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eMedNY Subsystem User Manual

1. SERVICE 05 13 10 05 14 10 05 14 10 05 12 10 91828 80814 91105 91105 NUMBER XX12345X XX234556X XX34557X XX45578X 07206 000033467 0 0 07206 000033468 0 0 07206 000035665 0 0 07206 000033560 0 0 SAMPLE EXAMPLE SPECIMEN PREVIOUSLY PENDED CLAIM NEW PEND NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS FEND FEND 168 34 0 00 0 00 0 00 TOTAL AMOUNT ORIGINAL CLAIMS AMOUNT ADJUSTMENTS NET AMOUNT VOIDS HET AMOUNT VOIDS ADJUSTS REMITTANCE TOTALS REF AMB YOIDS ADJUSTS TOTAL PENDS TOTAL PAID TOTAL DENIED NET TOTAL PAID 3 60 168 94 147 40 162 20 143 80 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS MEMBER ID 00112233 VOIDS ADJUSTS TOTAL PENDS TOTAL PAID TOTAL DENIED NET TOTAL PAID 3 60 158 54 147 40 162 20 143 80 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 Page 45 of 74 11 18 2010 REMITTANCE ADVICE Exhibit 3 5 4 D CAI DATE 05 3110 INFORMATION GYSTEM CYCLE 1710 MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT ETIN TO ABC HOSPITAL REF AMB 100 BROADWAY GRAND TOTALS ANYTOWN NEW YORK 11111 PROV ID 00112233 1123456789 REMITTANCE NO 07080600006 REMITTANCE TOTALS G
2. 5 1 64 Appendix D Acknowledgment of Receipt of Hysterectomy Information Form 1055 3113 69 Acknowledgement Receipt of Hysterectomy Information Form 1055 3113 Instructions 71 For eMedNY Billing Guideline questions please contact the eMedNY Call Center 1 800 343 9000 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 3 of 74 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 Hospital Based Free Standing Ordered Ambulatory Providers and should be used by the provider as an instructional as well as a reference tool For providers new to NYS Medicaid it is required to read the All Providers General Billing Guideline Information available at www emedny org by clicking on the link to the webpage as follows Information for All Providers FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 4 of 74 CLAIMS SUBMISSION 2 Claims Submission Hospital Based Free Standin
3. EL Z Tk TT TST FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 35 of 74 REMITTANCE ADVICE 3 1 1 Medicaid Check Stub Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Date 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 Page 36 of 74 11 18 2010 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 REMITTANCE 070805000
4. 07 262220867722 07206 000067 07206 000088167 0 0 147 00 PAID i 5 PAID 9 00 3 06 DATE OF SERVICE 0511710 05 12 10 0514 10 05 15 10 05 05 10 00510 PROC CODE 91108 209485 99221 53111 39281 PAGE CYCLE ETIN a n EF AMS PROVID 00112233 1123546783 REMITTANCE NO 070806000006 03 0531 2010 1710 UNITS CHARGED PAID 1 000 1 000 1 000 1 000 1 000 1 000 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER CLAIMS 14 30 14 30 52 80 66 00 17 60 14 30 14 39 14 30 52 80 65 00 17 62 14 30 STATUS FAID FAID FAD PAID ADJT ADJT ERRORS ORIGINAL CLAIM 05 74 10 w PREVIOUSLY PENDED CLAIM NEWPEND FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Page 44 of 74 11 18 2010 REMITTANCE ADVICE ABC HOSPITAL 100 BROADWAY ANYTOWN NEWYORK 11111 LM OFFICE ACCOUNT MEDICAL ASSISTANC CLIENT ID Exhibit 3 5 3 MANAGEMENT REMITTANCE STATEMENT DATE OF DICAID INFORMATION Dk w Sa T E F E TITLE XIX PROGRAM PROC PAGE 24 0531 2010 CYCLE 1710 ETIN REF AMB PROVID 00112233 1123456783 REMITTANCE 07080500005 NO 01 02 01 01 NUMBER 222222 CP444444 CESSSSSS ERRORS 00162 00162 00142 00131 UNITS CHARGED 1 000 69 30 1 000 T1 04 1 000 14 30 1 000 14 30 PAID 0 00 0 00 0 00 0 00 STATUS
5. of anar ar sang 9 ali uh ADDRESS GF TOR 27 PROVIDER IL DXNTFICATIDN AGNOS OF KLMISS FELATI TO PROCURE Ia COLUMN 4 LAR 1 3 ga jM w B or TET Medical Center Anytown Now York 11111 8 10 EMEDNY 150003 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 15 of 74 CLAIMS SUBMISSION 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 10299123454678900 contained two claim lines 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
6. New York State Electronic Medicaid System 150003 Billing Guidelines FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 TT TABLE OF CONTENTS TABLE OF CONTENTS L PUPO 4 2 Clamis Sul i eed uu MM E 5 2 1 Fl CI O NG C p uu u uu uuu 5 2 2 NER y 6 2 2 1 General Instructions for Completing Paper Claims r 6 2 3 T5000 3 Cla uu uuu 8 2 4 Hospital Based Free Standing Ordered Ambulator Services Billing Instructions 8 2 4 1 Instructions for the Submission of Medicare Crossover 8 2 4 2 eMedNY 150003 Claim Form Field 5 9 3 Explanation of Paper Remittance Advice Sections rr 34 3 1 Section One IVICCIC AICO MEL MH 35 31 1 Medea Check Stub Field DeSerpEIONS u 36 3 1 2 Medicaid Check Field 5 36 3 2 Section ONG ERE ode IOI TREE 37 3 2 1 EFT Notification Page Field 9
7. meri 1 COMNTION RELATED 2121 1 tuan TTY 3009uv MV1 2 uw Bo Yw SME REFERAR OF CTHER BOUNCE DRUG CODE Ta Ux QUANTITY COST m I 1 0 1 5 0 4 6 Tia pine ere 27 SERVICE I IEBTEKAE TE DAGMOSES OF LLMESES LATI DRGNDSES PROCEDURE IN CELUNMIN 144 To SUE OR ccr Ft i 3 B D Y 0 115 1 0 Anytown Medical Center 312 Main Street Anytown Now York 11111 8 10 EMEDNY 150003 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 23 of 74 CLAIMS SUBMISSION Name of Facility Where Services Rendered Field 21 Leave this field blank Address of Facility Field 21A Leave this field blank Service Provider Name Field 22 Leave this field blank Prof CD Profession Code Service Provider Field 22B Leave this field blank Identification Number Service Provider Field 22C Leave this field blank Sterilization Abortion Code Field 22D If applicable enter the appropriate code to indicate whether the service being claimed was related to an induced abortion or s
8. PATENTS MARAT Ux 5 SUSAN SAMPLE uer cr 12 COMDITICA RELATED PTT r yr lk pi p i 1 uw Bo Yw vu no ww 3 SME REFERAR OF CTHER BOUNCE sa mapa RR ADDRERS OF FACIUTY S ABO 20 DIL CODE 27 I NOME DAGMOSES MATURE OF LMS PRELATI DRAGNDSES PROCEDURE IN COLUMN 144 PO SUE OR ccr Anytown Medical center 312 Main Street Anytown Now York 11111 8 10 EMEDNY 150003 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 12 of 74 CLAIMS SUBMISSION Adjustment to Cancel One or More Claims Originally Submitted on the Same Document Record TCN An adjustment should be submitted to cancel or void one or more individual claim lines that were originally submitted on the same document record and share the same TCN The following instructions must be followed The adjustment must be submitted in a new claim form copy of the original form is unacceptable The adjustment must contain all claim lines submitted in the original document all claim lines with the same TCN except for the claim s line s to be voided these cl
9. 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 71 of 74 l ACKNOWLEDGEMENT OF RECEIPT OF HYSTERECTOMY INFO FORM 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
