as in Exhibit 2 4 2 3 Exhibit 2 4 2 3 OF BILL INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 10 of 48 CLAIMS SUBMISSION Statement Covers Period From Through Form Locator 6 Enter the date s of service claimed in accordance with the instructions provided below When billing for one date of service enter the date in the FROM box The THROUGH box may contain the same date or may be left blank When billing for multiple dates of service enter the first service date of the billing period in the FROM box and the last service date in the THROUGH box The FROM THROUGH dates must be in the same calendar month Instructions for
9. John cmi th INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 25 of 48 REMITTANCE ADVICE 3 1 1 Medicaid Check Stub Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Date on which the remittance advice was issued Remittance Number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Medicaid Provider ID NPI Date Provider s Name Address 3 1 2 Medicaid Check Field Descriptions Left Side Table Date on which the check was issued Remittance Number Provider ID No This field will contain the Medicaid Provider ID and the NPI Provider s Name Address Right Side Dollar amount This amount must equal the Net Total Paid Amount under the Grand Total subsection plus the total sum of the Financial Transaction section INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 26 of 48 REMITTANCE ADVICE 3 2 Section One EFT Notification For providers who have selected electronic funds transfer or direct deposit an EFT transaction is processed when the provider has claims approved during the cycle and the approved amount is greater than the recoupments if any scheduled for the cycle This section indicates the amount of the EFT Exhibit 3 2 1 DICAID BLA M A GEMTE INFORM ATION ABCINTERMEDIATE CARE FAC
10. company to pay the provider directly for the service whether or not the provider participates with the insurance plan The provider should contact the third party worker in the LDSS whenever he she encounters policyholders who are uncooperative in paying for covered services received by their dependents who are on Medicaid In other cases providers will be instructed to zero fill the Other Insurance payment in the Medicaid claim and the LDSS will retroactively pursue the third party resource The patient or an absent parent collects the insurance benefits and fails to submit payment to the provider The LDSS must be notified so that sanctions and or legal action can be brought against the patient or absent parent The provider is instructed to zero fill by the LDSS for circumstances not listed above The example in Exhibit 2 4 2 8 illustrates a correct Other Insurance Payment entry INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 15 of 48 CLAIMS SUBMISSION Exhibit 2 4 2 8 39 VALUE CODES CODE AMOUNT 100 00 Medicaid Covered Days Value Code 80 Value Code Code 80 should be used to indicate the total number of days that are covered by Medicaid If only co insurance days are claimed do not report code 80 Value Amount Enter the actual amount of days covered by Medicaid The sum of Medicaid Full covered days Medicaid non covered days and Medicare co insurance day
11. each financial transaction Financial Reason Code This code is for DOH CSC use only it has no relevance to providers It identifies the reason for the recoupment Financial Transaction Type This is the description of the Financial Reason Code For example Third Party Recovery Date The date on which the recoupment was applied Since all the recoupments listed on this page pertain to the current cycle all the recoupments will have the same date Amount The dollar amount corresponding to the particular fiscal transaction This amount is deducted from the provider s total payment for the cycle 3 6 1 2 Explanation of Totals Section The total dollar amount of the financial transactions Net Financial Transaction Amount and the total number of transactions Number of Financial Transactions appear below the last line of the transaction detail list The Net Financial Transaction Amount added to the Claim Detail Grand Total must equal the Medicaid Check or EFT amounts INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 42 of 48 REMITTANCE ADVICE 3 6 2 Accounts Receivable This subsection displays the original amount of each of the outstanding Financial Transactions and their current balance after the cycle recoupments were applied If there are no outstanding negative balances this section is not produced Exhibit 3 6 2 1 PAGE 058 DATE 05 31 10 DIC AID CYCLE 1710
12. facility to another facility Hospital to Residential Care or Residential Care to Hospital etc the entry must be the NPI of the practitioner in the facility who made the determination that the patient should be placed in another facility Example In the case of a patient moving to a hospital hospital bed reservation the practitioner who made the determination that the patient should be admitted to the hospital should be entered in this field as the referring provider The provider number entered should be the NPI of the practitioner Completion of this field is required if an admission or a discharge occurred during the service period covered by this statement Form Locator 6 If no admission or discharge occurred leave this field blank For an Admission Enter the NPI of the referring practitioner who determined that residential care was appropriate NOTE If the patient is admitted from home enter the NPI of the physician who last examined the patient and determined that ICF DD nursing home care was appropriate See instructions for entering an NPI below For a Discharge Enter the NPI of the practitioner who made the discharge determination For a Bed Reservation Enter NPI of the practitioner who admitted the patient to the hospital Instructions for Entering an NPI Enter the code DN in the unlabeled field between the words OTHER and NPI to indicate the 10 digit NPI of the provider is entered in the box labeled NPI
