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eMedNY Subsystem User Manual

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1. 56 3 6 2 Accounts Receivable 58 3 7 Section Five Edit Error Description 60 Appendix A Claim Samples 61 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 3 of 80 Appendix B Code Sets 63 Appendix C Sterilization Consent Form LDSS 3134 68 Sterilization consent Form LDSS 3134 and 3134 S Instructions 70 Appendix D Acknowledgment of Receipt of Hysterectomy Information Form LDSS 3113 75 Acknowledgement Receipt of Hysterectomy Information Form LDSS 3113 Instructions 77 For eMedNY Billing Guideline questions please
2. 43 3 3 1 Summout No Payment Field Descriptions 44 3 4 Section Two Provider Notification 45 3 4 1 Provider Notification Field Descriptions 46 3 5 Section Three Claim Detail 47 3 5 1 Claim Detail Page Field Descriptions 51 3 5 2 Explanation of Claim Detail Columns 51 3 5 3 Subtotals Totals Grand Totals 55 3 6 Section Four Financial Transactions and Accounts Receivable 56 3 6 1 Financial Transactions
3. 8 2 4 1 Instructions for the Submission of Medicare Crossover Claims 8 2 4 2 eMedNY 150003 Claim Form Field Instructions 9 3 Explanation of Paper Remittance Advice Sections 38 3 1 Section One Medicaid Check 39 3 1 1 Medicaid Check Stub Field Descriptions 40 3 1 2 Medicaid Check Field Descriptions 40 3 2 Section One EFT Notification 41 3 2 1 EFT Notification Page Field Descriptions 42 3 3 Section One Summout No Payment
4. 90238 90240 through 90282 94997 99231 through 99233 99296 through 99297 99433 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 35 of 80 MOD Modifier Field 24O If the procedure code entered in 24N requires the addition of a modifier to further define the procedure enter the modifier in this field NOTE 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 enter the total Charges Medicare Approved Amount Medicare Paid Amount or Other Insurance Paid Amount that results from multiplying the amount for each individual visit times the number of days entered in field 24M 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 For a Group Practice enter the NPI assigned to the group in this field A claim should be
5. PHYSICIAN Version 2010 01 11 18 2010 Page 78 of 80 Field 8 The surgeon who performed or will perform the hysterectomy must sign the form to certify that the procedure was for medical necessity and not primarily for family planning purposes Field 9 Enter the date of the surgeon s signature Part II Waiver of Acknowledgement The surgeon who performs the hysterectomy must complete this Part of the claim form if Part I the recipient s Acknowledgment Statement has not been completed for one of the reasons noted above This part need not be completed before the hysterectomy is performed Field 10 Enter the recipient s name Field 11 If the recipient s acknowledgment was not obtained because she was sterile prior to performance of the hysterectomy check this box and briefly describe the cause of sterility e g postmenopausal This waiver may apply to cases in which the woman was not a Medicaid recipient at the time the hysterectomy was performed Field 12 If the recipient s Acknowledgment was not obtained because the hysterectomy was performed in a life threatening emergency in which prior acknowledgment was not possible check this box and briefly describe the nature of the emergency This waiver may apply to cases in which the woman was not a Medicaid recipient at the time the hysterectomy was performed Field 13 If the patient s Acknowledgment was not obtained because she was not a Medicaid recipient at the time a hy
6. Type text Type text Type text PHYSICIAN NNeew w YYoorrkk SSttaattee EElleeccttrroonniicc M Meeddiiccaaiidd SSyysstteem m 115500000033 BBiilllliinngg G Guuiiddeelliinneess 11 18 2010 Version 2010 01 T A B L E O F C O N T E N T S PHYSICIAN Version 2010 01 11 18 2010 Page 2 of 80 TABLE OF CONTENTS 1 Purpose Statement 4 2 Claims Submission 5 2 1 Electronic Claims 5 2 2 Paper Claims 6 2 2 1 General Instructions for Completing Paper Claims 6 2 3 eMedNY 150003 Claim Form 8 2 4 Physician Services Billing Instructions
7. Version 2010 01 11 18 2010 Page 23 of 80 Unit Field 20A Use one of the following when completing this entry UN Unit F2 International Unit GR Gram ML Milliliter Quantity Field 20B Enter the numeric quantity administered to the client Report the quantity in relation to the decimal point as shown in Exhibit 2 4 2 4 NOTE The preprinted decimal point must be rewritten in blue or black ink when entering a value in this field The claim will not process correctly if the decimal is not entered in blue or black ink Exhibit 2 4 2 4 Cost Field 20C Enter based on price per unit e g if administering 0 150 grams GM enter the cost of only one gram or unit as shown in Exhibit 2 4 2 5 Exhibit 2 4 2 5 NOTE The preprinted decimal point must be rewritten in blue or black ink when entering a value in this field The claim will not process correctly if the decimal is not entered in blue or black ink Exhibit 2 4 2 6 contains a sample of how a drug code would be submitted along with another service provided on the same day C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 24 of 80 Exhibit 2 4 2 6 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 25 of 80 Name of Facility Where Services Rendered Field 21 This field should be completed only when the Place of Service Code entered in Field 24B is 99 Other Unlisted Facility Addr
8. 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 Box O has an entry value of 3 enter the Patient Participation amount If the patient is covered by other insurance and the insurance carrier s paid for the service add the Other Insurance payment to the Patient Participation amount and enter the sum in this field If the other insurance carrier denied payment enter 0 00 in field 24L Proof of denial of payment must be maintained in the patient s billing record Zeroes must also be entered in this field if any of the following situations apply Prior to billing the insurance company the provider knows that the service will not be covered because The provider has had a previous denial for payment for the service from the particular insurance policy However the provider sho
