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eMedNY Subsystem User Manual

1. 36 3 2 1 EFT Notification Page Field 37 3 3 Section ONG S uminout No 38 3 3 1 Summout No Payment Field Descriptions 39 3 4 uuu u u u uuu 40 3 4 1 Provider Notification Field Descriptions 41 3 5 Section Maree Claim Detail u uuu uu uu 42 3 5 1 Claim Detail Page Field r 46 3 5 2 Explanation of Claim Detail Columns a 46 3 5 3 Subtotals Totals Grand Totals cccceccccsseccccseccccssccccscceccucccececcccnscececaucececaccecnueececausececsececuaeececaeesecausceeuucececaueeeenanecs 49 3 6 Section Four Financial Transactions and Accounts Receivable 50 3 6 1 Financial Transactions P 51 20 7 use laud sec SNL OE C I ot 53 3 7 Section FIVE Edit Error DeSCHHIDUIOD u uu neus X usa dor UH Ex esas uot 55 Appendix 8 TIRES lE Suisse 56 NURSING SERVICES Version 2010 01 5 31 2010 Page 2 of 61 CLAIMS SUBMIS
2. Z3 PRIOR are PES PPPA PEPREFEN CHARGE 25 CERTIFICATION 20 ACCEPT BEGIGBUENT IJ CERTIFY THAT THE STATEMENTS ON THE APPLY TO THE BILL ANDARE MADE A PART HEREOF 31 EUFLO TERIDENTIFLCAT ION N UREEFY James Strong SOCIAL SECURITY M AER SIGNATURE OF FHS GAN OR ELIPRLLER 258 PAPAR NURSING SERVICES Version 2010 01 Page 11 of 61 CLAIMS SUBMISSION ORIGINAL CLAIM REFERENCE NUMBER 4 PATRNTS ACARS Zn Se Dp Coe amp IMGUREDFS SEK 5 B MEDICARE NLIUEER SE PATIENTS TELEPHONE MESS E INSURANOS EER BC PBATENTIREPLOTEH CDCLCUBATION OH SCRIOOL T PATIENFS RELATIONSHIP TO ASU amp IMRE EXNFLOVER OR OOGOUPRTIUN P OTHER HEALTH INSURANCE COVERAGE Grier rara ci Pei icu T WAS COMO TOM RELATED URED ADDRESS Sit Code BL HIES D TO WATS mam ma 112 819111213 bua pd PPW w hk Dod 1 eis us Jos n2 sinna ii oo h o H PHYSICA OF SUPPUERS BSDDPREES ZIP CODE James Strong R N 312 Main Street Anytown New York 11111 5 31 2010 CLAIMS SUBMISSION Exhibit 2 4 2 1 2 MEDICAL ASSISTANCE HEALTH INSURANCE mtn CLAIM FORM TITLE XIX PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION I BATA T 3 MANG Arr meiir lie JANE SMITH BATTS ACARS Zw Cu Dp Cras PREIS gt
3. Ws Ses VEO CARE MEE PATIEM ETHEPHUMEMUMEER PRIVATE PELRA EHNE L 1 EC PATIENT S OCCUPATION OF SCRIOOL T PATIENTS RELATIONSHIP TOLNSLIRED OTHER HEALTH NAURAN S COVER AGE Erisr rara ci Poitier ma CH RELATED TI HL MEDEEZKE BLUES Siam by Siete Zn Dade Pur farm src cera arc Peier Prrsig ranr EIU EMPLOYMENT Waly JO OSes y dS LON OO DENT t a E PATENT HAD OR SMLARS PTO gt DD 11 wow DD 1 NAME OF REF ERIE HS GAN OF OTHER SOURCE Peter cau 21 NATIONAL ORG CODE 21 OF WHERE SERVICES RENDEPRED Ur aar fan hama orice ADORESS OF FROLITY 22 LABORATORY WORK FERPORMED TLE YOUR OFFICE 22 oo 9023 i i i foe eis ns os os so 05233 i baa oi nn alila B D Y Y foe snes foe 160000 E 25 CERTIFICATION IJ CERTIFY THAT THE STATEMENTS QN THE FENEFEE SIDE APPLY TO THES ALL XL EMFLOYERIDENTIFLCAT CIN BLEEP 3t PHYSIC SMS OR ADDRES ZIP CODE James Strong ER ES James Strong R N SIGNATLURE OF FHS GAN OR SUPHER 263 PROVIDER DENTIR GXT EN 312 Main Street Anytown New York 11111 WYFEEHXSEEEN RUD TELEPHONE HIES EXT NURSING SERVICES Versi
4. PRACTITIONER GRAND TOTALS PROV ID 00112233 1123456873 REMITTANCE 070205000006 Pa a 4 5 31 2010 _ REMITTANCE ADVICE 3 5 1 Claim Detail Page Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files 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 PRACTITIONER PROV ID This field will contain the Medicaid Provider ID and the NPI Remittance Number 3 5 2 Explanation of Claim Detail Columns LN NO Line Number This column indicates the line number of each claim as it appears on the claim form Office Account Number If a 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 Number The patient s Medicaid ID number appears under this column NURSING SERVICES Version 2010 01 5 31 2010 Page 46 of 61 essere tance ADVICE TCN The TCN is a unique identifier assigned to each claim that is processed If multiple clai
5. 11111 YOUR CHECK IS BELOW TO DETACH TEAR ALONG PERFORATED DASHED LINE REMITTANCE NUMBER 2010 05 31 PROVIDER 2010 05 511 070806000006 00112233 1 123456789 ABC NURSING SERVICES 100 BROADWAY DICAID ANYTOWN NY 11111 iad INFORMATION MEDICAL ASSISTANCE TITLE AIX PROGRAM CHECKS DRAWN ON John Smi th KET BANK STATE STREET ALH ANE NEV YORK 12207 NURSING SERVICES Version 2010 01 5 31 2010 Page 34 of 61 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 The 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 The 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 NURSING SERVICES Version 2010 01 5 31 2010 Page 35 of 61 REMITTANCE ADVICE 3 2 Section One EFT Notification For providers who have selected electronic funds transfer
6. Both boxes need to be filled as follows Box M The values entered in this box define the nature of the amounts entered in fields 24J and 24K Box M is used to indicate whether the patient is covered by Medicare and whether Medicare approved or denied payment Enter the appropriate numeric indicator from the following list No Medicare involvement Source Code Indicator 1 This code indicates that the patient does not have Medicare coverage Patient has Medicare Part B Medicare approved the service Source Code Indicator 2 This code indicates that the service is covered by Medicare and that Medicare approved the service and either made a payment or paid 0 00 due to a deductible Medicaid is responsible for reimbursing the Medicare deductible and or full or partial coinsurance Patient has Medicare Part B Medicare denied payment Source Code Indicator 3 This code indicates that Medicare denied payment or did not cover the service billed NURSING SERVICES Version 2010 01 5 31 2010 Page 23 of 61 r CLAIMS SUBMISSION Box O Box O is used to indicate whether the patient has insurance coverage other than Medicare or Medicaid or whether the patient is responsible for a pre determined amount of his her medical expenses The values entered in this box define the nature of the amount entered in field 24L Enter the appropriate indicator from the followinsg list No Other Insurance involvement Source
7. Page 25 of 61 Code 1 No Other Insurance involvement Field 24Lmustbe left blank Code 2 Other Insurance involved Field 24L should contain the amount paid by the ofherinsurance or 0 00 if the other insurance did notcover the service ordenied payment You must indicate the two digit insurance code Code 3 ndizstes patient s participation Field 24L should contain the patents participation amount If Other Insurance is slao involved entrthe inta peyments in 24L and amp nterthe two digit insurance coda Code 1 No Other Insurance involvement Field 24L mustba et blank Code 2 Other Insurance involved Field 24L should contain the amount paid by the otherinsurance or S0 000 the otherinsuraence did notcover the service ordenied payment You must indicate the two digit insurance code Code 3 Indicstes patient s participation Field 24L should contain the patient s participation amount It Other Insurance is also involved enter the total payment in 24L and enter the two digit insurance coda Code 1 Other Insurance involvement Field 24L must be left blank Code 2 Other Insurance involved Field 24L should contain the amount paid by the other insurance or 0 00 if the other insurance did notcover the service ordenied payment roumust indicate the two digit insurance code Code 3 Indicstes patient s participation Field 24L should contain the patient s participstion amount If