10. A sample Sterilization Consent Form and step by step instructions follow on the next pages FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 62 of 74 PATIENT NAME LDSS 3134 2 01 STERILIZATION CONSENT FORM HOSPITAL CLINIC NOTICE APPENDIX C STERILIZATION CONSENT FORM CHART NO RECIPIENT ID NO YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS m CONSENT TO STERILIZATION m have asked for and received information about sterilization from 2 When asked for the doctor or clinic information was told that the decision to be sterilized is completely up to me was told that could decide not to be sterilized If decide not to be sterilized my decision will not affect my right to future care or treatment will not lose any help or benefits from programs receiving Federal funds such as A F D C or Medicaid that am now getting or for which may become eligible UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE HAVE DECIDED THAT DO NOT WANT TO BECOME PREGNANT BEAR CHILDREN OR FATHER CHILDREN was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father a child in the future have rejected these alternatives and chosen to be
11. The original amount or starting balance for any particular financial reason Current Balance The current amount owed to Medicaid after the cycle recoupment 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 54 of 74 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 PAGE 06 DATE 052110 E IMPO M ATION CYCLE 1710 MEDICAL ASSISTANCE TITLE XIX PROGRAM TO ABC HOSPITAL REMITTANCE STATEMENT REF AMB 100 BROADWAY EDIT DESCRIPTIONS NEW YORK 11111 PROVID Q0112233 1123455783 REMITTANCE O7 020500005 THE FOLLOWING 15 DESCRIPTION OF THE EDIT REASON CODES THAT APPEAR ON THE CLAIMS FOR THIS REMITTANCE 00131 PROVIDER NOT APPROVED FOR SERVICE 00142 SERVICE CODE NOT EQUAL 00162 RECIPIENT IMELIGIBLE OM DATE OF SERVICE 22244 HOT ON OR REMOVED FROM FILE FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 55 of 74 APPENDIX CLAIM SAMPLES APPEN
12. CG are subsets of the IGs which provide specific instructions on the NYS Medicaid requirements for 837P and 8371 transactions 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 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 5 of 74 _ CLAIMS SUBMISSION 2 2 Paper Claims Hospital Based Free Standing Ordered Ambulatory Providers who choose to submit their claims on paper forms must use the New York State eMedNY 150003 claim form To view a sample Hospital Based Free Standing Ordered Ambulatory eMedNY 150003 claim form see Appendix 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 a
13. APPENDIX C STERILIZATION CONSENT FORM STERILIZATION CONSENT FORM LDSS 3134 AND 3134 5 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 procedure Field 8 The patient must sign the form FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 64 of 74 APPENDIX STERILIZATION CONSENT FORM 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 de
14. 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 66 of 74 APPENDIX STERILIZATION CONSENT FORM 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 N
15. Hospital Based Ordered Ambulatory 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 characters If an office account number is indicated on the claim form it will be returned on the Remittance Advice Using an Office Account Number can be helpful for locating accounts when there is a question on patient identification Other Referring Ordering Provider ID License Number Field 33 Leave this field blank Prof CD Profession Code Other Referring Ordering Provider Field 34 Leave this field blank FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 33 of 74 REMITTANCE ADVICE 3 Explanation of Paper Remittance Advice Sections This Section presents samples of each section of the Hospital Based Free Standing Ordered Ambulatory provider 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 remitt
16. 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 19 of 74 _ 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 bo
17. Shortly before performed a sterilization operation upon on of individual to be sterilized Date of sterilization 20 explained to him her the Operation nature of the sterilization operation 21 type of operation fact that it is intended to be a final irreversible procedure and the discomforts risks and benefits associated with it counseled the individual to be sterilized that alternative methods of birth control are available which are temporary explained that sterilization is different because it is permanent informed the individual to be sterilized that his her consent can be withdrawn at any time and that he she will not lose any health services or benefits provided by Federal funds To the best of my knowledge and belief the individual to be sterilized is a least 21 years old and appears mentally competent He She knowingly and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure Instructions for use of alternative final paragraphs Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the individual s signature on the consent form In those cases the second paragraph below must be used Cross out the paragraph which is not used 1 At least thirty days have passed between the date of the individual s signature on t
18. 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 hysterectomy 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 72 of 74 D KNOWLEDGEMENT OF RECEIPT OF HYSTERECTOMY INFO FORM Field 15 Enter the date of the surgeon s signature FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 73 of 74 INFORMATION eMedNY is 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 f
19. one of the following when completing this entry UN Unit F2 International Unit GR lt Gram ML Milliliter Quantity Field 208 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 mas 208 QUANTIT Ye 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 22 of 74 CLAIMS SUBMISSION Exhibit 2 4 2 6 MEDICAL ASSISTANCE HEALTH INSURANCE ONLY TO BE ORIGINAL TRANSACTION CONTROL NUMBER CLAIM FORM TITLE XIX PROGRAM E PATIENT AND INSURED SUBSCRIBER INFORMATION PAD CLAMA 4 PATENTS MARAT uw mardi L DATI 1 Wael ama p SUSAN SAMPLE
20. sterilized understand that will be sterilized by an operation know as a c 28 The discomforts risks and benefits associated with the operation have been explained to me my questions have been answered to my satisfaction understand that the operation will not be done until at least thirty days after sign this form understand that can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs am at least 21 years of age and was born on 5 free will to be sterilized by 4 Month Day Year hereby consent of my own 6 Doctor by a method called 7 expires 180 days from the date of my signature below also consent to the release of this form and other medical records about the operation to Representatives of the Department of Health Education and VVelfare or Employees of programs or projects funded by that Department but only for determining if Federal laws were observed have received a copy of this form 8 9 Signature Month Day Year You are requested to supply the following information but it is not required LO My consent Date Race and ethnicity designation please check 011 American Indian O 4 Hispanic Alaska Native 12 Asian or Pacific Islander 5 White not of Hispanic origin Black not of Hispanic origin m INTERPRETER S ST
