Home

eMedNY Subsystem User Manual

1. New Vork State Electronic Medicaid System 0804 Billing Guidelines OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 um TABLE OF CONTENTS TABLE OF CONTENTS L PUPO SUA 4 Den Clamis e RU E MIETEN PU MM 5 2 1 edes cT 5 2 2 NER 6 2 2 1 General Instructions for Completing Paper 6 2 3 a ESI edil 8 2 4 OMH Certified Rehabilitation Services Billing 5 0 nanna r nanna tna nn ann 8 2 4 1 Instructions for the Submission of Medicare Crossover 8 2 4 2 UB 04 Claim Form Field 2 ia ee a a aa 9 3 Explanation of Paper Remittance Advice 5 00 00 000 21 3 1 Section OME Medicaid ii iii M 22 31 1 Mediegid Check St b Field Deser pront ea 23 3 1 2 Medicaid Check Field 5 23 3 2 section ONG ERE NOM EA IOI METRUM 24 3 2 1 EFT Notification Page Field 25 3 3 Section One Summeut NO Pavmen tea
2. ETIN not applicable Provider Service Classification HOME HEALTH PROV ID This field will contain the Medicaid Provider ID and the NPI Remittance Number 3 5 2 Explanation of Claim Detail Columns 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 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 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 34 of 45 oe essere tance 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 for the specific claim appears under this column The units are indicated with three 3 decimal positions Since Home Health
3. 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 See the example in Exhibit 2 4 2 13 Exhibit 2 4 2 13 267 Ascorbic Acid Deficiency Acceptable to Medicaid no subcategories 268 Vitamin D Deficiency Notacceptable to Medicaid subcategories exist Acceptable Diagnosis Codes 267 268 0 268 1 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 instances 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 14 Exhibit 2 4 2 14 The ordering referring provider is John Smith who is enrolled in Medicaid with an NPI of 1234567890
4. ADVICE 3 6 2 1 Explanation of Accounts Receivable Columns If a provider has negative balances of different types or negative balances created at different times each negative balance will be listed in a different line Reason Code Description This is the description of the Financial Reason Code For example Third Party Recovery Original Balance The original amount or starting balance for any particular financial reason Current Balance The current amount owed to Medicaid after the cycle recoupments if any were applied This balance may be equal to or less than the original balance Recoupment Amount The deduction recoupment scheduled for each cycle Total Amount Due the State This amount is the sum of all the Current Balances listed above OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 41 of 45 REMITTANCE ADVICE 3 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 EDICAID DATE 05 31 2010 CYCLE 1710 MFOPRP ATIGH MEDICAL ASSISTANCE TITLE XIX PROGRAM ETIN CITYHOME CARE MITT AN STATE HOME HEALTH 111 MAIN STREET STATEMENT EDIT DESCRIPTIONS ANTTOWN NEW YORK 11111 PROV ID 00111224 12345578590
5. NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS 8 000 5 000 CHARGED 300 20 188 41 po Fa p RO REMITTANCE NO 1 PAID STATUS PEND PEND ERRORS 00152 00244 00162 00244 PREVIOUSLY PENDED CLAIM NEW PEND OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 Page 32 of 45 5 31 2010 REMITTANCE ADVICE Exhibit 3 5 4 DICAID MA INFORMATION amp YSTEM MEDICAL ASSISTANCE TITLE XIX PROGRAM EINE CITY HOME CAR i ris HOME HEALT 111 MAIN STREET REMITTANCE STATEMENT GRAND TOTALS ANYTOWN NEW YORK 11111 PROVID 00111234 1234558790 REMITTANCE NO Q708060001 REMITTANCE TOTALS GRAND TOTALS VOIDS ADJUSTS 142 il NUMBER CLAIMS TOTAL PENDS 488 51 NUMBER OF CLAIMS TOTAL PAID 2025 41 NUMBER OF CLAIMS TOTAL DENY 212 13 NUMBER CLAIMS NET TOTAL PAID 1877 11 NUMBER OF CLAIMS Ra Ca RJ om OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 33 of 45 REMITTANCE ADVICE 3 5 1 Claim Detail Page Field Descriptions Upper Left Corner Provider s Name Address Upper Right Corner Remittance page number Date The date on which the remittance advice was issued Cycle number The cycle number should be used when calling the eMedNY Call Center with questions about specific processed claims or payments
