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eMedNY Subsystem User Manual

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1. nra P BEN A TO AMD AM MACH BARA Safty Sally Forth CHW 312 Main Street Anytown Now York 11111 8 10 EMEDNY 150003 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 11 of 59 EN CLAIMS SUBMISSION Exhibit 2 4 2 1 2 MEDICAL ASSISTANCE HEALTH INSURANCE CLAIM FORM TITLE XIX PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION g Fm om an DAT DN Um SUSAN SAMPLE 0 8 2 0 1 9 9 0 BRAE uu b v v 115 m Moses MARENI EMPLOYER OF DCCUPNTION BELATED SS ACM Eee Cy Sami Parents lie oru a OTHER Ui ITY rx nra TM BEN A TO AMD AM MACH A BARA HEN Safty Sally Forth GW 312 Main Street Anytown Now York 11111 8 10 EMEDNY 150003 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 12 of 59 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 th
2. ADDRESS OF A PROVIDER EX NTFICATIDN FUMUS gt Sra T BEN A TO AM AM MACH HEN Sal fy Fort Sally Forth CIW 312 Main Street Anytown Now York 11111 8 10 EMEDNY 150003 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 17 of 59 EN CLAIMS SUBMISSION Exhibit 2 4 2 2 2 MEDICAL ASSISTANCE HEALTH INSURANCE omiy rooe Acooe TRANSACHON CONTROL NUMBER CLAIM FORM TITLE XIX PROGRAM _ A Tx Pm oF SUSAN SAMPLE 118 WAS RELATED TO esce OF ONMT OF 50 Yu po ww LES CODE gu ADDRESS OF Da TOR 4 aa WER IDI BT F ICE TKD NONIS Cae re Cote k i D NIE C CET roams x gt Sra T BEN A TO AM AM MACH HEN Sal fy Fort Sally Forth GW 312 Main Street Anytown Now York 11111 8 10 EMEDNY 150003 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 18 of 59 SUBMISSION
3. ACCOUNTS RECEIVABLE MEDICAL ASSISTANCE TITLE XIX PROGRAM 3 PRoWID 20112233 1123455722 REMITTANCE STATEMENT muU E REASOM CODE DESCRIPTION ORIG BAL CURR BAL RECOUP AMT 3XXX XX TOTAL AMOUNT DUE THE STATE XX CLINICAL SOCIAL WORKER Version 2010 01 Page 51 of 59 11 18 2010 REMITTANCE ADVICE 3 6 2 1 Explanation of Accounts Receivable Columns f 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 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 52 of 59 REMITTANCE ADVICE 3 7 Section Five Edit Error Description The last section of the Remittance Advice features the description of each of the edit codes including approved codes failed by the claims listed in Section Three Exhibit 3 7 1 DICAID
4. Adjustments voids combined Pends Paid Deny Net total paid entire remittance CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 47 of 59 REMITTANCE ADVICE 3 6 Section Four Financial Transactions and Accounts Receivable This section has two subsections Financial Transactions Accounts Receivable CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 48 of 59 REMITTANCE ADVICE 3 6 1 Financial Transactions The Financial Transactions subsection lists all the recoupments that were applied to the provider during the specific cycle If there is no recoupment activity this subsection is not produced Exhibit 3 6 1 1 D CAI D DATE 55 21 10 CYCLE 1710 HAN E w Sa T E FN TO JAMES STRONG MEDICAL ASSISTANCE ITITLE PROGRAM ETIN 100 BROADWAY MIT TATEM FINANCIAL TRANSACTIONS ANYTOWN NEW YORK 11111 REMITTANCE STATEMENT PROVID 00112233 1122456783 REMITTANCE NO 070805000006 _ FINANCIAL FISCAL nmm FCN REASOM CODE TRANS TYPE DATE AMOUNT 201005060236547 XXX RECOUPMENT REASON DESCRIPTION 05 09 10 5 35 NET FINANCIAL TRANSACTION AMOUNT 555 ss NUMBER OF FINANCIAL TRANSACTIONS CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 49 of 59 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 Rea
5. 35 3 3 Section One Surmmout 36 3 3 1 Summout No Payment Field 0001 00 nennen nennen nennen nnns sess 37 3 4 Section TWO Provider NotiiCatiON temm 38 3 4 1 Provider Notification Field Descriptions 39 3 5 SECON T I DSN 40 3 5 1 Claim Detail Page Field Descriptions r r 44 3 5 2 Explanation of Claim Detail Columns r 44 3 5 3 Subtotals Totals Grand 47 3 6 Section Four Financial Transactions and Accounts Receivable 48 3 6 1 Financial Transactions e L H 49 51 3 7 Section Five Edit Error 53 Appendix Claim 5 ullu u 54 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 2 of 59 CLAIMS SUBMISSION ADDendix 56 For eMedNY Billing Guideline questions please contact the eMedNY Call Center 1 800 343 9000 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 3 of 59
6. CLAIMS TOTAL PENDS 158 94 NUMBER CLAIMS TOTAL PAID 147 40 NUMBER OF CLAIMS TOTAL DENIED 152 20 NUMBER OF CLAIMS NET TOTAL PAID 143 80 NUMBER CLAIMS MEMBER ID 00112233 VOIDS ADJUSTS 2 62 NUMBER OF CLAIMS TOTAL PENDS 158 34 NUMBER OF CLAIMS TOTAL PAID 147 42 NUMBER OF CLAIMS TOTAL DENIED 162 20 NUMBER CLAIMS NET TOTAL FAID 143 80 NUMBER CLAIMS bz dx CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 42 of 59 REMITTANCE ADVICE Exhibit 3 5 4 DICAID DATE CYCLE 1710 MAN AOCME NT ISIF a Sa T E Fi MED ICAL ASSISTANCE TITLE AIA PROGRAM ETIN REMITTANCE STATEMENT GRAND TOTALS ANTOWAN NEW YORK 11111 PROVID 00112233 11234565789 REMITTANCE 07080500006 REMITTANCE TOTALS GRAND TOTALS VOIDS ADJUSTS 3 60 NUMBER OF CLAIMS 1 TOTAL PENDS 168 94 NUMBER OF CLAIMS 4 TOTAL PAID 147 40 NUMBER OF CLAIMS 4 TOTAL DENY 162 20 NUMBER OF CLAIMS 4 NETTOTAL PAID 143 80 NUMBER OF CLAIMS 5 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 43 of 59 _ REMITTANCE ADVICE 3 5 1 Claim Detail Page Field Descriptions Upper Left Corner Provider s Name Address 5 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 paymen
7. BERENI EMPLOYER OF DCCUPNTION 15 RS ADDUNT Cum Dy Se Jp Lnd Waki Wives 50 no ww wr UR HAM BEE NATIONAL DRUG CODE Fa ou 708 IAWITIY rx nra P BEN A TO AMD AM MACH BARA Safty Sally Forth CHW 312 Main Street Anytown Now York 11111 8 10 EMEDNY 150003 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 14 of 59 EN CLAIMS SUBMISSION Exhibit 2 4 2 1 4 MEDICAL ASSISTANCE HEALTH INSURANCE ONLY TO BE ORIGINAL TRANSACTION CONTROL NUMBER CLAIM FORM TITLE XIX PROGRAM MAB PATIENT AND INSURED SUBSCRIBER INFORMATION PAND CLAM 1 0 3 0 0 1 9 716 161413121010 gcn BATI QE ESTIS evapo m E 0 5 2 0 1 9 9 0 777 paia L AE i PE E Te kama COMATION BELATED MEI no ww 03 Us NAME Kb BUTE Waki NI 15 MATIN A CODE wr POR QUANTITY 8 10 EMEDNY 150003 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 15 of 59 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 When submitting a void please follow the instructions below The void must be submitted a new claim form copy
