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eMedNY Subsystem User Manual

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1. New York State Electronic Medicaid System B04 Billing Guidelines HOME HEALTH SERVICES Version 2010 01 5 31 2010 TT TABLE OF CONTENTS TABLE OF CONTENTS TL Purpose E 4 2 Clamis eua ____________ ___ 5 2 1 Fl CI O C C p uu u uu uuu 5 2 2 y 6 2 2 1 General Instructions for Completing Paper Claims cccccccssssscccccesseccccsesececceesseceeeaueecesseuaeecessseaecesseeuseeessaaeeecessuggeseeees 6 2 3 044 z OU u u us 8 2 4 Home Health Services Billing 44 8 2 4 1 Instructions for the Submission of Medicare Crossover 8 242 UB O4 Claim Form Field Instructions _______________ _______ 6 9 3 Explanation of Paper Remittance Advice 5 22 3 1 Section One AICO uuu uu 23 31 1 Maeqicaid Check St b Field Description 24 3 1 2 Medicaid Check Descriptions 24 3 2 Section NOtITICAUOI MT 25 3 2 1 EFT Notification Page Field 26 3 3 Section One SUMMOUT NO Payment __ _ ____ 27 3 3 1 Summout No Payment Field Descript
2. 775 62 0 00 NUMBER OF CLAIMS 0 NUMBER OF CLAIMS 0 NUMBER OF CLAIMS 0 NUMBER OF CLAIMS 2 NUMBER OF CLAIMS 0 143 32 2026 41 272 19 1877 11 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS BRI HOME HEALTH SERVICES Page 33 of 46 PAGE 24 08 31 2010 CYCLE 1710 HOME HEALTH PROV ID Q0111224 1224567830 REMITTANCE O7 02000001 PAID STATUS t PEND s PEND ERRORS 00162 00244 00162 00244 PREVIOUSLY CLAIM NEW PEND 5 31 2010 REMITTANCE ADVICE Exhibit 3 5 4 CYCLE 1710 D ICAID DATE 582100010 T MA Pq ALCRIE Pq E FORMATION ree MEDICAL ASSISTANCE TITLE XIX PROGRAM EE uen 0 GI HOME CARI TATE HOME HEALT 111 MAIN STREET REMITTANCE STATEMENT GRAND TOTALS ANYTOWN NEW YORK 11111 PROVID 00111234 1234568720 REMITTANCE 070805600001 REMITTANCE TOTALS GRAMD TOTALS VOIDS ADJUSTS 144 7 NUMBER OF CLAIMS TOTAL PENDS 488 61 NUMBER OF CLAIMS TOTAL 2025 41 NUMBER OF CLAIMS TOTAL DENY 212 13 NUMBER CLAIMS NET TOTAL PAID 1877 11 NUMBER OF CLAIMS Ca HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 34 of 46 _ 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 a
3. 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 HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 8 of 46 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 li
4. HOME HEALTH SERVICES Page 31 of 46 PAGE 02 DATE 05 31 2010 CYCLE 1710 ETIN HOME HEALTH PROV ID 00111234 1224567890 REMITTANCE 07080500001 LOGATOR CD 003 PAID STATUS ERRORS 0 00 DENY 00162 00131 0 00 DENY 00244 00142 PREVIOUSLY PENDED CLAIM NEW 5 31 2010 REMITTANCE ADVICE Exhibit 3 5 2 PAGE 03 053172010 CYCLE 1710 MANAGEMENT INFORMATION SYSTEM CITY HOME CARE HOME HEALTH 111 MAIN STREET MEDICAL ASSISTANCE TITLE XIX PROGRAM PROV ID 00111224 12456789 ANYTOWN NEW YORK 11111 REMITTANCE STATEMENT REMITTANCE NO 07080600001 OFFICE ACCOUNT CLIENT CLIENT DATE OF RATE NUMBER NAME ID TCN SERVICE CODE UNITS CHARGED PAID STATUS ERRORS CPICTJ01234 DOE XX12345X 07205000034112 02 052510 2810 800 30020 _ 30020 PAID CPIC1 00987 5 SAMPLE XX23456X 07206 000445112 0 2 05 2340 2810 5 000 18841 18841 PAID EXAMPLE Xx34557x 07 206 000456333 0 2 2710 2810 5 000 300 20 300 20 PAID CPICi 56666 h SPECIMEN 4 0720600044555202 05 2240 2810 8000 2300 20 2300 20 PAID 1 223235 STANDARD XX56788X 07206 000447654 0 2 05 2210 2810 800 200 20 30020 PAID 1 555555 MODEL XX67890X 07206 000465553 0 2 05 2540 2810 18610 186 10 PAID CPIC1 77777 b DOE 07206 000455557 0 2 05 2540 2810 300 20 3200 20 PAID 1 11111 5 SAMPLE XXS8765X 07200 000544444 0 2 050510 2810 50 150
5. John Smith Y Sant SQ STATS STREET ALBANY m 1227 s NET ean s d HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 23 of 46 REMITTANCE ADVICE 3 1 1 Medicaid Check Stub Field Descriptions Upper Left Corner 5 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 HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 24 of 46 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 TO CITY HOME CARE DATE 2010 05 31 D CAI D REMITTAN NO 07080500001 PROV 10 00111234 123456 7
6. 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 Home Health Services Billing Instructions This subsection of the Billing Guidelines covers the specific NYS Medicaid billing requirements for Home Health 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 important 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