13. line A of this field Enter the word Medicaid on line B of this field Leave line C blank NPI Form Locator 56 Enter the provider s 10 digit National Provider Identifier NPI Other Prv ID Other Provider ID Form Locator 57 Leave this field blank Insured s Unique ID Form Locator 60 Enter the patient s ID number Client ID number This information may be obtained from the Client s Patient s Common Benefit ID Card Medicaid Client ID numbers are assigned by the State of New York and are composed of eight characters in the format AANNNNNA where A alpha character and N numeric character For example AB12345C INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 19 of 48 m CLAIMS SUBMISSION The Medicaid Client ID should be entered on the same line A B or C that matches the line assigned to Medicaid in Form Locators 50 and 57 If the patient s Medicaid Client ID number is entered on lines B or C the lines above the Medicaid ID number must contain either the patient s ID for the other payer s or the word NONE Treatment Authorization Codes Form Locator 63 Leave this field blank if the service does not require Prior Approval If the service requires Prior Approval enter the 11 digit Prior Approval number here The Prior Approval must be entered on the same line A B or C that matches the line assigned to Medicaid in Form Locators 50 and 57 If
14. the Prior Approval number is entered on lines B or C the word NONE must be written on the line s above the Prior Approval line Note For information regarding how to obtain Prior Approval Authorization for specific services please refer to the Policy Guidelines section located at www emedny org by clicking on the link to the webpage as follows Intermediate Care Facility Dev Disabled ICF DD Manual Document Control Number Form Locators 64 A B C Leave this field blank when submitting an original claim or a resubmission of a denied claim If submitting an Adjustment Replacement or a Void to a previously paid claim this field must be used to enter the Transaction Control Number TCN assigned to the claim to be adjusted or voided The TCN is the claim identifier and is listed in the Remittance Advice If a TCN is entered in this field the third position of Form Locator 4 Type of Bill must be 7 or 8 The TCN must be entered in the line A B or C that matches the line assigned to Medicaid in Form Locators 50 and 57 If the TCN is entered in lines B or C the word NONE must be written on the line s above the TCN line Adjustments An adjustment is submitted to correct one or more fields of a previously paid claim Any field except the Provider ID number or the Patient s Medicaid ID number can be adjusted The adjustment must be submitted in a new claim form copy of the original form is unacceptable and all applicable fields must
15. 6 7890 TO ABC INTERMEDIATE CARE FACILITY PAYMENT WILL BE RECEIVED THIS CYCLE SEE REMITTANCE FOR DETAILS INTERMEDIATE GARE FACILITY 123 MAIN ST ANYT OWN 11111 INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 Page 29 of 48 5 31 2010 REMITTANCE ADVICE 3 3 1 Summout No Payment Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Date on which the remittance advice was issued Remittance Number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Notification that no payment was made for the cycle no claims were approved Provider Name and Address INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 30 of 48 REMITTANCE ADVICE 3 4 Section Two Provider Notification This section is used to communicate important messages to providers Exhibit 3 4 1 DICAID PAGE 01 DATE 05 31 10 IMROPMATION SYSTEM CYCLE 1740 MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTAMCE STATEMENT ABCINTERMEDIATE CARE FACILITY ETIN 123 MAIM STREET PROVIDER NOTIFICATION ANYTOWN NEW YORK 11111 PROV ID 00123456 1234567890 07080600001 REMITTANCE ADVICE MESSAGE TEXT ELECTRONIC FUNDS TRANSFER EFT FOR PROVIDER PAYMENTS IS NOW AVAILABLE PROVIDERS WHO ENROLL IM EFT WILL HAVE THEIR MEDICAID PAYMENTS DI
16. ABLED ICF DD Version 2010 01 5 31 2010 Page 7 of 48 CLAIMS SUBMISSION 2 3 UB 04 Claim Form To view a sample ICF DD UB 04 claim form see Appendix A The displayed claim form is a sample and the information it contains is for illustration purposes only The UB 04 CMS 1450 is a CMS standard form therefore CSC does not supply it The form can be obtained from any of the national suppliers The UB 04 Manual National Uniform Billing Data Element Specifications as Developed by the National Uniform Billing Committee Current Revision should be used in conjunction with this Provider Billing Guideline as a reference guide for the preparation of claims to be submitted to NYS Medicaid The UB 04 manual is available at www nubc org Form Locators in this manual for which no instruction has been provided have no Medicaid application These Form Locators are ignored when the claim is processed 2 4 ICF DD Services Billing Instructions This subsection of the Billing Guidelines covers the specific NYS Medicaid billing requirements for ICF DD providers Although the instructions that follow are based on the UB 04 paper claim form they are also intended as a guideline for electronic billers to find out what information they need to provide in their claims in addition to the HIPAA Companion Guides which are available at www emedny org by clicking on the link to the webpage as follows eMedNY Companion Guides and Sample Files It is impor
17. ILITY DATE 05 31 2010 REMITTANCE NO 07080800001 PROV ID 00123455 1234567890 0012345 1234587890 05 31 2010 ABC INTERMEDIATE CARE FACILITY 123 MAIN ST 11111 INTERMEDIATE GARE FACILITY 51452 20 PAYMENT IN THE ABOVE AMOUNT WILL BE AM ELECTRONICFUNDS TRANSFER INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 27 of 48 REMITTANCE ADVICE 3 2 1 EFT Notification Page Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Date on which the remittance advice was issued Remittance Number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Medicaid Provider ID NPI Date Provider s Name Address Provider s Name Amount transferred to provider s account This amount must equal the Net Total Paid Amount under the Grand Total subsection plus the total sum of the Financial Transaction section INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 28 of 48 EMITTANCE ADVICE 3 3 Section One Summout No Payment A summout is produced when the provider has no positive total payment for the cycle and therefore there is no disbursement of moneys Exhibit 3 3 1 D D DATE 05 21 2010 REMITTANCE NO 07080800001 MAMAGEMENT ome PROV ID 00123456 12345
18. LAW FOR IMPROPER USE OR FURTHER DISCLOSURE OF INFORMATION IN THIS COMMUNICATION AND ANY ATTACHMENTS IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR PLEASE IMMEDIATELY NOTIFY NWYHIPPADESK CSC COM OR CALL 1 800 541 2831 PROVIDERS WHO DO HAVE ACCESS E MAIL SHOULD CONTACT 1 800 343 8000 INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 31 of 48 REMITTANCE ADVICE 3 4 1 Provider Notification Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Remittance page number Date on which the remittance advice was issued Cycle Number ETIN not applicable Name of section PROVIDER NOTIFICATION PROV ID This field will contain the Medicaid Provider ID and the NPI Remittance number Center Message text INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 32 of 48 REMITTANCE ADVICE 3 5 Section Three Claim Detail This section provides a listing of all new claims that were processed during the specific cycle plus claims that were previously pended and denied during the specific cycle This section may also contain claims that pended previously Exhibit 3 5 1 DICAID MANAGEMENT IRF OA ATOH bre Tee MEDICAL ASSISTANCE TITLE XIX PROGRAM TO ABC INTERMEDIATE CARE FACILITY REMITTANCE STATEMENT 123 MAIN STREET ANYTOWN NEW YORK 11111 REF TED FULL DAY
