eMedNY Subsystem User Manual
Contents
1. arar 29 3 4 Section TWO Provider NotiiCatiON uuu l iama E 30 3 4 1 Provider Notification Field Descriptions 31 3 5 SECTION Whee peu 32 3 5 1 Claim Detail Page Field r r 36 3 5 2 Explanation of Claim Detail Columns a 36 3 5 3 Subtotals Totals Grand Totals a rrarsrnrrsssssssssssssssssssssssssssssssssnsssssssssssssssssssssasssssa 38 3 6 Section Four Financial Transactions and Accounts Receivable 40 3 6 1 Financial Transactions 40 42 3 7 Section Five Edit Error l u u n 44 Appendix A Claim 138 21 5 ull u 45 RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 2 of 47 _ CLAIMS SUBMISSION For eMedNY Billing Guideline questions please contact the eMedNY Call Center 1 800 343 9000 RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 3 of 47 eee PURPOSE STATEMENT 1 Purpose Statement The purpose of this document is to assist the provider community in understanding and complying with the New2. TION E w MEDICAL ASSISTANCE TITLE XIX PROGRAM ABC RESIDENTIAL HEALTH CAR nais E EIMAN STREET REMITTANCE STATEMENT FINANCIAL TRANSACTIONS ANYTOWN NEW YORK 11111 PROY ID 0012345 122456 7890 REMITTANCE NO O7 020000001 FINANCIAL FISCAL Oh TRANS DATE AMOUNT RECOUPMENTREASON DESCRIPTION 05 08 10 REAS ON CODE 2010050502 2004 T PTT NET FINANCIAL AMOUNT TERT NUMBER OF FINANCIAL TRANSACTIONS XXX RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 40 of 47 REMITTANCE ADVICE 3 6 1 1 Explanation of Financial Transactions Columns FCN The Financial Control Number FCN is a unique identifier assigned to each financial transaction Financial Reason Code This code is for DOH CSC use only it has no relevance to providers It identifies the reason for the recoupment Financial Transaction Type This is the description of the Financial Reason Code For example Third Party Recovery Date The date on which the recoupment was applied Since all the recoupments listed on this page pertain to the current cycle all the recoupments will have the same date Amount The dollar amount corresponding to the particular fiscal transaction This amount is deducted from the provider s total 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
3. New York State Electronic Medicaid System B04 Billing Guidelines RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 TT TABLE OF CONTENTS TABLE OF CONTENTS 1 lbs EE 4 2 Clamis uu MM 5 2 1 Fl CI O NG C p uu u 5 2 2 lai y ua u uuu 6 2 2 1 General Instructions for Completing Paper 6 2 3 a ESI edi u o mu u u uuu 8 2 4 Residential Health Care Services Billing 8 2 4 1 Instructions for the Submission of Medicare Crossover 8 242 UB O4 Claim Form Field Instructions 9 3 Explanation of Paper Remittance Advice 5 23 3 1 Section One NiedicalidCh ecku uuu uu 24 31 1 Medicaid Check St b Field cecus dise cece toe ee 25 3 1 2 Medicaid Check Field Descriptions l 25 3 2 Section One ERE TREE 26 3 2 1 EFT Notification Page Field r 27 3 3 Section One SUMMOUT NO Payment oseca 28 3 3 1 Summout No Payment Field Descriptions
4. 2 3 Exhibit 2 4 2 3 4T PE OF BILL RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 10 of 47 CLAIMS SUBMISSION Statement Covers Period From Through Form Locator 6 When billing for one date of service enter the same date in the FROM and THROUGH boxes or leave the THROUGH box blank When billing for multiple dates of service enter the first service date of the billing period in the FROM box and the last service date in the THROUGH box The first and last service dates must be in the same calendar month Dates must be entered in the format MMDDYYYY Non Occupant Care In order to properly identify each date of service the FROM and THROUGH dates must be inclusive All services included in the FROM and THROUGH fields must indicate the same number of hours and must be for consecutive days within the same month If services rendered do not have a consistent number of hours scheduled for any given period then each service day must be billed separately NOTES Claims must be submitted within 90 days of the date of service entered in this field unless acceptable circumstances for the delay can be documented Information about billing clqims over 90 days or two years from the Date of Service is available in the All Providers General Billing Guideline Information section available at www emedny org by clicking on the link to the webpage as follows Information for All Providers not include full days cove
5. 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 collects the insurance benefits and fails to submit payment to the provider The LDSS must be notified so that sanctions and or legal action can be brought against the patient or absent parent The provider is instructed to zero fill by the LDSS for circumstances not listed above The example in Exhibit 2 4 2 8 illustrates a correct Other Insurance Payment entry Exhibit 2 4 2 8 99 VALUE CODES CODE AMOUNT 100 00 Medicaid Covered Days Value Code 80 Value Code Code 80 should be used to indi
6. 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 Residential Health Care Services Billing Instructions This subsection of the Billing Guidelines covers the specific NYS Medicaid billing requirements for Residential Health Care providers Although the instructions that follow are based on the UB 04 paper claim form they are also intended as a guideline for electronic billers to find out what information they need to provide in their claims in addition to the HIPAA Companion Guides which are available at www emedny org by clicking on the link to the webpage as follows eMedNY Companion Guides and Sample Files It is important that providers adhere to the instructions outlined below Claims that do not conform to the eMedNY requirements as described throughout this document may be rejected pended or denied 2 4 1 Instructions for the Submission of Medicare Crossover Claims This subsection is intended to familiarize the provider with the submission of crossover claims Providers can bill claims for Medicare Medicaid patients to Medicare Medicare will then reimburse its portion to the provider and the provider s Medicare remittance will indicate that the claim will be crossed over to Medicaid Claims for services not covered by Medicare should continue to be submitted directly to Medicaid as policy allows Also Medicare P
7. 345C gt m gt 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME ra omer DN wei 1234567890 T Last SMITH First SMITH RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 46 of 47 EMEDNY INFORMATION eMedNY is the name of the electronic New York State Medicaid system The eMedNY system allows New York Medicaid providers to submit claims and receive payments for Medicaid covered services provided to eligible clients eMedNY offers several innovative technical and architectural features facilitating the adjudication and payment of claims and providing extensive support and convenience for its users CSC isthe 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 RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 47 of 47