7. on line A of this field Enter the word Medicaid on line B of this field Leave line C blank Medicare Commercial Medicaid Claim If the patient is covered by Medicare and one or more commercial insurance carriers Enter the word Medicare on line A of this field Enter the name of the Other Insurance Carrier on line B of this field Enter the word Medicaid on line C of this field 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 numeric character For example AB12345C 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 HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 19 of 46 CLAIMS SUBMISSION Document Contr
8. 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 Home Health 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 837 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 the 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 NYS 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
9. 1 2010 Page 29 of 46 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 Remittance Number Center Message text HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 30 of 46 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 TO CITY HOME CARE 111 MAIN STREET NEW YORK 11111 OFFICE ACCOUNT NUMBER 1 001234 CPIC1 00887 6 SAMPLE TOTAL AMOUNT ORIGINAL CLAIMS HET AMOUNT ADJUSTMENTS AMOUNT VOIDS AMOUNT VOIDS ADJUSTS Version 2010 01 Exhibit 3 5 1 MANAGEMENT INFORMATION amp YSTEM MEDICAL ASSISTANCE TITLE PROGRAM REMITTANCE STATEMENT DATE OF TON SERVICE CODE UNITS CHARGED 07205 000012112 3 2 05 25 10 2810 10 000 187 81 07206 0131 13 3 1 ON 25 10 2810 5 000 84 38 212 19 NUMBER CLAIMS 0 00 NUMBER OF CLAIMS 0 00 NUMBER OF CLAIMS 0 00 NUMBER OF CLAIMS Fa
10. 50 15090 ADJT 1 999935 EXAMPLE XXB7554X 07205 000465477 0 05 0510 2810 800 30020 30020 PAD ORIGINAL CLAIM PAID 05 24 2010 PREVIOUSLY PENDED CLAIM NEW TOTAL AMOUNT ORIGINAL CLAIMS PAID 2025 41 NUMBER OF CLAIMS B NET AMOUNT ADJUSTMENTS PAID 49 30 NUMBER OF CLAIMS 1 NET AMOUNT VOIDS PAID 0 00 NUMBER OF CLAIMS 0 NET AMOUNT VOIDS ADJUSTS 149 30 NUMBER OF CLAIMS i HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 32 of 46 REMITTANCE ADVICE TO CITY HOME CARE 111 MAIN STREET ANYTOWN NEW YORK 11111 OFFICE ACCOUNT CLIENT CLIEMT NUMBER ID 1 001234 DOE XX12345X CPIC1 00887 6 SAMPLE XX23456X TOTAL AMOUNT ORIGINAL CLAIMS AMOUNT ADJUSTMENTS AMOUNT VOIDS NET AMOUNT VOIDS ADJUSTS REMITTANCE TOTALS HOME HEALTH VOIDS ADJUSTS TOTAL PENDS TOTAL PAID TOTAL DENIED NET TOTAL PAID MEMBER ID 00111234 VOIDS ADJUSTS TOTAL PENDS TOTAL PAID TOTAL DENY MET TOTAL PAID Version 2010 01 Exhibit 3 5 3 MANAGEMENT INFORMATION SYSTEM MEDICAL ASSISTANCE TITLE ALA PROGRAM OF 20 4 1 12 3 2 07205 000445113 3 1 DATE SERVICE 05 25 10 RATE CODE 2810 2810 UNITS 8 000 5 000 CHARGED 300 20 188 41 488 61 0 00 0 00 0 00 NUMBER OF CLAIMS NUMBER OF CLAIMS 0 NUMBER CLAIMS 0 NUMBER OF CLAIMS 0 0 00 0 00 0 00
11. 890 MA N A ME INFORMATION SYSTEM 00111234123456 7890 2010 05 31 CITY HOME CARE 111 MAIN STREET NY 11111 CITY HOME CARE 51877 11 PAYMENT IN THE ABOVE AMOUNT WILL DEPOSITED VIA ELECTRONICFUNDS TRANSFER HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 25 of 46 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 the 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 HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 26 of 46 REMITTANCE ADVICE 3 3 Section One Summout No Payment summout is produced when the provider has no positive total payment for the cycle and therefore there is disbursement of moneys Exhibit 3 3 1 TO CITY HOME CARE DATE 05 31 2010 DO IC A REMITTANCE NO 07080800001 D PROV ID 00111234 1234567890 MANAGEMENT INFORMATION SYSTEM NO PAYMENT WILL BE RECEIVED THIS CYCLE SEE REMITTANCE FOR DETAILS CITY HOME CARE 111 MAIN ST 11111 HOME HEALTH SERVICES Versi
12. 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 Providers HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 5 of 46 CLAIMS SUBMISSION 2 2 Paper Claims Home Health 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 Home Health UB 04 claim form see Appendix A 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 ETIN 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 1 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 im