8. Psychiatric facility partial hospitalization Community mental health center Intermediate care facility mentally retarded Residential substance abuse treatment facility Psychiatric residential treatment center Non residential substance abuse treatment facility Mass immunization center Comprehensive inpatient rehabilitation facility Comprehensive outpatient rehabilitation facility End stage renal disease treatment facility state or local public health clinic Rural health clinic Independent laboratory Other unlisted facility NURSING SERVICES Page 59 of 61 5 31 2010 State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois lowa Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota State Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin American Territories American Samoa Canal Zone Guam Puerto Rico Trust Territories Virgin Islands NOTE Required only when reporting out of state license numbers NURSING SERVICES Version 2010 01 Page 60 of 61 APPENDIX CODE SETS 5 31 2010 EMEDNY INFORMATION eMedNY is the name of the electronic New York State Medi
9. the normal hourly fee should be multiplied by 1 5 and divided by 2 The resulting amount is the maximum that can be billed for each patient For Example RN services two Medicaid patients simultaneously procedure code 9124 TT The associated 20 00 fee should be adjusted as follows for each patient 20 x 1 5 divided by 2 15 NURSING SERVICES Version 2010 01 5 31 2010 Page 27 of 61 CLAIMS SUBMISSION Medicare Approved Amount When Box in field 23B has an entry value of 2 enter the Medicare Approved Amount in field 24 NOTES The entries in field 23B Payment Source Code determine the entries in field s 24J 24K and 241 Field 24J must never be left blank or contain zero If the Medicare Approved amount from the EOMB equals zero then Medicaid should not be billed itis the responsibility of the provider to determine whether Medicare covers the service being billed for 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 Unlabeled Field 24K This field is used to indicate the Medicare Paid Amount and must be completed if Box M in field 23B has an entry value of 20r 3 M 2 When billing for the Medicare deductible enter 0 00 in this field When billing for the Medicare coinsurance enter the Medicare Paid amount as the sum of the actual Medicare paid amount
10. CODE James Strong James Strong 263 PROVIDER DENTIR GXT CN N REER 312 Main Street Anytown CN York 11111 EXT NURSING SERVICES Version 2010 01 5 31 2010 Page 14 of 61 CLAIMS SUBMISSION Exhibit 2 4 2 1 4 MEDICAL ASSISTANCE HEALTH INSURANCE CLAIM FORM TITLE PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION T RSTn TS Arr medir JANE SMITH 4 155 Zu Cuy Simin Dp Cece EC PATRHTAREPLITEH OCCUPATION OF ZCEDCOL PIEBE LOTR Ee HEALTH SUS CO eee rarna hice Par Mare sr Score are Peicyer PURGE i carm lm e e d x m m e m m m SAME OR FAPT m EVERGENCY RELATED 21 OF FAOUT WHERE SERVICES PENDERED Ran Aone unas ADOREZZ OF FACULTY TA 811111213 0 2 1 6 0 8 me CERTE Y THAT THE STATEMENTE ON THe SIDE APPLY TO TH BILL AMD ARI MADE APART HEREOF James Strong SIGNATURE OF FPS GAM COR SUPPER 232 PRONIDER IDENTIFICATION HEER E T PATIENTS RELATIONSHIP TOINSURED M Y Y 31 EMIPLOWER DEAT AGA Oa ALE ORGINAL CLAIM REFERENCE NUMBER 3 INSLIRETFS nama miis hb iz nama FAMILY INCOME B MEDICARE NUOUEER PRIVATE TE INSLERETFS ADDRES rea Oby Siehe Zin Code tr DATE PA
11. Code Indicator 1 This code indicates that the patient does not have other insurance coverage Patient has Other Insurance coverage Source Code Indicator 2 This code indicates that the patient has other insurance regardless of the fact that the insurance carrier s paid or denied payment or that the service was covered or not by the other insurance When the value 2 is entered in Box O the two character code that identifies the other insurance carrier must be entered in the space following Box O If more than one insurance carrier is involved enter the code of the insurance carrier who paid the largest amount For the appropriate Other Insurance codes refer to Information for All Providers Third Party Information which be found at www emedny org by clicking on the link to the webpage as follows Private Duty Nursing Manual Patient Participation Source Code Indicator 3 This code indicates that the patient has incurred a pre determined amount of medical expenses which qualify him her to become eligible for Medicaid Exhibit 2 4 2 4 provides a full illustration of how to complete field 23B and the relationship between this field and fields 24J 24K and 24L NURSING SERVICES Version 2010 01 5 31 2010 Page 24 of 61 CLAIMS SUBMISSION 23B SOURCE CO 171 236 PAYM T SOURCE 4 2 23B PAYM T SOURCE CO 4 3 77 23B SOURCE CO 2 93 23B
12. Other Insurances is also involved enter the tote payments in 24L and enter the two digit insurance coda 5 31 2010 CLAIMS SUBMISSION Encounter Section Fields 24A to 240 The claim form can accommodate up to seven encounters with a single patient plus a block of encounters in a hospital setting if all the information in the Header Section of the claim Fields 1 23 applies to all the encounters Date of Service Field 24A Enter the date on which the service was rendered in the format MM DD YY If the nursing hours extend over a period of 2 days enter each date with the appropriate number of hours on separate lines NOTE A service date must be entered for each procedure code listed Place of Service Field 24B This two digit code indicates the type of location where the service was rendered Please note that place of service code is different from locator code Select the appropriate codes from Appendix B Code Sets NOTE If code 99 Other Unlisted Facility is entered in this field for any claim line the exact address where the procedure was performed must be entered in fields 21 and 21A Procedure Code Field 24C This code identifies the type of service that was rendered to the patient Enter the appropriate five character procedure code in this field NOTE Procedure codes definitions prior approval requirements if applicable fees etc are available at www emedny org by clicking on the link to the webpa
13. SUBSCRIBER INFORMATION PAID CLAIM r mim s Th m zm m ESTE TS Fi SERS CH up ung DATI z db dl 3 URES mew hh Ba nama i UTR ES NSLS CeCe a ee ra Par Fa mr aes secre Era gr Pree TENTE OSL SUTHOR ROG URE HYSICIAN 1 NURSING SERVICES Version 2010 01 5 31 2010 Page 57 of 61 APPENDIX CODE SETS APPENDIX B CODE SETS The eMedNY Billing Guideline Appendix B Code Sets contains a list of Place of Service codes as well as a list of accepted Unites States Standard Postal Abbreviations NURSING SERVICES Version 2010 01 5 31 2010 Page 58 of 61 APPENDIX CODE SETS Version 2010 01 Description School Homeless shelter Indian health service free standing facility Indian health service provider based facility Tribal 638 free standing facility Tribal 638 provider based facility Doctors office Home Assisted living facility Group home Mobile unit Urgent care facility Inpatient hospital Qutpatient hospital Emergency room hospital Ambulatory surgical center Birthing center Military treatment facility Skilled nursing facility Nursing facility Custodial care facility Hospice Ambulance land Ambulance air or water Independent clinic Federally qualified health center Inpatient psychiatric facility
14. and the Medicare deductible if any Box M 3 Enter 0 00 in this field to indicate that Medicare denied payment or did not cover the service If none of the above situations are applicable leave this field blank Unlabeled Field 24L This field must be completed when Box O in field 23B has an entry value of 2 or 3 When Box O has an entry value of 2 enter the other insurance payment in this field If more than one insurance carrier contributes to payment of the claim add the payment amounts and enter the total amount paid by all other insurance carriers in this field When Box O has an entry value of 3 enter the Patient Participation amount If the patient is covered by other insurance and the insurance carrier s paid for the service add the Other Insurance payment to the Patient Participation amount and enter the sum in this field If the other insurance carrier denied payment enter 0 00 in field 24L Proof of denial of 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 Prior to billing the insurance company the provider knows that the service will not be covered because NURSING SERVICES Version 2010 01 5 31 2010 Page 28 of 61 _ CLAIMS SUBMISSION 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
