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eMedNY Subsystem User Manual

1. rura oh L IHREN ADDRES Siea Oby cade Pur farm arc ccr arc Ecirscr Freed rz rares orar c a a s T m EH a m DATE OF FIRST CONSULT 10 HAS PATIENT HAD EMERGENCY Wr DATE PATENT LAY OF CONDITION OR CONDIT ION SAME OR SMLAR RELATED RETURN TO 21 NAME OF FACIT WHERE SERIES RENDEPRET D aar fan hama anambs ADDRESS OF 22 LACH ORT FEREZFEIMETI STERILIZATION ACTION NUUEER 4i gt OR MI URE OF LESS mimm jenes vs ur noa TTE T IFICATION 23 AGCEPT za AHNT 0 euer THAT THE STATEMENTS ON THE SIDE APPLY TO THS BILL AND ARE MADE AFART HEREOF Bs L EMFLO YERIDENTIFLCAT KT Ld 3t PHYSIC ARS OF SUPPLIERS MAME ADDRESS ZIP CODE James Strong Te James Strong D P M REST 312 Main Street Anytown New York 11111 DGROUP DENTIFCATICH o TA MY FEE HSSEEEN FINI HIES EXT DO NOT WEITEM THIS SFECE me ECAY 18002 iL PATIENTS ACCOUNT MUUEER 34 PROF CD i IMAGE D PODIATRY Version 2010 01 5 31 2010 Page 15 of 60 i CLAIMS SUBMISSION 2 4 2 2 Void A void is submitted to nullify a individual claim lines originally submitted on the same document record and sharing the same TCN When submitting a void please fol
2. uniber Waly M adds LON OF E FIRST CEONSLETELI T ABE PATENT EMERGENOY T F DATES OF GSAS OF CONDITION FOR CONDIT ION SAME OR SMLAR TOTAL 21 NATIONAL CRUG CODE HL NAME OF FATT WHERE SERVICES RENDERED V aar hama anas ADDRESS OF FROLITY 22 LARC ORE WORK FERFORIUETI OUTSIDE TOUR OFFICE 225 M M D D w Y u landonoma loses 018 213 018 m 110101610 E 6 1816 9 CERTIFICATION CERTIFY THAT THE STATEMENTS ON THE ROERE SDE SPPLY TO TH S HILL AMO ARE MADE APART HEREOF 31 EMPLOYERIDENTIR GT KINN MEER 3 PHYECHIMEOREJTUENENAME SDDFESS Z CODE James Strong Mr James Strong D P M IL 312 Main Street deat wtb York 11111 XM FEE HAE BEEN FID EXT 32 SCODUNT PODIATRY Version 2010 01 5 31 2010 Page 14 of 60 CLAIMS SUBMISSION Exhibit 2 4 2 1 4 MEDICAL ASSISTANCE HEALTH INSURANCE ONLY TO BE sala ke E CLAIM FORM TITLE XIX PROGRAM sd PATIENT AND INSURED SUBSCRIBER INFORMATION LEATRAT Nam Sine inr 2 DATE F E weld v INCOME JANE SMITH ESTE TS ACAR Shee C Eus Dp ccc 5 5 1 MEDICARE NIMES PATIEMPS ATICMEHE THP amp INSURELFS OR 93 ROTHER HEALTH SUS Cee se
3. Stabe Coxe Par farm arc Acne src Prais rz rare further PATIENTS Waly JOTA ur T4 Ss LON A HAS PATIENT EMERGENCY tr DATE PATIENT SAME OR SULAR SP TOR ED RETURN TO OFLA OCDE Zt NAME OF FRG WHERE N aar homad area ADDRESS OF FRCLITE 22 LAHAT ORT WOR FERFORPIUETI OUTSIDE TIR OFFICE 22 12 DAGNOSECRNITURECF LLNESS POBEELE DISABILITY D FRIA FRAL NIER DIAGNOSIS CODE mimm ueni 11 Nah als TTET vs ne lois tas rows pod 21 TOTAL CHARGE 28 BAD D 1 CERTIFY THAT THE STATEMENT ON THE PEPLY TO THS BILL ADARE APART HERECF 31 EMFLO YERIDENTIFCAT KT AE 3t PHYelOIBMS OF SUPPLIERS ADDRESS ZIP CODE James Strong James Strong D P M SIGNATURE OF FHS GAH OR SUPPER TA PROVIDER DENTIFICATION 312 Main Street Z M York 11111 im MY FEE EXT PODIATRY Version 2010 01 5 31 2010 Page 18 of 60 SUBMISSION Patient s Name Field 1 Enter the patient s first name followed by the last name This information may be obtained from the Client s Patient s Common Benefit ID Card Date of Birth Field 2 Enter the patient s birth date This information may be obtained from the Clie
4. Date The date on which the recoupment was applied Since all the recoupments listed on this page pertain to the current cycle all the recoupments will have the same date Amount The dollar amount corresponding to the particular fiscal transaction This amount is deducted from the provider s total payment for the cycle 3 6 1 2 Explanation of Totals Section The total dollar amount of the financial transactions Net Financial Transaction Amount and the total number of transactions Number of Financial Transactions appear below the last line of the transaction detail list The Net Financial Transaction Amount added to the Claim Detail Grand Total must equal the Medicaid Check or EFT amounts PODIATRY Version 2010 01 5 31 2010 Page 51 of 60 REMITTANCE ADVICE 3 6 2 Accounts Receivable This subsection displays the original amount of each of the outstanding Financial Transactions and their current balance after the cycle recoupments were applied If there are no outstanding negative balances this section is not produced Exhibit 3 6 2 1 PAGE 08 DATE 05 31 10 DICAID oon 1 EROADWAY INFORMATION SYSTEM EL COUNTS RECEIVABLE KEJ eee m wy 5 hA LIT IS T em ANYTOWN NEW YORK 11111 MEDICAL ASSISTANCE TITLE XIX PROGRAM zazvip 00172222 122458722 REMITTANCE STATEMENT REMITTANCE NO 07080500005 REASON CODE DESCRIPTION CURR BAL RECOUP i AMT XX 999 TOTAL AMOUNT DUE THE STA
5. SANE QORSMLAREZHUPTONME Exhibit 2 4 2 2 1 E L 1 RELATICHZHP Am EMERGENOY ADDRESS OF FROLITY 23 DAGNOES OR MATURE OF LES I CERTIFY THAT THE STATEMENTS OM THE SDE APPLY TO THE BILL AMO ARIE MAE FARAT HEREOF James Strong Version 2010 01 TENET BEFOEL ENITEN ii 220 IDENTIR CAT IGNNLIUEER CLAIMS SUBMISSION ORIGINAL CLAIM REFERENCE NUMBER 3 IMSLIRETFS ama Fla iz nam 1 MED CARE HUME E CODE 31 EMFLOYERIDENTIF CAT ICON LE SEL SECURITY PODIATRY Page 17 of 60 LITE 3 PHYSICIANS OR SUPPLERS MAME ADDRESS James Strong D P M 312 Main Street Anytown New York 11111 5 31 2010 CLAIMS SUBMISSION Exhibit 2 4 2 2 2 MEDICAL ASSISTANCE HEALTH INSURANCE PIE E CLAIM FORM TITLE XIX PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION T EATISAT S MANG RICE modir ROBERT JOHNSON 016101311191316 4 PATENTS ADGA Nee Dir Dr Dp Cram MELRELDKE SEX a MEO CAFE NE PRIWATE EC RATENTS OCCUPATION OF ATIONSHE amp IRGUREDS OR OGCURATION E OTHER HEALTH SUES Cee ae rara ci Poirier ABE GOADITION RELATED To iL NSURELFS ADDRESS Sree
6. THE FOLLOWING 15 DESCRIPTION OF THE EDIT REASON CODES THAT APPEAR ON THE CLAIMS FOR THIS REMITTANCE 00131 PROVIDER NOT APPROVED FOR SERVICE 00142 SERVICE CODE NOT EQUAL 00162 RECIPIENT INELIGIBLE ON DATE OF SERVICE 00244 ON OR REMOVED FROM FILE PODIATRY Version 2010 01 5 31 2010 Page 54 of 60 APPENDIX A CLAIM SAMPLES APPENDIX A CLAIM SAMPLES The eMedNY Billing Guideline Appendix A Claim Samples contains an image of a claim with sample data PODIATRY Version 2010 01 5 31 2010 Page 55 of 60 APPENDIX A CLAIM SAMPLE MEDICAL ASSISTANCE HEALTH INSURANCE ONLY TO BE USED TO CLAIM FORM TITLE XIX PROGRAM ADJUST vOID PATIENT AND INSURED SUBSCRIBER INFORMATION PAID CLAIM 1ST T S Um ECE CUT GE Ie m m BnF imc mam K mu JANE SMITH F G T BSUS A CE Pi cer Bar Fo mr Sere Redeye Pred rrira Pr ana OF MENE IDOHESE ZE Coe James Strong D P W 312 Main Street Anytown New York 11111 EX PODIATRY Version 2010 01 5 31 2010 Page 56 of 60 APPENDIX B CODE SETS APPENDIX B CODE SETS The eMedNY Billing Guideline Appendix B Code Sets contains a list of Place of Service codes as well as a list of accepted Unites States Standard Postal Abbreviations PODIATRY Version 2010 01 5 31 2010 Page 57 of 60 APPENDIX B CODE SETS V
7. The status VOID refers to a claim submitted with the purpose of canceling a previously paid claim A void lists the credit transaction previously paid claim only Pending Claims Claims that require further review or recycling will be identified by the PEND status The following are examples of circumstances that commonly cause claims to be pended New York State Medical Review required Procedure requires manual pricing No match found in the Medicaid files for certain information submitted on the claim for example Patient ID Prior Approval Service Authorization These claims are recycled for a period of time during which the Medicaid files may be updated to match the information on the claim After manual review is completed a match is found in the Medicaid files or the recycling time expires pended claims may be approved for payment or denied A new pend is 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
8. Date The date on which the remittance advice was issued Cycle Number The cycle number should be used when calling the eMedNY Call Center with questions about specific processed claims or payments ETIN not applicable Name of Section PROVIDER NOTIFICATION PROV ID This field will contain the Medicaid Provider ID and the NPI Remittance Number Center Message Text PODIATRY Version 2010 01 5 31 2010 Page 41 of 60 REMITTANCE ADVICE 3 5 Section Three Claim Detail This section provides a listing of all new claims that were processed during the specific cycle plus claims that were previously pended and denied during the specific cycle TO ABC PODIATRY 100 BROADWAT ANYTOWN NEW YORK 11111 LN NO 01 01 01 01 OFFICE ACCOUNT NUMBER 111111 CP222222 CP444444 CLIEMT NAME DOE SAMPLE EXAMPLE SPECIMEN TOTAL AMOUNT ORIGINAL CLAIMS NET AMOUNT ADJUSTMENTS NET AMOUNT VOIDS NET AMOUNT VOIDS ADJUSTS Version 2010 01 CLIENT ID NUMBER Exhibit 3 5 1 DICAID MANAGEMENT INFORMATION SYSTEM MEDICAL ASSISTANCE TITLE AIX PROGRAM REMITTANCE STATEMENT TCN 07206 000000227 0 0 07206 000011334 0 0 07206 000013556 0 0 07206 000032456 0 0 DENIED DENIED DENIED DATE OF SERVICE 05 11 10 05 12 10 05 14 10 05 15 10 PROC CODE 11750 11721 20512 28100 1 000 1 000 1 000 1 000 162 20 0 00 0 00 0 00 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBE
9. single TCN which will be shared by all the individual claim lines submitted under that document record 2 4 2 1 Adjustment An adjustment may be submitted to accomplish any of the following purposes To change information contained in one or more claims submitted on a previously paid Tocancel one or more claim lines submitted on a previously paid except if the contained one single claim line or if all the claim lines contained in the TCN are to be voided Adjustment to Change Information If an adjustment is submitted to correct information on one or more claim lines sharing the same TCN follow the instructions below The Provider ID number the Group ID number the Patient s Medicaid ID number must be adjusted The adjustment must be submitted in a new claim form copy of the original form is unacceptable The adjustment must contain all claim lines originally submitted in the same document record all claim lines with the same TCN and all applicable fields must be completed with the necessary changes PODIATRY Version 2010 01 5 31 2010 Page 9 of 60 C SUBMISSION The adjustment will cause the correction of the adjusted information in the TCN history records as well as the cancellation of the original TCN payment and the re pricing of the TCN based on the adjusted information Exhibit 2 4 2 1 1 and Exhibit 2 4 2 1 2 illustrate an example of a claim with an adjustment
10. 60 CLAIMS SUBMISSION Tode 1 No Other Insurance involvement Field 241 must be left ther Insurance Involved Field 24L should containthe amount paid by the other insurance or 0 00 if the other insurance did not coverthe service ordenied payment You must indicate the two digit insurance Indicates patient s participation Field 24L should containthe patient s participation amount If Other Insurance is alsoinvolved enterthe total payments in 24L and enter the two digiti tne Field 24L should contain the icu paid by the other insurance or 50 00 if the other insurance did not cover the service or denied payment You must indicate the two digit insurance indicates patient s participation Field 24L should containthe patient s participation amount If Other Insurance is alsoinvolved enterthe total payments in 24L and enter the two digit i insurance code Field 241 should contain the amount paid by the other insurance or 0 00 if the other insurance did not cover the service or denied payment You must indicate the two digit insurance patient s participation Field 24L should contain the patient s participation amount lf Other Insurance is also invalved enter the total payments 241 and enter the two digit insurance code 5 31 2010 CLAIMS SUBMISSION Encounter Section Fields 24A to 240 The claim form can accommodate up to seven encounters with a single patient
11. Code Field 25 For electronic claims leave this field blank For paper claims enter the locator code assigned by NYS Medicaid Locator codes are assigned to the provider for each service address registered at the time of enrollment in the Medicaid program or at any time afterwards that a new location is added Enter the locator code that corresponds to the address where the service was performed Locator codes 001 and 002 are for administrative use only and are not entered in this field If the provider renders services at one location only enter locator code 003 If the provider renders service to Medicaid patients at more than one location the entry may be 003 or a higher locator code NOTE The provider is reminded of the obligation to notify Medicaid of all service locations as well as changes to any of them For information on where to direct locator code updates please refer to Information for All Providers Inquiry section located at www emedny org by clicking on the link to the webpage as follows Podiatry Manual PODIATRY Version 2010 01 5 31 2010 Page 30 of 60 CLAIMS SUBMISSION SA EXCP Code Service Authorization Exception Code Field 25D Leave this field blank County of Submittal Unnumbered Field Enter the name of the county wherein the claim form is signed The County may be left blank only when the provider s address is within the county wherein the claim form is signed Date Signed Field 25E Ente
12. Deductible When billing for the Medicare deductible modifier U2 must be used in conjunction with the Procedure Code for which the deductible is applicable Do not enter the U2 modifier if billing for Medicare coinsurance NOTE Modifier values and their definitions can be found on the web page for this manual under Procedure Codes and Fee Schedule which is located at www emedny org by clicking on the link to the webpage as follows Podiatry Manual PODIATRY Version 2010 01 5 31 2010 Page 26 of 60 CLAIMS SUBMISSION Diagnosis Code Field 24H Using the International Classification of Diseases Ninth Edition Clinical Modification ICD 9 CM coding system enter the appropriate code which describes the main condition or symptom of the patient The ICD 9 CM code must be entered exactly as it is listed in the manual in the correct spaces of this field and in relation to the decimal point Proper entry of an IDC 9 CM Diagnosis Code is shown in Exhibit 2 4 2 9 Exhibit 2 4 2 9 24H DIAGNOSIS CODE 6 8 6 9 NOTE three digit Diagnosis Code no entry following the decimal point will only be accepted when the Diagnosis Code has no subcategories Otherwise Diagnosis Codes with subcategories MUST be entered with the subcategories indicated after the decimal point Days or Units Field 241 If a procedure was performed and approved by Medicare more than one time on the same date of service enter the number of ti
13. Electronic Funds Transfer Summout no claims paid Section Two Provider Notification special messages Section Three Claim Detail Section Four Financial Transactions recoupments 6 Accounts Receivable cumulative financial information Section Five Edit Error Description PODIATRY Version 2010 01 Page 33 of 60 5 31 2010 REMITTANCE ADVICE 3 1 Section One Medicaid Check For providers who have selected to be paid by check a Medicaid check is issued when the provider has claims approved for the cycle and the approved amount is greater than the recoupments if any scheduled for the cycle This section contains the check stub and the actual Medicaid check payment Exhibit 3 1 1 DICAID RAN AGE INFORMATION SYSTEM TO ABC PODIATRY DATE 2010 05 31 REMITTANCE NO 07080600006 PROV ID 00112233 1123456 89 00112233 1123456 88 2010 05 31 ABC PODIATRY 100 BROADWAY ANY TOWN NY 11111 YOUR CHECK IS BELOW TO DETACH TEAR ALONG PERFORATED DASHED LINE REMITTANCE PROVIDER ID NO DOLLARS CENTS NUMBER 2010 05 21 07080600006 00112233 1123456789 143 80 VOD AFTER DATS PODIATRY 100 BROADWAY ANYTOWN 11111 DICA D INFORMATION 6YSTEM MEDICAL ASSISTANCE TITLE XIX PROGRAM on 3mi tl CHECKS DRAWN ON John smi tn EY BANE STATE STREET ALBANY NEW YORK 1220 PODIATRY Version 2010 01 5 31 2010 Page 34 of 60 REMITTANCE ADVI
14. 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 Priorto billing the insurance company the provider knows that the service will not be covered because 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 PODIATRY Version 2010 01 5 31 2010 Page 28 of 60 CLAIMS SUBMISSION n very limited situations the Local Department of Social Services LDSS has advised the provider to zero fill other insurance payment for same type of service This communication should be documented in the patient s billing record The provider bills the insurance company and receives a rejection because The service is not covered or deductible has not been met provider cannot directly bill the insurance carrier and the policyholder is either unavailable to or uncooperative in submitting claims to the insurance company In these cases the LDSS must be notified prior to zero filling LDSS has subrogation rights enabling them to complete claim forms on behalf of uncooperative policy