8. AL HEALTH CARE Page 44 of 47 5 31 2010 APPENDIX A CLAIM SAMPLES APPENDIX A CLAIM SAMPLES The eMedNY Billing Guideline Appendix A Claim Samples contains images of claims with sample data RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 45 of 47 APPENDIX A CLAIM SAMPLES Residential Health UB 04 Sample Claim APPROVED OMB NO 0938 0279 3a PAT CNTL AB1234567 4 TYPE OF BILL b MED RECS Anytown 11111 STATEMENT COVERS PERIOD 04012007 PATIENTNAME T 3 SPATEENTADDRESS T s 5 WILLIAM mL 12 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 STATE o Up upa 31 OCCURRENCE OCCURRENCE OCCURRENCE M OCCURRENCE 35 OCCURRENCE SPAN OCCURRENCE SPAN CODE DATE CODE DATE CODE DATE COD 3 DATE CODE FROM THROUGH CODE FROM THROUGH 1 Anytown Residence a Y c ow a LL l L ae Se 38 VALUE CODES VALUE CODES 41 VALUE CODES E AMOUNT AMOUNT CODE AMOUNT 10 0 4 wo 10 1 2 j 4 9 6 f 8 9 11 19 21 22 12 13 14 15 16 1 18 29 RS AS N lt lt lt s lt e d QG N C TOTALS seem Blue Cross Medicaid OTHER PRV ID 58 INSURED S NAME D9PREIU60 INSURED S UNIQUE ID GROUP NAME 62 INSURANCE GROUP NO 81GROUPNAME A None B AB12
9. ANCE STATEMENT al ee REPTED 2115 0 Mme Uu DAYS Lo INSURANCE DAYS DAYS PAYMENT 7 22 0 00 0 387 81 2 00 2 387 81 00 0 387 81 00 0 387 81 2 00 2 288 77 0 0 00 0 00 0 00 0 00 0 00 1551 24 E2 04 0 00 E2 04 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS RESIDENTIAL HEALTH CARE Page 33 of 47 FATIENT PARTICIPATION REPORTED C DEDUCTED 1 1 OTHER 0 00 0 00 0 00 0 00 0 00 0 00 PAGE 03 DATE 05 31 10 CYCLE 1710 ETIN NURSING HOME PROV ID Q0122455 12245578530 REMITTANCE OF 020500007 AMOUNT INSURANCE CHARGED AMOUNT STATUS ERRORS FAID 387 81 287 81 287 81 287 81 287 81 287 81 387 81 287 81 387 81 ADJT ORIGINAL CLAIM 387 81 PAID 08 11 2010 298 77 298 77 FAID FAID PAID ADJT PREVIOUSLY PENDED CLAIM NEW PEND 5 31 2010 CLIENT NAME ID NUMBER SAMPLE XX12345X EXAMPLE XXBTEXIX TO ABC RESIDENTIAL HEALTH CARE 123 MAIN STREET NEW YORK 11111 PATIENT ACCOUNT NUMBER OF AMR 1 12 3 0 CFIC1 20387 5 OTA 1 1 1 0 CFIC1 20345 5 TOTAL AMOUNT ORIGINAL CLAIMS MET AMOUT ADJUSTMENTS MET AMOUNT VOIDS NET AMOUNT VOIDS ADJUSTS Exhibit 3 5 3 DICAID AL CHE INTE RIT INFORMATION MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT SERVICE DATES FROM THR
10. H CARE 123 MAIN ST ANY TOWN NY 11111 ABC RESIDENTIAL HEALTH CARE 51452 20 PAYMENT IN THE ABOVE AMOUNT WILL BE DEPOSITEDVIA AM ELECTRONIC FUNDS TRANSFER RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 26 of 47 REMITTANCE ADVICE 3 2 1 EFT Notification Page Field Descriptions Upper Left Corner Provider s name as recorded in the Medicaid files Upper Right Corner Date on which the remittance advice was issued Remittance number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Medicaid Provider ID NPI Date Provider s Name Address Provider s Name Amount transferred to the provider s account This amount must equal the Net Total Paid Amount under the Grand Total subsection plus the total sum of the Financial Transaction section RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 27 of 47 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 ABC RESIDEHTIAL HEALTH CARE DATE 05 31 2010 1 77 MANAGEMENT INFORMATION amp tYSTEM HO PAYMENT WILL BE RECEIVED THIS CYCLE SEE REMITTANCE FOR DETAILS ABC RESIDENTIAL HEALTH CARE 123 MAIN ST ANYT OWN NY 11111 RESIDENTIAL HEALTH CARE Version 2010 01 Page 28 of 47 5 31 2010 REMITTANCE ADVICE 3 3 1 Summout No Payment Field De
11. IAL HEALTH CARE Version 2010 01 5 31 2010 Page 24 of 47 REMITTANCE ADVICE 3 1 1 Medicaid Check Stub Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Date on which the remittance advice was issued Remittance Number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Medicaid Provider ID NPI Date Provider s Name Address 3 1 2 Medicaid Check Field Descriptions Left Side Table Date on which the check was issued Remittance Number Provider ID No This field will contain the Medicaid Provider ID and the NPI Provider s Name Address Right Side Dollar amount This amount must equal the Net Total Paid Amount under the Grand Total subsection plus the total sum of the Financial Transaction section RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 25 of 47 REMITTANCE ADVICE 3 2 Section One EFT Notification For providers who have selected electronic funds transfer or direct deposit an EFT transaction is processed when the provider has claims approved during the cycle and the approved amount is greater than the recoupments if any scheduled for the cycle This section indicates the amount of the EFT Exhibit 3 2 1 TO ABC RESIDENTIAL HEALTH CARE DICAID 247E 2531 219 REMITTANCE NO 07080800001 MANAGEMENT PROV ID 001234561 23 4567 e90 INFORMATION SYSTEM 00123456 0123456709 05 31 2010 ABC RESIDENTIAL HEALT
12. IAL HEALTH CARE Version 2010 01 5 31 2010 Page 14 of 47 _ CLAIMS SUBMISSION Patient Participation NAMI Value Code 23 Value Code Code 23 should be used to indicate that the patient s Net Available Monthly Income NAMI amount is entered under Amount Value Amount Enter the NAMI amount approved by the local Social Services agency as the patient s monthly budget In cases where the patient s budget has increased the new amount rather than the current budgeted amount should be entered If billing occurs more than once a month enter the full NAMI amount on the first claim submitted for the month as illustrated in Exhibit 2 4 2 7 Exhibit 2 4 2 7 VALUE CODES CODE AMOUNT s ow _ NOTE For retroactive NAMI changes an adjustment to the previously paid claim needs to be submitted These adjustments can only be submitted when approval for a budget change has been received from the LDSS Other Insurance Payment Value Code A3 or B3 If the patient has insurance other than Medicare it is the responsibility of the provider to determine whether the service being billed for is covered by the patient s Other Insurance carrier If the service is covered or if the provider does not know if the service is covered the provider must first submit a claim to the Other Insurance carrier as Medicaid is always the payer of last resort Value Code If applicable code A3 or B3 should be used to indicate that the amou