19. N for paper submissions The ETIN and the associated certification qualify the provider to submit claims in both electronic and paper formats Information about these requirements is available at www emedny org by clicking on the link to the webpage as follows Information for All Providers 2 2 4 General Instructions for Completing Paper Claims Since the information entered on the claim form is captured via an automated data collection process imaging it is imperative that it be legible and placed appropriately in the required fields The following guidelines will help ensure the accuracy of the imaging output information should be typed or printed Alpha characters letters should be capitalized Numbers should be written as close to the example below in Exhibit 2 2 1 1 as possible Exhibit 2 2 1 1 e Circles the letter O the number 0 must be closed Avoid unfinished characters See the example in Exhibit 2 2 1 2 e Exhibit 2 2 1 2 Written As Intended As Interpreted As f felele 5 00 6 Zero interpreted as six When typing or printing stay within the box provided ensure that no characters letters or numbers touch the claim form lines See the example in Exhibit 2 2 1 3 INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 6 of 48 m CLAIMS SUBMISSION Exhibit 2 2 1 3 Intended As Interpreted As lwointerpr
20. NTADDRESS 5 PATIENTNAME SMITH WILLIAM b mu 12 DATE 13 14 TYPE 15 SRC 18 19 20 21 22 23 24 2 26 27 28 5 31 OCCURRENCE OCCURRENCE OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN Do OCCURRENCE SPAN CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH 38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES CODE AMOUNT CODE AMOUNT CODE AMOUNT a own a 42 43 DESCRIPTION 44 HCPCS RATE HIPPS CODE c co 04191940 c 29 21 22 23 gt O M Ow d CREATION DATE TOTALS 51 HEALTH PLAN ID ii iem 54 PRIORPAYMENTS 55 EST AMOUNT DUE 1234567890 Blue Cross 57 Medicaid 12345 64 DOCUMENT CONTROL NUMBER RAS AS N C e a PRV ID 62 INSURANCE GROUP NO m 65 EMPLOYER NAME gt m m 68 i f ji i 1 1 REASON CODE ECI LAST DATE Pm FIRST ODE ER PROCEDURE 3 OTHER PROCEDURE e OTHERPROCEDURE 77 OPERATI 3 a cme fom 80 REMARKS 78 OTHER DN wri 1234567890 tast Smith First John 8 1 FIR
21. OUNT UUS ERRORS F c DEDUCTED PAID 00 3E Bi 0 00 0 00 38781 PAID 0 00 387 81 387 81 0 00 0 00 38781 0 00 387 81 387 81 0 00 0 00 387 81 PAID 0 00 387 81 387 81 0 00 0 00 38781 PAID 0 00 387 8 0 00 0 00 387 81 ORIGINAL CLAIM 0 00 387 81 PAID 05 11 2010 0 29877 0 00 0 00 29877 ADJT 0 00 298 77 REF TED RATE CALC ED vu ND aud wu UN SERVICE i hil SEENT HAME FATENT ACCOUNT DATES D NUMBER FROM THRU SAMPLE 07206 000000112 3 0 010207 3822 123455 00987 5 07706 07 EXAMPLE 07206 000000111 1 0 070207 3822 XX67890X CPIC1 00345 6 07 06 07 MODEL 07206 000332456 0 0 070207 3822 XX28765X CPIC1 00542 6 07 06 07 SPECIMEN 07206 004445656 0 0 070207 3822 XXBI654X 1 00321 6 07 06 07 STANDARD 07206 007776546 0 1 070207 3822 XX76543X 1 00555 6 07 06 07 07206 007776546 0 2 07 02 07 3822 CPIC1 00444 5 07 08 07 FULL DAYS CO INSURANCE DAYS PAYMENT PREVIOUSLY PENDED CLAIM NEW TOTAL AMOUNT ORIGINAL CLAIMS PAID 1551 24 HUMBER OF CLAIMS NET AMOUNT ADJUSTMENTS FAID 83 04 NUMBER OF CLAIMS NET AMOUNT YOIDS FAID 0 00 NUMBER OF CLAIMS MET AMOUNT VOIDS ADJUSTS amp 3 04 NUMBER OF CLAIMS K3 INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 34 of 48 ABC INTERMEDIATE CARE FACILITY 123 MAIN S
22. RECTLY DEPOSITED INTO THEIR CHECKING OR SAVINGS ACCOUNT THE EFT TRANSACTIONS WILL BE INITIATED ON WEDNESDAYS AND DUE TO NORMAL BANKING PROCEDURES THE TRANSFERRED FUNDS MAY NOT BECOME AVAILABLE IN THE PROVIDER S CHOSEN ACCOUNTFOR UP TO 48 HOURS AFTER TRANSFER PLEASE CONTACT YOUR BANKING INSTITUTION REGARDING THE AVAILABILITY OF FUNDS PLEASE NOTE THAT EFT DOES NOT WAIVE THE TVO WEEK LAG FOR MEDICAID DISBURSEMENTS TO ENROLL IM EFT PROVIDERS MUST COMPLETE AN EFT ENROLLMENT FORM THAT CAN FOUND AT WWW EMEDNY ORG CLICK OM PROVIDER ENROLLMENT FORMS WHICH BE FOUND IM THE FEATURED LINKS SECTION DETAILED INSTRUCTIONS WILL ALSO BE FOUND THERE AFTER SENDING THE EFT ENROLLMENT FORM CSC PLEASE ALLOW A MINIMUM TIME OF SIX TO EIGHT WEEKS FOR PROCESSING DURING THIS PERIOD OF TIME YOU SHOULD REVIEW YOUR BANK STATEMENTS AND LOOK FOR EFT TRANSACTION IM THE AMOUNT OF 0 01 WHICH CSC WILL SUBMIT AS TEST YOUR FIRST REAL EFT TRANSACTION WILL TAKE PLACE APPROXIMATELY FOUR TO FIVE WEEKS LATER IF YOU HAVE AN Y QUESTIONS ABOUT THE EFT PROCESS PLEASE CALL THE EMEDNY CALL CENTER AT 1 800 343 9000 NOTICE THIS COMMUNICATION AND ATTACHMENTS MAY CONTAIN INFORMATION THAT PRIVILEGED AND CONFIDENTIAL UNDER STATE AND FEDERAL LAW AND 15 INTENDED ONLY FOR THE USE OF THE SPECIFIC INDIVIDUAL S TO WHOM IT IS ADDRESSED THIS INFORMATION MAY ONLY BE USED OR DISCLOSED IN ACCORDANCE WITH LAW AMD YOU MAY BE SUBJECT TO PENALTIES UNDER
23. S PATIENT DATES AC ED COINSURANCE FROM ogg DAYS PAYMENT THRU D 250210 3877 05 06 10 05 02 10 05 06 10 SERVIZE CLIENT NAME ipBNUMBER PATENT ACCOUNT NUMBER REPORTED DEDUCTED 0 0 00 0 00 0 00 0 0 00 0 00 Q7 206 0000001 12 3 0 1 X1887 5 Q7 206 0000001 11 1 0 1 X1345 5 SAMPLE XX12345X 0 00 5 5 4 5 5 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS 775 62 0 00 0 00 0 00 TOTAL AMOUNT ORIGIMAL CLAIMS AMOUNT ADJUSTMENTS NET AMOUNT VOIDS AMOUNT VOIDS ADJUSTS PARTICIPATION OTHER INSURANCE 0 00 0 00 DATE 05 31 10 CYCLE 1710 ETIN ICF DD PROV ID 00123455 123456578590 REMITTANCE NO OF 020600001 AMOUNT CHARGED AMOUNT PAID 38781 0 48781 0 STATUS ERRORS DENY 010230103 DENY 01023 SNEW PEND INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 Page 33 of 48 5 31 2010 Exhibit 3 5 2 PAGE 03 DATE 0531 10 CYCLE 1710 DICAID SS INFORMATION TO AMAIN STREET CHW MEDICAL ASSISTANCE TITLE XIX PROGRAM 90122496 1234567890 ANYTOWN NEW YORK 11111 REMITTANCE STATEMENT REMITTANCE 07020500001 PATIENT OTHER AMOUNT PARTICIPATION INSURANCE CHARGED o e ronan CODE DAYS REPORTED AM