8. New York State Electronic Medicaid System 150003 Billing Guidelines 2 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 TT TABLE OF CONTENTS TABLE OF CONTENTS L PUPO O 01 1 2 4 2 Clamis Sul i 5 2 1 Fl CI O C C p uu u 5 2 2 Paper 6 2 2 1 General Instructions for Completing Paper Claims r 6 2 3 150003 Claim Fform u 8 2 4 Clinical Social Worker Services Billing Instructions nnnm 8 2 4 1 Instructions for the Submission of Medicare Crossover 8 2 4 2 150003 Claim Form Field 5 nes 9 3 Explanation of Paper Remittance Advice 5 31 3 1 Section One IVICCIC AICO MEL 32 31 1 Maeqicaid Check St b Field DeSSHDEIONS u 33 3 1 2 Medicaid Check Field 5 33 3 2 uuu ERE 34 3 2 1 EFT Notification Page Field nennen nennen
9. ees PURPOSE STATEMENT 1 Purpose Statement The purpose of this document is to assist the provider community in understanding and complying with the New York State Medicaid NYS Medicaid requirements and expectations for Billing and submitting claims Interpreting and using the information returned in the Medicaid Remittance Advice This document is customized for Clinical Social Workers 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 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 4 of 59 CLAIMS SUBMISSION 2 Claims Submission Clinical Social Workers 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 Certification Statement is near expiration Information about these requirements i
10. 3 0 0 0 1 NOTE A three digit Diagnosis Code no entry following the decimal point will only be accepted when the Diagnosis Code has no subcategories Otherwise Diagnosis Codes with subcategories MUST be entered with the subcategories indicated after the decimal point Days or Units Field 241 If a procedure was performed and approved by Medicare more than one time on the same date of service enter the number of times in this field If the procedure was performed only one time this field may be left blank Charges Field 24 This field must contain the Medicare Approved Amount when billing for CSW diagnostic services When billing for therapeutic services enter the Medicare reasonable charge amount 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 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 26 of 59 CLAIMS SUBMISSION Medicare Reasonable Charge Amount Although this a
11. 2010 01 11 18 2010 Page 22 of 59 CLAIMS SUBMISSION Box M The values entered in this box define the nature of the amounts entered in fields 24 and 24K Box 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 Clinical Social Workers require that the client be a QMB Qualified Medicare Beneficiary and that Medicare approve the service in order to receive coinsurance and deductible payment from Medicaid Patient has Medicare Part B Medicare approved the service Source Code Indicator 2 This code indicates that the service is covered by Medicare and that Medicare approved the service and either made a payment or paid 0 00 due to a deductible Medicaid is responsible for reimbursing the Medicare deductible and or full or partial coinsurance Patient has Medicare Part B Medicare denied payment Source Code Indicator 3 Clinical Social Workers require that the client be a QMB Qualified Medicare Beneficiary and that Medicare approve the service in order to receive coinsurance and deductible payment from Medicaid 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
12. 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 1029919876543200 contained two claim lines both of which were paid on October 25 2010 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 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 16 of 59 EN CLAIMS SUBMISSION Exhibit 2 4 2 2 1 MEDICAL ASSISTANCE HEALTH INSURANCE CODE v 7 DRICUNAL TRANSACTION CONTROL NUMBER CLAIM FORM TITLE XIX PROGRAM 9010 RES PATIENT AMD INSURE AND INSURED SUBSCRIE INFORMATION CLAIM g ret Fun om an DATI OF ENIE i SUSAN SAMPLE OF ONMT OF em ib WAS COMDTEM RELATED TO esce 50 Yu po ww D PHYIAXGAN OM OTHER ROUBLE NATIONAL CODE 1 L Rea
13. the policyholder is either unavailable to or uncooperative in submitting claims to the insurance company In these cases the LDSS must be notified prior to zero filling LDSS has subrogation rights enabling them to complete claim forms on behalf of uncooperative policyholders who do not pay the provider for the services The LDSS office can direct the insurance company to pay the provider directly for the service whether or not the provider participates with the insurance plan The provider should contact the third party worker 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 reso
14. 12233 1123545 783 070805000006 UNITS CHARGED PAID 1 000 14 30 14 30 1 000 14 30 14 30 1 000 52 80 52 80 1 000 65 00 65 00 1 000 17 60 7 62 STATUS FAID PAID PAID PAID ADJT ERRORS ORIGINAL CLAIM PAID 05 24 10 13000 1430 14 30 ADJT PREVIOUSLY PEHDED CLAIM NEW PEND 11 18 2010 REMITTANCE ADVICE Exhibit 3 5 3 D IC AID Bu mu HAN AGEMENT INFORMATION SYSTEM MEDICAL ASSISTANCE TITLE XIX PROGRAM JAMES STRONG REMITTANCE STATEMENT ES AcTITIONER 100 BROADWAY PROVID 0011223234 1122450785 ANYTOWN NEW YORK 11111 REMITTANCE LN OFFICEACCOUNT CLIENT CLIENT ID DATE OF PROC NO NUMBER NAME NUMBER SERVICE CODE UNITS CHARGED PAID STATUS ERRORS 01 111111 DOE XX123459X OTST 0511710 92826 1 000 69 30 0 00 PEND 00162 02 CP222727 SAMPLE XX231455X 0172 468 0 0 ON 12710 90553 1 000 71 04 0 00 PEND 00162 01 EXAMPLE AAHIDI OTS OV T4710 95100 1 000 14 30 0 00 PEND 00142 27 SPECIMEN QUT206 000033550 0 10 90812 1 000 14 30 0 00 PEND 00131 PREVIOUSLY PENDED CLAIM NEWPEND TOTAL AMOUNT ORIGINAL CLAIMS 158 34 NUMBER OF CLAIMS AMOUNT ADJUSTMENTS PEND 0 00 NUMBER OF CLAIMS NET AMOUNT VOIDS PEND 0 00 NUMBER OF CLAIMS NET AMOUNT VOIDS ADJUSTS 0 00 NUMBER OF CLAIMS REMITTANCE TOTALS PRACTITIONER VOIDS ADJUSTS 3 60 NUMBER