9. 2 4 2 7 Both boxes need to be filled as follows Box M The values entered in this box define the nature of the amounts entered in fields 24J and 24K Box M is used to indicate whether the patient is covered by Medicare and whether Medicare approved or denied payment Enter the appropriate numeric indicator from the following list No Medicare involvement Source Code Indicator 1 This code indicates that the patient does not have Medicare coverage Patient has Medicare Part B Medicare approved the service Source Code Indicator 2 This code indicates that the service is covered by Medicare and that Medicare approved the service and either made a payment or paid 0 00 due to a deductible Medicaid is responsible for reimbursing the Medicare deductible and or full or partial coinsurance C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 28 of 80 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 Box O Box O is used to indicate whether the patient has insurance coverage other than Medicare or Medicaid or whether the patient is responsible for a pre determined amount of his her medical expenses The values entered in this box define the nature of the amount entered in field 24L Enter the appropriate indicator from the following list No Other Insurance involvement Source
10. 2010 Page 41 of 80 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 R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 42 of 80 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 R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 43 of 80 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 R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 44 of 80 3 3 1 Summout No Payment Field
11. Code Indicator 1 This code indicates that the patient does not have other insurance coverage Patient has Other Insurance coverage Source Code Indicator 2 This code indicates that the patient has other insurance regardless of the fact that the insurance carrier s paid or denied payment or that the service was covered or not by the other insurance When the value 2 is entered in Box O the two character code that identifies the other insurance carrier must be entered in the space following Box O If more than one insurance carrier is involved enter the code of the insurance carrier who paid the largest amount For the appropriate Other Insurance codes refer to Information for All Providers Third Party Information which can be found at www emedny org by clicking on the link to the webpage as follows Physician 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 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 29 of 80 Exhibit 2 4 2 8 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 30 of 80 Encounter Section Fields 24A to 24O The claim form can accommod
12. P T O F H Y S T E R E C T O M Y I N F O F O R M PHYSICIAN Version 2010 01 11 18 2010 Page 76 of 80 A P P E N D I X D A C K N O W L E D G E M E N T O F R E C E I P T O F H Y S T E R E C T O M Y I N F O F O R M PHYSICIAN Version 2010 01 11 18 2010 Page 77 of 80 ACKNOWLEDGEMENT RECEIPT OF HYSTERECTOMY INFORMATION FORM LDSS 3113 INSTRUCTIONS Either Part I or Part II must be completed depending on the circumstances of the operation In all cases Fields 1 and 2 must be completed Field 1 Enter the recipient s Medicaid ID number Field 2 Enter the surgeon s name Part I Recipient s Acknowledgement Statement and Surgeon s Certification This part must be signed and dated by the recipient or her representative unless one of the following situations exists The recipient was sterile prior to performance of the hysterectomy The hysterectomy was performed in a life threatening emergency in which prior acknowledgment was not possible or The patient was not a Medicaid recipient on the day the hysterectomy was performed Field 3 Enter the recipient s name Field 4 The recipient or her representative must sign the form Field 5 Enter the date of signature Field 6 If applicable the interpreter must sign the form Field 7 If applicable enter the date of interpreter s signature A P P E N D I X D A C K N O W L E D G E M E N T O F R E C E I P T O F H Y S T E R E C T O M Y I N F O F O R M
13. T I O N C O N S E N T F O R M PHYSICIAN Version 2010 01 11 18 2010 Page 72 of 80 Physician s Statement The physician should complete and date this form after the sterilization procedure is performed Field 18 Enter the patient s name Field 19 Enter the date the sterilization procedure was performed Field 20 Enter the name of the sterilization procedure Instructions for Use of Alternative Final Paragraphs If the sterilization was performed at least 30 days from the date of consent 9 then cross out the second paragraph and sign 26 and date the consent form If less than 30 days but more than 72 hours has elapsed from the date of consent as a consequence of either premature delivery or emergency abdominal surgery proceed as follows Field 21 Specify the type of operation Field 22 Select one of the check boxes as necessary Field 23 If the sterilization was scheduled to be performed in conjunction with delivery but the delivery was premature occurring within the 30 day waiting period check box one 22 and enter the expected date of delivery 23 Field 24 If the patient was scheduled to be sterilized but within the 30 day waiting period required emergency abdominal surgery and the sterilization was performed at that time then check box two 22 and describe the circumstances 25 Field 25 Describe the circumstances of the emergency abdominal surgery A P P E N D I X C S T E R I L I Z
14. THP Field 22G This field must be completed if the physician bills for a periodic health supervision well care examination for a patient under 21 years of age whether billing a Preventive Medicine Procedure Code or a Visit Code with a well care diagnosis If applicable place an X in the Y box for YES Family Planning Field 22H Medical family planning services include diagnosis treatment drugs supplies and related counseling which are furnished or prescribed by or are under the supervision of a physician or nurse practitioner The services include but are not limited to Physician clinic or hospital visits during which birth control pills contraceptive devices or other contraceptive methods are either provided during the visit or prescribed Periodic examinations associated with a contraceptive method Visits during which sterilization or other methods of birth control are discussed Sterilization procedures This field must always be completed Place an X in the YES box if all services being claimed are family planning services Place an X in the NO box if at least one of the services being claimed is not a family planning service If some of the services being claimed but not all are related to Family Planning place the modifier FP in the two digit space following the procedure code in Field 24D to designate those specific procedures which are family planning services C L A I M S S U B M I S S I O N PH