15. of 61 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 FAGE 0 05 31 10 D ICAID CYCLE 1710 ABC NURSING SERVICES MANAGEMENT ETIN 100 BROADWAY ACCOUNTS RECEIVABLE ANYTOWN NEW YORK 11111 MEDICAL ASSISTANCE TITLE XIX PROGRAM PROV ID 00112233 1123456788 REMITTANCE STATEMENT REMITTANCE NO 070806000006 REASON CODE DESCRIFTION ORIG BAL CURR BAL RECOUP SX XXX XX TOTAL AMOUNT DUE THE STATE XXX XX NURSING SERVICES Version 2010 01 5 31 2010 Page 53 of 61 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
16. originally submitted and Exhibit 2 4 2 1 4 shows the claim as it appears after the adjustment has been made NURSING SERVICES Version 2010 01 5 31 2010 Page 13 of 61 CLAIMS SUBMISSION Exhibit 2 4 2 1 3 CLAIM FORM TITLE XIX PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION 1 NUR cci inl 1 24 3 MELIRETYS ama hia az namal MEDICAL ASSISTANCE HEALTH INSURANCE ae ee E JANE SMITH ESTRNTS SCORES LUE Cu aue Do Coote OCCUPATION OF T RELATIONSHIP amp IMELIELFS EIPLOSER OR OCCUPRTION EL OTHER HEALTH INSURANCE COVERAGE roe rir il jTO H INSLIRELFS ADDRES zm Sipha Zip Code Par Marne arc cere arc Poieyer Prrsig ranir Wily JOTA y 1d LS LON a PATIENTS OR AUTHOR ED ars URE 16 FIRST CONSILTED TE AS FATEN EA EMERGENCY FCR CONDITION SAME OR AMLAR SME REATED 21 NATIONAL ORG Gone 21 OF WHERE SERVICES RENDEPRED Ur aar hama ADDRESS OF FACUTE 22 LABOGATOR WORK FERPORMED OUELE TOUR OFFICE 22 CODE 019 112 0 8 PLATE Pee vs 16 fore 12 819111213 _ CERTE THAT THE STATEMENTS ON THE RE EREE S NZ SPRL TO TH S BLL AND ARE SOE APART HEREOF 31 EMELGYERIDENTIRIGET ONN EER FHYSIGI EMS OF ADRESS ZF
17. payment add on Billing Instructions for the 30 add on payment In order to be reimbursed the 30 add on amount enter a Service Authorization SA Exception Code of 7 in this field otherwise leave this field blank County of Submittal Unnumbered Field Enter the name of the county wherein the claim form is signed The County may be left blank on y when the provider s address is within the county wherein the claim form is signed Date Signed Field 25E Enter the date on which the nurse or Agency authorized representative signed the claim form The date should be in the format MM DD YY NOTE In accordance with New York State regulations claims must be submitted within 90 days of the Date of Service unless acceptable circumstances for the delay can be documented For more information about billing claims over 90 days or two years from the Date of Service refer to Information for All Providers General Billing section which can be found at www emedny org by clicking on the link to the webpage as follows Private Duty Nursing Manual NURSING SERVICES Version 2010 01 5 31 2010 Page 31 of 61 CLAIMS SUBMISSION Physician s or Supplier s Name Address Zip Code Field 31 Enter the provider s name and correspondence address using the following rules for submitting the ZIP code Paper claim submissions Enter the 5 digit ZIP code or the ZIP plus four Electronic claim submissions Enter the 9 digit ZIP code The Locat
18. the document or record For example a document record containing a single service date procedure combination will be assigned a unique single TCN a document record containing five service date procedure combinations will be assigned a unique single TCN which will be shared by all the individual claim lines submitted under that document record 2 4 2 1 Adjustment An adjustment may be submitted to accomplish any of the following purposes To change information contained one or more claims submitted on a previously paid To cancel one more claim lines submitted on a previously paid except if the contained one single claim line or if all the claim lines contained in the TCN are to be voided NURSING SERVICES Version 2010 01 5 31 2010 Page 9 of 61 r CLAIMS SUBMISSION Adjustment to Change Information If an adjustment is submitted to correct information on one or more claim lines sharing the same follow the instructions below The Provider ID number the Group ID number and the Patient s Medicaid ID number must not be adjusted The adjustment must be submitted in a new claim form copy of the original form is unacceptable The adjustment must contain all claim lines originally submitted in the same document record all claim lines with the same TCN and all applicable fields must be completed with the necessary changes The adjustment will cause the correction of the adju
19. 08060005 ru JIN OSIPA FINANCIAL FISCAL REASON CODE TRANS TYPE DATE AMOUNT RECOUPMENT REASON DESCRIPTION 05 09 10 BS MET FINANCIAL TRANSACTION AMOUNT 25 55 NUMBER OF FINANCIAL TRANSACTIONS XXX 3 6 1 1 Explanation of Financial Transactions Columns FCN This is a unique identifier assigned to each financial transaction NURSING SERVICES Version 2010 01 5 31 2010 Page 51 of 61 REMITTANCE ADVICE 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 NURSING SERVICES Version 2010 01 5 31 2010 Page 52
20. 10 01 5 31 2010 Page 16 of 61 CLAIMS SUBMISSION Exhibit 2 4 2 2 1 MEDICAL ASSISTANCE HEALTH INSURANCE ia CLAIM FORM TITLE XIX PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION L PATENT Ful ira miii le STE A 1 I 3 MELIRETYS Pie na ma diaz ROBERT JOHNSON A PATENTE CE Eau Dp 5 INS ye BI L y MEDICARENLIUEER PRIVATE NSLEZINCE NUUEER EC BATENTTREELOYEH CICCUBATION OH PATIEMPS ATEH HARE amp ENFLOVER OF OOGOUFRTION Pur Mare ari ceri arc Podge regime ira rarum liora Waly 3uooegwig dS LON IMELIRELFZ SI GMATURE 11 HES PATIENT BER HAD SANE OF ves x Ui ADORESS OA SISVETUSE NATIONAL ORG CODE 21 NAME OF FRAGILITY WHERE SEPN ICESS E Dither Ban hona oraria ADORESS OF FROLITE one IS i 233 OF MATURE CF LULES 23 PRIOR NIER CERTIFY THAT THE STATEMENTS FRERE APPLY TO THSHLL AND ARE MADE APART HEREOF EUFLOYERIDENTIR CHTIGONNLIUEER 3 PATO SAE OF AAE ZF Doce James Stron Se gers usce wass g James Strong R N EUBMNITUSECEFPREHOSCAMTREJERIOIER 263 PROVIDER DEN
21. DEL TOTAL AMOUNT ORIGINAL CLAIMS NET AMOUNT ADJUSTMENTS NET AMOUNT VOIDS MET AMOUNT VOIDS ADJUSTS Version 2010 01 XKX67ESQX m 562205 0T208 200033087T 90 206 000045667 04 07206 00005676 124 T206 00008T761 2 2 07206 000083767 2 2 FAID 120 00 FAID 40 00 S 0 L 4200 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NURSING SERVICES Page 43 of 61 m ie PROS ae 084170 5123 509 1790 000 PAID 0s 12 10 59123 10000 20 209 00 PAID 0514710 39123 10 000 20000 200 00 PAID 1510 89123 amp 000 16000 16000 5059 593 8 000 16000 16000 ADIT ORIGINAL CLAIM FAID 05 24 10 05 05 10 123 10 000 200 00 20000 ADT PREVIOUSLY PENDED CLAIM NEWFEND 5 31 2010 REMITTANCE ADVICE Exhibit 3 5 3 PAGE 04 HAN AGEMENT INFORMATION SYSTEM MEDICAL ASSISTANCE TITLE XIX PROGRAM ABC NURSING SERVICES REMITTANCE STATEMENT PRACTITIONER 100 BROADWAY PROV ID 00112233 1123455783 ANYTOWN NEW YORK 11111 REMITTANCE NO LN OFFICE ACCOUNT CLIENT CLIENT ID DATE OF PROC NO NUMBER NAME NUMBER SERVICE CODE UNITS CHARGED PAID STATUS ERRORS 01 CP112346 SAMPLE AX231455X QUTZ200 0QOU33457 2 0 01710 5912 8 000 160 00 000 PEND 00162 02 CP112347 EXAMPLE AXi14557X QO7206 000033458 0 0 05 14 10 5912 8 000 160 00 00 PEND 00162 027 GF444444 SPECIMEN XX45578X QU7206 00003560565 0 0 05 14 10 59123 8 000 160 00 000 PE