15. B SOURCE CO 1 236 SOURCE 238 SOURCE 3 7 23B SOURCE CO 21 23B SOURCE CO 99 RR 23B PAYMT SOURCE 013 MERE 23b SOURCE CO Db 23B PAYM T SOURCE CO 3 2 23B SOURCE CO 33 Version 2010 01 Exhibit 2 4 2 8 Code 1 Medicare involvement Field 24 should contain the amount charged and field 24h must be blank Code 1 No Medicare involvement Field 24 should contin the amount charged and field 24h musibe lef blank Code 1 Medicare involvement Field 24 should contain the amount charged snd 24h mustbe left blank Code 2 Medicare Approved Service Field 24 should contain the Medicare Approved amountand field 24h shoud contain the Medicare payment amount Code 2 Medicare Approved Service Field 24 should contain the Medicare Approved amountand field 24h shoud contain the Medicare payment amount Code 2 Medicare Approved Service Field 24J should conisinthe Medicare Approved amountand field 24K should contain the Medicare payment amount Code 3 Medicare denied payment or did not cover the service Field 24 should contsin the amount charged andfield 24K should contain 0 00 Code 3 Medicare denied payment or did mot cover the service Field 241 should contsin the amount charged 24K should contain 0 00 Code 3 Med
16. DATE O53110 CYCLE 1710 ETE MH MEDICAL ASSISTANCE TITLE XIX PROGRAM ETIN TO JAMES STRONG PETS RA PRACTITIONER 100 BROADWAY REMITTANCE STATEMENT EDITDESCRIPTIONS ANYTOWN NEW YORK 11111 PROV ID 00112233 1123456783 REMITTANCE NO 07080500005 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 TO 00162 RECIPIENTINELIGIBLE ON DATE OF SERVICE 00244 ON OR REMOVED FROM FILE CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 53 of 59 APPENDIX CLAIM SAMPLES APPENDIX A CLAIM SAMPLES The eMedNY Billing Guideline Appendix A Claim Samples contains an image of a claim with sample data CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 54 of 59 APPENDIX A CLAIM SAMPLE MEDICAL ASSISTANCE HEALTH INSURANCE omy To CLAIM FORM TITLE PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION nnam E oe du TRANSACTION CONTROL NUMBER PAS COMATIOM BELATED Fal PAP T 3 ore OTHER 114 25 oo Yw C NAME OR ODER RUNE 1 OF GES RENDERED oF o aioe 15 ADOAESS OF 22 WAS LAB
17. IAL WORKER Version 2010 01 11 18 2010 Page 19 of 59 CLAIMS SUBMISSION Crime Victim Use this box to indicate that the condition treated was the result of an assault or crime Auto Accident Use this box to indicate Automobile No Fault Leave this box blank if condition is related to an auto accident other than no fault or if no fault benefits are exhausted Other Liability Use this box to indicate that the condition was related to an accident related injury of a different nature from those indicated above If the condition being treated is not related to any of these situations leave these boxes blank Emergency Related Field 16A Enter an X in the Yes box only when the condition being treated is related to an emergency the patient requires immediate intervention as a result of severe life threatening or potentially disabling condition otherwise leave this field blank Name of Referring Physician or Other Source Field 19 If the patient was referred for treatment or a specialty consultation by another provider enter the referring provider s name in this field If no order or referral was involved leave this field blank Address or Signature SHF Only Field 19A If the provider is a member of 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 signatu
18. ORATORY WORK PERFORMED LAB CHAPOES QUTMDE YOUR DEPER i wo OD PRCA IX EXNTFICATION CON i DESAG ITY rm DA T DE BRAE B D v Y E Sally Forth CIW 312 Main Street Anytown Now York 11111 TELEPHCPE MER L HOT TE 8 10 EMEDNY 150003 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 55 of 59 APPENDIX CODE SETS APPENDIX B CODE SETS The eMedNY Billing Guideline Appendix B Code Sets contains a list of Place of Service codes as well as a list of accepted Unites States Standard Postal Abbreviations CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 56 of 59 APPENDIX CODE SETS Version 2010 01 Description school Homeless shelter Indian health service free standing facility Indian health service provider based facility Tribal 638 free standing facility Tribal 638 provider based facility Doctors office Home Assisted living facility Group home Mobile unit Urgent care facility Inpatient hospital Qutpatient hospital Emergency room hospital Ambulatory surgical center Birthing center Military treatment facility Skilled nursing facility Nursing facility Custodial care facility Hospice Ambulance land Ambulance air or water Independent clinic Federally qualified health center Inpa
19. 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 required fields The following guidelines will help ensure the accuracy of the imaging output All information should be typed or printed Alpha characters letters should be capitalized Numbers should be written as close to the example below in Exhibit 2 1 1 1 as possible Exhibit 2 1 1 1 e Circles the letter O the number 0 must be closed e Avoid unfinished characters See the example in Exhibit 2 1 1 2 Exhibit 2 1 1 2 Written As Intended As Interpreted As 6 00 660 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 1 1 3 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 6 of 59 _ CLAIMS SUBMISSION Exhibit 2 1 1 3 Intended As Interpreted As lwoainterpreted as seven gt hree interpreted as two Characters should not touch each other as seen in Exhibit 2 1 1 4 Exhibit 2 1 1 4 Written As Intended As Interpreted As Pasa Entry cannot be 23 illegible interpreted properly Do not write between lines not use arrows or quotation marks to duplicate information Donotuse the dollar sign 5 to i