15. 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 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 20 of 80 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 conditi
16. applicable fees etc are available at www emedny org by clicking on the link to the webpage as follows Physician Manual C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 31 of 80 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 can be found on the web page for this manual under Procedure Codes and Fee Schedule which can be found at www emedny org by clicking on the link to the webpage as follows Diagnosis Code Field 24H Physician Manual 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 Cod
17. being made to cancel a line on submitted on the claim TCN 1025701234567890 contained three individual claim lines which were paid on September 14 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 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 14 of 80 Exhibit 2 4 2 1 3 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 15 of 80 Exhibit 2 4 2 1 4 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 16 of 80 2 4 2 2 Void A void is submitted to nullify all individual claim lines originally submitted on the same document record and sharing the same TCN When submitting a void please follow the instructions below The void must be submitted on a new claim form copy of the original form is unacceptable The void must contain all the claim lines to be cancelled and all applicable fields must be completed Voids cause the cancellation of the original TCN history records and payment Exhibit 2 4 2 2 1 and Exhibit 2 4 2 2 2 illustrate an example of a claim being voided TCN 1026301234567890 contained t
18. contact the eMedNY Call Center 1 800 343 9000 P U R P O S E S T A T E M E N T PHYSICIAN Version 2010 01 11 18 2010 Page 4 of 80 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 Physicians 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 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 5 of 80 2 Claims Submission Physicians 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 C
19. for the purpose of sterilization Code F a completed Sterilization Consent Form LDSS 3134 is required and must be attached to the paper claim form see Appendix C This type of claim must be submitted on paper with the LDSS 3134 form attached to it NOTES The following medical procedures are not induced abortions therefore when billing for these procedures leave this field blank Spontaneous abortion miscarriage Termination of ectopic pregnancy C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 26 of 80 Drugs or devices to prevent implantation of the fertilized ovum Menstrual extraction Medicaid does not reimburse providers for hysterectomies performed for the purpose of sterilization Please refer to the Policy Guidelines on the web page for this manual which can be found at www emedny org by clicking on the link to the webpage as follows Status Code Field 22E Physician Manual Leave this field blank Possible Disability Field 22F Place an X in the Y box for YES or an X in the N 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
20. 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 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 10 of 80 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 adjustment must contain all claim lines originally submitted in the same document record all claim lines with the same TCN and all applicable fields must be completed with the necessary changes The adjustment will cause the correction of the 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 1026501234567890 is shared by three individual claim lines This TCN was paid on September 22 2010 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 Exhibi
21. submitted under the Group ID only if payment for the service s being claimed is to be made to the group In such case the NPI of the group member that rendered the service must be entered in field 25A For a Shared Health Facility enter the NPI assigned to the facility If the provider or the service s rendered is not associated with a Group Practice or a Shared Health Facility 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 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 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 36 of 80 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 lo
22. the NPI of the primary operating physician must be entered in this field If no order or referral is involved or the claim is not from an assistant surgeon leave this field blank C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 22 of 80 DX Code Field 19D Leave this field blank Drug Claims Section Fields 20 to 20C The following instructions apply to drug code claims only The NDC in field 20 and the associated information in fields 20A through 20C must correspond directly to information on the first line of fields 24A through 24L Only the first line of fields 24A through 24L may be used for drug code billing Only one drug code claim may be submitted per 150003 claim form however other procedures may be billed on the same claim NDC National Drug Code Field 20 National Drug Code is a unique code that identifies a drug labeler vendor product and trade package size Enter the NDC as an 11 digit sequence of numbers Do not use spaces hyphens or other punctuation marks in this field NOTE Providers must pay particular attention to placement of zeroes because the labeler of a particular drug package may have omitted preceding leading zeros in any one of the NDC segments The provider must enter the required leading zeros within the affected segment See Exhibit 2 4 2 3 for examples of the NDC and leading zero placement Exhibit 2 4 2 3 C L A I M S S U B M I S S I O N PHYSICIAN