13. Locator 63 If the service requires Prior Approval enter the 11 digit Prior Approval number here The Prior Approval must be entered on the line A B or C that corresponds to the line assigned to Medicaid in Form Locators 50 and 57 If the Prior Approval number is entered on lines B or C the word NONE must be written in the line s above the Prior Approval line Leave this field blank if the service does not require Prior Approval RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 20 of 47 CLAIMS SUBMISSION NOTE For information regarding how to obtain Prior Approval Authorization for specific services please refer to www emedny org by clicking on the link to the webpage as follows Residential Health Manual Document Control Number Form Locators 64 A B C Leave this field blank when submitting an original claim or a resubmission of a denied claim If submitting an Adjustment Replacement or a Void to a previously paid claim this field must be used to enter the Transaction Control Number TCN assigned to the claim to be adjusted or voided The TCN is the claim identifier and is listed in the Remittance Advice If a TCN is entered in this field the third position of Form Locator 4 Type of Bill must be 7 or 8 The TCN must be entered in the line A B or C that matches the line assigned to Medicaid in Form Locators 50 and 57 If the TCN is entered in lines B or C the word NONE must be written on the line s abov
14. NSURANCE DAYS PAYMENT NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS RESIDENTIAL HEALTH CARE Page 32 of 47 MEDICAL ASSISTANCE TITLE XIX PROGRAM ra PAGE 02 0 31 10 CYCLE 1710 ETIN NURSING HOME PROV ID 00122456 1234567830 REMITTANCE O7 020500001 OTHER AMOUNT INSURANCE CHARGED AMOUNT STATUS ERRORS PAID 0 00 STET DENY 010220102 0 00 0 00 387 81 DENY 01023 0 00 PREVIOUSLY PENDED CLAIM NEW PEND 5 31 2010 REMITTANCE ADVICE TO 123 MAIN STREET ANYTOWN NEW YORK 11111 CLIENT NAME ID NUMBER NUMBER SAMPLE XX12345X EXAMPLE XXBT220X MODEL XXSBT55X SPECIMEN XX87654X STANDARD DOE XX65422X 17206 000000112 23 0 CPIC 1 00987 6 07206 000000111 1 0 CPIC1 00245 5 07206 000332456 0 0 CPIC1 00542 5 07206 004445555 0 0 CPIC1 00321 5 07205 007776546 0 1 CPIC1 00555 5 07205 007776546 0 2 CPIC1 00444 5 TOTAL AMOUNT ORIGINAL CLAIMS NET AMOUT ADJUSTMENTS NET AMOUNT VOIDS TCN PATIENT ACCOUNT MES mE MEDICAL ASSISTANCE TITLE AIA PROGRAM ABC RESIDENTIAL HEALTH CARE SERVICE DATES FROM THRU DATA 10 ORC 1 0 04 06 10 05 02 10 O5 0O5 10 05 02 10 OO 10 05 02 10 DO 10 05 02 10 O57 10 NET AMOUNT VOIDS ADJUSTS Version 2010 01 FAID PAID PAID RATE CODE 381 381 381 381 0 0 0 0 Exhibit 3 5 2 DIC AID MANAGEMENT REMITT
15. OTALS ANYTOWN NEW YORK 11111 REMITTANCE STATEMENT PROV ID 00122456 1224567890 REMITTANCE O7 020000007 REMITTANCE TOTALS GRAND TOTALS VOIDS ADJUSTS 83 04 NUMBER OF CLAIMS TOTAL PENDS 775 62 NUMBER OF CLAIMS TOTAL PAID 1551 24 NUMBER OF CLAIMS TOTAL DENY 775 62 NUMBER OF CLAIMS NETTOTAL PAID 1462 20 NUMBER OF CLAIMS Fi ks On M RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 35 of 47 REMITTANCE ADVICE 3 5 1 Claim Detail Page Field Descriptions Upper Left Corner Provider s Name Address Upper Right Corner Remittance page number Date The date on which the remittance advice was issued Cycle number The cycle number should be used when calling the eMedNY Call Center with questions about specific processed claims or payments ETIN not applicable Provider Service Classification NURSING HOME PROV ID This field will contain the Medicaid Provider ID and the NPI Remittance Number 3 5 2 Explanation of Claim Detail Columns Client Name ID Number This column indicates the last name of the patient first line and the Medicaid Client ID second line If an invalid Medicaid Client ID was entered in the claim form the ID will be listed as it was submitted but no name will appear in this column TCN Patient Account Number The TCN first line is a unique identifier assigned to each claim that is processed If a Patient Account Number was entered in the claim form that number up to 20 characters wi
16. TO ENROLL IM EFT PROVIDERS MUST COMPLETE AN EFT ENROLLMENT FORM THAT FOUND AT WWWEMEDNY ORG CLICK ON PROVIDER ENROLLMENT FORMS WHICH CAN BE FOUND IM THE FEATURED LINKS SECTION DETAILED INSTRUCTIONS WILL AL SO BE FOUND THERE AFTER SENDING THE EFT ENROLLMENT FORM TO CSC PLEASE ALLOW A MINIMUM TIME OF SIX TO EIGHT WEEKS FOR PROCESSING DURIMG THIS PERIOD OF TIME YOU SHOULD REVIEW YOUR BANK STATEMENTS AND LOOK FOR AM 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 AN Y 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 OF THE SPECIFIC INDIVIDUAL S TO WHOM IS ADDRESSED THIS INFORMATION MAY ONLY BE USED OR DISCLOSED IN ACCORDANCE WITH LAW AND YOU MAY BE SUBJECT TO PENALTIES UNDER LAW FOR IMPROPER USE OR FURTHER DISCLOSURE OF INFORMATION IN THIS COMMUNICATION AND ATTACHMENTS IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR PLEASE IMMEDIATELY NOTIFY NWYHIPPADESK CSC COM OR CALL 1 800 541 2831 PROVIDERS WHO DO HAVE ACCESS E MAIL SHOULD CONTACT 1 800 343 9000 RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 30 of 47 REMITTANCE ADVICE 3 4 1 Provider Notification Field Des
17. U PEND PEND PEND REMITTANCE TOTALS NURSING HOME YOIDS ADJUSTS TOTAL TOTAL PAID TOTAL DENY NET TOTAL PAID MEMBER ID 12345578 VOIDS ADJUSTS TOTAL PENDS TOTAL PAID TOTAL DENY NET TOTAL PAID Version 2010 01 RATE CODE 3810 3810 REFTED CALC ED DAYS _ 0 00 0 00 0 00 775 62 1551 24 775 62 1462 20 83 04 1551 24 775 62 1462 20 FULL DAYS PATIENT CO INSURANCE DAYS PAYMENT 255 5120 DEDUCTED 0 00 0 00 0 00 0 0 00 0 00 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS RESIDENTIAL HEALTH CARE Page 34 of 47 PARTICIPATION Ri Rl OTHER INSURANCE 0 00 0 00 REMITTANCE ADVICE PAGE 24 DATE 05 31 10 CYCLE i710 ETIN NURSING HOME PROV ID 00123456 122450753 REMITTANCE 07050500001 AMOUNT CHARGED 387 81 0 00 387 81 0 00 STATUS ERRORS PEND 0016200971 PEND 01131 PREVIOUSLY PENDED CLAIM ZHEW PEND 5 31 2010 REMITTANCE ADVICE Exhibit 3 5 4 PAGE 05 DATE 05 21 10 CYCLE 1710 MAM AEM F T I FORMATION M ETIN TO ABC RESIDENTIAL HEALTH CARE MEDICAL ASSISTANCE TITLE XIX PROGRAM NURSING HOME 23 MAIN STREET RAITT A CT ha GRAND T
18. 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 Residential Health Care providers and should be used by the provider as an instructional as well as a reference tool For providers new to NYS Medicaid it is required to read the All Providers General Billing Guideline Information available at www emedny org by clicking on the link to the webpage as follows Information for All Providers RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 4 of 47 C SUBMISSION 2 Claims Submission Residential Health Care providers can submit their claims to NYS Medicaid in electronic or paper formats Providers are required to submit an Electronic Paper Transmitter Identification Number ETIN Application and Certification Statement before submitting claims to NYS Medicaid Certification Statements remain in effect and apply to all claims until superseded by another properly executed Certification Statement Providers will be asked to update their Certification Statement on an annual basis Providers will be provided with renewal information when their Certification Statement is near expiration Information about these requirements is available at www emedny org by clicking on the link to the webpage as follows Information for All Providers 2 1 Electronic Claims P