13. LE ON DATE OF SERVICE 00244 PANOT FILE HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 43 of 46 APPENDIX CLAIM SAMPLES APPENDIX A CLAIM SAMPLES The eMedNY Billing Guideline Appendix A Claim Samples contains images of claims with sample data HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 44 of 46 APPENDIX CLAIM SAMPLES Home Health UB 04 Sample Claim APPROVED OMB NO 0938 0279 City Home Care ______ AB1234567 A4TYPE OF BILL T1 Main Street _ 2 TaROUG 04012007 04302007 5 PATIENTNANE TPATIENTADDRESS 5 pel SMITH WILLIAM peg ADMISSION 5 DHR ou 29 ACDT snme goats dim teme s sc EET ana nasa 3 aspis OCCUR 59 0 p A CODE FROM THROUGH CODE FROM THROUGH UB 04 VALUE CODES 41 VALUE CODES AMOUNT CODE AMOUNT 00 00 42 REV CD 43 DESCRIPTION 44 HCPCS RATE HIPPS CODE 180 00 04022007 4 40 00 2 04062007 4 40 00 04092007 6 60 00 4 04132007 4 40 00 5 5 5 8 8 10 10 11 12 13 14 19 15 2 10 1 19 19 20 29 21 21 22 ______ ___ TOTALS wy uem 23 Blue Cross B Medicaid 60 IN
14. OTE THAT EFT DOES WAIVE THE TWO WEEK LAG FOR MEDICAID DISBURSEMENTS TO ENROLL IM EFT PROVIDERS MUST COMPLETE AN EFT ENROLLMENT FORM THAT CANBE FOUND AT WWW ORG CLICK ON PROVIDER ENROLLMENT FORMS WHICH BE FOUND IM THE FEATURED LINKS SECTION DETAILED INSTRUCTIONS WILL ALSO BE FOUND THERE AFTER SENDING THE EFT ENROLLMENT FORM TO CSC PLEASE ALLOW A MINIMUM TIME OF SIA TO EIGHT WEEKS FOR PROCESSING DURING THIS PERIOD OF TIME YOU SHOULD REVIEW YOUR BANK STATEMENTS AND LOOK FOR AN EFT TRANSACTION IM THE AMOUNT OF 0 07 WHICH CSC WILL SUBMIT AS amp TEST YOUR FIRST REAL EFT TRANSACTIOM WILL TAKE PLACE APPROXIMATELY FOUR TO FIVE WEEKS LATER IF YOU HAVE ANY QUESTIONS ABOUT THE EFT PROCESS PLEASE CALL THE EMEDN CALL CENTER AT 1 800 343 9000 NOTICE THIS COMMUNICATION ANY ATTACHMENTS MAY CONTAIN INFORMATION THAT 15 PRIVILEGED AND CONFIDENTIAL UNDER STATE FEDERAL LAW AND 15 INTENDED ONLY FOR THE USE OF THE SPECIFIC INDIVIDUAL S WHOM IT IS ADDRESSED THIS INFORMATION MAY ONLY USED OR DISCLOSED IN ACCORDANCE WITH LAW AND YOU MAY BE SUBJECT PENALTIES UNDER LAW FOR IMPROPER USE OR FURTHER DISCLOSURE OF INFORMATION IM THIS COMMUNICATION AND ANY ATTACHMENTS IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR PLEASE IMMEDIATELY NOTIFY NYHIPPADESK CSC COM OR CALL 1 800 541 2831 PROVIDERS WHO DO NOT HAVE ACCESS E MAIL SHOULD CONTACT 1 800 343 9000 HOME HEALTH SERVICES Version 2010 01 5 3
15. SURED SUNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO None AB12345C 64 DOCUMENT CONTROL NUMBER 65 EMPLOYERNAME p DA CODE M mp DX CODE ECI je la mo wi fow UELLE x 58 INSURED S NAME gt 80 REMARKS sr noom 1209213257 THE CERTIFICATIONS ON THE REVERSE APPLY BL LAND ARE VADE PART HEREOF 48 34 5 1452 OME APPROVAL PENDING NUE Vo HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 45 of 46 EMEDNY INFORMATION eMedNY is the name of the electronic New York State Medicaid system The 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 HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 46 of 46
16. aging output All information should be typed or printed Alpha characters letters should be capitalized Numbers should 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 felele 6 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 HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 6 of 46 _ CLAIMS SUBMISSION Exhibit 2 2 1 3 Intended Interpreted As lwointerpreted 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 Do 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