15. define the nature of the amount entered in field 24L Enter the appropriate indicator from the following list No Other Insurance involvement Source Code Indicator 1 This code indicates that the patient does not have other insurance coverage Patient has Other Insurance coverage Source Code Indicator 2 This code indicates that the patient has other insurance regardless of the fact that the insurance carrier s paid or denied payment or that the service was covered or not by the other insurance When the value 2 is entered in Box O the two character code that identifies the other insurance carrier must be entered in the space following Box O If more than one insurance carrier is involved enter the code of the insurance carrier who paid PODIATRY Version 2010 01 5 31 2010 Page 23 of 60 i CLAIMS SUBMISSION the largest amount For the appropriate Other Insurance codes refer to Information for All Providers Third Party Information which can be found at www emedny org by clicking on the link to the webpage as follows Podiatry Manual Patient Participation Source Code Indicator 3 This code indicates that the patient has incurred a pre determined amount of medical expenses which qualify him her to become eligible for Medicaid Exhibit 2 4 2 8 provides a full illustration of how to complete field 23B and the relationship between this field and fields 24J 24K and 24L PODIATRY Version 2010 01 5
16. not have to be the facility address It should be the address where the service was rendered PODIATRY Version 2010 01 5 31 2010 Page 21 of 60 C CLAIMS SUBMISSION Service Provider Name Field 22A Leave this field blank Prof CD Profession Code Service Provider Field 22B Leave this field blank Identification Number Service Provider Field 22C Leave this field blank Sterilization Abortion Code Field 22D Leave this field blank Status Code Field 22E Leave this field blank Possible Disability Field 22F Place an X in the Y box for YES or an X in the box for NO to indicate whether the service was for treatment of a condition which appeared to be of a disabling nature the inability to engage in any substantial or gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months EPSDT C THP Field 22G Leave this field blank Family Planning Field 22H Leave this field blank Prior Approval Number Field 23A Leave this field blank Payment Source Code Box M and Box 0 Field 23B This field has two components Box M and Box O as shown in Exhibit 2 4 2 7 below PODIATRY Version 2010 01 5 31 2010 Page 22 of 60 CLAIMS SUBMISSION Exhibit 2 4 2 7 23B SOURCE M O Both boxes need to b
17. plus a block of encounters in a hospital setting if all the information in the Header Section of the claim Fields 1 23B applies to all the encounters Date of Service Field 24A Enter the date on which the service was rendered in the format MM DD YY NOTE A service date must be entered for each procedure code listed Place of Service Field 24B This two digit code indicates the type of location where the service was rendered Please note that place of service code is different from locator code Select the appropriate codes from Appendix B Code Sets NOTE If code 99 Other Unlisted Facility is entered in this field for any claim line the exact address where the procedure was performed must be entered in fields 21 and 21A Procedure Code Field 24C This code identifies the type of service that was rendered to the patient Enter the appropriate five character procedure code in this field NOTE Procedure codes definitions prior approval requirements if applicable fees etc are available at www emedny org by clicking on the link to the webpage as follows Podiatry Manual MOD Modifier Fields 24D 24E 24F and 24G Under certain circumstances the procedure code must be expanded by a two digit modifier to further explain or define the nature of the procedure If the Procedure Code requires the addition of modifiers enter one or more up to four modifiers in these fields Special Instructions for Claiming Medicare
18. required fields The following guidelines will help ensure the accuracy of the imaging output information should be typed or printed Alpha characters letters should be capitalized Numbers should be written as close to the example below in Exhibit 2 2 1 1 as possible Exhibit 2 2 1 1 Circles the letter O the number 0 must be closed Avoid unfinished characters See the example in Exhibit 2 2 1 2 Exhibit 2 2 1 2 Written As Intended As Interpreted As 1161010 6 00 HAHA 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 Exhibit 2 2 1 3 Intended As Interpreted As lwointerpreted as seven hree interpreted as two PODIATRY Version 2010 01 5 31 2010 Page 6 of 60 i CLAIMS SUBMISSION 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 uem _ A Entry cannot be 23 illegible interpreted properly Do not write between lines Do not use arrows or quotation marks to duplicate information Do not use the dollar sign S 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 ballpoi
19. s PODIATRY Version 2010 01 5 31 2010 Page 20 of 60 CLAIMS SUBMISSION NOTE A facility ID cannot be used for the Ordering Referring Provider In those instances where a service was ordered by a facility the NPI of a practitioner at the facility ordering the service must be entered in this field Restricted Recipients When providing services to a patient who is restricted to a primary physician the NPI of the patient s primary physician must be entered in this field If a patient is restricted to a facility the NPI of the practitioner at the facility the patient is restricted to must be entered in this field the ID of the facility cannot be used If no referral was involved leave this field blank DX Code Field 19D Leave this field blank Drug Claims Section Fields 20 to 20C The following section applies to drug code claims only NDC National Drug Code Field 20 Leave this field blank Unit Field 20A Leave this field blank Quantity Field 20 Leave this field blank Cost Field 20C Leave this field blank Name of Facility Where Services Rendered Field 21 This field should be completed when the Place of Service Code entered in Field 24B is 99 Other Unlisted Facility Address of Facility Field 21A This field should be completed on y when the Place of Service Code entered in Field 24B is 99 Other Unlisted Facility NOTE The address listed in this field does
20. 2 eMedNY 150002 Claim Form Field Instructions Header Section Fields 1 through 23B The information entered in the Header Section of the claim form fields 1 through 23B must apply to all claim lines entered in the Encounter Section of the form The following two unnumbered fields should only be used to adjust or void a paid claim Do not write in these fields when preparing an original claim form Adjustment Void Code Upper Right Corner of Form Leave this field blank when submitting an original claim or resubmission of a denied claim lf submitting an adjustment replacement to a previously paid claim enter X or the value 7 in the A box If submitting a void to a previously paid claim enter X or the value 8 in the V box Original Claim Reference Number Upper Right Corner of Form Leave this field blank when submitting an original claim or resubmission of a denied claim If submitting an adjustment or a void enter the appropriate Transaction Control Number TCN in this field A TCN is a 16 digit identifier that is assigned to each claim document or electronic record regardless of the number of individual claim lines service date procedure combinations submitted in the document or record For example a document record containing a single service date procedure combination will be assigned a unique single TCN a document record containing five service date procedure combinations will be assigned a unique
21. 31 2010 Page 24 of 60 23B PAYM I SOURCE CO 1 23B PAYM T SOURCE CO 1 2 23B SOURCE CO 1 5 23 SOURCE CO 23B SOURCE CO dE f w 22 23B SOURCE CO y 23 7 23 SOURCE CO 23 SOURCE CO 3 2 23B PAYM I SOURCE CO 3 Version 2010 01 Exhibit 2 4 2 8 Code 1 Mo Medicare involvement Field 24J should contain the amount charged andfield 24K must be left blank Code 1 Mo Medicare involvement Field 24J should containthe amount charged andfield 24K must be left blank Code 1 Mo Medicare involvement Field 24J should containthe amount charged andfield 24K must be left blank 2 Medicare Approved Service Field 24 shoulc contain the Medicare Approved amount and field 24K should contain the Medicare payment amount Field 244 should M Approved amount andfield 24K should containthe Medicare payment amount Field 244 should spp sania Medicare Approved amount andfield 24K should containthe Medicare payment amount did cover the scing Field 24 should containthe amount charged and field 24K should contain 0 00 did not cover the service Field 24 should containthe amount charged and field 24K should contain 0 00 did not cover the service Field 24 Should containthe amount charged and field 24K should contain 0 00 PODIATRY Page 25 of