19. arges entered in the claim form appear first under this column If the claim was approved the amount paid appears underneath the charges If the claim has a pend or deny status the amount paid will be zero 0 00 Status This column indicates the status DENY PAID ADJT VOID PEND of the claim line Denied Claims Claims for which payment is denied will be identified by the DENY status A claim may be denied for the following general reasons The service rendered is not covered by the New York State Medicaid Program The claim is a duplicate of a prior paid claim The required Prior Approval has not been obtained Information entered in the claim form is invalid or logically inconsistent Approved Claims Approved claims will be identified by the statuses PA D ADJT adjustment or VO D Paid Claims The status PAID refers to origina claims that have been approved RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 37 of 47 REMITTANCE ADVICE Adjustments The status ADJT refers to a claim submitted in replacement of a paid claim with the purpose of changing one or more fields An adjustment has two components the credit transaction previously paid claim and the debit transaction adjusted claim Voids The status VOID refers to a claim submitted with the purpose of canceling a previously paid claim A void lists the credit transaction previously paid claim only Pending Claims Claims that req
20. art 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 RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 8 of 47 CLAIMS SUBMISSION If a separate claim is submitted directly by the provider to Medicaid for a dual eligible recipient and the claim is paid before the Medicare crossover claim both claims will be paid The eMedNY system automatically voids the provider submitted claim in this scenario Providers may submit adjustments to Medicaid for their crossover claims because they are processed as a regular adjustment Electronic remittances from Medicaid for crossover claims will be sent to the default ETIN when the default is set to electronic If there is no default ETIN the crossover claims will be reported on a paper remittance The ETIN application is available at www emedny org by clicking on the link to the webpag
21. ayers are classified into three main categories Medicare Commercial any insurance other than Medicare and Medicaid Medicaid is always the payer of last resort Complete this field in accordance with the following instructions Direct Medicaid Claim No Third Party Involved Enter the word Medicaid on line A of this field Leave lines B and C blank Medicaid Third Party Other Than Medicare Claim Enter the name of the Other Insurance Carrier on line A of this field Enter the word Medicaid on line B of this field Leave line C blank NPI Form Locator 56 Enter the provider s 10 digit National Provider Identifier NPI Other Prv ID Other Provider ID Form Locator 57 Leave this field blank Insured s Unique ID Form Locator 60 Enter the patient s ID number Client ID number This information may be obtained from the Client s Patient s Common Benefit ID Card Medicaid Client ID numbers are assigned by the State of New York and are composed of eight characters in the format AANNNNNA where A alpha character and N numeric character For example AB12345C The Medicaid Client ID should be entered on the same line A B or C that matches the line assigned to Medicaid in Form Locators 50 and 57 If the patient s Medicaid Client ID number is entered on lines B or C the lines above the Medicaid ID number must contain either the patient s ID for the other payer s or the word NONE Treatment Authorization Codes Form
22. blank if the entry in Form Locator 17 Patient Status indicates that the patient is still a patient or is on therapeutic leave 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 The ICD 9 CM code must be entered exactly as it is listed in the manual The remaining Form Locators labeled A Q may be used to indicate secondary diagnosis information RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 21 of 47 CLAIMS SUBMISSION NOTE Three digit and four digit diagnosis codes will be accepted only when the category has no subcategories Principal Procedure Form Locator 74 Leave this field blank Other Form Locator 78 NYS Medicaid uses this field to report the Referring Destination Previous Provider Complete this field only if an admission or a discharge other than to home or self care occurred during the service period covered by this statement Form Locator 6 If no admission or discharge occurred or if the patient was discharged to home or self care leave this field blank For an admission Enter the NPI of the referring practitioner who determined that residential care was appropriate NOTE If the patient is admitted from home enter the NPI of the physician who last examined the patient and determined that ICF DD nursing home care was appropriate See instructions fo
23. cate the total number of days that are covered by Medicaid If only co insurance days are claimed do not report code 80 RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 16 of 47 _ CLAIMS SUBMISSION Value Amount Enter the actual amount of days covered by Medicaid The sum of Medicaid Full covered days Medicaid non covered days and Medicare co insurance days must correspond to the Statement Covers Period in Form Locator 6 and should not reflect the day of discharge The Covered Days must be entered to the left of the dollars cents delimiter The example in Exhibit 2 4 2 9 illustrates a correct Medicaid Covered Days entry Exhibit 2 4 2 9 VALUE CODES CODE AMOUNT Medicaid Non Covered Days Value Code 81 Value Code Code 81 should be used to indicate the total number of full days that are not reimbursable by Medicaid or any other third party This does not include full days covered by Medicare or other third party insurers Value Amount Enter the actual number of days non covered by Medicaid The sum of Medicaid full covered days Medicaid non covered days and Medicare co insurance days must correspond to the Statement Covers Period in Form Locator 6 and should not reflect the day of discharge The Non Covered Days must be entered to the left of the dollars cents delimiter NOTE For non resident health care patients non covered days are those days occurring within the service period on which health car