20. Patient s Name Field 1 Enter the patient s first name followed by the last name This information may be obtained from the Client s Patient s Common Benefit ID Card Date of Birth Field 2 Enter the patient s birth date This information may be obtained from the Client s Patient s Common Benefit ID Card The birth date must be in the format MMDDYYYY as shown in Exhibit 2 4 2 1 Exhibit 2 4 2 1 DATE OF BIRTH Patient s Sex Field 5A Place an X in the appropriate box to indicate the patient s sex This information may be obtained from the Client s Patient s Common Benefit ID Card Medicaid Number Field 6A Enter the patient s ID number Client ID number This information may be obtained from the Client s Patient s Common Benefit ID Card Medicaid Client ID numbers are assigned by NYS Medicaid and are composed of 8 characters in the format AANNNNNA where A alpha character and N numeric character as shown in Exhibit 2 4 2 2 Exhibit 2 4 2 2 Was Condition Related To Field 10 If applicable place an X in the appropriate box to indicate whether the service rendered to the patient was for 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 CLINICAL SOC
21. Provider ID and the NPI Center Notification that no payment was made for the cycle no claims were approved Provider s Name Address CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 37 of 59 REMITTANCE ADVICE 3 4 Section Two Provider Notification This section is used to communicate important messages to providers Exhibit 3 4 1 DICAID E x DATE 05 31 10 CYCLE 1710 MEDICAL ASSISTANCE TITLE PROGRAM REMITTANCE STATEMENT JAMES STRONG ETIN 100 BROADWAY PROVIDER NOTIFICATION ANYTOWN NEW YORK 11111 PROV ID 00112233H123456789 REMITTANCE NO 07080600006 REMITTANCE ADVICE MESSAGE TEXT ELECTRONIC FUNDS TRANSFER EFT FOR PROVIDER PAYMENTS IS NOW AVAILABLE PROVIDERS WHO ENROLL EFT WILL HAVE THEIR MEDICAID PAYMENTS DIRECTLY DEPOSITED IMTO THEIR CHECKING OR SAVINGS ACCOUNT THE EFT TRANSACTIONS WILL BE INITIATED WEDNESDAYS AND DUE TO NORMAL BANKING PROCEDURES THE TRANSFERRED FUNDS MAY NOT BECOME AVAILABLE IN THE PROVIDER S CHOSEN ACCOUNT FOR UP TO 48 HOURS AFTER TRANSFER PLEASE CONTACT YOUR BANKING INSTITUTION REGARDING THE AVAILABILITY OF FUNDS PLEASE NOTE THAT EFT DOES NOT WAIVE THE TWO WEEK LAG FOR MEDICAID DISBURSEMENTS TO EMROLL IM EFT PROVIDERS MUST COMPLETE AM EFT EMROLLMENT FORM THAT CAM BE FOUND AT WWWEMEDNY ORG CLICK OM PROVIDER ENROLLMENT FORMS WHICH CAN BE FOUND IM THE FEATURED LINKS SECTIOM DETAILED INSTRUCTIONS WILL ALSO BE FOUND THERE AFTER SENDING
22. 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 AMD LOOK FOR EFT TRANSACTION IN THE AMOUNT OF 0 01 WHICH CSC WILL SUBMIT 5 TEST YOUR FIRST REAL EFT TRANSACTION WILL TAKE PLACE APPROAIMATELY FOUR TO FIVE WEEKS LATER IF OU HAVE ANY QUESTIONS ABOUT THE EFT PROCESS PLEASE CALL THE CALL CENTER AT 1 800 343 8000 NOTICE THIS COMMUNICATION AND ANY ATTACHMENTS MAY CONTAIN INFORMATION THAT 15 PRIVILEGED AND CONFIDENTIAL UNDER STATE AND FEDERAL LAW AND IS INTENDED ONLY FOR THE USE OF THE SPECIFIC IMDIVIDUAL 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 IN ERROR PLEASE IMMEDIATELY NOTIFY NYHIPPADESK CSC COM OR CALL 1 800 541 2831 PROVIDERS WHO DO MOT HAVE ACCESS TO E MAIL SHOULD CONTACT 1 800 343 9000 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 38 of 59 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 Date The date on which the remittance advice was issued Cycle Number The cycle number should be used when c
23. alling 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 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 39 of 59 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 JAMES STRONG 100 BROADWAY NEW YORK 11111 LN NO 01 02 01 01 Version 2010 01 OFFICE ACCOUNT NUMBER CP111111 CP444444 CLIENT NAME DOE SAMPLE EXAMPLE SPECIMEN TOTAL AMOUNT ORIGINAL CLAIMS NET AMOUNT ADJUSTMENTS NET AMOUNT VOIDS NET AMOUNT VOIDS ADJUSTS MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT CLIENT ID NUMBER Xx 234 0bX Exhibit 3 5 1 HAN AGEMENT INFORMATION amp YSTEM DATE OF SERVICE 05 11 10 05 12 10 05 14 10 05 15 10 PROC CODE 96100 80818 30812 80806 TCN 07206 000000227 0 0 07206 000011224 0 0 07206 000013556 0 0 07206 0000324565 0 0 UNITS 8 000 8 000 10 000 8 000 DENIED DENIED DENIED 162 20 0 00 0 00 0 00 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS CLINICAL SOCIAL WORKER Page 40
24. ame 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 DOH and eMedNY CSC More information about eMedNY can be found at www emedny org CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 59 of 59
25. d payment must indicate the two digit insurance code Code 3 Indicetes patient s participation Field 24L should contain the patient s participation amount f Other Insurance is also involved enter the total payment in 24L and enter the two digit insurance coda 11 18 2010 CLAIMS SUBMISSION Encounter Section Fields 24A to 240 The claim form can accommodate up to seven encounters with a single patient plus a block of encounters in a hospital setting if all the information the Header Section of the claim Fields 1 23 applies to all the encounters Date of Service Field 24A Enter the date on which the service was rendered in the format MM DD YY 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 w
26. e 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 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 46 of 59 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 s fhe 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 e eee 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 eeee 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 he