22. 40 NUMBER OF CLAIMS 4 NET AMOUNT ADJUSTMENTS FAID 3 60 NUMBER OF CLAIMS 1 AMOUNT VOIDS FAID 0 00 NUMBER OF CLAIMS 0 NET AMOUNT VOIDS ADJUSTS 3 60 NUMBER OF CLAIMS 1 PODIATRY Version 2010 01 5 31 2010 Page 43 of 60 REMITTANCE ADVICE Exhibit 3 5 3 PAGE 24 0h 31 2010 D CYCLE 1710 IHE MEDICAL ASSISTANCE TITLE XIX PROGRAM TO ABC PODIATRY REMITTANCE STATEMENT PRACTITIONER 100 BROADWAY PROV ID 00112233 1123456783 ANY TOWN NEW YORK 11111 REMITTANCE 07080500005 LM OFFICE ACCOUNT CLIENT CLIENT ID DATE OF PROC NO NUMBER NUMBER TCN SERVICE CODE UNITS CHARGED PAID STATUS ERRORS 01 DOE XX12345xX QO7206 000033467 0 0 05 11 10 28100 1 000 69 30 0 00 PEND 00162 02 CPI SAMPLE Xx2i1455X OTH 051210 11750 100 T1 04 0 00 PEND 00162 01 EXAMPLE Xxi455IX OTHE 05 14 10 12001 1 000 14 30 0 00 PEND 00142 07 SPECIMEN XXASGIBX OTS ON 15010 20612 1 000 14 30 0 00 PEND 00131 NEW PEND TOTAL AMOUNT ORIGINAL CLAIMS PEND 158 34 NUMBER OF CLAIMS 4 AMOUNT ADJUSTMENTS PEND 0 00 NUMBER OF CLAIMS 0 AMOUNT VOIDS PEND 0 00 NUMBER CLAIMS 0 NET AMOUNT VOIDS ADJUSTS 0 00 NUMBER OF CLAIMS 0 REMITTANCE TOTALS PRACTITIONER VOIDS ADJUSTS 2 62 NUMBER CLAIMS TOTAL FENDS 108 94 NUMBER CLAIMS TOTAL 147 40 NUMBER CLAIMS TOTAL DENIED 162 20 NUMBER OF CLAIMS NET
23. CE 3 1 1 Medicaid Check Stub Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Date The date on which the remittance advice was issued Remittance Number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Medicaid Provider ID NPI Date Provider s Name Address 3 1 2 Medicaid Check Field Descriptions Left Side Table Date The date on which the check was issued Remittance Number Provider ID No This field will contain the Medicaid Provider ID and the NPI Provider s Name Address Right Side Dollar Amount This amount must equal the Net Total Paid Amount under the Grand Total subsection plus the total sum of the Financial Transaction section PODIATRY Version 2010 01 5 31 2010 Page 35 of 60 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 PODIATRY D CAI D DATE 2010 05 31 REMITTANCE 07080500005 INFORM ATION SYSTEM PROVID 00112233 1123455789 001 122351 123466709 2010 05 31 ABC PODIATRY 100 BROADWAY ANYT OWN 11111 ABC PODIATRY 5143 80 PAYMENT IN THE ABOVE AMOUNT
24. F FAGUTY 22 LAER ORE FERFOPIUETI OUTSIDE TIR OFFICE OF CD DENTIFICATIONMUUEER Y Y UNITS ove foe las onnon jenes i sod i nisi cr rien ove oe sr oso i i einem i asi rr rri HEN za BANQUNT CERTE Y THAT THE STATEMENTE ON THe SIDE APPLY TO THS BILL AND ARE MADE A PART HEREOF 31 EMIPLOWER DEAT AGA Oa ALE 3t PHYSIC ARS OF SUPPLIERS ADDRESS ZIP CODE James Strong VASA James Strong D P M SIGHATURE OF FHS GAH OR SUPPER EA PROVIDER NEER 312 Main Street Anytown New York 11111 PODIATRY Version 2010 01 5 31 2010 Page 12 of 60 SUBMISSION Adjustment to Cancel One or More Claims Originally Submitted on the Same Document Record TCN An adjustment should be submitted to cancel or void one or more individual claim lines that were originally submitted on the same document record and share the same TCN The following instructions must be followed The adjustment must be submitted in a new claim form copy of the original form is unacceptable The adjustment must contain all claim lines submitted in the original document all claim lines with the same TCN except for the claim s line s to be voided these claim lines must be omitted in the adjustment All applicable fields must be completed The adjustment will cause the
25. IONER PROV ID This field will contain the Medicaid Provider ID and the NPI Remittance Number 3 5 2 Explanation of Claim Detail Columns LN NO Line Number This column indicates the line number of each claim as it appears on the claim form Office Account Number If a Patient Office Account Number was entered in the claim form that number up to 20 characters will appear under this column Client Name This column indicates the last name of the patient If an invalid Medicaid Client ID was entered in the claim form the ID will be listed as it was submitted but no name will appear in this column Client ID Number The patient s Medicaid ID number appears under this column PODIATRY Version 2010 01 5 31 2010 Page 46 of 60 REMITTANCE ADVICE 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 Date of Service The first date of service From date entered in the claim appears under this column If a date different from the From date was entered in the Through date box that date is not returned in the Remittance Advice Procedure Code The five digit procedure code that was entered in the claim form appears under this column Units The total number of units of service for the specific claim appears under this column The units are indicated with three 3 decimal positions S
26. ISSION 2 4 Podiatry Services Billing Instructions This subsection of the Billing Guidelines covers the specific NYS Medicaid billing requirements for Podiatrists Although the instructions that follow are based on the eMedNY 150002 paper claim form they are also intended as a guideline for electronic billers to find out what information they need to provide in their claims in addition to the HIPAA Companion Guides which are available at www emedny org by clicking on the link to the webpage as follows eMedNY Companion Guides and Sample Files It is important that providers adhere to the instructions outlined below Claims that do not conform to the eMedNY requirements as described throughout this document may be rejected pended or denied 2 4 1 Instructions for the Submission of Medicare Crossover Claims This subsection is intended to familiarize the provider with the submission of crossover claims Providers can bill claims for Medicare Medicaid patients to Medicare Medicare will then reimburse its portion to the provider and the provider s Medicare remittance will indicate that the claim will be crossed over to Medicaid Claims for services not covered by Medicare should continue to be submitted 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 de
27. L SECURTY MEER SIGRATLEE OF AS OAM PROVIDE IDENTIFLCET EN PODIATRY Version 2010 01 Page 11 of 60 CLAIMS SUBMISSION ORIGINAL CLAIM REFERENCE NUMBER MEDCARE HME MLRAKEH MER amp IMNELIRELFE EPLER OR INSUREDKS ADOREES Eme hy Sete Cade 21 TOUR OFFICE PRIOR APPR HIER FAMILY TE PAYMET SOURCE CEDE 2a SMOUNT PAL 3t PHYSIC SMS OR SUPPLERES MALE ADORE James Strong D P M 312 Main Street id nere New York 11111 5 31 2010 CLAIMS SUBMISSION Exhibit 2 4 2 1 2 MEDICAL ASSISTANCE HEALTH INSURANCE CLAIM FORM TITLE XIX PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION T RSTn TS Arr medir JANE SMITH 4 155 Zu Cuy Simin Dp Cece PRIVATE EC PATRHTAREPLITEH OCCUPATION OF ZCEDCOL PATIENPS amp INSURED 08 OGCURATION E OTARRA HEALTH SUR REI AGE ier rana ci Pcie 01 WBE TH MSLEEDKS ADDRES sme Cy Sate Zn Code Pur Marne sre ee Podge Breads rarr e e d x m m e m m m T HAS PATIENT HAD m EVERGENCY tr DATE PATIENT SAME OR FAPT RELATED RETURN To ACER H OF FALUT WHERE REMOERED F oher hama anambs ADDRESS O
28. New York State Electronic Medicaid System 150002 Billing Guidelines 2 PODIATRY Version 2010 01 5 31 2010 TT TABLE OF CONTENTS TABLE OF CONTENTS L PUPO SUA 4 2 Clamis MEER 5 2 1 cece ccc u e 5 2 2 Paner 5 2 2 1 General Instructions for Completing Paper 6 2 3 eMedNY 150002 Claim Form a 7 2 4 Podiatry Services Billing Instructions r nennen nennen rne nennen 8 2 4 1 Instructions for the Submission of Medicare Crossover Claims sess 8 2 4 2 eMedNY 150002 Claim Form Field 9 3 Explanation of Paper Remittance Advice Sections 33 3 1 Section One Medicaid COCK 34 31 1 Maedicaid Check Stub Field Descriptions eee aes 35 3 1 2 Medicaid Check Field 35 3 2 DECOM OME EFT eie 36 3 2 1 EFT Notification Page Fiel
29. R OF CLAIMS PODIATRY Page 42 of 60 UNITS CHARGED PAID PAGE DATE CYCLE 02 05 21 2010 1710 ETIN PRACTITIONER PROV ID 00112233 1122456783 REMITTANCE 070806000005 STATUS DENY DENY DENY DENY ERRORS 00162 00244 00244 00152 00131 52 80 17 60 14 30 2 00 2 00 2 00 0 00 PREVIOUSLY PENDED CLAIM NEW PEND e a 5 31 2010 REMITTANCE ADVICE Exhibit 3 5 2 PAGE 03 DICAID DATE 0031 2010 MAN A CHE IM EE FIT lI FOR Ra TH Gon Sa TEM MEDICAL ASSISTANCE TITLE XIX PROGRAM EHE TO ABC PODIATRY REMITTANCE STATEMENT PRACTITIONER 100 BROADWAY PROV ID 00112233 1122456783 ANYTOWN NEW YORK 11111 REMITTANCE NO 07050600006 LN OFFICEACCOUNT CLIENT CLIENT ID DATEOF PROC NO NUMBER NAME NUMBER TCN SERVICE CODE UNITS CHARGED STATUS ERRORS 01 111111 DOE XX12345X 07206 000033657 0 0 05 11 10 28001 109 1430 1430 02 CP222222 SAMPLE XX23455X 07206 000033667 0 0 05 12 10 17000 109 1430 1430 01 cP111133 EXAMPLE XX34557X 07206 00004556 0 0 059410 109 52580 5280 01 CP444444 SPECIMEN XX45678X Q07206 000056767 0 0 05 15 10 11750 1000 6600 6500 01 CPTT7TIT STANDARD XX56783xX 07206 000067767 0 0 0505 10 17000 109 1760 17 6 ADJT ORIGINAL CLAIM PAID 05 24 10 01 CP555555 MODEL xXxX67890X UT205 OQ088767 0 0 05 05 10 17111 1 000 1430 1400 ADJT PREVIOUSLY PENDED CLAIM NEWPEND TOTAL AMOUNT ORIGINAL CLAIMS FAID 147