21. 06 INFORMATION amp EYSTEM PROV ID 001122331 123455783 00112233 123456789 2010 05 31 ABC HOSPITAL 100 BROADWAY ANYTOWN NY 11111 ABC HOSPITAL 143 80 PAYMENT IN THE ABOVE AMOUNT WILL BE DEPOSITED VIA AN ELECTRONIC FUNDS TRANSFER FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 37 of 74 REMITTANCE ADVICE 3 2 1 EFT Notification Page Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Date The date on which the remittance advice was issued Remittance Number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Medicaid Provider ID NPI Date Provider s Name Address Provider s Name Amount transferred to the provider s account This amount must equal the Net Total Paid Amount under the Grand Total subsection plus the total sum of the Financial Transaction section FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 38 of 74 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 disbursement of moneys Exhibit 3 3 1 TO ABC HOSPITAL D C AID DATE 05 31 2010 REMITTANCE NO 07080500005 mH vacui PROV ID 0011223371 123456783 NO PAYMENT WILL BE RECEIVED THIS CYCLE SEE REMITTAMCE FOR DETAILS ABC HOSPITAL 100 BROAD
22. 18 2010 Page 6 of 74 m CLAIMS SUBMISSION Exhibit 2 2 1 3 Intended As Interpreted As wo interpreted as seven 4 hree interpreted as two Characters should not touch each other as seen in Exhibit 2 2 1 4 Exhibit 2 2 1 4 Written As Intended As Interpreted As EJ pee Entry cannot be 23 illegible interpreted properly not write between lines not use arrows or quotation marks to duplicate information Do not use the dollar sign 5 to indicate dollar amounts do not use commas to separate thousands For example three thousand should be entered as 3000 not as 3 000 For writing it is best to use a felt tip pen with a fine point Avoid ballpoint pens that skip do not use pencils highlighters or markers Only blue or black ink is acceptable If 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 ee cc Do not write or use staples on the bar code area The address for submitting claim forms is COMPUTER SCIEN
23. 38 3 3 Section One Sutrmmout No Payment uuu u uuu 39 3 3 1 Summout No Payment Field nennen nnne nennen sess 40 3 4 Section TWO drogue T m 41 3 4 1 Provider Notification Field Descriptions 42 3 5 SECTION Ih SP 43 3 5 1 Claim Detail Page Field r 47 3 5 2 Explanation of Claim Detail Columns a r 47 3 5 3 Subtotals Totals Grand Totals tt etet estt orette etnos 50 3 6 Section Four Financial Transactions and Accounts 51 3 6 1 Financial Transactions n 51 2r ai Orco g RR UU t mw 53 3 7 Section Five Edit Error D ScrIDLIOTI ves mE bra ERUIT V PII UIS TE 55 POO CII A ull u 56 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 2 of 74 CLAIMS SUBMISSION ADDSDOIX B 6 58 Appendix C Sterilization Consent Form LDSS 3134 62 Sterilization consent Form 1055 3134 and 3134 S
24. ATEMENT If an interpreter is provided to assist the individual to be sterilized I have translated the information and advice presented orally to the individual to be sterilized by the person obtaining this consent have also read him her the consent form in 11 language and explained its contents to him her To the best of my knowledge and belief he she understood this explanation A Interpreter Date m STATEMENT OF PERSON OBTAINING CONSENTE of Individual consent form explained to him her the nature of the sterilization operation 14 the fact that it is intended to be a final and irreversible procedure and the discomforts risks and benefits associated with it counseled the individual to be sterilized that alternative methods of birth control are available which are temporary explained that sterilization is different because it is permanent informed the individual to be sterilized that his her consent can be withdrawn at any time and that he she will not lose any health services or any benefits provided by Federal funds To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent He She knowlingly and voluntarily requested to be sterilized and appears to understand the nature and consequence of the procedure Before signed the A Signature of person obtaining Date Facilit 17 Address m PHYSICIAN S STATEMENT m
25. ATO SYSTEM CYCLE 1710 MEDICAL ASSISTANCE TITLE XIX PROGRAM TO ABC HOSPITAL MITTANCE M ETIN 100 BROADWAY CEMENTO NEMORE FINANCIAL TRANSACTIONS ANYTOWN NEW YORK 11111 PROV ID 00112233 1123456788 REMITTANCE NO 07080500006 FINANCIAL FISCAL REASON CODE TRANS TYPE DATE 200705060236547 XXX RECOUPMENT REASON DESCRIPTION 05 09 10 NET FINANCIAL TRANSACTION AMOUNT 552 22 NUMBER FIMANCIAL TRANSACTIONS FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 51 of 74 REMITTANCE ADVICE 3 6 1 1 Explanation of Financial Transactions Columns FCN The Financial Control Number FCN is a unique identifier assigned to each financial transaction Financial Reason Code This code is for DOH CSC use only it has no relevance to providers It identifies the reason for the recoupment Financial Transaction Type This is the description of the Financial Reason Code For example Third Party Recovery Date The date on which the recoupment was applied Since all the recoupment listed on this page pertain to the current cycle all the recoupment 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 Num
26. CES CORPORATION P O Box 4601 Rensselaer NY 12144 4601 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 7 of 74 i 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 Hospital Based Free Standing Ordered Ambulatory 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 Hospital Based Free Standing Ordered Ambulatory Services Billing Instructions This subsection of the Billing Guidelines covers the specific NYS Medicaid billing requirements for Hospital Based Free Standing Ordered Ambulatory Providers 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 pr
27. CTION CONTROL NUMBER CLAIM FORM TITLE XIX PROGRAM a0 PATIENT AND INSURED SUBSCRIBER INFORMATION _ CLAIM 1 0 2 9 9 1 2 3 4 5 6 7 B 9 0 0 zi PATENTS Umi uide SUSAN SAMPLE gl am 12 WAS COMDITICA RELATED p mi gt In Ey CODNEKTION uw Bo Yw OF PH OTHER HUELE ls pou n Is 5 B 9 010 5 5 9 0 0 1 813 010 a e MADE DI ARENE SERVICES REMOERED af anar Pan sang 9 alie uk QF ELT AME PEDE IC OORT CeO AONE MATURE OF LLMISS MLATI PROCURE ee C B T 7 Anytown Medical Center 312 Main Street Anytown Now York 11111 8 10 EMEDNY 150003 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 18 of 74 SUBMISSION Patient s Name Field 1 Enter the patient s first name followed by the last name This information may be obtained from the Client s Patient s Common Benefit ID Card Date of Birth Field 2 Enter the patient s birth date This information may be obtained from the 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
28. 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 241 Only the first line of fields 24A through 241 may be used for drug code billing Only one drug code claim may be submitted per 150002 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 Package NDC Number Correct Leading Zero NDC Field Example Configuration Placementfor 5 4 2 11 X XX 5 24 42 11 5 4 2 XXXXXXXXXX XXXXX XXXX 0X 9 4 1 10 5 4 2 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 21 of 74 CLAIMS SUBMISSION Unit Field 20A Use