6. REMITTANCE O7 020500001 THE FOLLOWING ISA DESCRIPTION OF THE EDIT REASON CODES THAT APPEAR ON THE CLAIMS FOR THIS REMITTANCE 00131 THIRD PARTY INDICATED OTHER INSURANCE PAD BLANK 00142 RECIPIENT TEAR BIRTH DIFFERS FROM FILE 00162 RECIPIENT INELIGIBLE ON DATE OF SERVICE 00244 PANOT ON FILE OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 42 of 45 APPENDIX A CLAIM SAMPLES APPENDIXA CLAIM SAMPLES The eMedNY Billing Guideline Appendix A Claim Samples contains images of claims with sample data OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 43 of 45 _ APPENDIX A CLAIM SAMPLES OMH Certified Rehabilitation Services UB 04 Sample Claim APPROVED OMB NO 0938 0279 City Home Care Emm Tamar Mann ST 111 Main Street gt 8 PATIENT E e 4 ADMISSION ke pr 29 ACDT uman s cot ite ESI I 3 mi 1 32 OCCURRENCE 34 CODE DATE CODE DATE THROUGH ae AMOUNT ll AMOUNT AMOUNT 42 REV CD 43 DESCRIPTION 44 HCPCS RATE HIPPS CODE 45 SERV 46 SERV UNITS 47 TOTAL CHARGES NON COVERED CHARGES 4 5 7 B 9 10 11 12 13 14 15 16 17 18 19 20 21 22 PAGE ___ CREATION DATE a a 23 sees ntt jemmen jssmomu we
7. Name of section PROVIDER NOTIFICATION PROV ID This field will contain the Medicaid Provider ID and the NPI Remittance number Center Message text OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 29 of 45 REMITTANCE ADVICE 3 5 Section Three Claim Detail This section provides a listing of all new claims that were processed during the specific cvcle plus claims that were previously pended and denied during the specific cycle This section also contain claims that pended previously Exhibit 3 5 1 TO CITY HOME CARE 111 MAIN STREET ANTTOWN NEW YORK 11111 OFFICE ACCOUNT CLIENT CLIENT NUMBER NAME ID TCN 12001214 DOE 12345 07206 000012112 3 2 1 1 00987 6 SAMPLE xxz3455X 072056 0000129112 2 1 TOTAL AMOUNT ORIGINAL CLAIMS DENIED 212 13 NET AMOUNT ADJUSTMENTS DENIED 0 00 NET AMOUNT VOIDS DENIED 0 00 NET AMOUNT VOIDS ADJUSTS 0 00 DICAID HAN AGEMENT INFORMATION SYSTEM MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT DATE OF RATE SERVICE CODE Vea 10 4363 On 25 10 4353 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS UNITS CHARGED 187 81 0 00 84 38 0 00 DENY 00244 00142 ki FAGE 02 05 31 2010 CYCLE 1710 ETIN HOME HEALTH PROVID 00111234 1224567830 REMITTANCE NO O70260 PAID STATUS ERRORS DENY 00162 00131 PREVIOUSLY PENDED CLAIM NEW PEN
8. 2 2 Frequency Adjustment Void Code New York State Medicaid uses the third position of this field only 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 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 10 of 45 CLAIMS SUBMISSION 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 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 For monthly rates only one date of service can be billed per claim form Enter the date of service in the FROM box according to the instructions below The THROUGH box may contain the same date of service or be left blank Dates must be entered in the format MMDDYYYY NOTE Claims must be submitted within 90 days of the date of service entered in this field unless acceptable circumstances for the delay can be documented Information about billing claims over 90 days or two years from the Date of Service is available in the All Providers General Billing Guideline Information section available at www emedny org by clicking on the li
9. 26 3 3 1 Summout No Payment Field 20000 0 1 nennen nennen 27 3 4 Section TWO Provider NotifiCatlO ta ui 28 3 4 1 Provider Notification Field Descriptions 29 3 5 30 3 5 1 Claim Detail Page Field 34 3 5 2 Explanation of Claim Detail ColUMNS icisnscesausscocesauadoonsinsnceadnssarancadoainndausstosioadesnteawenssandad nesinonnsucsundioaieadsameadoatenctaesaiesboatsan 34 3 5 3 Subtotals Totals Grand Totals ccceccccsseccccseccccsecccecccecaucececauccecuecececauceeecaececaacececausececauececaucececsceeecauscecasececaueeeenauess 37 3 6 Section Four Financial Transactions and Accounts 38 3 6 1 Financial Transactions iii G d a aa 38 EO t m m 40 3 7 Section Five Edit Error D SCTEIDLIOTI ves hum DIA ERUIT V PII 42 POO SCION Claim 43 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 2 of 45 CLAIMS SUBMISSION For eMedNY Billing Guideline questions please contact the eMedNY Call Center 1 800 343 9000 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 3
10. Each claim form will be processed as a unique claim document and must contain only one Total Charges 0001 Revenue Code Serv Date Form Locator 45 Leave this field blank Serv Units Form Locator 46 Leave this field blank 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 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 Exhibit 2 4 2 11 42REVCD 43 DESCRIPTION 44 HCPCS IRATE HIPPS CODE 45 SERV DATE 4 SERV UNITS 47 TOTAL CHARGES 49 NON COVERED CHARGES d E Ub 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 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 17 of 45 CLAIMS SUBMISSION For NVS Medicaid billing pavers are classified into three main categories Medicare Commercial anv insurance other than Medicare and Medicaid Medicaid is alwavs the paver of last resort Complete this field in accordance with the following instructions Direct Medicaid Claim If Medicaid is the enter the word Medicaid on line A of this field Leave l