22. E SUBJECT TO PENALTIES UNDER 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 NYHIPPADESK CSC COM OR CALL 1 800 541 2831 PROVIDERS WHO DO NOT HAVE ACCESS E MAIL SHOULD CONTACT 1 800 343 9000 NURSING SERVICES Version 2010 01 5 31 2010 Page 40 of 61 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 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 Name of Section PROVIDER NOTIFICATION PROV ID This field will contain the Medicaid Provider ID and the NPI Remittance Number Center Message Text NURSING SERVICES Version 2010 01 5 31 2010 Page 41 of 61 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 TO ABC NURSING SERVICES 100 BROADWAY ANYTOWN NEW YORK 11111 LN OFFICE ACCOUNT CLIENT NO NUMBER NAME 01 CP112345 01 CP112346 SAMPLE 01 112347 EXAMPLE 27 CFPF444444 SPECIMEN TOTAL AMOUNT O
23. IA CATION NOMEER 312 Main Street Anytown New York 11111 251 FEE BEEN EFE EXT EXCP OME NURSING SERVICES Version 2010 01 5 31 2010 Page 17 of 61 CLAIMS SUBMISSION Exhibit 2 4 2 2 2 ORIGINAL CLAIM REFERENCE NUMBER MEDICAL ASSISTANCE HEALTH INSURANCE CLAIM FORM TITLE XIX PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION Arr mb irr ROBERT JOHNSON PATENTS ADCAESS Ze gg Shaw Dio Cooke MI Tz MEDICARE MER PRIWATE GRECE NO REGFPROCGITY MO EC FATEHTI EMPLOYER OCCUPATION OF SCHOOL PATIEMPS TCH NSU amp IMELIRELFZ EPLER OR OGCURATION D OTHER HEALTH IN SUR COVERAGE Erisr ra 14 2 22204 UL CONDITICR 1 11 INSLIEETES ADRES meet by Simba Jin Code Par Harm arc Scie Peicyer Prrsig ranra Waly atqve LON PATIENT S OF AUTHOR 220 SIGNASTLEBE T AAG PATENT HAD SAME OF SMLAR SP TOR DATES OF Peter pe DRUG CODE 21 OF WHERE SERVICES RENDERED T oher Puan hama anas ADDRESS OF FACRITE SERWDCEPROVDERNIME TE PROF TIFICATION NBER DieSEILITE 1116 0 010 111610 010 25 CERTIFICATION ACCEPT XEEXGNUENT TOTAL J CERTE THAT THE STATEMENTS OM THE REVEREE HOE PEL TD TH S SLL ANDARE WADE 4 FART HEREOF 31 EUPLOVERIDENTIRCATIONN MEER 3t PHYSIGI ENS
24. L IM EFT WILL HAVE THEIR MEDICAID PAYMENTS DIRECTLY DEPOSITED INTO THEIR CHECKING OR SAVINGS ACCOUNT THEEFT TRANSACTIONS WILL BE INITIATED ON WEDNESDAYS AND DUETO NORMAL BANKING PROCEDURES THE TRANSFERRED FUNDS MAY NOT BECOME AVAILABLE IN THE PROVIDER S CHOSEN ACCOUNT FOR UP TO 48 HOURS AFTER TRANSFER PLEASE CONTACT YOUR BANKING INSTITUTION REGARDING THE AVAILABILITY OF FUNDS PLEASE NOTE THAT EFT DOES NOT WAIVE THE TWO WEEK LAG FOR MEDICAID DISBURSEMENTS TO ENROLL IM EFT PROVIDERS MUST COMPLETE AN EFT ENROLLMENT FORM THAT CAN BE FOUND AT WWW EMEDNY ORG CLICK OM PROVIDER ENROLLMENT FORMS WHICH CAN 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 IN 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 ANY QUESTIONS ABOUT THE EFT PROCESS PLEASE CALL THE EMEDNY CALL CENTER AT 1 800 343 9000 NOTICE THIS COMMUNICATION AND ANY ATTACHMENTS MAY CONTAIN INFORMATION THAT Is PRIVILEGED AND CONFIDENTIAL UNDER STATE AND FEDERAL LAW AND IS INTENDED ONLY FOR THE USE THE SPECIFIC IMDIVIDUAL S TO WHOM IT IS ADDRESSED THIS INFORMATION MAY ONLY BE USED OR DISCLOSED IN ACCORDANCE WITH LAW AND YOU MAY B
25. ND 00142 01 456 STANDARD AXSOISSX OTDM 5 12 10 59123 8 000 160 00 000 PEND 00131 PREVIOUSLY PENDED CLAIM NEW PEND LE TOTAL AMOUNT ORIGINAL CLAIMS FEND 640 00 NUMBER OF CLAIMS NET AMOUNT ADJUSTMENTS PEND 0 00 NUMBER OF CLAIMS NET AMOUNT VOIDS PEND 0 00 NUMBER OF CLAIMS NET AMOUNT VOIDS ADJUSTS 0 00 NUMBER OF CLAIMS Ca C3 d REMITTANCE TOTALS PRACTITIONER VOIDS ADJUSTS 40 9 NUMBER OF CLAIMS TOTAL FENDS 640 00 NUMBER OF CLAIMS TOTAL PAID 720 00 NUMBER CLAIMS TOTAL DENIED 650 00 NUMBER OF CLAIMS NET TOTAL PAID 760 00 NUMBER OF CLAIMS MEMBER ID 00112233 VOIDS ADJUSTS 40 00 NUMBER OF CLAIMS TOTAL PENDS 640 00 NUMBER CLAIMS TOTAL PAID T20 00 NUMBER OF CLAIMS TOTAL DENIED 682 00 NUMBER CLAIMS NET TOTAL PAID 760 00 NUMBER OF CLAIMS oda gx NURSING SERVICES Version 2010 01 5 31 2010 Page 44 of 61 REMITTANCE ADVICE Exhibit 3 5 4 TO ABC NURSING SERVICES 100 BROADWAY REMITTANCE STATEMENT AN Y TOWN NEW YORK 11111 REMITTANCE TOTALS VOIDS ADJUSTS TOTAL PENDS TOTAL PAID TOTAL DENY NETTOTAL PAID Version 2010 01 GRAND TOTALS DICAID MANAGEMENT Ez W Sa T E MEDICAL ASSISTANCE TITLE ALA PROGRAM 40 00 640 00 720 00 680 00 760 00 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NURSING SERVICES Page 45 of 61 PAGE 05 DATE 05 31 10 CYCLE 1710
26. New York State Electronic Medicaid System 150002 Billing Guidelines 2 NURSING SERVICES Version 2010 01 5 31 2010 TT TABLE OF CONTENTS TABLE OF CONTENTS L PUPO SUA 4 2 Clamis EM M METRUM E EU MM 5 2 1 Flor oli OE Re 5 2 2 s S 6 2 2 1 General Instructions for Completing Paper Claims a 6 2 3 eMedNY 150002 Claim Form a 8 2 4 Nursing Services Billing 8 2 4 1 Instructions for the Submission of Medicare Crossover 00003 22 2 8 2 4 2 eMedNY 150002 Claim Form Field 9 3 Explanation of Paper Remittance Advice Sections nennen enne 33 3 1 34 31 1 Maedicaid Check St b Field 35 3 1 2 Medicaid Check Field 35 3 2 DECOM OME EFT eie
27. RIGINAL CLAIMS NET AMOUNT ADJUSTMENTS NET AMOUNT VOIDS NET AMOUNT VOIDS ADJUSTS Version 2010 01 MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT CLIENT ID NUMBER Ax 231455 XAH DETA Exhibit 3 5 1 HAN AGEMENT INFORMATION amp YSTEM DATE OF PROC SERVICE CODE UNITS Of206 000000227 20 0 011710 53123 8 000 07206 11334 0 02 O5 11 19 59123 8 000 Of206 000040353056 0 0 OU 13 10 59122 10 000 07206 000032456 0 0 VSD 10 53123 8 000 DENIED 682 90 NUMBER OF CLAIMS DENIED 0 00 NUMBER OF CLAIMS DENIED 0 00 NUMBER OF CLAIMS 0 00 NUMBER OF CLAIMS NURSING SERVICES Page 42 of 61 PAGE 02 DATE 05 21 2010 CYCLE 1710 ETIN PRACTITIONER PROV ID 00112233 1123455783 REMITTANCE O7 08050020005 CHARGED PAID STATUS ERRORS 160 00 0 00 DENY 00162 00244 160 00 0 00 DENY 00244 200 00 0 00 DENY 100162 160 00 0 00 DENY 00131 PREVIOUSLY PENDED CLAIM NEW FEND 5 31 2010 REMITTANCE ADVICE Exhibit 3 5 2 CDICAID MAN AOCME INFORMATION Gwi TEM MEDICAL ASSISTANCE TITLE XIX PROGRAM ABC NURSING SERVICES O0BROADWAY ANYTOWN NEW YORK 11111 LN OFFICEACCOUNT SLI ENT REMITTANCE STATEMENT CLIENT ID PAGE 03 DATE 05 31 4910 CYCLE 1710 RAC TITIONER PROV ID 00112233 1123546783 REMITTANCE NO 270506000006 NO NUMBER 01 CET DOE 02 CP222222 SAMPLE 01 cei EXAMPLE 01 SPECIMEN 01 CPTITTIT STANDARD 91 555555 MO
28. SION ADDendix B COUB GL MR EU 58 For eMedNY Billing Guideline questions please contact the eMedNY Call Center 1 800 343 9000 NURSING SERVICES Version 2010 01 5 31 2010 Page 3 of 61 ees su RP OSE 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 Nursing Services 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 NURSING SERVICES Version 2010 01 5 31 2010 Page 4 of 61 ExL Lt e LLIO CLAIMS SUBMISSION 2 Claims Submission Nursing Services 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 a 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 aske
29. SLEPT NENE X uelis nd aia James Strong R N SIGNATURE OF FHYSGAN ORSLPRURR 312 Main Street Anytown New York 11111 EXT 35 CASE D NURSING SERVICES Version 2010 01 5 31 2010 Page 18 of 61 SUBMISSION Patient s Name Field 1 Enter the patient s first name followed by the last name This information may be obtained from the Client s Patient s Common Benefit ID Card Date of Birth Field 2 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 as shown in Exhibit 2 4 2 1 Exhibit 2 4 2 1 DATE OF BIRTH Patient s Sex Field 5A Place an X in the appropriate box to indicate the patient s sex This information may be obtained from the Client s Patient s Common Benefit ID Card Medicaid Number Field 6A 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 NYS Medicaid and are composed of 8 characters in the format AANNNNNA where A alpha character and N numeric character as shown in Exhibit 2 4 2 2 Exhibit 2 4 2 2 Was Condition Related To Field 10 If applicable place an X in the appropriate box to indicate whether the service rendered to the patient was for condition resulting from an accident or a cr