29. DIX A CLAIM SAMPLES The eMedNY Billing Guideline Appendix A Claim Samples contains an image of a claim with sample data FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 56 of 74 APPENDIX A CLAIM SAMPLES MEDICAL ASSISTANCE HEALTH INSURANCE omy ro ORIGINAL TRANSACTION CONTROL NUMBER CLAIM FORM TITLE XIX PROGRAM USOT ip nnl PATIENT AND INSURE AND INSURED SU8SCFIE INFORMATION PAID ATP oF Or CON KETICA Pria TE oT WARED OF DCOIPATRON WAS COMPTION BELATED ote exem L_ 8 10 vw w ws SKM PHEN DN CTHER BOUNCE ls pey 5 5 3 9 0 0 5 5 5 9 ole R 0 0 4 M n NAME D ALANY REMOERED of Far ln ini ADDRESS OF FACRITS uo h SERVICE PRE AT PT 1 GMOS MATURE OF LLMISS MLATI DMGNOSE PAOU Es Aer i a T w en 312 Main Street Anytown Now York 11111 8 10 EMEDNY 150003 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 57 of 74 APPENDIX B CODE SETS APPENDIX B CODE SETS The eMedNY Billing Guideline Appendix B Code Sets contains a list of Pl
30. EE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 47 of 74 essere tance ADVICE TCN The TCN is a unique identifier assigned to each claim that is processed If multiple claim lines are submitted on the same claim form all the lines are assigned the same TCN Date of Service The first date of service From date entered in the claim appears under this column If a date different from the From date was entered in the Through date box that date is not returned in the Remittance Advice Procedure Code The five digit procedure code that was entered in the claim form appears under this column Units The total number of units of service for the specific claim appears under this column The units are indicated with three 3 decimal positions 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 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 reason
31. IDERS WHO DO NOT HAVE ACCESS E MAIL SHOULD CONTACT 1 000 343 8000 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 41 of 74 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 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 42 of 74 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 Exhibit 3 5 1 FAGE 02 DIC AID DATE 05 31 2107 CYCLE 1710 E i MANAGEMENT IRF ORAM ATION Trea T E MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT ETIN ABC HOSPITAL REF 100 BROADWAY PROV ID 00112233 1122456783 ANYTOWN NEW YORK 11111 REMITTANCE NO 07020500005 LN OFFICEACCOUNT CLIENT CLIENT ID DATE OF PROC NO NUMBER NAME NUMBER
32. K 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 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 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 rega
33. NDING OR HOSPITAL BASED ORDERED AMBULATORY Page 59 of 74 11 18 2010 APPENDIX B CODE SETS Sterilization Abortion Codes Code B C D E Version 2010 01 Description Induced Abortion Dangerto the woman s life Induced Abortion Physical health damage to the woman Induced Abortion Victim of rape or incest Induced Abortion Medically necessary Induced Abortion Elective i e not considered medically necessary by the attending physician provision of elective abortions is restricted to New York City recipients Procedure performed for the purpose of sterilization FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY 11 18 2010 Page 60 of 74 _ APPENDIX B CODE SETS State 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 American Territories American Canal Zone Guam Puerto Rico Trust Territories Virgin Islands 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 NOTE Required only when reporting out of state license numbers FREE STANDING OR HOSPITAL BA
34. NDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 10 of 74 EN CLAIMS SUBMISSION Exhibit 2 4 2 1 1 MEDICAL ASSISTANCE HEALTH INSURANCE CLAIM FORM TITLE XIX PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION niin ORIGINAL TRANSACTION CONTROL NUMBER mE sl PATIENTS MARAT suia DAT I Tim 1 PERS ME Pam 7 0 5 2 0 1 89 0 j TIE tip Pets PT 3 234 B K E ie RELATED fo W 7 v3uv pr X FUR D ODER RE DUAN P NAME OF BE SEMWICES AENA AED of uk ADDRESS i TOUR SERVICE PROVIDER NATIONAL DER CODE EEE h wi x a X 4 i APPER S4 Wi mE 0017 i 11 1 EM DA T W ja du D Y 7 o 9 15 1 0 8 10 EMEDNY 150003 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 11 of 74 CLAIMS SUBMISSION Exhibit 2 4 2 1 2 MEDICAL ASSISTANCE HEALTH INSURANCE omy ro CLAIM FORM TITLE XIX PROGRAM ORIGINAL TRANSACTION CONTROL NUMBER ROC ADJUST VOID PATIENT AND INSURED SUBSCRIBER INFORMATION on 1 0 3 0 1 1 9 8 7 6 5 4 3 2 0 0
35. OF HYSTERECTOMY INFORMATION FORM 1055 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 Becertain 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 69 of 74 KNOWLEDGEMENT OF RECEIPT OF HYSTERECTOMY INFO FORM 55 1113 Rev 4 84 ACKNOWLEDGEMENT OF RECEIPT OF HYSTERECTOMY INFORMATION NYS MEDICAID PROGRAM EITHER PART I OR PART MUST BE COMPLETED i RECIPIENT S ACKNOWLEDGEMENT STATEMENT AMD SURGEON S CERTIFICATION RECIPIENT S ACKNOWLEDGEMENT STATEMENT It has been explained 3 that the hysterectomy to be perf
36. RAND TOTALS VOIDS ADJUSTS 3 60 NUMBER OF CLAIMS TOTAL PENDS 105 94 NUMBER OF CLAIMS TOTAL PAID 141 40 NUMBER OF CLAIMS TOTAL DENY 152 20 NUMBER OF CLAIMS NETTOTAL PAID 143 8 NUMBER OF CLAIMS Kn o m dm FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 46 of 74 _ REMITTANCE ADVICE 3 5 1 Claim Detail Page Field Descriptions Upper Left Corner Provider s Name Address as recorded in the Medicaid files Upper Right Corner Remittance Page Number Date The date on which the remittance advice was issued Cycle Number The cycle number should be used when calling the eMedNY Call Center with questions about specific processed claims or payments ETIN not applicable Provider Service Classification REF AMB 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 FR
37. RDERED AMBULATORY Version 2010 01 11 18 2010 Page 9 of 74 CLAIMS SUBMISSION 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 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 records Exhibit 2 4 2 1 1 shows the claim as it was originally submitted and Exhibit 2 4 2 1 2 shows the claim as it appears after the adjustment has been made FREE STA
38. SED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 61 of 74 APPENDIX C STERILIZATION CONSENT FORM APPENDIX C STERILIZATION CONSENT FORM 1055 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 Becertain 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 woman is not currently Medicaid eligible at the time she signs the 1055 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 day waiting period starts from the date the LDSS form was signed regardless of the date the woman becomes Medicaid eligible
39. T 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 WEER LAG FOR MEDICAID DISBURSEMENTS TO ENROLL EFT PROVIDERS MUST COMPLETE EFT ENROLLMENT FORM THAT BE FOUND WWW ORG CLICK ON PROVIDER ENROLLMENT FORMS WHICH BE FOUND IN THE FEATURED LINKS SECTION DETAILED INSTRUCTIONS WILL ALSO BE FOUND THERE AFTER SENDING THE EFT ENROLLMENT FORM TO CSC PLEASE ALLOW A MINIMUM TIME OF SIX TO EIGHT WEEKS FOR PROCESSING DURING THIS PERIOD OF TIME YOU SHOULD REVIEW YOUR BANK STATEMENTS AND LOOK FOR AN EFT TRANSACTION IN THE AMOUNT OF 30 01 WHICH CSC WILL SUBMIT AS TEST YOUR FIRST REAL EFT TRANSACTION WILL TAKE PLACE APPROXIMATELY FOUR TO FIVEWEEKSLATER IF YOU HAVE ANY QUESTIONS ABOUT THE EFT PROCESS PLEASE CALL THE EMEDNY CALL CENTER AT 1 800 343 8000 NOTICE THIS COMMUNICATION AND ANY ATTACHMENTS MAY CONTAIN INFORMATION THAT IS PRIVILEGED AMD CONFIDENTIAL UNDER STATE AND FEDERAL LAW AND IS INTENDED ONLY FOR THE USE OF THE SPECIFIC INDIVIDUALS TO WHOM IT IS ADDRESSED THIS INFORMATION MAY ONLY USED OR DISCLOSED IN ACCORDANCE WITH LAW AND YOU MAY BE SUBJECT TO PENALTIES UNDER LAW FOR IMPROPER USE OR FURTHER DISCLOSURE OF INFORMATION THIS COMMUNICATION AND ANY ATTACHMENTS IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR PLEASE IMMEDIATELY NOTIFY NYHIPPADESKEICSC COM OR CALL 1 800 541 2831 PROV