24. ST THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILLAND ARE MADE A PART HEREOF INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 47 of 48 INFORMATION eMedNY is name of the electronic New York State Medicaid system eMedNY system allows New York Medicaid providers to submit claims and receive payments for Medicaid covered services provided to eligible clients eMedNY offers several innovative technical and architectural features facilitating the adjudication and payment of claims and providing extensive support and convenience for its users CSC is the eMedNY contractor and is responsible for its operation The information contained within this document was created in concert by eMedNY DOH and eMedNY CSC More information about eMedNY can be found at www emedny org INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 48 of 48
25. TREET ANYTOWN NEW YORK 11111 CLIENT NAME ID NUMBER ACCOUNT NUMBER SAMFLE XX12345X EXAMPLE XAET ESIK TASAA CPIC 1 00987 6 07206 000000111 1 0 CPIC 1 00245 5 SERVICE DATES FROM THRU 08702710 10 05 02 10 08 06 10 RATE CODE MEDICAL ASSISTANC Exhibit 3 5 3 DICAID MANAGEMENT INFORMATION SYSTEM REMITTANCE STATEMENT REPTED CALC ED DATS 0 TOTAL AMOUNT ORIGINAL CLAIMS HET AMOUNT ADJUSTMENTS HET AMOUNT VOIDS NET AMOUNT VOIDS ADJUSTS REMITTANCE TOTALS ICF DD VOIDS ADJUSTS TOTAL PENDS TOTAL PAID TOTAL DENY TOTAL PAID MEMBERID 12345578 VOIDS ADJUSTS TOTAL PENDS TOTAL TOTAL DENY MET TOTAL PAID PEND PEND PEND 0 00 0 00 0 00 83 04 1551 24 1452 20 83 04 1551 24 62 1462 20 FULL DAYS PATIENT CO IMSURANCE 0 00 0 00 0 00 0 00 0 00 0 00 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS PARTICIPATION E TITLE AIA PROGRAM RJ RI OTHER INSURANCE 0 00 387 81 0 00 04 053110 CYCLE 1710 ICF DD PROV ID 00723456 1234507890 REMITTANCE NO 070060001 AMOUNT CHARGED AMOUNT FAID
26. There are no calculated co insurance days Patient Participation Reported Deducted This column shows the patient participation amount NAMI as it was reported first line and as it was deducted second line If no patient participation is applicable this column will show 0 00 amount Other Insurance If applicable the amount paid by the patient s Other Insurance carrier as reported on the claim form is shown under this column If no Other Insurance payment is applicable this column will show 0 00 amount Amount Charged Amount Paid The total charges entered in the claim form appear first under this column If the claim was approved the amount paid appears underneath the charges If the claim has a pend or deny status the amount paid will be zero 0 00 Status This column indicates the status DENY PAID ADJT VOID PEND of the claim line Denied Claims Claims for which payment is denied will be identified by the DENY status A claim may be denied for the following general reasons The service rendered is not covered by the New York State Medicaid Program The claim is a duplicate of a prior paid claim The required Prior Approval has not been obtained Information entered in the claim form is invalid or logically inconsistent Approved Claims Approved claims will be identified by the statuses PAID ADJT adjustment or VOID Paid Claims The status PAID refers to original claims that have been appro
27. aid of any change of address or other pertinent information within 15 days of the change For information on where to direct address change requests please refer to Information for All Providers Inquiry section which can be found at www emedny org by clicking on the link to the webpage as follows Intermediate Care Facility Dev Disabled ICF DD Manual Patient Control Number Form Locator 3a For record keeping purposes the provider may choose to identify a patient by using an account patient control number This field can accommodate up to 30 alphanumeric characters If an account patient control number is indicated on the claim form the first 20 characters will be returned on the paper Remittance Advice Using an account patient control number can be helpful for locating accounts when there is a question on patient identification INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 9 of 48 CLAIMS SUBMISSION Type of Bill Form Locator 4 Completion of this field is required for all provider types All entries in this field must contain three digits Each digit identifies a different category as follows 1st Digit Type of Facility 2nd Digit Bill Classification 3rd Digit Frequency Type of Facility Enter the value 6 from the UB 04 Manual Form Locator 4 and Type of Facility category to indicate Intermediate Care Bill Classification Using the UB 04 Manual
28. be completed An adjustment is identified by the value 7 in the third position of Form Locator 4 Type of Bill and the claim to be adjusted is identified by the TCN entered in this field Form Locator 64 Adjustments cause the correction of the adjusted information in the claim history records as well as the cancellation of the original claim payment and the re pricing of the claim based on the adjusted information Voids A void is submitted to nullify a paid claim The void must be submitted in a new claim form copy of the original form is unacceptable and all applicable fields must be completed A void is identified by the value 8 in the third position of Form Locator 4 Type of Bill and the claim to be voided is identified by the TCN entered in this field Form Locator 64 INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 20 of 48 CLAIMS SUBMISSION Voids cause the cancellation of the original claim history records and payment Untitled Principal Diagnosis Code Form Locator 67 A Q Leave all fields blank Principal Procedure Form Locator 74 Leave this field blank Other Form Locator 78 NYS Medicaid uses this field to report the Referring Destination Previous Provider The National Provider ID NPI regulations do not allow the submission of a facility NPI as a referring provider In those instances where the patient is transferred or moved to or from one
29. billing multiple dates of service are provided below in Form Locators 42 47 Dates must be entered in the format MMDDYYYY NOTES Claims must be submitted within 90 days of the date of service entered in this field unless acceptable circumstances for the delay can be documented Information about billing claims over 90 days or two years from the Date of Service is available in the All Providers General Billing Guideline Information section available at www emedny org by clicking on the link to the webpage as follows Information for All Providers Do not include full days covered by Medicare or other third party insurers as part of the period of service separate claim must be completed if the period of service includes therapeutic or hospital leave days The provider s paper remittance statement will only contain the date of service the FROM box with the total number of units for the sum of all dates of service reported below Providers who receive an electronic 835 remittance will receive only the claim level dates of service from and through as reported on the incoming claim transaction Patient Name Form Locator 8 line b Enter the patient s last name followed by the first name This information may be obtained from the Client s Patient s Common Benefit ID Card Birthdate Form Locator 10 Enter the patient s birth date This information may be obtained from the Client s Patient s Common Benefit ID Card The b