11. LAST SMITH FIRST JOHN OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 20 of 45 REMITTANCE ADVICE 3 Explanation of Paper Remittance Advice Sections This Section present a sample of each section of the remittance advice for OMH Certified Rehabilitation Services providers followed by an explanation of the elements contained in the section The information displayed in the remittance advice samples is for illustration purposes only The following information applies to a remittance advice with the default sort pattern General Remittance Advice Information is available in the All Providers General Billing Guideline Information section available at www emedny org by clicking on the link to the webpage as follows Information for All Providers The remittance advice is composed of five sections Section One may be one of the following Medicaid Check Notice of Electronic Funds Transfer Summout no claims paid Section Two Provider Notification special messages Section Three Claim Detail Section Four Financial Transactions recoupments Accounts Receivable cumulative financial information Section Five Edit Error Description OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 Page 21 of 45 5 31 2010 ADVICE 3 1 Section One Medicaid Check For providers who have selected to
12. NEW PEND TOTAL AMOUNT ORIGINAL CLAIMS PAID 2226 41 NUMBER CLAIMS 5 NET AMOUNT ADJUSTMENTS PAID 43 30 NUMBER OF CLAIMS i NET AMOUNT VOIDS PAID 0 00 NUMBER OF CLAIMS 0 NET AMOUNT VOIDS ADJUSTS 143 30 NUMBER OF CLAIMS i OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 31 of 45 REMITTANCE ADVICE MEDICAL ASSISTANC TO CITY HOME CARE 111 MAIN STREET ANYTOWN NEW YORK 11111 OFFICE ACCOUNT NUMBER CPIC 1 200125 DOE CFIC1 20387 b SAMPLE CLIENT TOTAL AMOUNT ORIGINAL CLAIMS NET AMOUNT ADJUSTMENTS MET AMOUNT VOIDS NET AMOUNT VOIDS ADJUSTS REMITTANCE TOTALS HOME HEALTH VOIDS ADJUSTS TOTAL PENDS TOTAL FAID TOTAL DENIED NET TOTAL PAID MEMBERID 0011123 VOIDS ADJUSTS TOTAL PENDS TOTAL PAID TOTAL DENY NETTOTAL PAID CLIEMT Exhibit 3 5 3 REMITTANCE STATEMENT INFORMATION Be E TITLE AIA PROGRAM FAGE 04 DATE 05 21 2010 CYCLE 1710 ETIN HOME HEALTH PROVID 00111224 1234567890 07206 341 12 3 2 OT 206 XX0445113 3 1 FEND FEND FEND 488 61 0 00 0 00 0 00 0 00 0 00 0 00 775 62 0 00 143 30 488 61 2026 41 272 19 1877 11 SERVICE DATE OF RATE CODE 0252510 4365 ear id 4353 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS
13. 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 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 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 approved edits may be listed for each claim Edit code definitions will be listed on a separate p
14. a condition resulting from an accident or crime Select the code from the UB 04 Manual Form Locators 31 34 Accident Related Codes Date If an entrv was made under Code enter the date when the accident occurred in the format MMDDVV Value Codes Form Locators 39 41 NVS 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 eec cec 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 leave this field blank The Locator Code will be defaulted to 003 if the nine digit ZIP Code submitted on the claim does not match what is on file For paper claims enter the locator code assigned by NYS Medicaid Locator codes are assigned to the provider for each service address registered at the time of enrollment in the Medicaid program or at anytime afterwards that a new location is added Value Code Code 61 should be used to indicate that a Locator Code is entered under Amount Value Amount Locator codes 001 and 002 are for administrative use only and are not to be entered in this field
15. 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 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 23 of 45 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 cvcle and the approved amount is greater than the recoupments if anv scheduled for the cvcle This section indicates the amount of the EFT Exhibit 3 2 1 TO CITY HOME CARE DATE 2010 05 31 D l GA LJ MO 07080600001 PROVID 00111234 1234567880 MANAGEMENT INFORMATION SYSTEM 0011123 4123 466 7090 2010 05 31 CITY HOME CARE 111 MAIN STREET ANYT OWN 11111 CITY HOME CARE 51877 11 PAYMENT IN THE AMOUNT WILL BE DEPOSITED VIA AN ELECTRONICFUNDS TRANSFER OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 24 of 45 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 a