24. ce 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 RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 23 of 47 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 PA AG EP E INFORM ATION SYSTEM TO ABC RESIDENTIAL HEALTH CARE DATE 2010 05 31 REMITTANCE NO 07080600001 PROV ID 00123456 123436 7 890 00123456 1234567590 2010 05 31 ABC RESIDENTIAL HEALTH CARE 123 MAIN ST ANYTOWN NY 11111 YOUR CHECK IS BELOW TO DETACH TEAR ALONG PERFORATED DASHED LINE DOLLARS CENTS REMITTANCE PROVIDER ID NUMBER 1 0 0 2010 05 31 07080600001 00123456 0123456789 AFTER 90 DATZ ABC RESIDENTIAL HEALTH CARE 423MAIN ST ANYTOWN NY 11111 D JICAI LP INF FORMATION TFE inc MEDICAL ASSISTANCE TITLE XIX PROGRAM CHECKS DRAWN ON John Smi th KEY BANK NA 50 STATE STREET bea NEM YORE 12207 RESIDENT
25. criptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Remittance page number Date on which the remittance advice was issued Cycle Number ETIN not applicable Name of section PROVIDER NOTIFICATION PROV ID This field will contain the Medicaid Provider ID and the NPI Remittance number Center Message text RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 31 of 47 REMITTANCE ADVICE 3 5 Section Three Claim Detail This section provides a listing of all new claims that were processed during the specific cycle plus claims that were previously pended and denied during the specific cycle This section may also contain claims that pended previously TO ABC RESIDENTIAL HEALTH CARE 123 MAIN STREET ANYTOWN NEW YORK 11111 CLIENT SN SERVICE SLIEN PATIENTACCOUNT DATES n NUMBER FROM THRU SAMPLE 0720500000011230 08702710 XX12345X CPICT D0987 5 05 06 10 EXAMPLE 07206 000000111 1 0 05 02 10 XX67890X CPICI 00245 5 05 06 10 Exhibit 3 5 1 DICAID MANAGEMENT INFORMATION REMITTANCE STATEMENT REP TED RATE CALCED CODE DAYS E 3810 0 0 5 5 3810 5 5 TOTAL AMOUNT ORIGINAL CLAIMS DENIED TT5 52 MET AMOUT ADJUSTMENTS DENIED 0 00 NET AMOUNT VOIDS DENIED 0 00 NET AMOUNT VOIDS ADJUSTS Version 2010 01 0 00 PATIENT PARTICIPATION REPORTED DEDUCTED 0 05 0 00 009 0 00 0 00 0 00 FULL DAYS CO I
26. d If bed retention for hospitalization was not involved hospital leave is not applicable Please refer to the Residential Health Care Manual Policy Guidelines section for Bed Reservation information If applicable use Revenue Code 0185 to indicate that the number of Hospital Leave days is entered in Form Locator 46 Hospital Leave must not be claimed together with regular billing these claims must be submitted on a separate form RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 18 of 47 i CLAIMS SUBMISSION Therapeutic Leave These are overnight absences that include leave for personal reasons or to participate in medically acceptable therapeutic or rehabilitative plans of care Please refer to the Residential Health Care Manual Policy Guidelines section for Bed Reservation information If applicable use Revenue Code 0183 to indicate that the number of Therapeutic Leave days is entered in Form Locator 46 Therapeutic Leave must not be claimed together with regular billing these claims must be submitted on a separate form Serv Units Form Locator 46 If Revenue Code 0185 Hospital Leave was used in Form Locator 42 enter the total number of Hospital Leave days on the same line where the Revenue Code appears The number of units entered in this field must match the entry in Form Locators 39 41 Value Code 80 Covered Days If Revenue Code 0183 Therapeutic Leave was used in Form Locator 42 enter the total n
27. e as follows Provider Enrollment Forms NOTE For crossover claims the Locator Code will default to 003 if zip 4 does not match information in the provider s Medicaid file 2 4 2 UB 04 Claim Form Field Instructions Provider Name Address and Telephone Number Form Locator 1 Enter the billing provider s name and address using the following rules for submitting the ZIP code Paper claim submissions Enter the five digit ZIP code or the ZIP plus four Electronic claim submissions Enter the nine digit ZIP code The Locator Code will default to 003 if the nine digit ZIP code does not match information in the provider s Medicaid file NOTE It is the responsibility of the provider to notify Medicaid of any change of address or other pertinent information within 15 days of the change For information on where to direct address change requests please refer to Information for All Providers Inquiry section which can be found at www emedny org by clicking on the link to the webpage as follows Residential Health Manual Patient Control Number Form Locator 3a For record keeping purposes the provider may choose to identify a patient by using an account patient control number This field can accommodate up to 30 alphanumeric characters If an account patient control number is indicated on the claim form the first 20 characters will be returned on the paper Remittance Advice Using an account patient control number can be helpful for locating accou
28. e services were not rendered for example weekends The example in Exhibit 2 4 2 10 illustrates a correct Medicaid Non Covered Days entry Exhibit 2 4 2 10 39 VALUE CODES CODE AMOUNT P RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 17 of 47 C SUBMISSION Medicare Co Insurance Days Value Code 82 Value Code Code 82 should be used to indicate the total number of Medicare co insurance days claimed during the service period Value Amount Enter the actual number of Medicare co insurance days The sum of Medicaid full covered days Medicaid non covered days and Medicare co insurance days must correspond to the Statement Covers Period in Form Locator 6 and should not reflect the day of discharge The Co Insurance Days must be entered to the left of the dollars cents delimiter The example in Exhibit 2 4 2 11 illustrates a correct Medicare Co Insurance Days entry Exhibit 2 4 2 11 CODES CODE AMOUNT Rev Cd Revenue Code Form Locator 42 Revenue Codes identify specific accommodations ancillary services or billing calculations NYS Medicaid uses Revenue Codes to identify the following information Total Charges Title XIX Days Hospital Leave Title XIX Days Therapeutic Leave Total Charges Use Revenue Code 0001 to indicate that total charges are entered in Form Locator 47 Hospital Leave The patient was hospitalized during the billing period and bed retention was involve
29. e the TCN line Adjustments An adjustment is submitted to correct one or more fields of a previously paid claim Any field except the Provider ID number or the Patient s Medicaid ID number can be adjusted The adjustment must be submitted in a new claim form copy of the original form is unacceptable and all applicable fields must be completed An adjustment is identified by the value 7 in the third position of Form Locator 4 Type of Bill and the claim to be adjusted is identified by the TCN entered in this field Form Locator 64 Adjustments cause the correction of the adjusted information in the claim history records as well as the cancellation of the original claim payment and the re pricing of the claim based on the adjusted 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 This field must be completed upon admission of a patient if there is any change in the diagnosis including a diagnosis change for a patient on bed reservation and when a patient is discharged Leave