30. dgeted amount should be entered If billing occurs more than once a month enter the full NAMI amount on the first claim submitted for the month as illustrated in Exhibit 2 4 2 7 Exhibit 2 4 2 7 34 CODES CODE AMOUNT m mo _ Note For retroactive NAMI changes an adjustment to the previously paid claim needs to be submitted These adjustments can only be submitted when approval for a budget change has been received from the LDSS Other Insurance Payment Value Code A3 or B3 If the patient has insurance other than Medicare it is the responsibility of the provider to determine whether the service being billed for is covered by the patient s Other Insurance carrier If the service is covered or if the provider does not know if the service is covered the provider must first submit a claim to the Other Insurance carrier as Medicaid is always the payer of last resort INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 14 of 48 CLAIMS SUBMISSION Value Code If applicable code A3 or B3 should be used to indicate that the amount paid by an insurance carrier other than Medicare is entered under Amount The line A or B assigned to the Insurance Carrier in Form Locator 50 determines the choice of codes or B3 Value Amount Enter the actual amount paid by the other insurance carrier If the other insurance carrier denied payment enter 0 00 Proof of denial o
31. dicates the NYS Medicaid edit error numeric code s that caused the claim to deny or pend Some edit codes may also be indicated for a PAID claim These are approved edits which identify certain errors found in the claim and that do not prevent the claim from being approved Up to twenty five 25 edit codes including approved edits may be listed for each claim Edit code definitions will be listed on a separate page of the remittance advice at the end of the claim detail section 3 5 3 Subtotals Totals Grand Totals Subtotals of dollar amounts and number of claims are provided as follows Subtotals by claim status appear at the end of the claim listing for each status The subtotals are broken down by Original claims Adjustments Voids Adjustments voids combined eee INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 39 of 48 REMITTANCE ADVICE Totals by service classification and by member ID are provided next to the subtotals for service classification locator code These totals are broken down by Adjustments voids combined Pends Paid Deny eeee Net total paid for the specific service classification Grand Totals for the entire provider remittance advice which include all the provider s service classifications appear on a separate page following the page containing the totals by service classification The grand total is broken down A
32. djustments voids combined Pends Paid Deny Net total paid entire remittance INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 40 of 48 REMITTANCE ADVICE 3 6 Section Four Financial Transactions and Accounts Receivable This section has two subsections Financial Transactions Accounts Receivable 3 6 1 Financial Transactions The Financial Transactions subsection lists all the recoupments that were applied to the provider during the specific cycle If there is no recoupment activity this subsection is not produced Exhibit 3 6 1 1 EDICAID ACE E PEUT INFORMATION ESTE MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT PAGE 07 DATE 05 21 10 CYCLE 1710 TO ABC INTERMEDIATE CARE FACILITY ETIN 123 MAIN STREET FINANCIAL TRANSACTIONS ANYTOWNM NEW YORK 11111 PROV ID 000234565 1234557830 REMITTANCE O07 080600001 FINANCIAL FISCAL REASON CODE TRANS TYPE DATE AMOUNT RECOUPMENT REASON DESCRIPTION 05 09 10 T2 FCN 20100500072 3554 7 NET FINANCIAL AMOUNT NUMBER OF FINANCIAL TRANSACTIONS XXX INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 41 of 48 REMITTANCE ADVICE 3 6 1 1 Explanation of Financial Transactions Columns FCN The Financial Control Number FCN is a unique identifier assigned to
33. e Revenue Code 0185 to indicate that the number of Hospital Leave days is entered in Form Locator 46 Hospital Leave must not be claimed together with regular billing these claims must be submitted on a separate form Therapeutic Leave These are overnight absences that include leave for personal reasons or to participate in medically acceptable therapeutic or rehabilitative plans of care Please refer to the ICF DD Manual Policy Guidelines Section for Bed Reservation information If applicable use Revenue Code 0183 to indicate that the number of Therapeutic Leave days is entered in Form Locator 46 Therapeutic Leave must not be claimed together with regular billing these claims must be submitted on a separate form Serv Units Form Locator 46 If Revenue Code 0185 Hospital Leave was used in Form Locator 42 enter the total number of Hospital Leave days on the same line where the revenue code appears The number of units entered in this field must match the entry in Form Locators 39 41 Value Code 80 Covered Days If Revenue Code 0183 Therapeutic Leave was used in Form Locator 42 enter the total number of Therapeutic Leave days on the same line where the revenue code appears The number of units entered in this field must match the entry in Form Locators 39 41 Value Code 80 Covered Days Total Charges Form Locator 47 Enter the total amount charged for the service s rendered This is computed by multiplying the tota
34. e required to submit an Electronic Paper Transmitter Identification Number ETIN Application and Certification Statement before submitting claims to NYS Medicaid Certification Statements remain in effect and apply to all claims until superseded by another properly executed Certification Statement Providers will be asked to update their Certification Statement on an annual basis Providers will be provided with renewal information when their Certification Statement is near expiration Information about these requirements is available at www emedny org by clicking on the link to the webpage as follows Information for All Providers 2 1 Electronic Claims Pursuant to the Health Insurance Portability and Accountability Act HIPAA Public Law 104 191 which was signed into law August 12 1996 the NYS Medicaid Program adopted the HIPAA compliant transactions as the sole acceptable format for electronic claim submission effective November 2003 ICF DD providers who choose to submit their Medicaid claims electronically are required to use the HIPAA 837 Institutional 8371 transaction Direct billers should also refer to the sources listed below to comply with the NYS Medicaid requirements HIPAA 8371 Implementation Guide IG explains the proper use of the 8371 standards and program specifications This document is available at www wpc edi com hipaa NYS Medicaid 8371 Companion Guide CG is a subset of the IG which provides instructions for t