40. TCN SERVICE CODE UNITS CHARGED PAID STATUS ERRORS 01 XX12345X OTST 0511710 926239 1 000 52 80 0 00 DENY 00162 00244 27 CPH SAMPLE XX21455X QO7206 000001334 0 0 O 11 10 1 000 17 60 0 00 DENY 00244 01 CPobbbbb EXAMPLE QO7206 0900013555 0 0 0513 10 91105 1 000 14 30 0 00 DENY 00162 01 59999 SPECIMEN RASTER UT206 000032456 0 AN 30945 1 000 77 50 0 00 DENY 00131 PREVIOUSLY PENDED CLAIM NEW TOTAL AMOUNT ORIGINAL CLAIMS 15220 NUMBER OF CLAIMS 4 NET AMOUNT ADJUSTMENTS DENIED 0 00 NUMBER OF CLAIMS 0 MET AMOUNT VOIDS DENIED 0 00 NUMBER OF CLAIMS 0 AMOUNT VOIDS ADJUSTS 0 00 NUMBER OF CLAIMS 0 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 43 of 74 REMITTANCE ADVICE Exhibit 3 5 2 ABC HOSPITAL 100 BROADWAY DICAID MAN A CHE Pt D INFORMATION MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT ANYTOWN NEW YORK 11111 LN NO o1 02 i 01 01 01 Version 2010 01 OFFICE ACCOUNT CLIENT NUMBER CF111111 222222 CP555555 NAME DOE SAMPLE EXAMPLE SPECIMEN STANDARD MODEL TOTAL AMOUNT ORIGINAL CLAIMS NET AMOUNT ADJUSTMENTS NET AMOUNT VOIDS NET AMOUNT VOIDS ADJUSTS CLIENT ID NUMBER XX12345X XX23486X XX345E7X XX45572X XX55783X XX67850X TCN 07206 009033667 2 0 0729000083867
41. WAY ANYTOWM NY 11111 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 39 of 74 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 Provider ID and the NPI Center Notification that no payment was made for the cycle no claims were approved Provider s Name Address FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 40 of 74 REMITTANCE ADVICE 3 4 Section Two Provider Notification This section is used to communicate important messages to providers Exhibit 3 4 1 i PAGE 01 DATE 05 31 10 MANNI rvavEM CYCLE 1719 MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT TO ABC HOSPITAL 100 BROADWAY PROVIDER NOTIFICATION ANYTOWM HEW YORK 11111 PROY ID 00112233 1123456789 REMITTANCE NO 07080500006 REMITTANCE ADVICE MESSAGE TEXT E ECTRONIC FUNDS TRANSFER EFT FOR PROVIDER PAYMENTS IS NOW AVAILABLE PROVIDERS WHO ENROLL IN EFT WILL THEIR MEDICAID PAYMENTS DIRECTLY DEPOSITED INTO THEIR CHECKING OR SAVINGS ACCOUNT THEEFT TRANSACTIONS WILL BE INITIATED ON WEDNESDAYS AND DUE TO NORMAL BANKING PROCEDURES THE TRANSFERRED FUNDS MAY NOT BECOME AVAILABLE IN THE PROVIDER S CHOSEN ACCOUN
42. ace of Service codes Sterilization Abortion Codes and a list of accepted Unites States Standard Postal Abbreviations FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 58 of 74 APPENDIX CODE SETS Version 2010 01 Description School Homeless shelter Indian health service free standing facility Indian health service provider based facility Tribal 636 free standing facility Tribal 638 provider based facility Doctors office Home Assisted living facility Group home Mobile unit Urgent care facility Inpatient hospital Qutpatient hospital Emergency room hospital Ambulatory surgical center Birthing center Military treatment facility Skilled nursing facility Nursing facility Custodial care facility Hospice Ambulance land Ambulance air or water Independent clinic Federally qualified health center Inpatient psychiatric facility Psychiatric facility partial hospitalization Community mental health center Intermediate care facility mentally retarded Residential substance abuse treatment facility Psychiatric residential treatment center Non residential substance abuse treatment facility Mass immunization center Comprehensive inpatient rehabilitation facility Comprehensive outpatient rehabilitation facility End stage renal disease treatment facility state or local public health clinic Rural health clinic Independent laboratory Other unlisted facility FREE STA
43. ad COMNTION RELATED weiner E Cie gt L ini croe 2 CONTA ww oo Yw SME D REFERAR PHYIXZAN OF BOUNCE k ww is 0 5 0 0 2 5 00 a Tt DF VACAT RE SERVICES of anar ar sang 9 ali uh ADDRESS GF FAITE s ABU TA SERVICE CDU DFICATCON NOME DAGMOSES OF LMS PRELATI DRGNDSES PROCEDURE IN 144 To SUE oh i 3 B B 0 81115 110 Medical Center Anytown Now York 11111 8 10 EMEDNY 150003 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 14 of 74 CLAIMS SUBMISSION Exhibit 2 4 2 1 4 MEDICAL ASSISTANCE HEALTH INSURANCE omy ro ORIGINAL TRANSACTION CONTROL NUMBER CLAIM FORM TITLE XIX PROGRAM US 0 TO E x PATIENT AND INSURED SUBSCRIBER INFORMATION PAX CLARI R urs wed Fon ch i T SUSAN SAMPLE Wolfs tt I T WAS COMDTION BELATED F Du t gt vas scone ini croe 2 CONTA ww oo Yw SME D REFERAR PHYIXZAN OF BOUNCE K Pus Y gt g maa E 0001150 50 2 41 0 500 pr Tt DE VACAT EHE SERVICES
44. aim 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 billed inadvertently 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 13 of 74 CLAIMS SUBMISSION Exhibit 2 4 2 1 3 MEDICAL ASSISTANCE HEALTH INSURANCE omy ro CLAIM FORM TITLE XIX PROGRAM ORIGINAL TRANSACTION CONTROL NUMBER USED TO ADJUST VOID PATIENT ATIENT AND INSURE INSURED SUBSCRIBER INFORMATION PATENTS MARAT jx muda 1 Eee SAMPLE m e m W
45. ance 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 recoupment Accounts Receivable cumulative financial information Section Five Edit Error Description FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 Page 34 of 74 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 recoupment if any scheduled for the cycle This section contains the check stub and the actual Medicaid check payment Exhibit 3 1 1 DICAID INFO ERI ATION ES T EE TO ABC HOSPITAL DATE 2010 05 31 REMITTANCE 07080600006 PROV ID 00112233 1123456 89 00112233 1123456789 2010 05 31 ABC HOSPITAL 100 BROADWAY ANY TOWN 11111 YOUR CHECK IS BELOW TO DETACH TEAR ALONG PERFORATED DASHED LINE DOLLARS CENTS 2010 05 31 07050600006 00112233 1123456789 ui 143 80 _ ABC HOSPITAL DICAID 100 BROADWAY MAN AGEMENT ANYTOWN NY 11111 MEDICAL ASSISTANCE TITLE XIX PROGRAM J ohn S mit n CHECKS DRAWN OM
46. ber 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 52 of 74 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 recoupment were applied If there are no outstanding negative balances this section is not produced Exhibit 3 6 2 1 PAGE 08 DICAID DATE 05 31 10 CYCLE 1710 SYSTEM TO ABC HOSPITAL MEDICAL ASSISTANCE TITLE XIX PROGRAM ETN 100 BROADWAY bi ACCOUNTS RECEIVABLE ANYTOWN NEWYORK 11111 REMITTANCE STATEMENT PROVID 00112223 1122456783 REMITTANCE NO 07080600006 REASON CODE DESCRIPTION ORIG BAL CURR BAL RECOUP TOTAL AMOUNT DUE THE STATE XXX XX FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 Page 53 of 74 11 18 2010 REMITTANCE ADVICE 3 6 2 1 Explanation of Accounts Receivable Columns If a provider has negative balances of different types or negative balances created at different times each negative balance will be listed in a different line Reason Code Description This is the description of the Financial Reason Code For example Third Party Recovery Original Balance