27. e original form is unacceptable The adjustment must contain all claim lines submitted in the original document all claim lines with the same except for the claim s line s to be voided these claim lines must be omitted in the adjustment All applicable fields must be completed The adjustment will cause the cancellation of the omitted individual claim lines from the TCN history records as well as the cancellation of the original TCN payment and the re pricing of the new TCN Adjustment based on the adjusted information Exhibit 2 4 2 1 3 and Exhibit 2 4 2 1 4 illustrate an example of a claim with an adjustment being made to cancel a line submitted on the claim TCN 1030019876543200 contained two individual claim lines which were paid on October 26 2010 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 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 13 of 59 EN CLAIMS SUBMISSION Exhibit 2 4 2 1 3 MEDICAL ASSISTANCE HEALTH INSURANCE CLAIM FORM TITLE XIX PROGRAM PATIENT AND INSURED SUBSCRIBER EN OK OOMDCION ai Mosis mulis
28. ed by other insurance and the insurance 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 241 Proof of denial of payment must be maintained in the patient s billing record Zeroes must also be entered in this field if any of the following situations apply Prior to billing the insurance company the provider knows that the service will not be covered because The provider has had a previous denial for payment for the service from the particular insurance policy However the provider should be aware that the service should be billed if the insurance policy changes Proof of denials must be maintained in the patient s billing record Prior claims denied due to deductibles not being met are not to be counted as denials for subsequent billings CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 27 of 59 _ CLAIMS SUBMISSION In very limited situations the Local Department of Social Services LDSS has advised the provider to zero fill other insurance payment for same type of service This communication should be documented in the patient s billing record The provider bills the insurance company and receives a rejection because The service is not covered or The deductible has not been met The provider cannot directly bill the insurance carrier and
29. ents Accounts Receivable cumulative financial information Section Five Edit Error Description CLINICAL SOCIAL WORKER Version 2010 01 Page 31 of 59 11 18 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 BLZ AGE It FORM ATION SYSTEM TO JAMES STRONG DATE 2010 05 31 REMITTANCE 07080600006 PROV ID 00112233 1123456789 00112233 1123456789 2010 05 31 JAMES STRONG 100 BROADWAY ANYTOWN 11111 YOUR CHECK I5 BELOW DETACH TEAR ALONG PERFORATED DASHED LINE REMITTANCE PROVIDER ID NO DOLLARS CENTS NUMBER FAY 2010 05 31 07080600006 00112233 1123456780 143 80 AFTER 0 DAYE JAMES STRONG 100 BROADWAY DICAID INFORM ATION SYSTEM MEDICAL ASSISTANCE TITLE XIX PROGRAM EN CHECKS DRAWN ON John Smith KEY BANEK STREET ALBANY YORE 1227 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 32 of 59 REMITTANCE ADVICE 3 1 1 Medicaid Check Stub Field Descriptions Upper Left Corner 5 Name as recorded in the Medicaid files Upper Right Corner Date The date on which
30. eviously paid claim and the debit transaction adjusted claim Voids The status VOID refers to a claim submitted with the purpose of canceling a previously paid claim A void lists the credit transaction previously paid claim only Pending Claims Claims that require further review or recycling will be identified by the PEND status The following are examples of circumstances that commonly cause claims to be pended New York State Medical Review required Procedure requires manual pricing No match found in the Medicaid files for certain information submitted on the claim for example Patient ID Prior Approval Service Authorization These claims are recycled for a period of time during which the Medicaid files may be updated to match the information on the claim After manual review is completed a match is found in the Medicaid files or the recycling time expires pended claims may be approved for payment or denied A new pend is 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 b
31. fication 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 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 35 of 59 REMITTANCE ADVICE 3 3 Section One Summout No Payment summout is produced when the provider has no positive total payment for the cycle and therefore there is no disbursement of moneys Exhibit 3 3 1 TO JAMES STRONG DATE 05 31 2010 REMITTANCE NO 07080500006 D ICAI D ID 00112233 11234 8789 M INFORMATIC M PAYMENT WILL RECEIVED THIS CYCLE SEE REMITTANCE FOR DETAILS JAMES STRONG 100 BROADWAY ANYT OWN 11111 CLINICAL SOCIAL WORKER Version 2010 01 Page 36 of 59 11 18 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 remittance advice was issued Remittance Number PROV ID This field will contain the Medicaid
32. haracters If an office account number is indicated on the claim form it will be returned on the Remittance Advice Using an Office Account Number can be helpful for locating accounts when there is a question on patient identification Other Referring Ordering Provider ID License Number Field 33 Leave this field blank Prof CD Profession Code Other Referring Ordering Provider Field 34 Leave this field blank CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 30 of 59 REMITTANCE ADVICE 3 Explanation of Paper Remittance Advice Sections This Section presents samples of each section of the Clinical Social Worker 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 Electronic Funds Transfer Summout no claims paid Section Two Provider Notification special messages Section Three Claim Detail Section Four Financial Transactions recoupm