17. ained within the billing period FROM THROUGH in Form Locator 6 Serv Units Form Locator 46 If billing for more than one unit of service enter the number of units on the same line where a Revenue Code other than Revenue Code 0001 was entered in Form Locator 42 For determining the number of units follow the guidelines below HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 17 of 46 SUBMISSION Hour based Rate If the rate is based on one hour service enter the number of hours that reflect the total of long term home health time being claimed The service units must be reported as full units only Partial hours of service must be rounded to the nearest whole hour In situations where the total amount of service rendered is less than 30 minutes one 1 hour of service may be claimed For example 4 units would be used for services rendered in 3 hours and 30 minutes 3 units would be used used for services rendered in 3 hours and 25 minutes 1 unit would be used for services rendered in 15 minutes Total Charges Form Locator 47 Enter the total amount charged for the service s rendered on the lines corresponding to Revenue Code 0001 in Form Locator 42 total charges for all lines billed and for any other Revenue Code individual charges for that one line 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 11 for an exa
18. alth service claims Possibile Disability 5 If applicable enter Condition Code A5 to indicate that the patient s condition appeared to be of a disabling nature Otherwise leave these fields blank Occurrence Code Date Form Locators 31 34 NYS Medicaid uses Occurrence Codes to report Accident Code This field has two components Code and Date both are required when applicable Code If applicable enter the appropriate Accident Code to indicate whether the service rendered to the patient was for a condition resulting from an accident or crime Select the code from the UB 04 Manual Form Locators 31 34 Accident Related Codes HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 12 of 46 CLAIMS SUBMISSION Date If an entry was made under Code enter the date when the accident occurred in the format MMDDYY Value Codes Form Locators 39 41 NYS Medicaid uses Value Codes to report the following information Locator Code required see note for conditions Rate Code required Medicare Information only if applicable Other Insurance Payment only if applicable e eee Patient Participation Spend down only if applicable Value Codes have two components Code and Amount The Code component is used to indicate the type 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 lea
19. ance 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 HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 42 of 46 REMITTANCE ADVICE 3 7 Section Five Edit Error Description The last section of the Remittance 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 DATE att p P 4 DATE 05 21 2010 CYCLE 1710 s MAM PE CHEY PE Fd T IR TA ors MEDICAL ASSISTANCE TITLE XIX PROGRAM ETIN TO CITY HOME CARE REMITTANCE STATEMENT OME HEALT ANYTOWNM NEW YORK 11111 PROV ID G0111204 12234567890 REMITTANCE O7 020500001 THE FOLLOWING 15 DESCRIPTION OF THE EDIT REASON CODES THAT APPEAR ON THE CLAIMS FOR THIS REMITTANCE 00131 THIRD PARTY INDICATED OTHER INSURANCE BLANK 00142 RECIPIENT TEAR BIRTH DIFFERS FROM FILE 00162 RECIPIENTINELIGIB
20. ances where an order or referral was made by a facility the ID of the practitioner at the facility must be used When providing services to a patient who is restricted to a primary physician or facility the NPI of the patient s primary physician must be entered in this field The ID of the facility cannot be used 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 On the line below the ID number enter the last name and first name of the provider See the example in Exhibit 2 4 2 13 Exhibit 2 4 2 13 The ordering referring provider is John Smith who is enrolled in Medicaid with an NPI of 1234567890 LAST SMITH FIRST JOHN HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 21 of 46 REMITTANCE ADVICE 3 Explanation of Paper Remittance Advice Sections This Section present a sample of each section of the remittance advice for Home Health 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 li
21. ating accounts when there is a question on patient identification HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 9 of 46 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 3 Home Health as the first digit of this field as seen in Exhibit 2 4 2 1 The source of this code is the UB 04 Manual Form Locator 4 Type of Facility category Exhibit 2 4 2 1 Bill Classification Enter the value 4 Other as the second digit of this field as in Exhibit 2 4 2 2 The source of this code is the UB 04 Manual Form Locator 4 Bill Classification Except Clinics and Special Facilities category Exhibit 2 4 2 2 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 3 Exhibit 2 4 2 3 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 4 HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 10 o