47. 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 in this field A 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 claims submitted on a previously paid TCN To cancel one more claim lines submitted on a previously paid except if the contained one single claim line or if all the claim lines contained in the TCN are to be voided FREE STANDING OR HOSPITAL BASED O
48. e broken down by e e eee Adjustments voids combined Pends Paid Deny Net total paid for the specific service classification Totals by member 10 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 W e eee Adjustments voids combined Pends Paid Deny Net total paid sum of approved adjustments voids and paid original claims Grand Totals for the entire provider remittance advice appear on a separate page following the page containing the totals by provider type and member ID The grand total is broken down by Adjustments voids combined Pends Paid Deny Nettotal paid entire remittance FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 50 of 74 REMITTANCE ADVICE 3 6 Section Four Financial Transactions and Accounts Receivable This section has two subsections Financial Transactions Accounts Receivable 3 6 1 Financial Transactions The Financial Transactions subsection lists all the recoupment that were applied to the provider during the specific cycle If there is no recoupment activity this subsection is not produced Exhibit 3 6 1 1 DICAID PAGE 07 o 31 10 FORM
49. e 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 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 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 31 of 74 CLAIMS SUBMISSION Medicaid Group Identification Number Field 25B Leave this field blank Locator Code Field 25 For electronic claims
50. ew 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 67 of 74 APPENDIX C STERILIZATION CONSENT FORM Field 34 Enter the date of the patient s signature This date should be shortly prior to or same as date of sterilization 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 68 of 74 KNOWLEDGEMENT OF RECEIPT OF HYSTERECTOMY INFO FORM APPENDIX D ACKNOWLEDGMENT OF RECEIPT
51. format MM DD YY NOTE A service date must be entered for each procedure code listed Place of Service Field 24B This two digit code indicates the type of location where the service was rendered Please note that place of service code is different from locator code Select the appropriate codes from Appendix B Code Sets NOTE If code 99 Other Unlisted Facility is entered in this field for any claim line the exact address where the procedure was performed must be entered in fields 21 and 21A Procedure Code Field 24C This code identifies the type of service that was rendered to the patient Enter the appropriate five character procedure code in this field NOTE Procedure codes definitions prior approval requirements if applicable fees etc are available at www emedny org by clicking on the link to the webpage as follows Free Standing or Hospital Based Ordered Ambulatory 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 Note Modifier values and their definitions are available at www emedny org by clicking on the link to the webpage as follows Free Standing or Hospital Based Ordered Ambulatory Manual Diagnosis Code Field 24H Using the International C
52. g Ordered Ambulatory Providers can submit their claims to NYS Medicaid in electronic or paper formats Providers are required to submit an Electronic Paper Transmitter Identification Number ETIN Application and 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 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 Hospital Based Free Standing Ordered Ambulatory Providers who choose to submit their Medicaid claims electronically are required to use the HIPAA 837 Professional 837P or 837 Institutional 8371 transactions Direct billers should also refer to the sources listed below to comply with the NYS Medicaid requirements HIPAA 837P and 8371 Implementation Guides IG explain the proper use of the 837P standards and program specifications These documents are available at www wpc edi com hipaa NYS Medicaid 837P and 8371 Companion Guides
53. his consent form and the date sterilization was performed This sterilization was preformed less than 30 days but more than 72 hours after the date of the individual s signature on this consent form because of the following circumstances check applicable and fill in information requested 22 the 2 Lj 1 Premature delivery Individual s expected date of delivery 23 Lj 2 Emergency abdominal surgery 24 describe circumstances 25 S Physician Date THE FOLLOWING MUST BE COMPLETED FOR STERILIZATIONS PERFORMED IN NEW YORK CITY WITNESS CERTIFICATION do certify that on 28 I was present while the counselor read and explained the consent 9 and saw patient sign the consent form in his her handwriting patient s name SIGNATURE OF WITNESS x 30 REAFFIRMATION to be signed by the patient on admission for Sterilization TITLE DATE I certify that have carefully considered all the information advice and explanations given to me at the time originally signed the consent form I have decided that still want to be stenlized by the procedure noted in the original consent form and hereby affirm that decision SIGNATURE OF PATIENT x 33 DISTRIBUTION 1 Medical Record File 2 Hospital Claim SIGNATURE OF WITNESS 45 x 3 Surgeon Claim 4 Anesthesiologist Claim 5 Patient FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 63 of 74
54. ider 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 30 of 74 _ CLAIMS SUBMISSION provider should contact the third party worker in the local social services office whenever he she encounters policyholders who are uncooperative in paying for covered services received by their dependents who are on Medicaid In other cases the provider will be instructed to zero fill the Other Insurance Payment in the Medicaid claim and the LDSS will retroactively pursue the third party resource The patient or an absent parent collects the insurance benefits and fails to submit payment to the provider The LDSS must be notified so that sanctions and or legal action can be brought against the patient or absent parent The provider is instructed to zero fill by the 1055 for circumstances not listed above If none of the above situations are applicable leave this field blank NOTES 115 th
55. im form The date should be in the format MM DD YY NOTE In accordance with New York State regulations claims must be submitted within 90 days of the Date of Service unless acceptable circumstances for the delay can be documented For more information about billing claims over 90 days or two years from the Date of Service refer to Information for All Providers General Billing section which can be found at www emedny org by clicking on the link to the webpage as follows Free Standing or Hospital Based Ordered Ambulatory 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 32 of 74 CLAIMS SUBMISSION 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 Free Standing or