30. TE XXX XX PODIATRY Version 2010 01 5 31 2010 Page 52 of 60 REMITTANCE ADVICE 3 6 2 1 Explanation of Accounts Receivable Columns If a provider has negative balances of different types or negative balances created at different times each negative balance will be listed in a different line Reason Code Description This is the description of the Financial Reason Code For example Third Party Recovery Original Balance The original amount or starting balance for any particular financial reason Current Balance The current amount owed to Medicaid after the cycle recoupments if any were applied This balance may be equal to or less than the original balance Recoupment Amount The deduction recoupment scheduled for each cycle Total Amount Due the State This amount is the sum of all the Current Balances listed above PODIATRY Version 2010 01 5 31 2010 Page 53 of 60 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 DICAID PAGE 06 MANAGEMENT DATE 31 10 INFORMATION amp YSTEM CYCLE 1710 MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT ETIN TO ABC PODIATRY PRACTITIONER 100 BROADWAY EDIT DESCRIFTIONS ANYTOWN NEW YORK 11111 PROVID O0112233 1123450783 REMITTANCE NO 07020500005
31. TOTAL PAID 143 80 NUMBER OF CLAIMS n Pa 4 4 MEMBER ID 00112233 YOIDS ADJUSTS 3 62 NUMBER CLAIMS TOTAL PENDS 158 94 NUMBER CLAIMS TOTAL PAID 147 40 NUMBER OF CLAIMS TOTAL DENIED 162 20 NUMBER CLAIMS NET TOTAL PAID 143 80 NUMBER OF CLAIMS n 4 PODIATRY Version 2010 01 Page 44 of 60 PREVIOUSLY PENDED CLAIM 5 31 2010 REMITTANCE ADVICE Exhibit 3 5 4 DIC AID PAGE 05 E DATE Us 31 10 INFORMATION SYSTEM CYCLE 1710 MEDICAL ASSISTANCE TITLE XIX PROGRAM NTT AM ATEN ETIM TO ABC PODIATRY REMITTANCE STATEMENT PRACTITIONER 100 BROADWAY GRAND TOTALS ANYTOWNM NEW YORK 11111 PROV ID Q0112233 1123455783 REMITTANCE REMITTANCE TOTALS GRAND TOTALS YOIDS ADJUSTS 3 60 NUMBER OF CLAIMS TOTAL PENDS 168 94 NUMBER OF CLAIMS TOTAL FAID 147 42 NUMBER OF CLAIMS TOTAL DENY 152 20 NUMBER OF CLAIMS MET TOTAL PAID 143 80 NUMBER OF CLAIMS e dx dx PODIATRY Version 2010 01 5 31 2010 Page 45 of 60 _ REMITTANCE ADVICE 3 5 1 Claim Detail Page Field Descriptions Upper Left Corner Provider s Name Address as recorded in the Medicaid files Upper Right Corner Remittance Page Number Date The date on which the remittance advice was issued Cycle Number The cycle number should be used when calling the eMedNY Call Center with questions about specific processed claims or payments ETIN not applicable Provider Service Classification PRACTIT
32. VIDER 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 DURING 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 A TEST YOUR FIRST REAL EFT TRANSACTION WILL TAKE PLACE APPROXIMATELY FOUR TO FIVE WEEKS LATER IF YOU HAVE ANY QUESTIONS ABOUT THE EFT PROCESS PLEASE CALL THE EMEDNY CALL CENTER AT 1 800 343 8000 NOTICE THIS COMMUNICATION AND ANY ATTACHMENTS MAY CONTAIN INFORMATION THAT 15 PRIVILEGED AND CONFIDENTIAL UNDER STATE AMD FEDERAL LAW AND Is INTENDED ONLY FOR THE USEOF THE SPECIFIC INDIVIDUAL S TO WHOM IT 15 ADDRESSED THIS INFORMATION ONLY BE USED OR DISCLOSED IM ACCORDANCE WITH LAW AND YOU MAY BE SUBJECT TO PENALTIES UNDER LAW FOR IMPROPER USE OR FURTHER DISCLOSURE OF INFORMATION IN THIS COMMUNICATION AND ANY ATTACHMENTS IF YOU HAVE RECEIVED THIS COMMUNICATION ERROR PLEASE IMMEDIATELY NOTIFY NYHIPPADESKGCSC COM OR CALL 1 800 541 2831 PROVIDERS WHO DO NOT HAVE ACCESS TO E MAIL SHOULD CONTACT 1 800 343 9000 PODIATRY Version 2010 01 5 31 2010 Page 40 of 60 REMITTANCE ADVICE 3 4 1 Provider Notification Field Descriptions Upper Left Corner Provider s Name Address as recorded in the Medicaid files Upper Right Corner Remittance Page Number
33. WILL DEPOSITED VIA AN ELECTRONIC FUNDS TRANSFER PODIATRY Version 2010 01 5 31 2010 Page 36 of 60 REMITTANCE ADVICE 3 2 1 EFT Notification Page Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Date The date on which the remittance advice was issued Remittance Number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Medicaid Provider ID NPI Date Provider s Name Address Provider s Name Amount transferred to the provider s account This amount must equal the Net Total Paid Amount under the Grand Total subsection plus the total sum of the Financial Transaction section PODIATRY Version 2010 01 5 31 2010 Page 37 of 60 REMITTANC EMITTANCE ADVICE 3 3 Section One Summout No Payment A summout is produced when the provider has no positive total payment for the cycle and therefore there is no disbursement of moneys Exhibit 3 3 1 TO ABC PODIATRY j D IC AI L ARIA 07080800008 MAMAGEMEN PROV ID 001122339 1233565769 IME O RMATION Ew HO PAYMENT WILL BE RECEIVED THIS CYCLE SEE REMITTANCE FOR DETAILS ABC PODIATRY 100 BROADWAY ANT OWN 11111 PODIATRY Version 2010 01 Page 38 of 60 5 31 2010 REMITTANCE ADVICE 3 3 1 Summout No Payment Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Date The date on which the remi
34. age of the remittance advice at the end of the claim detail section PODIATRY Version 2010 01 5 31 2010 Page 48 of 60 REMITTANCE ADVICE 3 5 3 Subtotals Totals Grand Totals Subtotals of dollar amounts and number of claims are provided as follows Subtotals by claim status appear at the end of the claim listing for each status The subtotals are broken down by amp Original claims Adjustments Voids Adjustments voids combined Subtotals by provider type are provided at the end of the claim detail listing These subtotals are broken down by e Adjustments voids combined Pends Paid Deny Net total paid for the specific service classification Totals by member ID are provided next to the subtotals for provider type For individual practitioners these totals are exactly the same as the subtotals by provider type For practitioner groups this subtotal category refers to the specific member of the group who provided the services These subtotals are broken down by eee e Adjustments voids combined Pends Paid Deny Net total paid sum of approved adjustments voids and paid original claims Grand Totals for the entire provider remittance advice appear on a separate page following the page containing the totals by provider type and member ID The grand total is broken down by Adjustments voids combined Pends Paid Deny Net total paid entire remi
35. being made to change information submitted on the claim TCN 0826019876543200 is shared by three individual claim lines This TCN was paid on September 16 2008 After receiving payment the provider determines that the service date of one of the claim line records is incorrect An adjustment must be submitted to correct the records Exhibit 2 4 2 1 1 shows the claim as it was originally submitted and Exhibit 2 4 2 1 2 shows the claim as it appears after the adjustment has been made PODIATRY Version 2010 01 5 31 2010 Page 10 of 60 Exhibit 2 4 2 1 1 MEDICAL ASSISTANCE HEALTH INSURANCE CLAIM FORM TITLE XIX PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION LPATENTS MARS er curi irr JANE SMITH ADDRESS Sek Cy Sue Dp Cri EC PATENT SPLOT OCCUPATOA CH ZCECCOL E OTHER CERTES SUSAN Cee ier rara Pcie Par farm arc Scie arc Prrsig rx rares hunter Waly 3uoogwg y qTdw LS LON PATIENTS OR AUTHORIZED SIGNATURE T FATEN Gee TA EMERGENCY SAME OF BIMLAR SME TONES ABATED E MENE OF SEEEERINSEHYS GENE R UT HS SOLUBLE PETER STH 21 OF FACLITE WHERE SERVICES RENDEPRED hawaripi ADDRESS OF FAGLTY SERVICE Pes ae L PROF ZX IDENTIRGATIONNUVEER 21 DiBGNOSzORNMSTUREOF LLMEZ aedem CERTE Y THAT THE STATEMENTS THE FENEFEE SLE APPLY TO THES BL AND ARE MADE A PART HEREOF XL BIPLOWER DEAT A CATO Ae James Strong SOCIA