16. does not supplv it The form can be obtained from anv of the national suppliers The UB 04 Manual National Uniform Billing Data Element Specifications as Developed by the National Uniform Billing Committee Current Revision should be used in conjunction with this Provider Billing Guideline as a reference guide for the preparation of claims to be submitted to NYS Medicaid The UB 04 manual is available at www nubc org Form Locators in this manual for which no instruction has been provided have no Medicaid application These Form Locators are ignored when the claim is processed 2 4 Certified Rehabilitation Services Billing Instructions This subsection of the Billing Guidelines covers the specific NYS Medicaid billing requirements for OMH Certified Rehabilitation Services 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 subsecti
17. housing programs 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 Exhibit 2 4 2 6 Sex Form Locator 11 Enter M 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 Leave all 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 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 12 of 45 SUBMISSION Code If applicable enter the appropriate Accident Code to indicate whether the service rendered to the patient was for
18. 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 VOID Paid Claims The status PAID refers to origina claims that have been approved OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 35 of 45 REMITTANCE ADVICE Adjustments The status ADJT refers to a claim submitted in replacement of a paid claim with the purpose of changing one or more fields An adjustment has two components the credit transaction previously paid claim and the debit transaction adjusted claim Voids
19. no claims were approved Provider Name and Address OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 27 of 45 REMITTANCE ADVICE 34 Section Two Provider Notification This section is used to communicate important messages to providers Exhibit 3 4 1 FAGE 01 DATE 05 31 10 DICAID CYCLE 1710 MANAGEMENT INFORMATION Gy Tee MEDICAL ASSISTANCE TITLE AIX PROGRAM TO CITY HOME CARE REMITTANCE STATEMENT ETIN 111 MAIN STREET FROVIDER NOTIFICATION ANYTOWN NEWYORK 11111 PROV ID 007112349 23456 7890 REMITTANCE NO 07080600001 REMITTANCE ADVICE MESSAGE ELECTRONIC FUNDS TRANSFER EFT FOR PROVIDER PAYMENTS 15 NOW AVAILABLE PROVIDERS WHO ENROLL IN 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 MAN 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 PLEASENOTE THAT EFT DOES NOT WAIVE THE TWO WEEK LAG FOR MEDICAID DISBURSEMENTS TO ENROLL IM EFT PROVIDERS MUST COMPLETE AM EFT ENROLLMENT FORM THAT CAM BE FOUND AT WWW CLICK ON PROVIDER ENROLLMENT FORMS WHICH BE FOUND IM THE FEATURED LINKS SECTION DETAILED IMSTRUCTIONS WILL ALSO BE FOUND THERE AFTER SENDING THE EFT E
20. of 45 PURPOSE STATEMENT 1 Purpose Statement The purpose of this document is to assist the provider community in understanding and complying with the New York State Medicaid NYS Medicaid requirements and expectations for Billing and submitting claims Interpreting and using the information returned in the Medicaid Remittance Advice This document is customized for OMH Certified Rehabilitation Services 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 All Providers OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 4 of 45 A CLAIMS SUBMISSION 2 Claims Submission OMH Certified Rehabilitation Services providers can submit their claims to NVS 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 NVS Medicaid Certification Statements remain in effect and to all claims until superseded another executed Certification Statement Providers will be asked to update their Certification Statement on an annual basis Providers will be provided with re
21. 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 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 39 of 45 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 MAN AGEMENT lI FOAM ATION MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT TO CITY HOME CARE 111 MAIN STREET ANYTOWN NEW YORK 11111 REASON CODE DESCRIFTION ORIG BAL CURR BAL RECOUPS AMT TOTAL AMOUNT DUE THE STATE SXXX PAGE 05 DATE 05 31 10 CYCLE 1710 ETIN ACCOUNTS RECEIVABLE PROV ID 00111234 124557830 REMITTANCE NO OF 020000007 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 Page 40 of 45 5 31 2010
22. Blue Cross 57 Medicaid OTHER B PRV ID w N tad co 4 WH 9 CO 9 Cn A a gt SENGUREDSNANE SSPRESONSUREDSUNGUED O _ 63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER A B B C u m NENNEN ASON DX ES OTHER PROCEDURE OTHER PRI mew jan DATE THER PR RE E ee ce 7 7 mem Mi uus SMITH FIRST JOHN UB 04 CMS 1450 APPROVAL PENDING NUBC LIC9213257 THE CERTIFICATIONS ON THE REVERSE APPLV TO THIS BILL AND ARE MADE A PART HEREOF TEE PRO CODE DATE 80 REMARKS OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 44 of 45 EMEDNV INFORMATION eMedNY is the name of the electronic New York State Medicaid system The eMedNY system allows New Vork Medicaid providers to submit claims and receive pavments 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 e