22. cial 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 PAGE 07 DICAID DATE osamo CYCLE 1710 CARE MEDICAL ASSISTANCE TITLE XIX PROGRAM ETIN 11 MAIN STREET FINANCIAL TRANSACTIONS ANYTOWN NEW YORK 11111 REMITTANCE STATEMENT PROV ID 00111234 1234567890 REMITTANCE NO 07080500001 FINANCIAL FISCAL FCN TRANS TYPE DATE AMOUNT 200r 0300023554 T XXX RECOUPMENT REASON DESCRIPTION 05 09 10 55 55 NET FINANCIAL AMOUNT 55 55 NUMBER OF FINANCIAL TRANSACTIONS HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 39 of 46 REMITTANCE ADVICE 3 6 1 1 Explanation of Financial Transactions Columns FCN The Financial Control Number FCN is a unique identifier assigned to 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 paym
23. d 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 HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 37 of 46 REMITTANCE ADVICE 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 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 eec cc 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 by Adjustments voids combined Pends Paid Deny eeee Net total paid entire remittance HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 38 of 46 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 Finan
24. ders General Billing Guideline Information section available at www emedny org by clicking on the link to the webpage as follows Information for All Providers 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 birth date must be in the format MMDDYYYY See the example in Exhibit 2 4 2 6 that follows HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 11 of 46 _ CLAIMS SUBMISSION Exhibit 2 4 2 6 Sex Form Locator 11 Enter for male or F for female to indicate the patient s sex This information may be obtained from the Client s Patient s Common Benefit ID Card 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 NYS Medicaid uses Condition Codes to indicate the following EPSDT CTHP Family Planning Possible Disability eee Abortion Sterilization NOTE EPSDT CTHP Family Planning and Abortion Sterilization do not apply to Home He
25. dvice 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 HOME HEALTH PROV ID This field will contain the Medicaid Provider ID and the Remittance Number 3 5 2 Explanation of Claim Detail Columns Office Account Number Ifa Patient Office Account Number was entered in the claim form that number up to 20 characters will appear under this column Client Name This column indicates the last name of the patient 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 Client ID The patient s Medicaid ID number appears under this column TCN The TCN is a unique identifier assigned to each claim that is processed If multiple claim lines are submitted on the same claim form all the lines are assigned the same TCN HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 35 of 46 ADVICE Date of Service The first date of service From date entered in the claim appears under this column If a date different from the From date was entered in the Through date box that date is not returned in the Remittance Advice Rate Code The four digit rate code that was entered in the claim form appears under this column Units The total number of units of service
26. ent 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 HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 40 of 46 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 DICAID MAM AGL ME MT lI FOAM ATION T E Fi MEDICAL ASSISTANCE TITLE AIA PROGRAM REMITTANCE STATEMENT TO CITY HOME CARE 111 STREET ANYTOWN NEW YORK 11111 REASON CODE DESCRIPTION ORIG BAL CURR BAL RECOUP AMT TOTAL AMOUNT DUE THE STATE X5 HOME HEALTH SERVICES Version 2010 01 Page 41 of 46 FAGE 05 DATE 05 31 10 CYCLE 1710 ETIN ACCOUNTS RECEIVABLE PROV ID 0011123412456 7890 REMITTANCE NO OF 020000007 5 31 2010 REMITTANCE ADVICE 3 6 2 1 Explanation of Accounts Receivable Columns provider has negative balances of different types or negative balances created at different times each negative bal