56. lassification of Diseases Ninth Edition Clinical Modification ICD 9 CM coding system enter the appropriate code which describes the main condition or symptom of the patient The ICD 9 CM code must be entered exactly as it is listed in the manual in the correct spaces of this field and in relation to the decimal point Proper entry of an IDC 9 CM Diagnosis Code is shown in Exhibit 2 4 2 9 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 28 of 74 CLAIMS SUBMISSION Exhibit 2 4 2 9 24H DIAGNOSIS CODE NOTE three digit Diagnosis Code no entry following the decimal point will only be accepted when the Diagnosis Code has no subcategories Otherwise Diagnosis Codes with subcategories MUST be entered with the subcategories indicated after the decimal point Days or Units Field 241 If a procedure was performed and approved by Medicare more than one time on the same date of service enter the number of 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 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 amount charged in this field The Amount Charged may not exceed the provider s customary charge for the procedure Medicare Approved Amount Box M in field 23B must have an entry value of 2 Enter the Medicare Approved A
57. leave this field blank For paper claims enter the locator code assigned by NYS Medicaid Locator codes are assigned to the provider for each service address registered at the time of enrollment in the Medicaid program or at any time afterwards that a new location is added Enter the locator code that corresponds to the address where the service was performed Locator codes 001 and 002 are for administrative use only and are not entered in this field If the provider renders services at one location only enter locator code 003 If the provider renders service to Medicaid patients at more than one location the entry may be 003 or a higher locator code NOTE The provider is reminded of the obligation to notify Medicaid of all service locations as well as changes to any of them For information on where to direct locator code updates please refer to Information for Providers Inquiry section located at www emedny org by clicking on the link to the webpage as follows Free Standing or Hospital Based Ordered Ambulatory 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 on y 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 cla
58. led for a period of time during which the Medicaid files may be updated to match the information on the claim After manual review is completed a match is found in the Medicaid files or the recycling time expires pended claims may be approved for payment or denied A new pend is signified by two asterisks A previously pended claim is signified by one asterisk Errors For claims with a DENY or PEND status this column indicates the NYS Medicaid edit error numeric code s that caused the claim to deny or pend Some edit codes may also be indicated for a PAID claim These are approved edits which identify certain errors found in the claim and that do not prevent the claim from being approved Up to twenty five 25 edit codes including approved edits may be listed for each claim Edit code definitions will be listed on a separate page of the remittance advice at the end of the claim detail section FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 49 of 74 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 the claim detail listing These subtotals ar
59. ligible 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 8 of 74 CLAIMS SUBMISSION 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 21 4 does not match information in the provider s Medicaid file 2 4 2 eMedNyY 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
60. livery 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 65 of 74 APPENDIX STERILIZATION CONSENT FORM 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
61. mount in field 24 NOTES The entries in field 23B Payment Source Code determine the entries in field s 24J 24K and 241 Field 24 must never be left blank or contain zeroes tis 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 Box 2 When billing for the Medicare deductible enter 0 00 in this field FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 29 of 74 C e CLAIMS SUBMISSION 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 3 Enter 0 00 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 O 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 e
62. nt Field 24J should contain the amount charged Field 24K must be left blank Code 1 Medicare involvement Field 24 1 should contain the amount charged Field 24K must be left blank Code z Medicare Approved Service Field 24 1 should contain the Medicare Approved amount In Field 24K enter the Medicare payment Code z Medicare Approved Service Field 24J should cantainthe Medicare Approved amount In Field 24K enter the Medicare payment Code z Medicare Approved Service Field 24J should containthe Medicare Approved amount Field 24K enter the Medicare payment Code3 Medicare denied payment did not cover the service Field 24J should containthe amount charged In Field 24K you must enter 50 00 Code3 Medicare denied payment did not cover the service Field 24J should containthe amount charged In Field 24K you must enter 0 00 Code3 Medicare denied payment did not cover the service Field 24J should containthe amount charged In Field 24K you must enter 0 00 CLAIMS SUBMISSION Code 1 Other Insurance involvement Field 241 must be left blank Code 2 Other Insurance involved In Field 24L enter the payment amount or enter 0 00 if Other Insurance did nat coverthe service You must indicate the two digit insurance code Code 3 Indicates patient s participation In Field ZAL enterthe Participation Amount If Other Insurance is alsoinvolved enterthe total payment
63. nter the total amount paid by all other insurance carriers in this field 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 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 n very limited situations the Local Department of Social Services LDSS has advised the provider to zero fill other insurance payment for same type of service This communication should be documented in the patient s billing record The provider bills the insurance company and receives a rejection because service is not covered or The deductible has not been met The prov
64. or 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 74 of 74
65. or nurse practitioner The services include but are not limited to Physician clinic or hospital visits during which birth control pills are prescribed Periodic examinations associated with a contraceptive method Visits during which sterilization or other methods of birth control are discussed Sterilization procedures e e c Procedures to promote fertility The ordering provider must indicate whether the ordered services are related to family planning 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 Prior Approval Number Field 23A Leave this field blank Payment Source Code Box M and Box 0 Field 23B This field has two components Box M and Box O as shown in Exhibit 2 4 2 7 below Exhibit 2 4 2 7 23B SOURCE M O Both boxes need to be filled as follows FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 25 of 74 CLAIMS SUBMISSION Box M The values entered in this box define the nature of the amounts entered in fields 24J and 24