30. g in information through a computer ensure that all information is aligned properly and that the printer ink is dark enough to provide clear legibility e Do not submit claim forms with corrections such as information written over correction fluid or crossed out information If mistakes are made a new form should be used Separate forms using perforations do not cut the edges Do not fold the claim forms Do not use adhesive labels for example for address do not place stickers on the form Do write use staples the bar code area The address for submitting claim forms is COMPUTER SCIENCES CORPORATION P O Box 4601 Rensselaer NY 12144 4601 RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 7 of 47 i CLAIMS SUBMISSION 2 33 UB 04 Claim Form To view a sample Residential Health Care UB 04 claim form see Appendix A The displayed claim form is a sample and the information it contains is for illustration purposes only The UB 04 CMS 1450 is a CMS standard form therefore CSC does not supply it The form can be obtained from any of the national suppliers The UB 04 Manual National Uniform Billing Data Element Specifications as Developed by the National Uniform Billing Committee Current Revision should be used in conjunction with this Provider Billing Guideline as a reference guide for the preparation of claims to be submitted to NYS Medicaid The UB 04 manual is available at www nubc
31. hat corresponds to the address where the service was performed The example in Exhibit 2 4 2 5 illustrates a correct Locator Code entry Exhibit 2 4 2 5 39 VALUE CODES 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 Residential Health Manual Rate Code Value Code 24 Rates are established by the Department of Health and other State agencies At the time of enrollment in Medicaid providers receive notification of the rate codes and rate amounts assigned to their category of service Any time that rate codes or amounts change providers also receive notification from the Department of Health Value Code Code 24 should be used to indicate that a rate code is entered under Amount Value Amount Enter the rate code that applies to the service rendered The four digit rate code must be entered to the left of the dollars cents delimiter The example in Exhibit 2 4 2 6 illustrates a correct rate code entry RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 13 of 47 CLAIMS SUBMISSION Exhibit 2 4 2 6 39 CODES CODE AMOUNT 3810 In order for claims to be processed correctly it is essential that the correct Rate Code be
32. ion Locator Code required see notes for conditions Rate Code required Patient Participation only if applicable Other Insurance Payment only if applicable Medicaid Covered Days only if applicable Medicaid Non Covered Days only if applicable eec ecce Medicare Co Insurance Days 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 RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 12 of 47 CLAIMS SUBMISSION Locator codes are assigned to the provider for each service address registered at the time of enrollment in the Medicaid program or at anytime afterwards that a new location is added Value Code Code 61 should be used to indicate that a Locator Code is entered under Amount Value Amount Entry must be three digits and must be placed to the left of the dollars cents delimiter Locator codes 001 and 002 are for administrative use only and are not to be entered in this field The entry may be 003 or a higher locator code Enter the locator code t
33. laim status appear at the end of the claim listing for each status The subtotals are broken down by Original claims Adjustments Voids Adjustments voids combined eee RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 38 of 47 REMITTANCE ADVICE Totals by service classification and by member ID are provided next to the subtotals for service classification locator code These totals are broken down by Adjustments voids combined Pends Paid Deny eeee Net total paid for the specific service classification Grand Totals for the entire provider remittance advice which include all the provider s service classifications appear on a separate page following the page containing the totals by service classification The grand total is broken down by Adjustments voids combined Pends Paid Deny Net total paid entire remittance RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 39 of 47 REMITTANCE ADVICE 3 6 Section Four Financial Transactions and Accounts Receivable This section has two subsections Financial Transactions Accounts Receivable 3 6 1 Financial Transactions The Financial Transactions subsection lists all the recoupments that were applied to the provider during the specific cycle If there is no recoupment activity this subsection is not produced Exhibit 3 6 1 1 EDICAID PAGE 07 DATE 05 31 10 2 MANAGEMENT CYCLE 1710
34. ll appear under this column second line Service Dates From Through The first date of service covered by the claim From date appears on the first line the last date of service Through date appears on the second line Rate Code The four digit rate code that was entered in the claim form appears under this column RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 36 of 47 REMITTANCE ADVICE Reported Calculated Days This column has two sub columns one is labeled F full days and the other is labeled C co insurance days The number of days within the reported first FROM service date and the last THROUGH service date appear in the first line under the F sub column The number of full days calculated by the system appears in the second line under the F sub column The number of co insurance days reported on the claim form appears under the C sub column There are no calculated co insurance days Patient Participation Reported Deducted This column shows the patient participation amount NAMI as it was reported first line and as it was deducted second line If no patient participation is applicable this column will show 0 00 amount Other Insurance If applicable the amount paid by the patient s Other Insurance carrier as reported on the claim form is shown under this column If no Other Insurance payment is applicable this column will show 0 00 amount Amount Charged Amount Paid The total ch