36. cancellation of the omitted individual claim lines from the TCN history records as well as the cancellation of the original TCN payment and the re pricing of the new TCN Adjustment based on the adjusted information Exhibit 2 4 2 1 3 and Exhibit 2 4 2 1 4 illustrate an example of a claim with an adjustment being made to cancel a line on submitted on the claim TCN 0826018765432100 contained three individual claim lines which were paid on September 16 2008 Later it was determined that one of the claims was incorrectly billed since the service was never rendered The claim line for that service must be cancelled to reimburse Medicaid for the overpayment An adjustment should be submitted Exhibit 2 4 2 1 3 shows the claim as it was originally submitted and Exhibit 2 4 2 1 4 shows the claim as it appears after the adjustment has been made PODIATRY Version 2010 01 5 31 2010 Page 13 of 60 CLAIMS SUBMISSION Exhibit 2 4 2 1 3 MEDICAL ASSISTANCE HEALTH INSURANCE SEEN TITLE XIX PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION L ESTISN T MANG Arr irr JANE SMITH PATENTS Zee C Sue Dp Criso MARED TES MEDICARE MER PRIVATE INZLIEZNCE NLIUEER EC FATEHTI OCCUPATION OF SCHOOL PATIENPS RELATIONSHIP TCHMRURETI amp EPLER OR OGCURATION LOTR EA HEALTH MASURAT CO Ae Eris rara Price Par Farne arc Prrsig
37. d 37 3 3 Section ONG S uminout No 38 3 3 1 Summout No Payment Field Descriptions 39 3 4 Se l oh S Provider NOTICO amma Ua nU decur uud uod Mum UEM 40 3 4 1 Provider Notification Field Descriptions 41 3 5 Section e Ig 5 u uuu uu 42 3 5 1 Claim Detail Page Field 8 46 3 5 2 Explanation of Claim Detail Columns a 46 3 5 3 Subtotals Totals Grand Totals cccceccccsseccccseccccssccccscceccucccececcccnscececaucececaccecnueececausececsececuaeececaeesecausceeuucececaueeeenanecs 49 3 6 Section Four Financial Transactions and Accounts Receivable 50 3 6 1 Financial Transactions HR 50 20 07 use laud sec SNL OE D ot 52 3 7 Section FIVE Edit Error Descriptio EE eH sabe bor Un ew dor URN esas 54 Appendix Claim Sample 55 PODIATRY Version 2010 01 5 31 2010 Page 2 of 60 CLAIMS SUBMISSION ADDendix 57 For eMedNY Billing Guideline questio
38. e filled as follows Box M The values entered in this box define the nature of the amounts entered in fields 24 and 24K Box M is used to indicate whether the patient is covered by Medicare and whether Medicare approved or denied payment Enter the appropriate numeric indicator from the following list No Medicare involvement Source Code Indicator 1 This code indicates that the patient does not have Medicare coverage Patient has Medicare Part Medicare approved the service Source Code Indicator 2 This code indicates that the service is covered by Medicare and that Medicare approved the service and either made a payment or paid 0 00 due to a deductible Medicaid is responsible for reimbursing the Medicare deductible and or full or partial coinsurance Patient has Medicare Part B Medicare denied payment Source Code Indicator 3 This code indicates that Medicare denied payment or did not cover the service billed NOTE Fee for service Podiatrists can bill for NY Medicaid members that fit one of the following criteria the member has Medicare OR if the member is under the age of 21 has a written referral from a physician physician assistant nurse practitioner or nurse midwife Box O Box O is used to indicate whether the patient has insurance coverage other than Medicare or Medicaid or whether the patient is responsible for a pre determined amount of his her medical expenses The values entered in this box
39. ersion 2010 01 Description school Homeless shelter Indian health service free standing facility Indian health service provider based facility Tribal 638 free standing facility Tribal 638 provider based facility Doctors office Home Assisted living facility Group home Mobile unit Urgent care facility Inpatient hospital Qutpatient hospital Emergency room hospital Ambulatory surgical center Birthing center Military treatment facility Skilled nursing facility Nursing facility Custodial care facility Hospice Ambulance land Ambulance air or water Independent clinic Federally qualified health center Inpatient psychiatric facility Psychiatric facility partial hospitalization Community mental health center Intermediate care facility mentally retarded Residential substance abuse treatment facility Psychiatric residential treatment center Non residential substance abuse treatment facility Mass immunization center Comprehensive inpatient rehabilitation facility Comprehensive outpatient rehabilitation facility End stage renal disease treatment facility state or local public health clinic Rural health clinic Independent laboratory Other unlisted facility PODIATRY Page 58 of 60 5 31 2010 State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois lowa Indiana Kansas Kentucky Louisiana Maine Maryland Mas
40. holders who do not pay the provider for the services The LDSS office can direct the insurance company to pay the provider directly for the service whether or not the provider participates with the insurance plan The provider should contact the third party worker in the local social services office whenever he she encounters policyholders who are uncooperative in paying for covered services received by their dependents who are on Medicaid In other cases the provider will be instructed to zero fill the Other Insurance Payment 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 provider is instructed to zero fill by the LDSS for circumstances not listed above If none of the above situations are applicable leave this field blank NOTES tis the responsibility of the provider to determine whether the patient s Other Insurance carrier covers the service being billed for as Medicaid is always the payer of last resort The last row of Fields 24H 24J 24K and 24L must be used to enter the appropriate information to complete the block billing of Inpatient Hospital Visits For fields 24J 24K and 24L the entries must reflect the dollar amounts for the total number of visits entered
41. in field 24M Consecutive Billing Section Fields 24M to 240 This section may be used for block billing consecutive visits within the SAME IMONTH YEAR made to a patient in a hospital inpatient status Inpatient Hospital Visit From Through Dates Field 24M In the FROM box enter the date of the first hospital visit in the format MM DD YY In the THROUGH box enter the date of the last hospital visit in the format MM DD YY PODIATRY Version 2010 01 5 31 2010 Page 29 of 60 _ CLAIMS SUBMISSION Proc Code Procedure Code Field 24N If dates were entered in 24M enter the appropriate five character procedure code for the visit Block billing may be used with the following procedure codes 99221 99223 99231 99233 MOD Modifier Field 240 Leave this field blank Trailer Section Fields 25 through 34 The information entered in the Trailer Section of the claim form fields 25 through 34 must apply to all claim lines entered in the Encounter Section of the form Certification Signature of Physician or Supplier Field 25 The billing provider or authorized representative must sign the claim form Rubber stamp signatures are not acceptable Please note that the certification statement is on the back of the form Provider Identification Number Field 25A Enter the provider s 10 digit National Provider Identifier NPI Medicaid Group Identification Number Field 25B Leave this field blank Locator
42. ince Podiatrists 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 This column lists either the amount the provider charged for the claim or the Medicare Approved amount if applicable Paid If the claim was approved the amount paid appears under this column If the claim has a pend or deny status the amount paid will be zero 0 00 Status This column indicates the status DENY PAID ADJT VOID PEND of the claim line Denied Claims Claims for which payment is denied will be identified by the DENY status A claim may be denied for the following general reasons The service rendered is not covered by the New York State Medicaid Program The claim is a duplicate of a prior paid claim The required Prior Approval has not been obtained Information entered in the claim form is invalid or logically inconsistent PODIATRY Version 2010 01 5 31 2010 Page 47 of 60 REMITTANCE ADVICE Approved Claims Approved claims will be identified by the statuses PAID ADJT adjustment or VOID Paid Claims The status PAID refers to original claims that have been approved Adjustments The status ADJT refers to a claim submitted in replacement of a paid claim with the purpose of changing one or more fields An adjustment has two components the credit transaction previously paid claim and the debit transaction adjusted claim Voids