30. SOURCE CO 2 236 PAYM T SOURCE CO 0 3 ss 23B PAYM T SOURCE CO Bit 236 PAYM T SOURCE CO 3 2 23B SOURCE CO 313 Version 2010 01 Exhibit 2 4 2 4 Code 1 Medicare involvement Field 24 1 should contain the amount charged and field 24h must be left blank Code 1 No Medicare involvement Field 24 should contain the amount charged and field 24K mustbe left blank lode 1 MoMedicareinvolvement Field 24 should contain the amount charged and field 24h mustbe left blank Code 2 Medicare Approved Service Field 24J should contain the Medicare Approved amountand field 24K shoud contain the Medicare payment amount Code 2 Medicare Approved Service Field 24 should contain the Medicare Approved amountand 24K shoud contain the Medicare payment amount Code 2 Medicare Approved Service Field 24J should containthe Medicare Approved amount and field 24K should contain the Medicare payment amount Code 3 Medicare denied payment or did not cover the service Field 24 should contain the amount charged and field 24K should contain 50 00 Code 3 Medicare denied payment or did not cover the service Field 241 should contain the amount charged and field 24K should contain 50 00 Code 3 Medicare denied payment or did not cover the service Field 241 should contsin the amount charged and field 24h should contain 0 00 NURSING SERVICES
31. TIENT RETURATO WORK NTIRCHTIONNUMEER 22 LAER ORE FERFOPIUETI OUTSIDE TIR OFFICE DENTIFICATIONMUUEER 31 PHYSICA OF SUPPLIERS MAME SDDREZS ZF James Strong 312 Main Street Anytown New York 11111 TELEPHONE HIER EXT NURSING SERVICES Version 2010 01 5 31 2010 Page 15 of 61 i CLAIMS SUBMISSION 2 4 2 2 Void A void is submitted to nullify a individual claim lines originally submitted on the same document record and sharing the same TCN When submitting a void please follow the instructions below The void must be submitted on a new claim form copy of the original form is unacceptable The void must contain all the claim lines to be cancelled and all applicable fields must be completed Voids cause the cancellation of the original TCN history records and payment Exhibit 2 4 2 2 1 and Exhibit 2 4 2 2 2 illustrate an example of a claim being voided TCN 0826011234567800 contained two claim lines which were paid on October 1 2008 Later the provider became aware that the patient had other insurance coverage The other insurance was billed and the provider was paid in full for all the services Medicaid must be reimbursed by submitting a void for the two claim lines paid in the specific TCN Exhibit 2 4 2 2 1 shows the claim as it was originally submitted and Exhibit 2 4 2 2 2 shows the claim being submitted as voided NURSING SERVICES Version 20
32. 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 other insurance payment for same type of service This communication should be documented in the patient s billing record The provider bills the insurance company and receives a rejection because 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 to or uncooperative in submitting claims to the insurance company In these cases the LDSS must be notified prior to zero filling LDSS has subrogation rights enabling them to complete claim forms on behalf of uncooperative policyholders who do not pay the provider for the services The LDSS office 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 local social services office whenever he she encounters policyholders who are uncooperative in paying for covered services received by their dependents who are on Medicaid In other cases the provider will be instructed to zero fill the Other Insurance Payment
33. caid 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 NURSING SERVICES Version 2010 01 5 31 2010 Page 61 of 61
34. cate 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 lf 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 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 on the bar code area The address for submitting claim forms is COMPUTER SCIENCES CORPORATION P O Box 4601 Rensselaer NY 12144 4601 NURSING SERVICES Version 2010 01 5 31 2010 Page 7 of 61 i CLAIMS SUBMISSION 2 3 eMedNY 150002 Claim Form The 150002 form is a New York State Medicaid form that can be obtained through the financial contractor CSC To order the forms please contact the eMedNY call center at 1 800 343 9000 To view a sample Nursing Services eMedNY 150002 claim form see Appendix A The displayed claim form is a sample and the information it contains is f
35. d 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 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 NURSING SERVICES Version 2010 01 5 31 2010 Page 48 of 61 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 amp amp amp Original claims Adjustments Voids Adjustments voids combined Subtotals by provider type are provided at the end of the claim detail listing These subtotals are broken down by Adjustments voids combined Pends Paid Deny Net total paid for the specific service classification Totals by member ID are provided next to the subtotals for provider type For individual practitioners these totals are exactly the same as the subtotals by provider type F
36. d 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 Nursing Services providers who choose to submit their Medicaid claims electronically are required to use the HIPAA 837 Professional 837P transaction Direct billers should also refer to the sources listed below to comply with the NYS Medicaid requirements HIPAA 837P Implementation Guide IG explains the proper use of the 837P standards and program specifications This document is available at www wpc edi com hipaa NYS Medicaid 837P Companion Guide CG is a subset of the IG which provides specific instructions for the NYS Medicaid requirements for the 837P transaction This document is available at www emedny org by clicking on the link to the web page as follows eMedNY Companion Guides and Sample Files NYS Medicaid Technical Supplementary Companion Guide provides technical information needed to successfully
37. 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 the submitted ZIP 4 does not match information in the provider s Medicaid file 2 4 2 eMedNY 150002 Claim Form Field Instructions Header Section Fields 1 through 23B The information entered in the Header Section of the claim form fields 1 through 23B must apply to all claim lines entered in the Encounter Section of the form The following two unnumbered fields should only be used to adjust or void a paid claim Do not write in these fields when preparing an original claim form Adjustment Void Code Upper Right Corner of Form Leave this field blank when submitting an original claim or resubmission of a denied claim If submitting an adjustment replacement to a previously paid claim enter X or the value 7 in the A box f submitting a void to a previously paid claim enter X or the value 8 in the V box Original Claim Reference Number Upper Right Corner of Form Leave this field blank when submitting an original claim or resubmission of a denied claim If submitting an adjustment or a void enter the appropriate Transaction Control Number TCN in this field A TCN is a 16 digit identifier that is assigned to each claim document or electronic record regardless of the number of individual claim lines service date procedure combinations submitted in