35. nt 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 RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 15 of 47 C 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 billed if the insurance policy changes Proof of denials must be maintained in the patient s billing record Prior claims denied due to deductibles not being met are not to be counted as denials for subsequent billings In very limited situations the Local Department of Social Services LDSS has advised the provider to zero fill the Other Insurance payment for the same type of service This communication should be documented in the client s billing record The provider bills the insurance company and receives a rejection because The service is not covered or The deductible has not been
36. nts is available at www emedny org by clicking on the link to the webpage as follows Information for All Providers RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 5 of 47 _ CLAIMS SUBMISSION 2 2 Paper Claims Residential Health Care 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 Residential Health Care UB 04 claim form see Appendix A The displayed claim form is a sample and the information it contains is for illustration purposes only An Electronic Transmission Identification Number ETIN and a Certification Statement are required to submit paper claims Providers who have a valid ETIN for the submission of electronic claims do not need an additional ETIN for paper submissions The ETIN and the associated certification qualify the provider to submit claims in both electronic and paper formats Information about these requirements is available at www emedny org by clicking on the link to the webpage as follows Information for All Providers 2 2 1 General Instructions for Completing Paper Claims Since the information entered on the claim form is captured via an automated data collection process imaging it is imperative that it be legible and placed appropriately in the required fields The following guidelines will help ensure the accuracy of the imaging output All information should be typed or
37. nts when there is a question on patient identification RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 9 of 47 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 Using the UB 04 Manual Form Locator 4 Type of Facility category select the code that best describes the facility type For SNF Free Standing only use Type of Facility Code 2 Skilled Nursing Bill Classification Using the UB 04 Manual Form Locator 4 Bill Classification category select the code that best describes the type of service being claimed Frequency Adjustment Void Code New York State Medicaid uses the third position of this field on y to identify whether the claim is an original a replacement adjustment or a void If submitting an original claim enter the value 0 in the third position of this field as in Exhibit 2 4 2 1 Exhibit 2 4 2 1 4TYPE OF BILL If submitting an adjustment replacement to a previously paid claim enter the value 7 in the third position of this field as in Exhibit 2 4 2 2 Exhibit 2 4 2 2 4TYPE OF BILL If submitting a void to a previously paid claim enter the value 8 in the third position of this field as in Exhibit 2 4
38. printed Alpha characters letters should be capitalized Numbers should be written as close to the example below in Exhibit 2 2 1 1 as possible Exhibit 2 2 1 1 e Circles the letter O the number 0 must be closed Avoid unfinished characters See the example in Exhibit 2 2 1 2 e Exhibit 2 2 1 2 Written As Intended As Interpreted As f felele 6 00 6 Zero interpreted as six When typing or printing stay within the box provided ensure that no characters letters or numbers touch the claim form lines See the example in Exhibit 2 2 1 3 RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 6 of 47 _ CLAIMS SUBMISSION Exhibit 2 2 1 3 Intended As Interpreted As lwointerpreted as seven hree interpreted as two Characters should not touch each other as seen in Exhibit 2 2 1 4 Exhibit 2 2 1 4 Written As Intended As Interpreted As Pes Entry cannot be 23 illegible interpreted properly Donot write between lines Do not use arrows or quotation marks to duplicate information Do not use the dollar sign 5 to indicate dollar amounts do not use commas to separate thousands For example three thousand should be entered as 3000 not as 3 000 For writing it is best to use a felt tip pen with a fine point Avoid ballpoint pens that skip do not use pencils highlighters or markers Only blue or black ink is acceptable if fillin
39. r entering an NPI below For a discharge Enter the NPI of the practitioner who made the discharge determination 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 numbers enter the last name and first name of the provider See the example in Exhibit 2 4 2 14 Exhibit 2 4 2 14 The referring provider is John Smith with an NPI number 1234567890 78 OTHER NPL 1224567890 QUAL s LAST SMITH FIRST JOHN RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 22 of 47 ADVICE 3 Explanation of Paper Remittance Advice Sections This Section present a sample of each section of the remittance advice for Residential Health providers followed by an explanation of the elements contained in the section The information displayed in the remittance advice samples is for illustration purposes only The following information applies to a remittance advice with the default sort pattern General Remittance Advice Information is available in the All Providers General Billing Guideline Information section available at www emedny org by clicking on the 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 Noti
40. red by Medicare or other third party insurers as part of the period of service Aseparate claim must be completed if the period of service includes therapeutic or hospital leave days 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 4 that follows Exhibit 2 4 2 4 RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 11 of 47 lt lt SUBMISSION Sex Form Locator 11 Enter for male or F for female to indicate the patient s sex This information may be obtained from the Client s Patient s Common Benefit ID Card Admission Form Locators 12 15 Leave all fields blank Stat Patient Status Form Locator 17 This field is used to indicate the specific condition or status of the patient as of the last date of service indicated in Form Locator 6 Select the appropriate code except for 43 and 65 from the UB 04 Manual Condition Codes Form Locators18 28 Leave all fields blank Occurrence Code Date Form Locators 31 34 Leave all fields blank Value Codes Form Locators 39 41 NYS Medicaid uses Value Codes to report the following informat