27. f 46 CLAIMS SUBMISSION Exhibit 2 4 2 4 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 5 Exhibit 2 4 2 5 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 the last service date in the THROUGH box The FROM THROUGH dates must be in the same calendar month Instructions for billing multiple dates of service are provided below in Form Locators 42 47 Dates must be entered in the format MMDDYYYY NOTES 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 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 Provi
28. for the specific claim appears under this column The units are indicated with three 3 decimal positions Since Home Health must only report whole units of service the decimal positions will always be 000 For example 3 units will be indicated as 3 000 Charged The total charges entered in the claim form appear under this column Paid If the claim was approved the amount paid appears under this column 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 eee Information entered in the claim form is invalid or logically inconsistent Approved Claims Approved claims will be identified by the statuses PA D ADJT adjustment or VO D Paid Claims The status PAID refers to original claims that have been approved HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 36 of 46 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 tra
29. ions ccccccccsssssseeecceeeseessseecccceeseesseeececeeeuaeaesececeeeeauenseeeceeeseauenseeeeseesuaggeeeeeeeeas 28 3 4 Section TWO T 29 3 4 1 Provider Notification Field Descriptions ieabeaesanestaseeds 30 3 5 SECTION Whee u 31 3 5 1 Claim Detail Page Field r 35 3 5 2 Explanation of Claim Detail r 35 3 5 3 Subtotals Totals Grand Totals ccceccccsseccccseccccccccceccceccucececauccecnscececaucececauccecaacececausececaccecaucececaceeecauscecasececaueeeenausss 38 3 6 Section Four Financial Transactions and Accounts Receivable 39 3 6 1 Financial s ____________________________ _____ 0 39 Orco RR UU t m 41 3 7 Section Five Edit Error D s erlBtl RRuuuuuuu ______________ ___4_ _ 43 Appendix A Claim u uy 44 HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 2 of 46 _ CLAIMS SUBMISSION For eMedNY Billing Guideline questions please contact the eMedNY Call Center 1 800 343 9000 HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 3 of 46 ees PURPOSE STATEMENT 1 Purpo
30. mple Exhibit 2 4 2 11 42 m GD 43 DESCRIPTION 4 HOPS RATE HIPPS COCE 45 SERI DATE 45 SERI UNITS 4 TOTALOHARGES 49 NON COWEFED CHARGES 03012002 30272007 If billing for multiple units the total charges should equal the number of units entered in Form Locator 46 multiplied by the rate amount If no units were reported in Form Locator 46 the total charges should equal the rate amount Payer Name Form Locator 50 A B C This field identifies the payer s responsible for the claim payment The field lines A B and C are devised to indicate primary A secondary B and tertiary C responsibility for 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 with the following instructions Direct Medicaid Claim If Medicaid is the only payer enter the word Medicaid on line A of this field Leave lines B and C blank HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 18 of 46 CLAIMS SUBMISSION Medicare Medicaid Claim If the patient has Medicare coverage Enter the word Medicare on line A of this field Enter the word Medicaid on line B of this field Leave line C blank Commercial Insurance Medicaid Claim If the patient has insurance coverage other than Medicare Enter the name of the Insurance Carrier
31. n 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 Voids cause the cancellation of the original claim history records and payment Untitled Principal Diagnosis Code Form Locator 67 Using the nternational Classification of Diseases Ninth Edition Clinical Modification ICD 9 CM coding system enter the appropriate code that describes the main condition or symptom of the patient as indicated in the service order form Only designated OMH diagnosis codes will be accepted The ICD 9 CM code must be entered exactly as it is listed in the manual See the example in Exhibit 2 4 2 12 The remaining Form Locators labeled A Q may be used to indicate secondary diagnosis information Exhibit 2 4 2 12 NOTE Three digit and four digit diagnosis codes will be accepted only when the category has no subcategories HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 20 of 46 CLAIMS SUBMISSION Other Form Locator 78 NYS Medicaid uses this field to report the Ordering Referring Provider Enter the NPI of the provider ordering the services A facility ID cannot be used for the referring ordering provider In those inst