33. icare denied payment or did not cover the service Field 241 should contsin the amount changed and feld 24H should contain 0 00 CLINICAL SOCIAL WORKER Page 24 of 59 Code 1 Other Insurance involvement Field 24Lmustbe lefi blank Code 2 Other Insurance involved Field 24L should contain the amount paid by the other insurance or 0 00 if the ntherinsurance did notcover the service ordeanied payment You must indicate the two digit insurance code Code 3 Indicstes patient s participation Field 24L should contain the patent s participation amount Other Insurance is also involved enter the total payment in 24L and enter the two digit insurance coda Code 1 No Other Insurance involvement Fizid24L mustba et blank Code 2 Other Insurance involved Field 24L should contain the amount paid by the other insurance or 0 00 if the other insurance did service ordeniedpsyment You must indicate the two digit insurance code Code 3 Indicstes patient s participation Field 24L should contain the patient s participation amount It Other Insursnce is aln invalved enter the total payments in 24L and anter the two digit insurance code Code 1 Other Insurance involvement Field 24L must be lef blank Code 2 Other Insurance involved Field 24L should contain the amount paid by the ofherinsurance or 0 00 if the other insurance did notcover the service ordenie
34. icare will then reimburse its portion to the provider and the provider s Medicare remittance will indicate that the claim will be crossed over to Medicaid Claims for services not covered by Medicare should continue to be submitted directly to Medicaid as policy allows Also Medicare Part C Medicare Managed Care and Medicare Part D claims are not part of this process Providers are urged to review their Medicare remittances for crossovers beginning December 1 2009 to determine whether their claims have been crossed over to Medicaid for processing Any claim that was indicated by Medicare as a crossover should not be submitted to Medicaid as a separate claim If the Medicare remittance does not indicate 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 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 8 of 59 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
35. in this field does not have to be the facility address It should be the address where the service was rendered Service Provider Name Field 22A Leave this field blank CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 21 of 59 CLAIMS SUBMISSION 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 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 and 0 Field 23B This field has two components Box M and Box O as shown in Exhibit 2 4 2 7 below Exhibit 2 4 2 7 23B PAYM T SOURCE Mi Both boxes need to be filled as follows CLINICAL SOCIAL WORKER Version
36. mation 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 2 4 Clinical Social Worker Services Billing Instructions This subsection of the Billing Guidelines covers the specific NYS Medicaid billing requirements for Clinical Social Workers Although the instructions that follow are based on the eMedNY 150003 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 NOTE Clinical Social Workers require that the client be a QMB Qualified Medicare Beneficiary and that Medicare approve the service in order to receive coinsurance and deductible payment from Medicaid 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 Med
37. mount does not appear on the Medicare Explanation of Benefits EOMB it can be calculated by increasing the Medicare Allowed amount by 60 It may also be calculated by adding together the Medicare Paid amount and the Amount Due from the Patient both found on the EOMB NOTES Field 24J must never be left blank or contain zeroes Ifthe Medicare approved amount from the EOMB equals zero then Medicaid should not be billed the responsibility of the provider to determine whether Medicare covers the service being billed for If the service is covered or if the provider does not know if the service is covered the provider must first submit a claim to Medicare as Medicaid is always the payer of last resort Unlabeled Field 24K This field must contain the Medicare Paid amount 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 Unlabeled Field 24L This field must be completed when Box O in field 23B has an entry value of 2 or 3 O 2 Enter the other insurance payment in this field more than 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 Enter the Patient Participation amount If the patient is cover
38. n 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 Clinical Social Worker 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 Clinical Social Worker Manual Patient s Account Number Field 32 For record keeping purposes the provider may choose to identify a patient by using an office account number This field can accommodate up to 20 alphanumeric c
39. ndicate dollar amounts do not use commas to separate thousands For example three thousand should be entered as 3000 not as 3 000 For writing it is best to use a felt tip pen with a fine point Avoid ballpoint pens that skip do not use pencils highlighters or markers Only blue or black ink is acceptable If filling in information through a computer ensure that all information is aligned properly and that the printer ink is dark enough to provide clear legibility e Do not submit claim forms with corrections such as information written over correction fluid or crossed out information If mistakes are made a new form should be used Separate forms using perforations do not cut the edges Do not fold the claim forms Do not use adhesive labels for example for address do not place stickers on the form e eee Do not write or use staples on the bar code area The address for submitting claim forms is COMPUTER SCIENCES CORPORATION P O Box 4601 Rensselaer NY 12144 4601 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 7 of 59 CLAIMS SUBMISSION 2 3 eMedNY 150003 Claim Form The 150003 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 Clinical Social Worker eMedNY 150003 claim form see Appendix The displayed claim form is a sample and the infor