35. eted as seven hree interpreted as two Characters should not touch each other as seen in Exhibit 2 2 1 4 Exhibit 2 2 1 4 Written As Intended As Interpreted As Entry cannot be 23 illegible interpreted properly not write between lines not use arrows or quotation marks to duplicate information Do not use the dollar sign 5 to indicate dollar amounts do not use commas to separate thousands For example three thousand should be entered as 3000 not as 3 000 For writing it is best to use a felt tip pen with a fine point Avoid ballpoint pens that skip do not use pencils highlighters or markers Only blue or black ink is acceptable if filling in information through a computer ensure that all information is aligned properly and that the printer ink is dark enough to provide clear legibility e Do not submit claim forms with corrections such as information written over correction fluid or crossed out information If mistakes are made a new form should be used Separate forms using perforations do not cut the edges Do not fold the claim forms Do not use adhesive labels for example for address do not place stickers on the form eec cc Do not write or use staples on the bar code area The address for submitting claim forms is COMPUTER SCIENCES CORPORATION P O Box 4601 Rensselaer NY 12144 4601 INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DIS
36. f payment must be maintained in the patient s billing record Zeroes must also be entered in this field if any of the following situations apply 5 A thes Prior to billing the insurance company the provider knows that the service will not be covered because The provider has had a previous denial for payment for the service from the particular insurance policy However the provider should be aware that the service should be billed if the insurance policy changes Proof of denials must be maintained in the patient s billing record Prior claims denied due to deductibles not being met are not to be counted as denials for subsequent billings In very limited situations the Local Department of Social Services LDSS has advised the provider to zero fill the Other Insurance payment for the same type of service This communication should be documented in the client s billing record The provider bills the insurance company and receives a rejection because The service is not covered or The deductible has not been met The provider cannot directly bill the insurance carrier and the policyholder is either unavailable or uncooperative in submitting claims to the insurance company In these cases the LDSS must be notified prior to zero filling The LDSS has subrogation rights enabling it to complete claim forms on behalf of uncooperative policyholders who do not pay the provider for the services The LDSS can direct the insurance
37. he specific requirements of NYS Medicaid for the 8371 This document is available at www emedny org by clicking on the link to the web page as follows Companion Guides and Sample Files 5 Medicaid Technical Supplementary Companion Guide provides technical information needed to successfully transmit and receive electronic data Some of the topics put forth in this CG are testing requirements error report information and communication specifications This document is available at www emedny org by clicking on the link to the web page as follows Companion Guides and Sample Files Further information about electronic claim pre requirements is available at www emedny org by clicking on the link to the webpage as follows Information for All Providers INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 5 of 48 m CLAIMS SUBMISSION 2 2 Paper Claims ICF DD providers who choose to submit their claims on paper forms must use the Centers for Medicare and Medicaid Services CMS standard UB 04 claim form To view a sample ICF DD UB 04 claim form see Appendix The displayed claim form is a sample and the information it contains is for illustration purposes only An Electronic Transmission Identification Number ETIN and a Certification Statement are required to submit paper claims Providers who have a valid ETIN for the submission of electronic claims do not need an additional ETI
38. hould be used to indicate the total number of Medicare co insurance days claimed during the service period Value Amount Enter the actual number of Medicare co insurance days The sum of Medicaid full covered days Medicaid non covered days and Medicare co insurance days must correspond to the Statement Covers Period in Form Locator 6 and should not reflect the day of discharge The Co Insurance Days must be entered to the left of the dollars cents delimiter Exhibit 2 4 2 11 illustrates a correct Medicare Co Insurance Days entry Exhibit 2 4 2 11 38 CODES CODE AMOUNT 30 e w Rev Cd Revenue Form Locator 42 Revenue Codes identify specific accommodations ancillary services or billing calculations NYS Medicaid uses Revenue Codes to identify the following information Total Charges Title XIX Days Hospital Leave Title XIX Days Therapeutic Leave INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 17 of 48 SUBMISSION Total Charges Use Revenue Code 0001 to indicate that total charges are entered in Form Locator 47 Hospital Leave The patient was hospitalized during the billing period and bed retention was involved If bed retention for hospitalization was not involved hospital leave is not applicable Please refer to the ICF DD Provider Manual Policy Guidelines section for bed reservation information If applicable us