32. nk 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 Financial Transactions recoupments Accounts Receivable cumulative financial information Section Five Edit Error Description HOME HEALTH SERVICES Version 2010 01 Page 22 of 46 5 31 2010 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 Exhibit 3 1 1 DICAID MAM NT INFORMATION TO CITY HOME CARE DATE 2010 05 31 REMITTANCE NO 07080600001 PROV ID 00111234 1234567890 00111234 1234567890 2010 05 31 CITY HOME CARE 111 MAIN ST ANYTOWN NY 11111 YOUR CHECK IS BELOW TO DETACH TEAR ALONG PERFORATED DASHED LINE 2010 05 31 07080600001 00111234 1234567890 8 CITY HOME CARE 111 ST ANYTOWN NY 11111 DICAID HAA EOC T INFORMATION MEDICAL ASSISTANCE TITLE XIX PROGRAM CHECKS DRAWN
33. nk 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 Medicaid 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 Home Health 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 loc
34. nsaction 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 indicates 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 approve
35. ntained in the patient s billing record Zeroes must also be entered in this field if any of the following situations apply Priorto 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 HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 15 of 46 C SUBMISSION 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 p
36. ol 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 assigned to the claim to be adjusted or voided The 15 the claim identifier and 15 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 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 informatio
37. on 2010 01 5 31 2010 Page 27 of 46 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 HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 28 of 46 REMITTANCE ADVICE 3 4 Section Two Provider Notification This section is used to communicate important messages to providers Exhibit 3 4 1 PAGE 01 DICAID DATE 05 31 40 CYCLE 1710 EYETEM MEDICAL ASSISTANCE TITLE XIX PROGRAM TO HOME CARE REMITTANCE STATEMENT ETIN 111 STREET PROVIDER NOTIFICATION ANYTOWN NEW YORK 11111 PROVID 00111234 1234567890 REMITTANCE 07080600004 REMITTANCE ADVICE MESSAGE TEXT ELECTRONIC FUNDS TRANSFER EFT FOR PROVIDER PAYMENTS IS NOW AVAILABLE PROVIDERS WHO ENROLL IM EFT WILL HAVE THEIR MEDICAID PAYMENTS DIRECTLY DEPOSITED INTO THEIR CHECKING OR SAVINGS ACCOUNT THEEFT TRANSACTIONS WILL BE INITIATED ON WEDNESDAYS AND DUE NORMAL BANKING PROCEDURES THE TRANSFERRED FUNDS NOT BECOME AVAILABLE IN THE PROVIDER S CHOSEN ACCOUNT FOR UP TO 48 HOURS AFTER TRANSFER PLEASE CONTACT YOUR BANKING IMSTITUTIOM REGARDING THE AVAILABILITY OF FUNDS PLEASE N
38. or to indicate that the Medicare Payment is entered under Amount NOTE The line A or B assigned to Medicare in Form Locator 50 determines the choice of codes AX or BX Value Amount Enter the corresponding amount for each value code entered Enter the amount that Medicare actually paid for the service If Medicare denied payment or if the provider knows that the service would not be covered by Medicare or has received a previous denial of payment for the same service enter 0 00 Proof of denial of payment must be maintained in the patient s billing record 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 Value Code If applicable code 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 of payment must be mai
39. 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 Do not write or use staples the bar code area The address for submitting claim forms is COMPUTER SCIENCES CORPORATION P O Box 4601 Rensselaer NY 12144 4601 HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 7 of 46 CLAIMS SUBMISSION 2 3 UB 04 Claim Form To view a sample Home Health 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