43. ion Statement is near expiration Information about these requirements is available at www emedny org by clicking on the link to the webpage as follows Information for All Providers 2 1 Electronic Claims Pursuant to the Health Insurance Portability and Accountability Act HIPAA Public Law 104 191 which was signed into law August 12 1996 the NYS Medicaid Program adopted the HIPAA compliant transactions as the sole acceptable format for electronic claim submission effective November 2003 Podiatrists who choose to submit their Medicaid claims electronically are required to use the HIPAA 837 Professional 837P transaction Direct billers should refer to the sources listed below to comply with the NYS Medicaid requirements HIPAA 837P Implementation Guide IG explains the proper use of the 837P standards and program specifications This document is available at www wpc edi com hipaa NYS Medicaid 837P Companion Guide CG is a subset of the IG which provides specific instructions on the NYS Medicaid requirements for the 837P transaction This document is available at www emedny org by clicking on the link to the web page as follows eMedNY Companion Guides and Sample Files NYS Medicaid Technical Supplementary Companion Guide provides technical information needed to successfully transmit and receive electronic data Some of the topics put forth in this CG are testing requirements error report information and communication specificat
44. ions This document is available at www emedny org by clicking on the link to the web page as follows eMedNY Companion Guides and Sample Files Further information about electronic claim pre requirements is available at www emedny org by clicking on the link to the webpage as follows Information for All Providers 2 2 Paper Claims Podiatrists who choose to submit their claims on paper forms must use the New York State eMedNY 150002 claim form To view a sample Podiatry eMedNY 150002 claim form see Appendix A below The displayed claim form is a sample and the information it contains is for illustration purposes only PODIATRY Version 2010 01 5 31 2010 Page 5 of 60 CLAIMS SUBMISSION 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 entries are legible and placed appropriately in the
45. low the instructions below The void must be submitted on a new claim form copy of the original form is unacceptable The void must contain all the claim lines to be cancelled and all applicable fields must be completed Voids cause the cancellation of the original TCN history records and payment Exhibit 2 4 2 2 1 and Exhibit 2 4 2 2 2 illustrate an example of a claim being voided TCN 082601234567800 contained two claim lines both of which were paid on September 16 2008 Later the provider became aware that the patient had another insurance coverage The other insurance was billed and the provider was paid in full for all the services Medicaid must be reimbursed by submitting a void for the two claim lines paid in the specific TCN Exhibit 2 4 2 2 1 shows the claim as it was originally submitted and Exhibit 2 4 2 2 2 shows the claim being submitted as voided PODIATRY Version 2010 01 5 31 2010 Page 16 of 60 MEDICAL ASSISTANCE HEALTH INSURANCE CLAIM FORM TITLE XIX PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION Waly 3uq oovg M 1d LS LON 1 amp FIRST CONSULTED FOR GONDIT ON 22 Arr mucius IRE ROBERT JOHNSON ESTRNTS ACARI LES Maus Ip Toir SPLOT DICECUPSTION OF SCR E OTHER CERTE SUSAN TS se rara cr Pcie Pur farm arc Scie arc Peier Preis rx rares further PATIENTS OF AUTHOR JGM LFE
46. mes in this field If the procedure was performed only one time this field may be left blank Charges Field 24J This field must contain either the Amount Charged or the Medicare Approved Amount Amount Charged When Box in field 23B has an entry value of 1 or 3 enter the amount charged in this field The Amount Charged may not exceed the provider s customary charge for the procedure Medicare Approved Amount When Box M in field 23B has an entry value of 2 Enter the Medicare Approved Amount in field 24J The Medicare Approved amount is determined as follows If billing for the Medicare deductible the Medicare Approved amount should equal the Deductible amount claimed which must not exceed the established amount for the year in which the service was rendered If billing for the Medicare coinsurance the Medicare Approved amount should equal the sum of the amount paid by Medicare plus the Medicare co insurance amount plus the Medicare deductible amount if any NOTES The entries in field 23B Payment Source Code determine the entries in field s 24J 24K and 241 PODIATRY Version 2010 01 5 31 2010 Page 27 of 60 CLAIMS SUBMISSION Field 24J must never be left blank or contain zeroes If the Medicare Approved amount from the EOMB equals zero then Medicaid should not be billed itis the responsibility of the provider to determine whether Medicare covers the service being billed for If the service is co
47. ns please contact the eMedNY Call Center 1 800 343 9000 PODIATRY Version 2010 01 5 31 2010 Page 3 of 60 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 Podiatrists 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 PODIATRY Version 2010 01 5 31 2010 Page 4 of 60 CLAIMS SUBMISSION 2 Claims Submission Podiatrists can submit their claims to NYS Medicaid in electronic or paper formats Providers are required to submit an Electronic Paper Transmitter Identification Number ETIN Application and a Certification Statement before submitting claims to NYS Medicaid Certification Statements remain in effect and apply to all claims until superseded by another properly executed Certification Statement Providers will be asked to update their Certification Statement on an annual basis Providers will be provided with renewal information when their Certificat
48. nt 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 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 6 Separate forms using perforations do not cut the edges Donot fold the claim forms Donot use adhesive labels for example for address do not place stickers on the form Do not write or use staples on the bar code area The address for submitting claim forms is COMPUTER SCIENCES CORPORATION P O Box 4601 Rensselaer NY 12144 4601 2 3 eMedNY 150002 Claim Form The 150002 form is a New York State Medicaid form that can be obtained through the financial contractor CSC To order the forms please contact the eMedNY call center at 1 800 343 9000 To view a sample Podiatry eMedNY 150002 claim form see Appendix A The displayed claim form is a sample and the information it contains is for illustration purposes only Shaded fields are not required to be completed unless noted otherwise Therefore shaded fields that are not required to be completed in any circumstance are not listed in the instructions that follow PODIATRY Version 2010 01 5 31 2010 Page 7 of 60 _ CLAIMS SUBM
49. nt s Patient s Common Benefit ID Card The birth date must be in the format MMDDYYYY as shown in Exhibit 2 4 2 1 Exhibit 2 4 2 1 DATE OF BIRTH Patient s Sex Field 5A Place an X in the appropriate box to indicate the patient s sex This information may be obtained from the Client s Patient s Common Benefit ID Card Medicaid Number Field 6A Enter the patient s ID number Client ID number This information may be obtained from the Client s Patient s Common Benefit ID Card Medicaid Client ID numbers are assigned by NYS Medicaid and are composed of 8 characters in the format AANNNNNA where A alpha character and N numeric character as shown in Exhibit 2 4 2 2 Exhibit 2 4 2 2 Was Condition Related To Field 10 If applicable place an X in the appropriate box to indicate whether the service rendered to the patient was for a condition resulting from an accident or a crime Select the boxes in accordance with the following Patient s Employment Use this box to indicate Worker s Compensation Leave this box blank if condition is related to patient s employment but not to Worker s Compensation PODIATRY Version 2010 01 5 31 2010 Page 19 of 60 SUBMISSION Crime Victim Use this box to indicate that the condition treated was the result of an assault or crime Auto Accident Use this box to indicate Automobile No Fault Leave this box blank if condition is related t