40. 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 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 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 5 of 59 _ CLAIMS SUBMISSION 2 2 Paper Claims Clinical Social Workers who choose to submit their claims on paper forms must use the New York State eMedNY 150003 claim form To view a sample eMedNY 150003 claim form see Appendix A below The displayed claim form is a sample and the information it contains is for illustration purposes only An Electronic Transmission Identification Number ETIN and a Certification Statement are required to submit paper claims Providers who have a valid ETIN for the submission of electronic claims do not need an additional ETIN for paper submissions The ETIN and the associated certification qualify the provider to submit claims in both electronic and paper formats Information about these requirements is available at www emedny org by clicking on the link to the webpage as follows Information for All Providers 2 2 1 General Instructions for Completing
41. nt 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 Enter the locator code that corresponds to the address where the service was performed 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 Providers Inquiry section located at www emedny org by clicking on the link to the webpage as follows Clinical Social Worker Manual 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 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 29 of 59 CLAIMS SUBMISSION Date Signed Field 25E Enter the date on which the Clinical Social Worker signed the claim form The date should be in the format MM DD YY NOTE I
42. nt must contain all claim lines originally submitted in the same document record all claim lines with the same TCN and all applicable fields must be completed with the necessary changes The adjustment will cause the correction of the 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 being made to change information submitted on the claim TCN 1030119876543200 is shared by two individual claim lines This TCN was paid on October 27 2010 After receiving payment the provider determined that the service date of one of the claim line records is incorrect An adjustment must be submitted to correct the record 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 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 10 of 59 EN CLAIMS SUBMISSION Exhibit 2 4 2 1 1 MEDICAL ASSISTANCE HEALTH INSURANCE CLAIM FORM TITLE XIX PROGRAM PATIENT AND INSURED SUBSCRIBER s n p m BL t 15 MERTI Dy Or QT OF 50 no ww wr UR HAM BEE NATIONAL DRUG CODE Fa ou 708 IAWITIY rx
43. of 59 PAGE 02 DATE 05 21 2010 CYCLE 1710 ETIN PRACTITIONER PROV ID 00112233 1123455783 REMITTANCE CHARGED 52 80 17 60 14 30 PAID 0 00 0 00 0 00 0 00 STATUS DENY DENY DENY DENY ERRORS 00162 00244 00244 00162 00131 PREVIOUSLY PENDED CLAIM NEW FEND 11 18 2010 REMITTANCE ADVICE Exhibit 3 5 2 TO JAMES STRONG 100880 DWAT ANY TOWN NEW YORK 11111 LN NO 01 02 01 01 01 01 NUMBER 111111 222222 CF444444 moe of 555555 CLIENT NAME DOE SAMPLE EXAMPLE SPECIMEN STANDARD MODEL TOTAL AMOUNT ORIGINAL CLAIMS NET AMOUNT ADJUSTMENTS NET AMOUNT VOIDS NET AMOUNT VOIDS ADJUSTS Version 2010 01 CLIENT ID NUMBER XX12345X 34567 XX45578X DICAID MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT TCN 07206 33661 0 0 07206 33661 0 0 07205 000045667 0 0 7206 000056767 0 0 206 0 00067767 0 0 206 000088767 0 0 PAID PAID PAID 147 00 3 60 0 00 3 05 DATE OF SERVICE 011 10 05 12 10 ON 14 10 ON 15 10 OO 10 05 05 10 NUMBER CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS PROC CODE 99812 95100 1 30818 CLINICAL SOCIAL WORKER Page 41 of 59 PAGE DATE CYCLE 03 05 31 2010 1710 PRACTITIONER PROV ID Q01
44. pears under this column The units are indicated with three 3 decimal positions Since Clinical Social Workers must only report whole units of service the decimal positions will always be 000 For example 3 units will be indicated as 3 000 Charged The total charges entered in the claim form appear under this column Paid If the claim was approved the amount paid appears under this column If the claim has a pend or deny status the amount paid will be zero 0 00 Status This column indicates the status DENY PAID ADJT VOID PEND of the claim line Denied Claims Claims for which payment is denied will be identified by the DENY status A claim may be denied for the following general reasons 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 the claim form is invalid or logically inconsistent CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 45 of 59 ADVICE Approved Claims Approved claims will be identified by the statuses PA D 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 pr
45. propriate 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 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 Tochange information contained in one or more claim lines submitted on a previously paid TCN CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 9 of 59 SUBMISSION Tocancel one or more claim lines submitted on a previously paid TCN except if the TCN 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 and the Patient s Medicaid ID number must not be adjusted The adjustment must be submitted in a new claim form copy of the original form is unacceptable The adjustme
46. re 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 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 20 of 59 CLAIMS SUBMISSION For Referring Provider Enter the Referring Provider s NPI NOTE A facility ID cannot be used for the Ordering Referring Provider In those instances where a service was ordered by a facility the NPI of a practitioner at the facility ordering the service must be entered in this field 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 20B 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 when the Place of Service Code entered in Field 24B is 99 Other Unlisted Facility NOTE The address listed
47. 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 the provider s Medicaid file 2 4 2 eMedNY 150003 Claim Form Field Instructions Header Section Fields 1 through 23B The information entered in the Header Section of the claim form fields 1 through 23B must apply to all claim lines entered in the Encounter Section of the form The following two unnumbered fields should only be used to adjust or void a paid claim Do not write in these fields when preparing an original claim form Adjustment Void Code Upper Right Corner of Form Leave this field blank when submitting an original claim or resubmission of a denied claim If submitting an adjustment replacement to a previously paid claim enter X or the value 7 in the A box lf submitting a void to a previously paid claim enter X or the value 8 in the 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 ap