38. ge as follows Private Duty Nursing Manual MOD Modifier Fields 24D 24E 24F and 24G Under certain circumstances the procedure code must be expanded by a two digit modifier to further explain or define the nature of the procedure If the Procedure Code requires the addition of modifiers enter one or more up to four modifiers in these fields Enter modifier TT to indicate individualized service provided to more than one patient in the same setting Only enter modifier U1 to indicate the Care at Home Waiver Program when resubmitting or adjusting claims for a date of service when no prior approval was required When a Prior Approval Number is entered in Field 23A Modifier U1 should not be entered on the claim Special Instructions for Claiming Medicare Deductible When billing for the Medicare deductible modifier U2 must be used in conjunction with the Procedure Code for which the deductible is applicable Do not enter the U2 modifier if billing for Medicare coinsurance NOTE Modifier values and their definitions are available under Procedure Codes and Fee Schedule at www emedny org by clicking on the link to the webpage as follows Private Duty Nursing Manual NURSING SERVICES Version 2010 01 5 31 2010 Page 26 of 61 CLAIMS SUBMISSION Diagnosis Code Field 24H Using the International Classification of Diseases Ninth Edition Clinical Modification ICD 9 CM coding system enter the appro
39. ime Select the boxes in accordance with the following Patient s Employment Use this box to indicate Worker s Compensation Leave this box blank if condition is related to patient s employment but not to Worker s Compensation NURSING SERVICES Version 2010 01 5 31 2010 Page 19 of 61 _ CLAIMS SUBMISSION Crime Victim Use this box to indicate that the condition treated was the result of an assault or crime Auto Accident Use this box to indicate Automobile No Fault Leave this box blank if condition is related to an auto accident other than no fault or if no fault benefits are exhausted Other Liability Use this box to indicate that the condition was related to an accident related injury of a different nature from those indicated above If the condition being treated is not related to any of these situations leave these boxes blank Emergency Related Field 16A Enter an X in the Yes box only when the condition being treated is related to an emergency the patient requires immediate intervention as a result of severe life threatening or potentially disabling condition otherwise leave this field blank Name of Referring Physician or Other Source Field 19 Enter the ordering provider s name in this field Address or Signature SHF Only Field 19A If the provider is a member of a Shared Health Facility and another Medicaid provider in the same Shared Health Facility ordered the services ob
40. 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 If none of the above situations are applicable leave this field blank NOTES tis the responsibility of the provider to determine whether the patient s Other Insurance carrier covers the service being billed for as Medicaid is always the payer of last resort Leave the last row of Fields 24H 24J 24K and 24L blank Consecutive Billing Section Fields 24M to 240 This section may be used for block billing consecutive visits within the SAME MONTH YEAR made to a patient in a hospital inpatient status Inpatient Hospital Visit From Through Dates Field 24M Leave this field blank NURSING SERVICES Version 2010 01 5 31 2010 Page 29 of 61 CLAIMS SUBMISSION Proc Code Procedure Code Field 24N Leave this field blank MOD Modifier Field 240 Leave this field blank Trailer Section Fields 25 through 34 The information entered in the Trailer Section of the claim form fields 25 through 34 must apply to all claim lines entered in the Encounter Section of the form Certification Signature of Physician or Su
41. ink to the webpage as follows Private Duty Nursing Manual NURSING SERVICES Version 2010 01 5 31 2010 Page 30 of 61 CLAIMS SUBMISSION SA EXCP Code Service Authorization Exception Code Field 25D Chapter 57 of the Laws of 2006 requires an increase in the amount of Medicaid payment for continuous nursing services provided to Medically Fragile Children outside of the institutional environment Such increases are applicable to Private Duty Nursing Services provided to any Medicaid client including those in the Care at Home Waiver programs up to age 21 This will result in a 30 add on to the amounts otherwise payable on Medicaid claims for such services In order to be eligible to receive this add on payment you must first attest that you possess the training and experience necessary to provide the specific care and satisfactorily address the nursing needs of the Medically Fragile Children to whom you are providing nursing service To accomplish this fill out either the Individually Enrolled Provider or Licensed Home Health Care Services Agency attestation These attestations can be found at under Private Duty Nursing Provider Communications at www emedny org by clicking on the link to the webpage as follows Private Duty Nursing Manual Upon receipt of your satisfactorily completed attestation a new Specialty Code 579 will be added to your enrollment file to enable you to receive the Medically Fragile Children s service
42. k Name of Facility Where Services Rendered Field 21 This field should be completed only when the Place of Service Code entered in Field 24B is 99 Other Unlisted Facility Address of Facility Field 21A This field should be completed on y when the Place of Service Code entered in Field 24B is 99 Other Unlisted Facility NOTE The address listed in this field does not have to be the facility address It should be the address where the service was rendered NURSING SERVICES Version 2010 01 5 31 2010 Page 21 of 61 lt SUBMISSION Service Provider Name Field 22A Agencies Only Enter the name of the private duty nurse who provided the service If more than one nurse rendered services to the patient on the same day a separate claim must be submitted for each nurse Prof CD Profession Code Service Provider Field 22B Agencies Only Enter Profession code 010 or 022 in this field to identify the service provider s profession Identification Number Service Provider Field 22C Agencies Only Enter the NPI of the nurse that provided the services in this field Sterilization Abortion Code Field 22D Leave this field blank Status Code Field 22E Leave this field blank Possible Disability Field 22F Place an X in the Y box for YES or an X in the box for NO to indicate whether the service was for treatment of a condition which appeared to be of a disabling nature the i
43. lly inconsistent Approved Claims NURSING SERVICES Version 2010 01 5 31 2010 Page 47 of 61 oe essere tance ADVICE 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 approved 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 No match found in 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 signifie
44. m lines are submitted on the same claim form all the lines are assigned the same TCN 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 Procedure Code The five digit procedure code that was entered in the claim form appears under this column Units The total number of units of service for the specific claim appears under this column The units are indicated with three 3 decimal positions Since Nursing Services providers must only report whole units of service the decimal positions will always be OOO 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 Information entered in the claim form is invalid or logica