50. o an auto accident other than no fault or if no fault benefits are exhausted Other Liability Use this box to indicate that the condition was related to an accident related injury of a different nature from those indicated above If the condition being treated is not related to any of these situations leave these boxes blank Emergency Related Field 16A Enter an X in the Yes box only when the condition being treated is related to an emergency the patient requires immediate intervention as a result of severe life threatening or potentially disabling condition otherwise leave this field blank Name of Referring Physician or Other Source Field 19 If the service was ordered or the patient was referred by another provider enter the ordering referring provider s name in this field Address or Signature SHF Only Field 19 If services were rendered in a Shared Health Facility and the patient was referred for treatment or a specialty consultation by another Medicaid provider in the same Shared Health Facility obtain the referring ordering provider s signature in this field If not applicable leave blank Prof CD Professional Code Ordering Referring Provider Field 19B Leave this field blank Identification Number Ordering Referring Provider Field 19C For Ordering Provider Enter the ordering provider s National Provider Identifier NPI in this field For Referring Provider Enter the Referring Provider
51. ose to identify a patient by using an office account number This field can accommodate up to 20 alphanumeric characters If an office account number is indicated on the claim form it will be returned on the Remittance Advice Using an Office Account Number can be helpful for locating accounts when there is a question on patient identification Other Referring Ordering Provider ID License Number Field 33 Leave this field blank PODIATRY Version 2010 01 5 31 2010 Page 31 of 60 CLAIMS SUBMISSION Prof CD Profession Code Other Referring Ordering Provider Field 34 Leave this field blank PODIATRY Version 2010 01 5 31 2010 Page 32 of 60 REMITTANCE ADVICE 3 Explanation of Paper Remittance Advice Sections This Section presents samples of each section of the Chiropractors Portable X Ray Supplier s remittance advice 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
52. r the date on which the provider or an authorized representative signed the claim form The date should be in the format MM DD YY NOTE In accordance with New York State regulations claims must be submitted within 90 days of the Date of Service unless acceptable circumstances for the delay can be documented For more information about billing claims over 90 days or two years from the Date of Service refer to Information for All Providers General Billing section which can be found at www emedny org by clicking on the link to the webpage as follows Podiatry Manual Physician s or Supplier s Name Address Zip Code Field 31 Enter the provider s name and correspondence address using the following rules for submitting the ZIP code Paper claim submissions Enter the 5 digit ZIP code or the ZIP plus four Electronic claim submissions Enter the 9 digit ZIP code The 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 Podiatry Manual Patient s Account Number Field 32 For record keeping purposes the provider may cho
53. sachusetts Michigan Minnesota State Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico North Carolina Morth Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin American Territories American Samoa Canal Zone Guam Puerto Rico Trust Territories Virgin Islands NOTE Required only when reporting out of state license numbers PODIATRY Version 2010 01 Page 59 of 60 APPENDIX B CODE SETS 5 31 2010 EMEDNY INFORMATION eMedNY is the name of the electronic New York State Medicaid system The eMedNY system allows New York Medicaid providers to submit claims and receive payments for Medicaid covered services provided to eligible clients eMedNY offers several innovative technical and architectural features facilitating the adjudication and payment of claims and providing extensive support and convenience for its users CSC is the eMedNY contractor and is responsible for its operation The information contained within this document was created in concert by eMedNY DOH and eMedNY CSC More information about eMedNY can be found at www emedny org PODIATRY Version 2010 01 5 31 2010 Page 60 of 60
54. termine whether their claims have been crossed over to Medicaid for processing Any claim that was indicated by Medicare as a crossover should not be submitted to Medicaid as a separate claim If the Medicare remittance does not indicate that the claim has been crossed over to Medicaid the provider should submit the claim directly to Medicaid Claims that are denied by Medicare will not be crossed over Medicaid will deny claims that are crossed over without a Patient Responsibility If a separate claim is submitted directly by the provider to Medicaid for a dual eligible recipient and the claim is paid before the Medicare crossover claim both claims will be paid The eMedNY system automatically voids the provider submitted claim in this scenario Providers may submit adjustments to Medicaid for their crossover claims because they are processed as a regular adjustment Electronic remittances from Medicaid for crossover claims will be sent to the default ETIN when the default is set to electronic If there is no default ETIN the crossover claims will be reported on a paper remittance The ETIN application is available at www emedny org by clicking on the link to the webpage as follows Provider Enrollment Forms NOTE For crossover claims the Locator Code will default to 003 if the submitted ZIP 4 does not match information in the provider s Medicaid file PODIATRY Version 2010 01 5 31 2010 Page 8 of 60 _ CLAIMS SUBMISSION 2 4
55. ttance PODIATRY Version 2010 01 5 31 2010 Page 49 of 60 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 DICAID Mn J CYCLE 1710 IR FORMATION hy ee MEDICAL ASS TITLE XIX PROGRAM EE 100 BROADWAY REMITTANCE STATEMENT FINANCIAL TRANSACTIONS ANYTOWN NEW YORK 11111 PROVID 20112233 1122455783 REMITTANCE NO OF 080600006 FINANCIAL FISCAL 2 REASON CODE TRANS TYPE CATE _ 201005060235547 XXX RECOUPMENT REASON DESCRIPTION 05 08 10 5553 NET FINANCIAL TRANSACTION AMOUNT 25 33 NUMBER OF FINANCIAL TRANSACTIONS PODIATRY Version 2010 01 5 31 2010 Page 50 of 60 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
56. ttance advice was issued Remittance Number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Notification that no payment was made for the cycle no claims were approved Provider s Name Address PODIATRY Version 2010 01 5 31 2010 Page 39 of 60 REMITTANCE ADVICE 3 4 Section Two Provider Notification This section is used to communicate important messages to providers Exhibit 3 4 1 PAGE 01 D ICAID DATE 05 31 10 NAOEME CYCLE 1710 IN FORM TIO bre Te F MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT TO ABC PODIATRY ETIN 100 BROADWAY PROVIDER NOTIFICATION NEW YORK 11111 PROV ID 00112233 1123458789 REMITTANCE NO 07080600006 REMITTANCE ADVICE MESSAGE TEXT ELECTRONIC FUNDS TRANSFER EFT FOR PROVIDER PAYMENTS IS NOW AVAILABLE PROVIDERS WHO ENROLL IM EFT WILL HAVE THEIR MEDICAID PAYMENTS DIRECTLY DEPOSITED INTO THEIR CHECKING OR SAVINGS ACCOUNT THEEFT TRANSACTIONS WILL BE INITIATED ON WEDNESDAYS AND DUE TO NORMAL BANKING PROCEDURES THE TRANSFERRED FUNDS MAY NOT BECOME AVAILABLE IN THE PROVIDER S CHOSEN ACCOUNTFOR UP TO 48 HOURS AFTER TRANSFER PLEASE CONTACT YOUR BANKING INSTITUTION REGARDING THE AVAILABILITY OF FUNDS PLEASE NOTE THAT EFT DOES NOT WAIVE THE LAG FOR MEDICAID DISBURSEMENTS TO ENROLL IM EFT PROVIDERS MUST COMPLETE AN EFT ENROLLMENT FORM THAT CAM BE FOUND WWW EMEDNNY ORG CLICK ON PRO
57. vered or if the provider does not know if the service is covered the provider must first submit a claim to Medicare as Medicaid is always the payer of last resort Unlabeled Field 24K This field is used to indicate the Medicare Paid Amount and must be completed if Box M in field 23B has an entry value of 2 or 3 Box 2 When billing for the Medicare deductible enter 0 00 in this field When billing for the Medicare coinsurance enter the Medicare Paid amount as the sum of the actual Medicare paid amount and the Medicare deductible if any Box M 3 Enter 0 00 in this field to indicate that Medicare denied payment or did not cover the service If none of the above situations are applicable leave this field blank Unlabeled Field 24L This field must be completed when Box O in field 23B has an entry value of 2 or 3 When Box O has an entry value of 2 enter the other insurance payment in this field If more than one insurance carrier contributes to payment of the claim add the payment amounts and enter the total amount paid by all other insurance carriers in this field When has an entry value of 3 enter the Patient Participation amount If the patient is covered by other insurance and the insurance carrier s paid for the service add the Other Insurance payment to the Patient Participation amount and enter the sum in this field If the other insurance carrier denied payment enter 0 00 in field 24L

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