40. 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 8 illustrates a correct rate code entry Exhibit 2 4 2 8 39 VALUE CODES CODE AMOUNT Medicare Information See Value Codes Below If the patient is also a Medicare beneficiary it is the responsibility of the provider to determine whether the service being billed for is covered by the patient s Medicare coverage 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 Medicare as Medicaid is always the payer of last resort HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 14 of 46 CLAIMS SUBMISSION Value Code Ifapplicable enter the appropriate code from the UB 04 manual Form Locator 39 41 to indicate that more of the following items is entered under Amount Medicare Deductible 1 Medicare Co insurance 2 B2 Medicare Co payment A7or B7 Enter code
41. rovider for the services The LDSS can direct the insurance 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 9 illustrates a correct Other Insurance Payment entry Exhibit 2 4 2 9 39 VALUE CODES CODE AMOUNT fe on Patient Participation Spend Down Value Code 31 Some patients of the Home Health services do not become eligible for Medicaid until they pay an overage or monthly amount spend down toward the cost of their medical care Value Code If applicable enter Code 31 to indicate that the patient s spend down participation is entered under Amount Value Amount Enter the spend down amount paid by the patient The example in Exhibit 2 4 2 10 illus
42. se 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 Home Health 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 Providers General Billing Guideline Information available at www emedny org by clicking on the link to the webpage as follows Information for Providers HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 4 of 46 CLAIMS SUBMISSION 2 Claims Submission Home Health providers can submit their claims to NYS Medicaid in electronic or paper formats Providers are 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
43. trates a correct Patient Participation entry HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 16 of 46 CLAIMS SUBMISSION Exhibit 2 4 2 10 39 VALUE CODES CODE AMOUNT wm Rev Cd Revenue Code Form Locator 42 Revenue Codes identify specific accommodations ancillary services or billing calculations NYS Medicaid uses Revenue Codes to report the following information Total Amount Charged Units Total Amount Charged Use Revenue Code 0001 to indicate that total charges for the services being claimed in the form are entered in Form Locator 47 Units Use an appropriate Revenue Code from the UB 04 manual to indicate that the units of service are entered in Form Locator 46 If billing for multiple dates of service a revenue code must be entered on each line that corresponds to Form Locator 45 Serv Date and 46 Serv Units NOTE If the number of service lines dates of service exceed the number of lines that can be accommodated on a single UB 04 form another claim form must be entirely completed Medicaid cannot process additional claim lines without all the required information Each claim form will be processed as a unique claim document and must contain only one Total Charges 0001 Revenue Code Multi paged documents cannot be accepted either Serv Date Form Locator 45 Enter the service date corresponding to each iteration of a revenue code other than 0001 The dates entered here must be cont
44. ve 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 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 7 illustrates a correct Locator Code entry HOME HEALTH SERVICES Version 2010 01 5 31 2010 Page 13 of 46 CLAIMS SUBMISSION Exhibit 2 4 2 7 39 VALUE CODES CODE AMOUNT 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 refer to Information for All Providers Inquiry section located at www emedny org by clicking on the link to the webpage as follows Home Health Manual Rate Code Value Code 24 Rates are established by the Department of Health and

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