23. A T I O N C O N S E N T F O R M PHYSICIAN Version 2010 01 11 18 2010 Page 73 of 80 Field 26 The physician who performed the sterilization must sign and date the form The date of the physician s signature should indicate that the physician s statement was signed after the procedure was performed that is on the day of or a day subsequent to the sterilization For Sterilizations Performed In New York City New York City local law requires the presence of a witness chosen by the patient when the patient consents to sterilization In addition upon admission for sterilization in New York City the patient is required to review his her decision to be sterilized and to reaffirm that decision in writing Witness Certification Field 27 Enter the name of the witness to the consent to sterilization Field 28 Enter the date the witness observed the consent to sterilization This date will be the same date of consent to sterilization 9 Field 29 Enter the patient s name Field 30 The witness must sign the form Field 31 Enter the title if any of the witness Field 32 Enter the date of witness s signature Reaffirmation Field 33 The patient must sign the form A P P E N D I X C S T E R I L I Z A T I O N C O N S E N T F O R M PHYSICIAN Version 2010 01 11 18 2010 Page 74 of 80 Field 34 Enter the date of the patient s signature This date should be shortly prior to or same as date of steriliza
24. 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 Notification that no payment was made for the cycle no claims were approved Provider s Name Address R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 45 of 80 3 4 Section Two Provider Notification This section is used to communicate important messages to providers Exhibit 3 4 1 R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 46 of 80 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 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 R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 47 of 80 3 5 Section Three Claim Detail This section provides a listing of all new claims that were processed dur
25. PHYSICIAN Version 2010 01 11 18 2010 Page 67 of 80 NOTE Required only when reporting out of state license numbers A P P E N D I X C S T E R I L I Z A T I O N C O N S E N T F O R M PHYSICIAN Version 2010 01 11 18 2010 Page 68 of 80 APPENDIX C STERILIZATION CONSENT FORM LDSS 3134 A Sterilization Consent Form LDSS 3134 must be completed for each sterilization procedure No other form can be used in place of the LDSS 3134 A supply of these forms available in English and in Spanish LDSS 3134 S can be obtained from the New York State Department of Health s website by clicking on the link to the webpage as follows Local Districts Social Service Forms Claims for sterilization procedures must be submitted on paper and a copy of the completed and signed Sterilization Consent Form LDSS 3134 or LDSS 3134 S must be attached to the claim When completing the DSS 3134 please follow the guidelines below Be certain that the form is completed so it can be read easily An illegible or altered form is unacceptable will cause a paper claim to deny Also the persons completing the form should check to see that all five copies are legible Each required field or blank must be completed in order to ensure payment If a woman is not currently Medicaid eligible at the time she signs the LDSS 3134 or LDSS 3134 S form but becomes eligible prior to the procedure and if she is 21 years of age when the form was signed the 30
26. YSICIAN Version 2010 01 11 18 2010 Page 27 of 80 Prior Approval Number Field 23A If the provider is billing for a service that requires Prior Approval Prior Authorization enter in this field the 11 digit prior approval number assigned for this service by the appropriate agency of the New York State Department of Health If several service dates and or procedures need to be claimed and they are covered by different prior approvals a separate claim form has to be submitted for each prior approval NOTES For information regarding how to obtain Prior Approval Prior Authorization for specific services please refer to Information for All Providers Inquiry section on the web page for this manual which can be found at www emedny org by clicking on the link to the webpage as follows Physician Manual For information on how to complete the prior approval form please refer to the Prior Approval Guidelines for this manua which can be found at www emedny org by clicking on the link to the webpage as follows Physician Manual For information regarding procedures that require prior approval please consult the Procedure Codes and Fee Schedules which can be found on the web page for this manual which can be found at www emedny org by clicking on the link to the webpage as follows Payment Source Code Box M and Box O Field 23B Physician Manual This field has two components Box M and Box O as shown in Exhibit 2 4 2 7 below Exhibit
27. action previously paid claim and the debit transaction adjusted claim Voids The status VOID refers to a claim submitted with the purpose of canceling a previously paid claim A void lists the credit transaction previously paid claim only Pending Claims Claims that require further review or recycling will be identified by the PEND status The following are examples of circumstances that commonly cause claims to be pended New York State Medical Review required Procedure requires manual pricing No match found in the Medicaid files for certain information submitted on the claim for example Patient ID Prior Approval Service Authorization These claims are recycled for a period of time during which the Medicaid files may be updated to match the information on the claim After manual review is completed a match is found in the Medicaid files or the recycling time expires pended claims may be approved for payment or denied R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 54 of 80 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 cl