48. rt Leave the last row of Fields 24H 24J 24K 241 blank Consecutive Billing Section Fields 24M to 240 This section may be used for block billing consecutive visits within the SAME made to a patient in a hospital inpatient status Inpatient Hospital Visit From Through Dates Field 24M Leave this field blank Proc Code Procedure Code Field 24N Leave this field blank MOD Modifier Field 240 Leave this field blank CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 28 of 59 _ CLAIMS SUBMISSION 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 Medicaid Group Identification Number Field 25B Leave this field blank Locator Code Field 25C 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 enrollme
49. s available at www emedny org by clicking on the link to the webpage as follows Information for All Providers NOTE Clinical Social Workers require that the client be a QMB Qualified Medicare Beneficiary and that Medicare approve the service in order to receive coinsurance and deductible payment from Medicaid 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 Clinical Social Workers who choose to submit their Medicaid claims electronically are required to use the HIPAA 837 Professional 837P transaction In addition to this document 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 5 Medicaid 837P Companion Guide 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
50. son Code This code is for DOH CSC use only it has no relevance to providers It identifies the reason for the recoupment Financial Transaction Type This is the description of the Financial Reason Code For example Third Party Recovery Date The date on which the recoupment was applied Since all the recoupments listed on this page pertain to the current cycle all the recoupments will have the same date Amount The dollar amount corresponding to the particular fiscal transaction This amount is deducted from the provider s total payment for the cycle 3 6 1 2 Explanation of Totals Section The total dollar amount of the financial transactions Net Financial Transaction Amount and the total number of transactions Number of Financial Transactions appear below the last line of the transaction detail list The Net Financial Transaction Amount added to the Claim Detail Grand Total must equal the Medicaid Check or EFT amounts CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 50 of 59 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 05 DICAID HAM AGEMENT TO JAMES STRONG 100 BROADWAT ANYTON NEW YORK 11111 FORM TIM DOSE FN
51. 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 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 33 of 59 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 recoupment if any scheduled for the cycle This section indicates the amount of the EFT Exhibit 3 2 1 TO JAMES STRONG DATE 2010 05 31 CAI D REMIT TANCE NO 07080800008 PROV ID 001122341 123456709 INFORMATION amp Yx STEM 00112233 11234 8789 2010 05 31 JAMES STRONG 100 BROADWAY 11111 JAMES STRONG 5143 80 PAYMENT IN THE ABOVE AMOUNT WILL BE DEPOSITED VIA ELECTRONIC FUNDS TRANSFER CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 34 of 59 REMITTANCE ADVICE 3 2 1 EFT Noti
52. this box 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 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 Clinical Social Worker 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 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 23 of 59 CLAIMS SUBMISSION 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 241 23
53. tient 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 CLINICAL SOCIAL WORKER Page 57 of 59 11 18 2010 State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois lowa Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota State Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico North Carolina 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 CLINICAL SOCIAL WORKER Version 2010 01 Page 58 of 59 APPENDIX CODE SETS 11 18 2010 EMEDNY INFORMATION eMedNY is the n
54. ts ETIN not applicable Provider Service Classification PRACTITIONER PROV ID This field will contain the Medicaid Provider ID and the NPI Remittance Number 3 5 2 Explanation of Claim Detail Columns LN NO Line Number This column indicates the line number of each claim as it appears on the claim form Office Account Number If a Patient Office Account Number was entered in the claim form that number up to 20 characters will appear under this column Client Name This column indicates the last name of the patient If an invalid Medicaid Client ID was entered in the claim form the ID will be listed as it was submitted but no name will appear in this column Client ID Number The patient s Medicaid ID number appears under this column CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 44 of 59 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 ap
55. ww emedny org by clicking on the link to the webpage as follows Clinical Social Worker 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 Deductible When billing for the Medicare deductible modifier U2 must be used in conjunction with the Procedure Code for which the deductible is applicable Do not enter the U2 modifier if billing for Medicare coinsurance NOTE Modifier values and their definitions are available under Procedure Codes and Fee Schedule at www emedny org by clicking on the link to the webpage as follows Clinical Social Worker Manual 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 CLINICAL SOCIAL WORKER Version 2010 01 11 18 2010 Page 25 of 59 CLAIMS SUBMISSION 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

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