23. D OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 Page 30 of 45 5 31 2010 REMITTANCE ADVICE Exhibit 3 5 2 PAGE 03 DICAID ME ko a In FORMATION MEDICAL ASSISTANCE TITLE XIX PROGRAM MAT j E CITY HOME CARE REMITTANCE STATEMENT HOME HEALTH 177 MAIN STREET FROVID S0111224 1224567890 AN YTOWN NEW YORK 11111 REMITTANCE NO OFFICE ACCOUNT CLIENT CLIENT DATE OF RATE NUMBER NAME ID TCN SERVICE CODE UNITS CHARGED STATUS ERRORS ees OOE XX12345X 072060000411220 2 052510 4368 8000 30020 30020 PAID CPIC1 200987 b SAMPLE XX2231455X OTZO05 DXX4 451 12 0 2 05 2210 4265 S000 4 1 44444 55 EXAMPLE xxaz4557X 07206 000456331 0 2 05 27 10 4355 809 30020 300 70 CPIC1 5b5666 b SPECIMEN XX45578X 07205 000445663 0 2 05 22 10 4369 8 000 30020 PAID CPIC1 33333 8 STANDARD XX55789X 072 95 0004476540 2 0522110 4369 amp 000 30020 30020 PAID CP cTSONEHS MODEL XX67890X 07206 0004565551 0 2 0525 10 4369 7 000 186 10 18610 PAID CPIC1 77777 5 DOE Xxx0eg76x 07206 000455557 0 2 05 2510 4369 amp 000 300 20 30020 PAID CPIC1 111116 SAMPLE XXS8765X 07206 000544444 01 2 0505 10 5 000 150 90 150 90 1 1 59999 6 EXAMPLE XXETEBAX DTZOGDODAGS4TT L 2 050510 8000 20020 30020 FAID ORIGINAL CLAIM PAID O5 Z4 2010 te PREVIOUSLY CLAIM
24. ICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 15 of 45 SUBMISSION Invervlimited situations the Local Department of Social Services LDSS has advised the provider to zero fill the Other Insurance pavment for the same tvpe of service This communication should be documented in the client s billing record The provider bills the insurance company and receives a rejection because The service is not covered or The deductible has not been met The provider cannot directly bill the insurance carrier and the policyholder is either unavailable or uncooperative in submitting claims to the insurance company In these cases the LDSS must be notified prior to zero filling The LDSS has subrogation rights enabling it to complete claim forms on behalf of uncooperative policyholders who do not pay the provider for the services The LDSS can direct the insurance 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 col
25. MedNY CSC More information about eMedNY can be found at www emedny org OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 45 of 45
26. NROLLMENT FORM TO CSC PLEASE ALLOW MINIMUM TIME OF SIX TO EIGHT WEEKS FOR PROCESSING DURING THIS PERIOD OF TIME YOU SHOULD REVIEW YOUR BANK STATEMENTS AND LOOK FOR AM EFT TRANSACTION IN THE AMOUNT OF 0 07 WHICH CSC WILL SUBMIT 5 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 CALL CENTER AT 1 800 343 8000 NOTICE THIS COMMUNICATION AND ANY ATTACHMENTS MAY CONTAIN INFORMATION THAT 15 PRIVILEGED AND CONFIDENTIAL UNDER STATE AND FEDERAL LAW AND IS INTENDED ONLY FOR THE USE OF THE SPECIFIC INDIVIDUAL S TO WHOM IT 15 ADDRESSED THIS INFORMATION MAY ONLY BE USED OR DISCLOSED IN ACCORDANCE WITH LAW AMD YOU MAY BE SUBJECT TO PENALTIES UNDER LAWFOR IMPROPER USE OR FURTHER DISCLOSURE OF INFORMATION IN THIS COMMUNICATION AND ATTACHMENTS IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR PLEASE IMMEDIATELY NOTIFY NYHIPPADESK QCSC COM OR CALL 1 800 541 2831 PROVIDERS WHO DO NOT HAVE ACCESS TO E MAIL SHOULD CONTACT 1 800 343 9000 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 28 of 45 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
27. 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 PAGE OF D ICAID um m 10 MANAGEMENT INFORMATION SYSTEM CITY HOME CARE MEDICAL ASSISTANCE TITLE XIX PROGRAM ETIN 111 MAIN STREET FINANCIAL TRANSACTIONS ANY TOWN NEW YORK 11111 REMITTANCE STATEMENT PROV ID 00111224 1224567890 REMITTANCE NO 07080600001 FINANCIAL FISCAL FCN REASON CODE TRANS TYPE DATE AMOUNT 2007 0506023554 T RECOUPMENT REASON DESCRIPTION 08 10 55 52 NET FINANCIAL AMOUNT 253 55 NUMBER OF FINANCIAL TRANSACTIONS OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 38 of 45 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
28. 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 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 13 of 45 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 OMH Certified Rehabilitation Services Manual Rate Code Value Code 24 Rates are established by the Department of Health and other State agencies At the time of enrollment in Medicaid providers receive notification of the rate codes and rate amounts assigned to their category of service Any time that rate codes or amounts change providers also receive notification from the Department of Health Value Code Code 24 should be used to indicate that a rate code is entered under Amount Value Amount Enter the rate code that applies to the service rendered The four digit rate code must be entered to the left of the dollars cents delimiter The example in Exhibit 2 4 2 8 illustrates a correct rate code entry Exhibit 2 4 2 8 Medicare I