28. aim from being approved Up to twenty five 25 edit codes including approved edits may be listed for each claim Edit code definitions will be listed on a separate page of the remittance advice at the end of the claim detail section R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 55 of 80 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 Original claims Adjustments Voids Adjustments voids combined Subtotals by provider type are provided at the end of the claim detail listing These subtotals are broken down by Adjustments voids combined Pends Paid Deny Net total paid for the specific service classification Totals by member ID are provided next to the subtotals for provider type For individual practitioners these totals are exactly the same as the subtotals by provider type For practitioner groups this subtotal category refers to the specific member of the group who provided the services These subtotals are broken down by 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 i
29. 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 R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 58 of 80 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 R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 59 of 80 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 eac
30. ate up to seven encounters with a single patient plus a block of encounters in a hospital setting if all the information in the Header Section of the claim Fields 1 23B applies to all the encounters The following instructions apply to drug code claims only The NDC in field 20 and the associated information in fields 20A through 20C must correspond directly to information on the first line of fields 24A through 24L Only the first line of fields 24A through 24L may be used for drug code billing Only one drug code claim may be submitted per 150003 claim form however other procedures may be billed on the same claim 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
31. cated at www emedny org by clicking on the link to the webpage as follows SA EXCP Code Service Authorization Exception Code Field 25D Physician Manual If it was necessary to provide a service covered under the Utilization Threshold UT program and service authorization SA could not be obtained enter the SA exception code that best describes the reason for the exception For valid SA exception codes please refer to Appendix B Code Sets NOTE If the services being claimed require a specialty that is exempted from the Utilization Threshold program see list of exempted specialties in Appendix A Codes the value 7 must be entered in this field For more information on the UT Program please refer to Information for All Providers General Policy subsection Utilization Threshold Program which can be found at www emedny org by clicking on the link to the webpage as follows Physician Manual If not applicable 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 Enter 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 Serv
32. ceivable cumulative financial information Section Five Edit Error Description R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 39 of 80 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 R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 40 of 80 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 R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18
33. day waiting period starts from the date the LDSS form was signed regardless of the date the woman becomes Medicaid eligible A sample Sterilization Consent Form and step by step instructions follow on the next pages A P P E N D I X C S T E R I L I Z A T I O N C O N S E N T F O R M PHYSICIAN Version 2010 01 11 18 2010 Page 69 of 80 A P P E N D I X C S T E R I L I Z A T I O N C O N S E N T F O R M PHYSICIAN Version 2010 01 11 18 2010 Page 70 of 80 STERILIZATION CONSENT FORM LDSS 3134 AND 3134 S INSTRUCTIONS Patient Identification Field 1 Enter the patient s name Medicaid ID number and chart number name of hospital or clinic is optional Consent to Sterilization Field 2 Enter the name of the individual doctor or clinic obtaining consent If the sterilization is to be performed in New York City the physician who performs the sterilization 26 cannot obtain the consent Field 3 Enter the name of sterilization procedure to be performed Field 4 Enter the patient s date of birth Check to see that the patient is at least 21 years old If the patient is not 21 on the date consent is given 9 Medicaid will not pay for the sterilization Field 5 Enter the patient s name Field 6 Enter the name of doctor who will probably perform the sterilization It is understood that this might not be the doctor who eventually performs the sterilization 26 Field 7 Enter the name of sterilization pr
34. e is shown in Exhibit 2 4 2 9 Exhibit 2 4 2 9 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 24I 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 Instructions for Anesthesia Claims Only Enter the total minutes of reportable anesthesia right justified in the field as shown in exhibit 2 4 2 10 The exhibit shows how 40 minutes of anesthesiology would be reported C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 32 of 80 Exhibit 2 4 2 10 The minutes entered in this field must represent the actual time in which the anesthesiologist or the supervising anesthesiologist was present with the patient during the procedure If the anesthesiologist is supervising or medically directing the minutes entered in this field must represent the actual time that the resident or CRNA was present with the patient during the procedure Charges Field 24J This field must contain either the Amount Charged or the Medicare Approved Amount Amount Charged When Box M in field 23B has an entry value of 1 or 3 enter the amo
35. ependents 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 The provider is instructed to zero fill by the LDSS for circumstances not listed above If none of the above situations are applicable leave this field blank NOTES It is the responsibility of the provider to determine whether the patient s Other Insurance carrier covers the service being billed for as Medicaid is always the payer of last resort Leave the last row of Fields 24H 24J 24K and 24L blank Consecutive Billing Section Fields 24M to 24O This section may be used for block billing consecutive visits within the SAME MONTH YEAR made to a patient in a hospital inpatient status Inpatient Hospital Visit From Through Dates Field 24M 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 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