45. ms Since the information entered on the claim form is captured via an automated data collection process imaging it is imperative that entries are legible and placed appropriately in the required fields The following guidelines will help ensure the accuracy of the imaging output All information should be typed or printed e 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 6 00 6 ero 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 NURSING SERVICES Version 2010 01 5 31 2010 Page 6 of 61 _ CLAIMS SUBMISSION Exhibit 2 2 1 3 Intended As Interpreted As wo interpreted as seven gt hree interpreted as two amp 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 Do not write between lines Do not use arrows or quotation marks to duplicate information Donot use dollar sign S to indi
46. nability to engage in any substantial or gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months EPSDT C THP Field 22G Leave this field blank Family Planning Field 22H Leave this field blank Prior Approval Number Field 23A Prior Approval is required for all services rendered by Private Duty Nurses and Agencies Enter in this field the 11 digit Prior Approval number assigned by the New York State Department of Health for the service rendered NURSING SERVICES Version 2010 01 5 31 2010 Page 22 of 61 CLAIMS SUBMISSION NOTES For information regarding how to obtain Prior Approval Prior Authorization for specific services please refer to Information for All Providers Inquiry section on the web page for this manual which can be found at www emedny org by clicking on the link to the webpage as follows Private Duty Nursing Manual For information on how to complete the prior approval form please refer to the Prior Approval Guidelines for this manual which can be found at www emedny org by clicking on the link to the webpage as follows Private Duty Nursing Manual Payment Source Code Box and Box 0 Field 23B This field has two components Box M and Box O as shown in Exhibit 2 4 2 3 below Exhibit 2 4 2 3 23B PAYM TI SOURCE CO M O
47. on 2010 01 5 31 2010 Page 12 of 61 r CLAIMS SUBMISSION Adjustment to Cancel One or More Claims Originally Submitted on the Same Document Record TCN An adjustment should be submitted to cancel or void one or more individual claim lines that were originally submitted on the same document record and share the same TCN The following instructions must be followed The adjustment must be submitted in a new claim form copy of the original form is unacceptable The adjustment must contain all claim lines submitted in the original document all claim lines with the same except for the claim s line s to be voided these claim lines must be omitted in the adjustment All applicable fields must be completed The adjustment will cause the cancellation of the omitted individual claim lines from the TCN history records as well as the cancellation of the original TCN payment and the re pricing of the new TCN Adjustment based on the adjusted information Exhibit 2 4 2 1 3 and Exhibit 2 4 2 1 4 illustrate an example of a claim with an adjustment being made to cancel a line on submitted on the claim TCN 0826018765432100 contained three individual claim lines which were paid on October 1 2008 Later it was determined that one of the claims was incorrectly billed since the service was never rendered The claim line for that service must be cancelled to reimburse Medicaid for the overpayment Exhibit 2 4 2 1 3 shows the claim as it was
48. or 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 be found at www emedny org by clicking on the link to the webpage as follows Private Duty Nursing Manual Patient s Account Number Field 32 For record keeping purposes the provider may choose to identify a patient by using an office account number This field can accommodate up to 20 alphanumeric characters If an office account number is indicated on the claim form it will be returned on the Remittance Advice Using an Office Account Number can be helpful for locating accounts when there is a question on patient identification Other Referring Ordering Provider ID License Number Field 33 Leave this field blank Prof CD Profession Code Other Referring Ordering Provider Field 34 Leave this field blank NURSING SERVICES Version 2010 01 5 31 2010 Page 32 of 61 REMITTANCE ADVICE 3 Explanation of Paper Remittance Advice Sections This Section presents samples of each section of the Nursing Services remittance advice followed by an explanation of the elements contained in the section The information displayed in the remit
49. 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 ABC NURSING SERVICES L HE DATE 2010 05 31 D CAI D REMITTANCE NO 070806000006 PROVID 001122331 123456789 MAM AGEME Fd T INFORMATION 00112233 1123455789 2010 05 31 ABC NURSIMG SERVICES 100 BROADWAY ANYT OWN 11111 ABC NURSING SERVICES 5760 00 PAYMENT IN THE ABOVE AMOUNT WILL BE DEPOSITED VIA ELECTRONICFUNDS TRANSFER NURSING SERVICES Version 2010 01 Page 36 of 61 5 31 2010 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 The 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 NURSING SERVICES Version 2010 01 5 31 2010 Page 37 of 61 REMITTANCE ADVICE 3 3 Section One Summout No Payment A summout is produced when the provider has no positive total paymen
50. or illustration purposes only Shaded fields are not required to be completed unless noted otherwise Therefore shaded fields that are not required to be completed in any circumstance are not listed in the instructions that follow 2 4 Nursing Services Billing Instructions This subsection of the Billing Guidelines covers the specific NYS Medicaid billing requirements for Nursing Services providers Although the instructions that follow are based on the eMedNY 150002 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 directl
51. or practitioner groups this subtotal category refers to the specific member of the group who provided the services These subtotals are broken down by amp eee e Adjustments voids combined Pends Paid Deny Net total paid sum of approved adjustments voids and paid original claims Grand Totals for the entire provider remittance advice appear on a separate page following the page containing the totals by provider type and member ID The grand total is broken down by Adjustments voids combined Pends Paid Deny Net total paid entire remittance NURSING SERVICES Version 2010 01 5 31 2010 Page 49 of 61 REMITTANCE ADVICE 3 6 Section Four Financial Transactions and Accounts Receivable This section has two subsections Financial Transactions Accounts Receivable NURSING SERVICES Version 2010 01 5 31 2010 Page 50 of 61 REMITTANCE ADVICE 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 DICAID DATE DATE 05 31 10 CYCLE 1710 INFORMATION ABC NURSING SERVICES MEDICAL ASSISTANCE TITLE XIX PROGRAM ETIN 100 BROADWAY TA 1 FINANCIAL TRANSACTIONS ANYTOWN NEW YORK 11111 REMITTANCE STATEMENT PROV ID 00112223 1122456783 REMITTANCE 07
52. pplier Field 25 The private duty nurse must sign the claim form For Agencies an authorized representative of the agency must sign the claim form Rubber stamp signatures are not acceptable Please note that the certification statement is on the back of the form Provider Identification Number Field 25A Enter the provider s 10 digit National Provider Identifier NPI Medicaid Group Identification Number Field 25B Leave this field blank Locator Code Field 25 For electronic claims leave this field blank 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 any time afterwards that a new location is added Enter the locator code that corresponds to the address where the service was performed Locator codes 001 and 002 are for administrative use only and are not entered in this field If the provider renders services at one location only enter locator code 003 If the provider renders service to Medicaid patients at more than one location the entry may be 003 or a higher locator code 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 l