41. rty 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 RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 43 of 47 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 TO ABC RESIDENTIAL HEALTH CARE 123 MAIN STREET AN TTOWNM NEW YORK 11111 MEDICAL ASSISTANC Exhibit 3 7 1 DICAID E TITLE XIX PROGRAM REMITTANCE STATEMENT PAGE 06 DATE 05 31 10 CYCLE 1710 ETIN NURSING HOME EDITDESCRIPTIONS PROV ID 00123456 1224567890 REMITTANCE NO 07080500001 THE FOLLOWING 15 DESCRIPTION OF THE EDIT REASON CODES THAT APPEAR ON THE CLAIMS FOR THIS REMITTANCE 00162 RECIPIENT IMELIGIBLE FOR DATE OF SERVICE 00971 RECIPIENT NOT ON LONG TERM CAE FILE 01023 HOSPITAL LEAVE NOT SEPARATE LINE 01035 MAUS DISCHARGED DESTINATION PROVIDER BLANK 01131 MEDICAID NOT ALLOWED UNTIL MEDICARE IS MAXIMIZED Version 2010 01 RESIDENTI
42. scriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Date on which the remittance advice was issued Remittance Number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Notification that no payment was made for the cycle no claims were approved Provider Name and Address RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 29 of 47 REMITTANCE ADVICE 3 amp Section Two Provider Notification This section is used to communicate important messages to providers Exhibit 3 4 1 PAGE 01 DICAID 5 222 MANAGEMENT UTE MEDICAL ASSISTANCE TITLE XIX PROGRAM EMIT STA EN ABC RESIDENTIAL HEALTH CARE a 123 MAIN STREET PROVIDER NOTIFICATION ANYTOWNM NEW YORK 11111 PROV ID 00123456 123456 7890 REMITTANCE NO 07080600001 REMITTANCE ADVICE MESSAGE TEXT ELECTRONIC FUNDS TRANSFER EFT FOR PROVIDER PAYMENTS IS NOW AVAILABLE PROVIDERS WHO ENROLL IM EFT WILL HAVE THEIR MEDICAID PAYMENTS DIRECTLY DEPOSITED INTO THEIR CHECKIMG OR SAVINGS ACCOUNT THEEFT TRANSACTIONS WILL BE INITIATED ON WEDNESDAYS AND DUE TO NORMAL BANKING PROCEDURES THE TRANSFERRED FUNDS MAY NOT BECOME AVAILABLE IM 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
43. 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 RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 41 of 47 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 ATION brs T E FN MEDICAL ASSISTANCE TITLE AIA PROGRAM REMITTANCE STATEMENT TO ABC RESIDENTIAL HEALTH CARE 123 MAIN STREET AN TTOWNM NEW YORK 11111 REASON CODE DESCRIFTION PREV BAL CURR BAL RECOUP AMT TOTAL AMOUNT DUE THE STATE XXX XX RESIDENTIAL HEALTH CARE Version 2010 01 Page 42 of 47 PAGE DATE 05 31 10 CYCLE 1710 ETIN ACCOUNTS RECEIVABLE PROV ID 00123456 1234557830 REMITTANCE OF 02000001 5 31 2010 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 Pa
44. uire further review or recycling will be identified by the PEND status The following are examples of circumstances that commonly cause claims to be pended New York State Medical Review required Procedure requires manual pricing match found the Medicaid files for certain information submitted on the claim for example Patient ID Prior Approval Service Authorization These claims are recycled for a period of time during which the Medicaid files may be updated to match the information on the claim After manual review is completed a match is found in the Medicaid files or the recycling time expires pended claims may be approved for payment or denied A new pend is signified by two asterisks A previously pended claim is signified by one asterisk Errors For claims with a DENY or PEND status this column indicates the NYS Medicaid edit error numeric code s that caused the claim to deny or pend Some edit codes may also be indicated for a PAID claim These are approved edits which identify certain errors found in the claim and that do not prevent the claim from being approved Up to twenty five 25 edit codes including approved edits may be listed for each claim Edit code definitions will be listed on a separate page of the remittance advice at the end of the claim detail section 3 5 3 Subtotals Totals Grand Totals Subtotals of dollar amounts and number of claims are provided as follows Subtotals by c
45. umber of Therapeutic Leave days on the same line where the Revenue Code appears The number of units entered in this field must match the entry in Form Locators 39 41 Value Code 80 Covered Days Total Charges Form Locator 47 Enter the total amount charged for the service s rendered This is computed by multiplying the total number of full days times the per diem rate The charged amount must be entered on the line corresponding to Revenue Code 0001 and both sections of the field dollars and cents must be completed if the charges contain no cents enter OO in the cents box Exhibit 2 4 2 12 REY CD DER DESCRIPTION 44HCRCSIRATETHIPPS CODE IRATE HIPPS CODE SERY DATE SERY UNITS SI TOTAL CHARGES 48 NON COWERED CHARGES P od od E T If Therapeutic Leave or Hospital Leave units were entered in Form Locator 46 enter the charges for that line in this field as well Exhibit 2 4 2 13 2 REV d DESCRIPTION 44 HEPES RATE HIPPS CODE 45 SERV DATE 46 SERW UNITS di TOTAL CHARGES d NON CO VERED CHARGES DN 1500 00 1500 00 RESIDENTIAL HEALTH CARE Version 2010 01 5 31 2010 Page 19 of 47 SUBMISSION Payer Name Form Locator 50 A B C This field identifies the payer s responsible for the claim payment The field lines A B and C are devised to indicate primary A secondary B and tertiary C responsibility for claim payment For NYS Medicaid billing p
46. ursuant 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 Residential Health Care 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 requirements error report information and communication specifications This document is available at www emedny org by clicking on the link to the web page as follows Companion Guides and Sample Files Further information about electronic claim pre requireme
47. used for each patient Rate Codes vary depending on the facility type and the patient s additional coverage Select the appropriate Rate Code according to the following list Free Standing Nursing Facilities Use Code 3810 when billing for Medicaid patients who either don t have Medicare coverage or have only Medicare Part A coverage Use Code 3812 when billing for patients who either have Medicare Part A and B coverage or have only Medicare Part B coverage Use code 3838 when billing for patients who have only Medicare Part D coverage Use code 3839 when billing for patients who have Medicare Part B and Part D coverage Hospital Based Nursing Facilities Use Rate Code 2863 when billing for Medicaid patients who either don t have Medicare coverage or have only Part A coverage Use Rate Code 2862 when billing for patients who either have Medicare Part A and B coverage or have only Medicare Part B coverage Use code 3838 when billing for patients who have only Medicare Part D coverage Use code 3839 when billing for patients who have Medicare Part B and Part D coverage NOTES The Medicare coverage information should be obtained from the eMedNY Eligibility Verification System MEVS Claims for bed reservations may be billed to the higher non Medicare Part B rate Free Standing Day Care Services Use Rate Code 3800 Hospital Based Day Care Services Use Rate Code 3800 RESIDENT
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