36. ertification 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 Physicians 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 specifica
37. ess of Facility Field 21A This field should be completed only when the Place of Service Code entered in Field 24B is 99 Other Unlisted Facility NOTE The address listed in this field does not have to be the facility address It should be the address where the service was rendered Service Provider Name Field 22A If the service was provided by a physician s assistant certified diabetes educator certified asthma educator or a social worker enter his her name in this field Otherwise leave this field blank Prof CD Profession Code Service Provider Field 22B Leave this field blank Identification Number Service Provider Field 22C If the service was provided by a physician s assistant certified diabetes educator certified asthma educator or by a social worker enter the service provider s NPI in this field Otherwise leave this field blank Sterilization Abortion Code Field 22D If applicable enter the appropriate code to indicate whether the service being claimed was related to an induced abortion or sterilization The abortion sterilization codes can be found in Appendix B Code Sets If the procedure is unrelated to abortion sterilization leave this field blank If a code is entered in this field it must be applicable to all procedures listed on the claim Procedures that are not related to abortion or sterilization must be submitted on separate claim form s When billing for procedures performed
38. f 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 R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 52 of 80 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 Since Physicians 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 Office based practitioners and cli
39. h cycle Total Amount Due the State This amount is the sum of all the Current Balances listed above R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 60 of 80 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 A P P E N D I X A C L A I M S A M P L E S PHYSICIAN Version 2010 01 11 18 2010 Page 61 of 80 APPENDIX A CLAIM SAMPLES The eMedNY Billing Guideline Appendix A Claim Samples contains an image of a claim with sample data A P P E N D I X A C L A I M S A M P L E PHYSICIAN Version 2010 01 11 18 2010 Page 62 of 80 A P P E N D I X B C O D E S E T S PHYSICIAN Version 2010 01 11 18 2010 Page 63 of 80 APPENDIX B CODE SETS The eMedNY Billing Guideline Appendix B Code Sets contains a list of Place of Service codes SA Exception Codes Specialty Codes Exempted from UT Sterilization Abortion Codes and a list of accepted Unites States Standard Postal Abbreviations A P P E N D I X B C O D E S E T S PHYSICIAN Version 2010 01 11 18 2010 Page 64 of 80 A P P E N D I X B C O D E S E T S PHYSICIAN Version 2010 01 11 18 2010 Page 65 of 80 A P P E N D I X B C O D E S E T S PHYSICIAN Version 2010 01 11 18 2010 Page 66 of 80 A P P E N D I X B C O D E S E T S
40. he required fields The following guidelines will help ensure the accuracy of the imaging output All information should be typed or printed Alpha characters letters should be capitalized Numbers should be written as close to the example below in Exhibit 2 2 1 1 as possible Exhibit 2 2 1 1 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 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 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 7 of 80 Exhibit 2 2 1 3 Characters should not touch each other as seen in Exhibit 2 2 1 4 Exhibit 2 2 1 4 Do not write between lines Do not use arrows or quotation marks to duplicate information Do not use the dollar sign to indicate dollar amounts do not use commas to separate thousands For example three thousand should be entered as 3000 not as 3 000 For writing it is best to use a felt tip pen with a fine point Avoid ballpoint pens that skip do not use pencils highlighters or markers Only blue or black ink is acceptable If filling in information through a computer ensure that all information is aligned properly and that the printer ink is dark enough to provide clear legibility Do not submit claim forms with corrections such as infor
41. ice 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 Physician Manual C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 37 of 80 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 Patient s Account Number Field 32 Physician Manual For record keeping purposes the provider may choose to identify a patient by using an office account number This field can accommodate up to 20 alphanumeric characters If an office acco
42. 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 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 directl
43. ing the specific cycle plus claims that were previously pended and denied during the specific cycle Exhibit 3 5 1 R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 48 of 80 Exhibit 3 5 2 R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 49 of 80 Exhibit 3 5 3 R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 50 of 80 Exhibit 3 5 4 R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 51 of 80 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 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 I
44. mation written over correction fluid or crossed out information If mistakes are made a new form should be used Separate forms using perforations do not cut the edges Do not fold the claim forms Do not use adhesive labels for example for address do not place stickers on the form Do not write or use staples on the bar code area The address for submitting claim forms is COMPUTER SCIENCES CORPORATION P O Box 4601 Rensselaer NY 12144 4601 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 8 of 80 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 Physican eMedNY 150003 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 2 4 Physician Services Billing Instructions This subsection of the Billing Guidelines covers the specific NYS Medicaid billing requirements for Physicians 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