53. priate code which describes the main condition or symptom of the patient The ICD 9 CM code must be entered exactly as it is listed in the manual in the correct spaces of this field and in relation to the decimal point Proper entry of an IDC 9 CM Diagnosis Code is shown in Exhibit 2 4 2 5 Exhibit 2 4 2 5 24H DIAGNOSIS CODE NOTE A three digit Diagnosis Code no entry following the decimal point will only be accepted when the Diagnosis Code has no subcategories Otherwise Diagnosis Codes with subcategories MUST be entered with the subcategories indicated after the decimal point Days or Units Field 241 One hour of nursing service equals one unit Partial hours 30 minutes or more should be rounded up to one hour The total number of hours of service provided to the patient during the same day by the same nurse should be entered in one line only even if the service was provided in separate shifts Charges Field 24J This field must contain either the Amount Charged or the Medicare Approved Amount Amount Charged When Box M in field 23B has an entry value of 1 or 3 enter the amount charged in this field The Amount Charged may not exceed the provider s customary charge for the procedure Ifthe provider has indicated more than 1 unit of service in Field 241 Days or Units multiply the number of units by the procedure fee Special Instructions When two patients are simultaneously under the care of a private duty nurse
54. scheduled for each cycle Total Amount Due the State This amount is the sum of all the Current Balances listed above NURSING SERVICES Version 2010 01 5 31 2010 Page 54 of 61 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 TO ABC NURSING SERVICES 100 BROADWAY ANYTOWN NEW YORK 11111 Exhibit 3 7 1 DICAID MANAGEMENT MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT PAGE 06 DATE 053711 CYCLE 1710 PRACTITIONER EDIT DESCRIPTIONS PROV ID 00112223 1123456783 REMITTANCE NO O71660 THE FOLLOWING ISA DESCRIPTION OF THE EDIT REASON CODES THAT APPEAR ON THE CLAIMS FOR THIS REMITTANCE 00131 PROVIDER NOT APPROVED FOR SERVIGE 00142 SERVIGE GODE NOT EQUAL TO PA 00162 RECIPIENT INELIGIBLE ON DATE OF SERVICE 00244 ON OR REMOVED FROM FILE Version 2010 01 NURSING SERVICES Page 55 of 61 5 31 2010 APPENDIX CLAIM SAMPLES APPENDIX A CLAIM SAMPLES The eMedNY Billing Guideline Appendix A Claim Samples contains an image of a claim with sample data NURSING SERVICES Version 2010 01 5 31 2010 Page 56 of 61 APPENDIX A CLAIM SAMPLE MEDICAL ASSISTANCE HEALTH INSURANCE ONLY TO BE CLAIM FORM TITLE XIX PROGRAM ADU STAID PATIENT AND INSURED
55. sted information in the TCN history records as well as the cancellation of the original TCN payment and the re pricing of the TCN based on the adjusted information Exhibit 2 4 2 1 1 and Exhibit 2 4 2 1 2 illustrate an example of a claim with an adjustment being made to change information submitted on the claim TCN 0826019876543200 is shared by three individual claim lines This TCN was paid on October 1 2008 After receiving payment the provider determines that the units and charges on one of the claim line records are incorrect An adjustment must be submitted to correct the records Exhibit 2 4 2 1 1 shows the claim as it was originally submitted and Exhibit 2 4 2 1 2 shows the claim as it appears after the adjustment has been made NURSING SERVICES Version 2010 01 5 31 2010 Page 10 of 61 Exhibit 2 4 2 1 1 MEDICAL ASSISTANCE HEALTH INSURANCE CLAIM FORM TITLE AIX PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION 1 LEATRNT Mais Finn eii irg 1 DATE OF ERTI ahh a NCOME JANE SMITH 520199 SELF Par Fir arc Scream are Peicyer Prrsig rarr uniber a q m m 1 amp FIRST OMALT 11 HS PATENT Bre HAD OF CONDITION FOR CONDIT ION SAME OR SMLAR c LA E E TY Wow DD Peter amit 21 NATIONAL DRUG Gone 2 NAME OF FAOU T WHERE SERVICES RENDERED L aar Ban hama ara ba HA XDORESS OF FACUT SSR Ce PROVIDER NIE
56. t for the cycle and therefore there is no disbursement of moneys Exhibit 3 3 1 TO ABC NURSING SERVICES DATE 05 31 2010 REMITTANCE NO 070806000006 D ICAI D PROVID 001122331 123456789 BLA Pd ME Pal T INFORMATION HO PAYMENT WILL RECEIVED THIS CYCLE SEE REMITTANCE FOR DETAILS ABC NURSING SERVICES 100 BROADWAY ANT OWN NY 11111 NURSING SERVICES Version 2010 01 5 31 2010 Page 38 of 61 REMITTANCE ADVICE 3 3 1 Summout No Payment Field Descriptions Upper Left Corner 5 Name as recorded in the Medicaid files Upper Right Corner Date The 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 s Name Address NURSING SERVICES Version 2010 01 5 31 2010 Page 39 of 61 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 o0 MANAGEMENT erem MEDICAL ASSISTANCE TITLE XIX PROGRAM TO ABC NURSING SERVICES EE OU ETIN 100 BROADWAY PROVIDER NOTIFICATION ANYTOWN NEW YORK 11111 PROV ID 00112233 1 123456789 REMITTANCE NO 070806000006 REMITTANCE ADVICE MESSAGE TEXT ELECTRONIC FUNDS TRANSFER EFT FOR PROVIDER PAYMENTS IS NOW AVAILABLE PROVIDERS WHO ENROL
57. tain the ordering provider s signature in this field Prof CD Professional Code Ordering Referring Provider Field 19B Leave this field blank Identification Number Ordering Referring Provider Field 19C For Ordering Provider Enter the ordering provider s National Provider Identifier NPI in this field For Referring Provider Enter the Referring Provider s NPI NOTE A facility ID cannot be used for the Ordering Referring Provider In those instances where a service was ordered by a facility the NPI of a practitioner at the facility ordering the service must be entered in this field NURSING SERVICES Version 2010 01 5 31 2010 Page 20 of 61 _ CLAIMS SUBMISSION Restricted Recipients When providing services to a patient who is restricted to a primary physician the NPI of the patient s primary physician must be entered in this field If a patient is restricted to a facility the NPI of the practitioner at the facility the patient is restricted to must be entered in this field the ID of the facility cannot be used If no referral was involved leave this field blank DX Code Field 19D Leave this field blank Drug Claims Section Fields 20 to 20C The following section applies to drug code claims only NDC National Drug Code Field 20 Leave this field blank Unit Field 20A Leave this field blank Quantity Field 20 Leave this field blank Cost Field 20C Leave this field blan
58. tance 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 Financial Transactions recoupments Accounts Receivable cumulative financial information Section Five Edit Error Description NURSING SERVICES Version 2010 01 Page 33 of 61 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 AGEMENT INFORMATION SYSTEM TO ABC NURSING SERVICES DATE 2010 05 31 REMITTANCE NO 070806000006 PROV ID 00112233 1123456 7 69 00112233 1123456789 2010 05 31 ABC NURSING SERVICES 100 BROADWAY ANY TOWN
59. 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 eMedNY 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 NURSING SERVICES Version 2010 01 5 31 2010 Page 5 of 61 _ CLAIMS SUBMISSION 2 2 Paper Claims Nursing Services providers who choose to submit their claims on paper forms must use the New York State eMedNY 150002 claim form To view a sample Nursing Services eMedNY 150002 claim form see Appendix A below 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 Clai
60. y 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 that 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 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 NURSING SERVICES Version 2010 01 5 31 2010 Page 8 of 61 CLAIMS SUBMISSION 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

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