29. age of the remittance advice at the end of the claim detail section OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 36 of 45 REMITTANCE ADVICE 3 5 3 Subtotals Totals Grand Totals Subtotals of dollar amounts and number of claims are provided as follows Subtotals bv claim status appear at the end of the claim listing for each status The subtotals are broken down bv 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 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 37 of 45 ADVICE 3 6 Section Four Financial Transactions and Accounts Receivable This section has two subsections Financial Transactions Accounts Receivable 3 6 1 Financial Transactions
30. aper Claims Since the information entered on the claim form is captured via an automated data collection process imaging it is imperative that it be legible and placed appropriately in the required fields The following guidelines will help ensure the accuracy of the imaging output All information should be typed or printed Alpha characters letters should be capitalized Numbers should be written as close to the example below in Exhibit 2 2 1 1 as possible Exhibit 2 2 1 1 e Circles the letter O the number 0 must be closed e Avoid unfinished characters See the example in Exhibit 2 2 1 2 Exhibit 2 2 1 2 Written As Intended As Interpreted As j felele 6 00 16 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 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 6 of 45 m CLAIMS SUBMISSION Exhibit 2 2 1 3 Intended As Interpreted As lwointerpreted as seven Ihreeinterpreted 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 Entrv cannot be 23 illeqible interpreted properly Donot write between lines Do not use arrows or quotation marks to duplicate in
31. 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 AFTEM CITY HOME CARE 111MAIN ST ANYTOWN NY 11111 DICAID HAAR OCM CAT _ J INFORMATION amp YBTEM MEDICAL ASSISTANCE TITLE XIX PROGRAM CHECKS DRAWN ON John Smith an BAN STATE STREET RANT AW OR 12507 ila tel BEL al OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 22 0f 45 REMITTANCE ADVICE 3 1 1 Medicaid Check Stub Field Descriptions Upper Left Corner Provider s name as recorded in the Medicaid files Upper Right Corner Date on which the remittance advice was issued Remittance number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Medicaid Provider ID NPI Date Provider s Name Address 3 1 2 Medicaid Check Field Descriptions Left Side Table Date on which the
32. dvice 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 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 25 of 45 REMITTANCE ADVICE 3 3 Section One Summout No Payment A summout is produced when the provider has no positive total payment for the cycle and therefore there is no disbursement of moneys Exhibit 3 3 1 TO CITY HOME CARE DATE 05 31 2010 rn IC A REMITTANCE NO 07080800001 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 OFFICE OF MENTAL HEALTH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 26 of 45 ADVICE 3 3 1 Summout No Pavment 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 Notification that no pavment was made for the cvcle
33. equirements error report information and communication specifications This document is available at www emedny org by clicking on the link to the web page as follows Companion Guides and Sample Files Further information about electronic claim pre requirements is available at www emedny org by clicking on the link to the webpage as follows Information for All Providers OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 5 of 45 m CLAIMS SUBMISSION 2 2 Paper Claims OMH Certified Rehabilitation Services 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 OMH Certified Rehabilitation Services 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 4 General Instructions for Completing P
34. formation Do not use the dollar sign 5 to indicate dollar amounts do not use commas to separate thousands For example three thousand should be entered as 3000 not as 3 000 For writing it is best to use a felt tip pen with a fine point Avoid ballpoint pens that skip do not use pencils highlighters or markers Only blue or black ink is acceptable if filling in information through a computer ensure that all information is aligned properly and that the printer ink is dark enough to provide clear legibility e Do not submit claim forms with corrections such as information written over correction fluid or crossed out information If mistakes are made a new form should be used Separate forms using perforations do not cut the edges Do not fold the claim forms Do not use adhesive labels for example for address do not place stickers on the form eee 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 NV 12144 4601 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 7 0f 45 CLAIMS SUBMISSION 2 3 UB 04 Claim Form To view a sample OMH Certified Rehabilitation Services UB 04 claim form see Appendix A The displaved claim form is a sample and the information it contains is for illustration purposes oniv The UB 04 CMS 1450 is a CMS standard form therefore CSC