45. nics participating in the Patient Centered Medical Home Program may receive enhanced payments for qualifying services A payment line on the remittance will appear as shown in Exhibit 3 5 2 1 Exhibit 3 5 2 1 Information about this program is available by clicking on the link to the webpage as follows NOTE The Patient Centered Medical Home Program does not apply to Hospital Outpatient Department claims at this time New York s Medicaid Statewide Patient Centered Medical Home Incentive Program R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 53 of 80 Status This column indicates the status DENY PAID ADJT VOID PEND of the claim line Denied Claims Claims for which payment is denied will be identified by the DENY status A claim may be denied for the following general reasons The service rendered is not covered by the New York State Medicaid Program The claim is a duplicate of a prior paid claim The required Prior Approval has not been obtained Information entered in the claim form is invalid or logically inconsistent Approved Claims Approved claims will be identified by the statuses 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 trans
46. ocedure Field 8 The patient must sign the form A P P E N D I X C S T E R I L I Z A T I O N C O N S E N T F O R M PHYSICIAN Version 2010 01 11 18 2010 Page 71 of 80 Field 9 Enter the date of patient s signature This is the date on which the consent was obtained The sterilization procedure must be performed no less than 30 days nor more than 180 days from this date except in instances of premature delivery 23 or emergency abdominal surgery 24 25 when at least 72 hours three days must have elapsed Field 10 Completion of the race and ethnicity designation is optional Interpreter s Statement Field 11 If the person to be sterilized does not understand the language of the consent form the services of an interpreter will be required Enter the language employed Field 12 The interpreter must sign and date the form Statement of Person Obtaining Consent Field 13 Enter the patient s name Field 14 Enter the name of the sterilization operation Field 15 The person who obtained consent from the patient must sign and date the form If the sterilization is to be performed in New York City this person cannot be the operating physician 26 Field 16 Enter the name of the facility with which the person who obtained the consent is associated This may be a clinic hospital Midwife s or physician s office Field 17 Enter the address of the facility A P P E N D I X C S T E R I L I Z A
47. on 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 This field should be completed only when claiming the following Ordered Procedure Referred Service Surgical Assistance Ordered Procedures If claiming any of the procedures listed below the name of the ordering provider must be entered in this field If the procedures were performed by the billing physician the billing physician s name should be entered in this field All Radiology Procedures Cardiac Fluoroscopy Echocardiography Non invasive Vascular Diagnostic Studies Consultations Note Consultation codes must not be claimed for a physician s own patient Referred Service If the patient was referred by another provider enter the name of the referring provider in this field C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 21 of 80 Surgical Assistance If the claim is for surgical assistance services the primary surgeon s name must be entered in this field If no order or referral is involved or the claim is not for surgical assistance leave thisfield blank Address or Signature SHF Only Field 19A If services were rendered in a Shared Health Facility and the patient was referred for treatment or a specialty consultation b
48. s broken down by Adjustments voids combined Pends Paid Deny Net total paid entire remittance R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 56 of 80 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 R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 57 of 80 3 6 1 1 Explanation of Financial Transactions Columns FCN This is a unique identifier assigned to each financial transaction Financial Reason Code This code is for DOH CSC use only it has no relevance to providers It identifies the reason for the recoupment Financial Transaction Type This is the description of the Financial Reason Code For example Third Party Recovery Date The date on which the recoupment was applied Since all the recoupments listed on this page pertain to the current cycle all the recoupments will have the same date Amount The dollar amount corresponding to the particular fiscal transaction This amount is deducted from the provider s total payment for the cycle 3 6 1 2 Explanation of Totals Section The total dollar
49. sterectomy was performed but the performing surgeon did inform her before the procedure that the hysterectomy would make her permanently incapable of reproducing check this box Field 14 The surgeon who performed the hysterectomy must sign the form to certify that the procedure was for medical necessity and not primarily or secondarily for family planning purposes and that one of the conditions indicated in Fields 11 12 and 13 existed A P P E N D I X D A C K N O W L E D G E M E N T O F R E C E I P T O F H Y S T E R E C T O M Y I N F O F O R M PHYSICIAN Version 2010 01 11 18 2010 Page 79 of 80 Field 15 Enter the date of the surgeon s signature E M E D N Y I N F O R M A T I O N PHYSICIAN Version 2010 01 11 18 2010 Page 80 of 80 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
50. t 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 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 11 of 80 Exhibit 2 4 2 1 1 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 12 of 80 Exhibit 2 4 2 1 2 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 13 of 80 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 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