39. irth date must be in the format MMDDYYYY See the example in Exhibit 2 4 2 4 that follows Exhibit 2 4 2 4 Sex Form Locator 11 Enter for male or for female to indicate the patient s sex This information may be obtained from the Client s Patient s Common Benefit ID Card INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 11 of 48 SUBMISSION Admission Form Locators 12 15 Leave all fields blank Stat Patient Status Form Locator 17 This field is used to indicate the specific condition or status of the patient as of the last date of service indicated in Form Locator 6 Select the appropriate code except for 43 and 65 from the UB 04 Manual Condition Codes Form Locators18 28 Leave all fields blank Occurrence Code Date Form Locators 31 34 Leave all fields blank Occurrence Code Span Form Locators 35 36 Leave all fields blank Value Codes Form Locators 39 41 NYS Medicaid uses Value Codes to report the following information Locator Code required see notes for conditions Rate Code required Patient Participation only if applicable Other Insurance Payment only if applicable Medicaid Covered Days only if applicable Medicaid Non Covered Days only if applicable Medicare Co Insurance Days only if applicable ec c cec Value Codes have two components Code and Amount The Code component is used to indicate the t
40. l number of full days times the per diem rate plus Medicare co insurance days if any times the Medicare co insurance rate The charged amount must be entered on the line corresponding to Revenue Code 0001 and both sections of the field dollars and cents must be completed if the charges contain no cents enter 00 in the cents box See Exhibit 2 4 2 12 for an example INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 18 of 48 CLAIMS SUBMISSION Exhibit 2 4 2 12 3000 00 If Therapeutic Leave or Hospital Leave units were entered in Form Locator 46 enter the charges for that line in this field as well as shown in Exhibit 2 4 2 13 Exhibit 2 4 2 13 42 REV CD 45 DESCRIPTION dd HEPES RATE HIPPS CODE 45 SERV DATE 45 SERV UNITS qr TOTAL CHARGES 45 NON COVERED CHARGES DN 1500 00 1500 00 Payer Name Form Locator 50 C This field identifies the payer s responsible for the claim payment For NYS Medicaid billing payers are classified into three main categories Medicare Commercial any insurance other than Medicare and Medicaid Medicaid is always the payer of last resort Complete this field in accordance to the following instructions Direct Medicaid Claim No Third Party Involved Enter the word Medicaid on line A of this field Leave lines B and C blank Medicaid Third Party Other Than Medicare Claim Enter the name of the Other Insurance Carrier on
41. planation of Claim Detail Columns Client Name ID Number This column indicates the last name of the patient first line and the Medicaid Client ID second line If an invalid Medicaid Client ID was entered in the claim form the ID will be listed as it was submitted but no name will appear in this column TCN Patient Account Number The TCN first line is a unique identifier assigned to each claim that is processed If a Patient Account Number was entered in the claim form that number up to 20 characters will appear under this column second line Service Dates From Through The first date of service covered by the claim From date appears on the first line the last date of service Through date appears on the second line Rate Code The four digit rate code that was entered in the claim form appears under this column INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 37 of 48 REMITTANCE ADVICE Reported Calculated Days This column has two sub columns one is labeled full days and the other is labeled co insurance days The number of days within the reported first FROM service date and the last THROUGH service date appear in the first line under the F sub column The number of full days calculated by the system appears in the second line under the F sub column The number of co insurance days reported on the claim form appears under the C sub column
42. r to Information for All Providers Inquiry section located at www emedny org by clicking on the link to the webpage as follows Intermediate Care Facility Dev Disabled ICF DD Manual Rate Code Value Code 24 Rates are established by the Department of Health and other State agencies At the time of enrollment in Medicaid providers receive notification of the rate codes and rate amounts assigned to their category of service Any time that rate codes or amounts change providers also receive notification from the Department of Health Value Code Code 24 should be used to indicate that a rate code is entered under Amount Value Amount Enter the rate code that applies to the service rendered The four digit rate code must be entered to the left of the dollars cents delimiter The example in Exhibit 2 4 2 6 illustrates a correct rate code entry INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 13 of 48 CLAIMS SUBMISSION Exhibit 2 4 2 6 39 VALUE CODES CODE AMOUNT 3924 Patient Participation Value Code 23 Value Code Code 23 should be used to indicate that the patient s Net Available Monthly Income NAMI amount is entered under Amount Value Amount Enter the NAMI amount approved by the local Social Services agency as the patient s monthly budget In cases where the patient s budget has increased the new amount rather than the current bu
43. s must correspond to the Statement Covers Period in Form Locator 6 and should not reflect the day of discharge The Covered Days must be entered to the left of the dollars cents delimiter The example in Exhibit 2 4 2 9 illustrates a correct Medicaid Covered Days entry Exhibit 2 4 2 9 VALUE CODES CODE AMOUNT Medicaid Non Covered Days Value Code 81 Value Code Code 81 should be used to indicate the total number of full days that are not reimbursable by Medicaid or any other third party This does not include full days covered by Medicare or other third party insurers Value Amount Enter the actual number of days non covered by Medicaid The sum of Medicaid full covered days Medicaid non covered days and Medicare co insurance days must correspond to the Statement Covers Period in Form Locator 6 and should not reflect the day of discharge The Non Covered Days must be entered to the left of the dollars cents delimiter INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 16 of 48 m CLAIMS SUBMISSION NOTE For non resident health care patients non covered days are those days occurring within the service period on which health care services were not rendered for example weekends Exhibit 2 4 2 10 illustrates a correct Medicaid Non Covered Days entry Exhibit 2 4 2 10 39 VALUE CODES CODE Medicare Co Insurance Days Value Code 82 Value Code Code 82 s