35. ines B and C blank 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 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 N numeric character For example AB12345C OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 18 of 45 m CLAIMS SUBMISSION The Medicaid Client ID sho
36. lects 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 OMH Certified Rehabilitation 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 illustrates a correct Patient Participation entry OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 16 of 45 CLAIMS SUBMISSION Exhibit 2 4 2 10 39 VALUE CODES CODE AMOUNT Pa 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 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 NOTE
37. newal information when their Certification Statement is near expiration Information about these requirements is available at www emednv 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 OMH Certified Rehabilitation Services providers who choose to submit their Medicaid claims electronically are required to use the HIPAA 837 Institutional 8371 transaction Direct billers should also refer to the sources listed below to comply with the NYS Medicaid requirements HIPAA 8371 Implementation Guide IG explains the proper use of the 8371 standards and program specifications This document is available at www wpc edi com hipaa NYS Medicaid 8371 Companion Guide CG is a subset of the IG which provides instructions for 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 r
38. nformation 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 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 14 of 45 CLAIMS SUBMISSION Value Code lf applicable enter the appropriate code from the UB 04 manual Form Locator 39 41 to indicate that one or more of the following items is entered under Amount Medicare Deductible A1orB1 Medicare Co insurance A2or B2 Medicare Co pavment A7orB7 Enter code 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
39. nk to the webpage as follows Information for All Providers Date of Service Rules For monthly and semi monthly rate codes the date of service should be as follows Monthly Full month 21 Days in residence with 4 services delivered The date of service must be the first day of the month subsequent to the month in which the services were rendered Semi Monthly 1st half 11 Days in residence with 2 services delivered The patient must be admitted prior to the 11th day of the month The date of service is the first day of the subsequent month Semi Monthly 2nd half 11 Days in residence with 2 services delivered The patient must be admitted on or after the 11th day of the month The date of service is the 2nd day of the subsequent month OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 11 of 45 9 SUBMISSION If the patient loses eligibility before the first of the month subsequent to the service month the date on which the last of the required face to face contacts was made should be entered as service date Providers are required to verify patient eligibility through MEVS in order to ensure payment The discharge day will not count toward the 11 days or 21 days required for semi monthly and monthly billings respectively Also patient days in a hospital or any Medicaid reimbursable facility will not count toward days in residence within these licensed residential
40. on is intended to familiarize the provider with the submission of crossover claims Providers can bill claims for Medicare Medicaid patients to Medicare Medicare will then reimburse its portion to the provider and the provider s Medicare remittance will indicate that the claim will be crossed over to Medicaid Claims for services not covered by Medicare should continue to be submitted directly to Medicaid as policy allows Also Medicare Part C Medicare Managed Care and Medicare Part D claims are not part of this process Providers are urged to review their Medicare remittances for crossovers beginning December 1 2009 to determine whether their claims have been crossed over to Medicaid for processing Any claim that was indicated by Medicare as a crossover should not be submitted to Medicaid as a separate claim If the Medicare remittance does not indicate the claim has been crossed over to Medicaid the provider should submit the claim directly to Medicaid Claims that are denied by Medicare will not be crossed over Medicaid will deny claims that are crossed over without a Patient Responsibility OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 8 of 45 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 void