51. tion in field 19 Field 35 The witness must sign the form for reaffirmation This witness need not be the same person whose signature appears in field 30 Field 36 Enter the date of witness s signature A P P E N D I X D A C K N O W L E D G E M E N T O F R E C E I P T O F H Y S T E R E C T O M Y I N F O F O R M PHYSICIAN Version 2010 01 11 18 2010 Page 75 of 80 APPENDIX D ACKNOWLEDGMENT OF RECEIPT OF HYSTERECTOMY INFORMATION FORM LDSS 3113 An Acknowledgment of Receipt of Hysterectomy Information Form LDSS 3113 must be completed for each hysterectomy procedure No other form can be used in place of the LDSS 3113 A supply of these forms available in English and in Spanish can be obtained from the New York State Department of Health s website by clicking on the link to the webpage as follows Local Districts Social Service Forms Claims for hysterectomy procedures must be submitted on paper forms and a copy of the completed and signed LDSS 3113 must be attached to the claim When completing the LDSS 3113 please follow the guidelines below Be certain that the form is completed so it can be read easily An illegible or altered form is unacceptable will cause a paper claim to deny Each required field or blank must be completed in order to ensure payment A sample Hysterectomy Consent Form and step by step instructions follow on the next pages A P P E N D I X D A C K N O W L E D G E M E N T O F R E C E I
52. tions 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 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 6 of 80 2 2 Paper Claims Physicians 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 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 t
53. uld be aware that the service should be billed if the insurance policy changes Proof of denials must be maintained in the patient s billing record Prior claims denied due to deductibles not being met are not to be counted as denials for subsequent billings In very limited situations the Local Department of Social Services LDSS has advised the provider to zero fill 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 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 34 of 80 The provider cannot directly bill the insurance carrier and the policyholder is either unavailable to or uncooperative in submitting claims to the insurance company In these cases the LDSS must be notified prior to zero filling LDSS has subrogation rights enabling them to complete claim forms on behalf of uncooperative policyholders who do not pay the provider for the services The LDSS office can direct the insurance company to pay the provider directly for the service whether or not the provider participates with the insurance plan The provider should contact the third party worker in the local social services office whenever he she encounters policyholders who are uncooperative in paying for covered services received by their d
54. unt 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 24L Field 24J must never be left blank or contain zeroes It is the responsibility of the provider to determine whether Medicare covers the service being billed for If the service is covered or if the provider does not know if the service is covered the provider must first submit a claim to Medicare as Medicaid is always the payer of last resort Unlabeled Field 24K This field is used to indicate the Medicare Paid Amount and must be completed if Box M in field 23B has an entry value of 2 or 3 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 33 of 80 Box M 2 When billing for the Medicare deductible enter 0
55. unt 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 R E M I T T A N C E A D V I C E PHYSICIAN Version 2010 01 11 18 2010 Page 38 of 80 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 Electronic Funds Transfer Summout no claims paid Section Two Provider Notification special messages Section Three Claim Detail Section Four Financial Transactions recoupments Accounts Re
56. 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 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 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 TCN To cancel one or more claim
57. wo claim lines which were paid on September 20 2010 Later the provider became aware that the patient had other insurance coverage The other insurance was billed and the provider was paid in full for all the services Medicaid must be reimbursed by submitting a void for the two claim lines paid in the specific TCN Exhibit 2 4 2 2 1 shows the claim as it was originally submitted and Exhibit 2 4 2 2 2 shows the claim being submitted as voided C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 17 of 80 Exhibit 2 4 2 2 1 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 18 of 80 Exhibit 2 4 2 2 2 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 19 of 80 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 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
58. y 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 This field must be completed when the claim involves any of the following Ordered Procedure Referred Service Surgical Assistance Ordered Procedures If the service was ordered by another provider see field 19 for the list of ordered procedures enter the ordering provider s National Provider ID NPI in this field Referred Service If the patient was referred for treatment by another physician enter the referring provider s NPI in this field A facility ID cannot be used for the referring ordering provider In those instances where an order or referral was made by a facility the NPI of the practitioner at the facility must be used When providing services to a patient who is restricted to a primary physician or facility the NPI of the patient s primary physician must be entered in this field The license number of the primary physician is not acceptable in this case If a patient is restricted to a facility the NPI of the practitioner in the facility the patient is restricted to must be entered The ID of the facility cannot be used Surgical Assistance If the claim is for surgical assistance services
59. y 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 C L A I M S S U B M I S S I O N PHYSICIAN Version 2010 01 11 18 2010 Page 9 of 80 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 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

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