44. sion 2010 01 5 31 2010 Page 8 of 48 CLAIMS SUBMISSION If a separate claim is submitted directly by the provider to Medicaid for a dual eligible recipient and the claim is paid before the Medicare crossover claim both claims will be paid The eMedNY system automatically voids the provider submitted claim in this scenario Providers may submit adjustments to Medicaid for their crossover claims because they are processed as a regular adjustment Electronic remittances from Medicaid for crossover claims will be sent to the default ETIN when the default is set to electronic If there is no default ETIN the crossover claims will be reported on a paper remittance The ETIN application is available at www emedny org by clicking on the link to the webpage as follows Provider Enrollment Forms NOTE For crossover claims the Locator Code will default to 003 if zip 4 does not match information in the provider s Medicaid file 2 4 2 UB 04 Claim Form Field Instructions Provider Name Address and Telephone Number Form Locator 1 Enter the billing provider s name and address using the following rules for submitting the ZIP code Paper claim submissions Enter the five digit ZIP code or the ZIP plus four Electronic claim submissions Enter the nine digit ZIP code The Locator Code will default to 003 if the nine digit ZIP code does not match information in the provider s Medicaid file NOTE It is the responsibility of the provider to notify Medic
45. tant that providers adhere to the instructions outlined below Claims that do not conform to the eMedNY requirements as described throughout this document may be rejected pended or denied 2 4 1 Instructions for the Submission of Medicare Crossover Claims This subsection is intended to familiarize the provider with the submission of crossover claims Providers can bill claims for Medicare Medicaid patients to Medicare Medicare will then reimburse its portion to the provider and the provider s Medicare remittance will indicate that the claim will be crossed over to Medicaid Claims for services not covered by Medicare should continue to be submitted directly to Medicaid as policy allows Also Medicare Part C Medicare Managed Care and Medicare Part D claims are not part of this process Providers are urged to review their Medicare remittances for crossovers beginning December 1 2009 to determine whether their claims have been crossed over to Medicaid for processing Any claim that was indicated by Medicare as a crossover should not be submitted to Medicaid as a separate claim If the Medicare remittance does not indicate the claim has been crossed over to Medicaid the provider should submit the claim directly to Medicaid Claims that are denied by Medicare will not be crossed over Medicaid will deny claims that are crossed over without a Patient Responsibility INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Ver
46. ttance Advice features the description of each of the edit codes including approved codes failed by the claims listed in Section Three Exhibit 3 7 1 DICAID PAGE MAN AGCMENT CYCLE 1710 ATION MEDICAL ASSISTANCE TITLE XIX PROGRAM ETIN TO ABC INTERMEDIATE CARE FACILITY REMITTANCE STATEMENT CF DD 123 MAIN STREET EDIT DESCRIPTIONS ANYTOWN NEW YORK 11111 PROV ID 00122456 1234557 830 REMITTANCE 1 THE FOLLOWING IS DESCRIPTION OF THE EDIT REASON CODES THAT APPEAR ON THE CLAIMS FOR THIS REMITTANCE 00162 RECIPIENT IMELIGIBLE FOR DATE OF SERVICE 00971 RECIPIENT NOT ON LONG TERM CAE FILE 01023 HOSPITAL LEAVE NOT SEPARATE LINE 01035 STAUS DISCHARGED DESTINATION PROVIDER BLANK 01131 MEDICAID NOT ALLOWED UNTIL MEDICARE 15 MAXIMIZED INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 45 of 48 APPENDIX CLAIM SAMPLES APPENDIX A CLAIM SAMPLES The eMedNY Billing Guideline Appendix A Claim Samples contains images of claims with sample data INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 46 of 48 APPENDIX CLAIM SAMPLES ICF DD UB 04 Sample Claim APPROVED OMB NO 0938 0279 Anytown ICFIDD 1234567 4 TYPE OF BILL 1 Maple Avenue wee o Anytown NY 11111 1111 TAYAK 6 STATEMENT COVERS PERIOD LL 09702008 JPATIE
47. ved INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 38 of 48 REMITTANCE ADVICE Adjustments The status ADJT refers to a claim submitted in replacement of a paid claim with the purpose of changing one or more fields An adjustment has two components the credit transaction previously paid claim and the debit transaction adjusted claim Voids The status VOID refers to a claim submitted with the purpose of canceling a previously paid claim A void lists the credit transaction previously paid claim only Pending Claims Claims that require further review or recycling will be identified by the PEND status The following are examples of circumstances that commonly cause claims to be pended New York State Medical Review required Procedure requires manual pricing match found the Medicaid files for certain information submitted on the claim for example Patient ID Prior Approval Service Authorization These claims are recycled for a period of time during which the Medicaid files may be updated to match the information on the claim After manual review is completed a match is found in the Medicaid files or the recycling time expires pended claims may be approved for payment or denied A new pend is signified by two asterisks A previously pended claim is signified by one asterisk Errors For claims with a DENY or PEND status this column in
48. ype of information reported The Amount component is used to enter the information itself Both components are required for each entry Locator Code Value Code 61 For electronic claims leave this field blank The Locator Code will be defaulted to 003 if the nine digit ZIP Code submitted on the claim does not match what is on file For paper claims enter the locator code assigned by NYS Medicaid Locator codes are assigned to the provider for each service address registered at the time of enrollment in the Medicaid program or at anytime afterwards that a new location is added INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED ICF DD Version 2010 01 5 31 2010 Page 12 of 48 CLAIMS SUBMISSION Value Code Code 61 should be used to indicate that a Locator Code is entered under Amount Value Amount Entry must be three digits and must be placed to the left of the dollars cents delimiter Locator codes 001 and 002 are for administrative use only and are not to be entered in this field The entry may be 003 or a higher locator code Enter the locator code that corresponds to the address where the service was performed The example in Exhibit 2 4 2 5 illustrates a correct Locator Code entry Exhibit 2 4 2 5 39 VALUE CODES NOTE The provider is reminded of the obligation to notify Medicaid of all service locations as well as changes to any of them For information on where to direct locator code updates please refe

eMedNY Subsystem User Manual

Contents

Download Pdf Manuals

Related Search

Related Contents