41. s identified by the value 7 in the third position of Form Locator 4 Type of Bill and the claim to be adjusted is identified by the TCN entered in this field Form Locator 64 Adjustments cause the correction of the adjusted information in the claim history records as well as the cancellation of the original claim payment and the re pricing of the claim based on the adjusted information Voids A void is submitted to nullify a paid claim The void must be submitted in a new claim form copy of the original form is unacceptable and all applicable fields must be completed A void is identified by the value 8 in the third position of Form Locator 4 Type of Bill and the claim to be voided is identified by the TCN entered in this field Form Locator 64 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 OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 19 of 45 CLAIMS SUBMISSION 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
42. s the provider submitted claim in this scenario Providers mav submit adjustments to Medicaid for their crossover claims because thev 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 emednv org clicking on the link to the webpage as follows Provider Enrollment Forms NOTE For crossover claims the Locator Code will default to 003 if zip 4 does not match information in the provider s Medicaid file 2 4 2 UB 04 Claim Form Field Instructions Provider Name Address and Telephone Number Form Locator 1 Enter the billing provider s name and address using the following rules for submitting the ZIP code Paper claim submissions Enter the five digit ZIP code or the ZIP plus four Electronic claim submissions Enter the nine digit ZIP code The Locator Code will default to 003 if the nine digit ZIP code does not match information in the provider s Medicaid file NOTE It is the responsibility of the provider to notify 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
43. 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 A3 or B3 should be used to indicate that the amount paid by an insurance carrier other than Medicare is entered under Amount The line A or B assigned to the Insurance Carrier in Form Locator 50 determines the choice of codes A3 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 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 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 OFF
44. uld 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 Document Control Number Form Locators 64 A B C Leave this field blank when submitting an original claim or a resubmission of a denied claim If submitting an Adjustment Replacement or a Void to a previously paid claim this field must be used to enter the Transaction Control Number TCN assigned to the claim to be adjusted or voided The TCN is the claim identifier and is listed in the Remittance Advice If a TCN is entered in this field the third position of Form Locator 4 Type of Bill must be 7 or 8 The TCN must be entered in the line A B or C that matches the line assigned to Medicaid in Form Locators 50 and 57 If the TCN is entered in lines B or C the word NONE must be written on the line s above the TCN line Adjustments An adjustment is submitted to correct one or more fields of a previously paid claim Any field except the Provider ID number or the Patient s Medicaid ID number can be adjusted The adjustment must be submitted in a new claim form copy of the original form is unacceptable and all applicable fields must be completed An adjustment i
45. webpage as follows OMH Certified Rehabilitation Services Manual Patient Control Number Form Locator 3a For record keeping purposes the provider may choose to identify a patient by using an account patient control number This field can accommodate up to 30 alphanumeric characters If an account patient control number is indicated on the claim form the first 20 characters will be returned on the paper Remittance Advice Using an account patient control number can be helpful for locating accounts when there is a question on patient identification OFFICE OF MENTAL HEALTH OMH CERTIFIED REHABILITATION SERVICES Version 2010 01 5 31 2010 Page 9 of 45 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 Z 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

eMedNY Subsystem User Manual

Contents

Download Pdf Manuals

Related Search

Related Contents