66. ormed me will RECIPIENT make itimpoassible formeto become pregnant orbear children understandthat a hysterectomy 15 a permanent operation Thereasonforperfonningthe hysterectomy andthe discomforts risks and benefits associated withthe hysterectomy have been explained me and all my questions have been answered to my satisfaction prior to the surgery 4 RECIPIENT OR REPRESENTATIVE 5 DATE INTERPRETER S SIGNATURE If required SIGNATURE X X SURGEON S CERTIFICATION The hysterectomy to be performedfor the above mentioned recipientis solely for medical indications The hysterectomy is not primarily or secondarily for family planning reasons that is for rendering the recipient permanently incapable of reproducing 11 WAIVER OF ACKNOWLEDGEMENT AND SURGEON S CERTIFICATION The hysterectomy performed on 10 was solely for medical reasons The RECIPIENT hysterectomy was not primarily or secondarily forfamily planningreas ons thatis forrendering the recipient permanently incapable of reproducing didnot obtain Acknowledgement of Receipt of Hysterectomy information from her and have her complete Part of this form because please check the appropriate statement and describe the circumstances where indicated She was sterile priorto the hysterectomy briefly describethe cause of sterility The hysterectomy was performed in life threatening emergency in which prior acknowledgement was not p
67. ossible briefly describe the nature of the emergency Shewas Medicaid recipient at the time the hysterectomy was performed buti did inform her prior to surgery that the procedure would make her permanently incapable of reproducing 15 DATE DISTRIBUTION File patient s medicalrecord hospital submit with claim for payment surgeon and anesthesiologist submit with claims for payment patient FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 70 of 74 ACKNOWLEDGEMENT OF RECEIPT OF HYSTERECTOMY INFO FORM ACKNOWLEDGEMENT RECEIPT OF HYSTERECTOMY INFORMATION FORM 1055 3113 INSTRUCTIONS Either Part 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 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
68. oviders 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 directly to Medicaid Claims that are denied by Medicare will not be crossed over Medicaid will deny claims that are crossed over without a Patient Responsibility If a separate claim is submitted directly by the provider to Medicaid for a dual e
69. rdless 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 Free Standing or Hospital Based Ordered Ambulatory 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 26 of 74 23B PAYM I SOURCE CO 23B PAYM I SOURCE CO 2 2 i 23B PAYM I SOURCE CO Midi ts 23B SOURCE CO 9 23B PAYM T SOURCE CO 32 23B SOURCE CO Exhibit 2 4 2 8 Gode 1 Mo Medicare involvement Field 24J should contain the amount charged Field 24K must be left blank Code 1 No Medicare involveme
70. re required to submit paper claims Providers who have a valid ETIN for the submission of electronic claims do not need an additional ETIN for paper submissions The ETIN and the associated certification qualify the provider to submit claims in both electronic and paper formats Information about these requirements is available at www emedny org by clicking on the link to the webpage as follows Information for All Providers 2 2 4 General Instructions for Completing 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 2 1 1 as possible Exhibit 2 2 1 1 e Circles the letter O the number 0 must be closed Avoid unfinished characters See the example in Exhibit 2 2 1 2 e Exhibit 2 2 1 2 Written As Intended As Interpreted As 6 00 6 interpreted as six When typing or printing stay within the box provided ensure that no characters letters or numbers touch the claim form lines See the example in Exhibit 2 2 1 3 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11
71. s 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 48 of 74 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 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 recyc
72. sin Fidd24L and enter the two digit insurance code Code 1 Other Insurance involvement Field 24L must be left blank Codes Other Insurance involved In Field 24L enter the payment amount ar enter 0 00 if Other Insurance did not cover the service You must indicate the two digit insurance code Code 3 Indicates patient s participation In Field24L enter the Participation Amount If Other Insurance is alsoinvolved enterthe total paymentsin Fidd24L and enter the2 digitinsurance code Code 1 Other Insurance involvement Field 24L must be left blank Cadez Other Insurance involved In Field 24L enter the payment amount ar enter 0 00 if Other Insurance did nat cover the service You must indicate the two digit insurance code Code 3 Indicates patient s participation In Field 24L enter the Participation Amount lf Other Insurance is also involved enter the total paymentsin Fiad24L and enter the two digit insurance code FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 Page 27 of 74 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 23B applies to all the encounters Date of Service Field 24A Enter the date on which the service was rendered in the
73. terilization 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 for the purpose of sterilization Code F a completed Sterilization Consent Form DSS 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 DSS 3134 form attached to it NOTE 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 Drugs or devices to prevent implantation of the fertilized ovum Menstrual extraction Status Code Field 22E Leave this field blank FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 24 of 74 i CLAIMS SUBMISSION Possible Disability Field 22F Leave this field blank EPSDT C THP Field 22G Leave this field blank 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
74. the claim as it was originally submitted and Exhibit 2 4 2 2 2 shows the claim being submitted as voided FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 16 of 74 CLAIMS SUBMISSION Exhibit 2 4 2 2 1 MEDICAL ASSISTANCE HEALTH INSURANCE ONLY TO BE ORIGINAL TRANSACTION CONTROL NUMBER CLAIM FORM TITLE XIX PROGRAM E PATIENT AND INSURED SUBSCRIBER INFORMATION PA CLAM 4 PATENTS MARAT uw maria 1 BATI 4 SUSAN SAMPLE 20 wei 12 WU COMDTIDA Nou cont 1 3009uv TAVIS LON In Ey CODNEKTION uw Bo Yw OF PH OTHER HUELE ls pou n Is 5 B 9 010 5 5 9 0 0 1 813 010 a e MADE DI ARENE SERVICES REMOERED af anar Pan sang 9 alie uk QF ELT AME PEDE IC OORT CeO DAGMOSE OF NATURE OF LLMISS FRAT DOMME TU IN De EY ee C B T 7 Anytown Medical Center 312 Main Street Anytown Now York 11111 8 10 EMEDNY 150003 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 17 of 74 CLAIMS SUBMISSION Exhibit 2 4 2 2 2 MEDICAL ASSISTANCE HEALTH INSURANCE ONLY TO BE ORIGINAL TRANSA
75. x 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 Enter the ordering provider s name in this field Address or Signature SHF Only Field 19A Leave this field blank Prof CD Professional Code Ordering Referring Provider Field 19B Leave this field blank Identification Number Ordering Referring Provider Field 19C For Ordering Provider Enter the ordering provider s National Provider Identifier NPI in this field For Referring Provider Enter the Referring Provider 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 FREE STANDING OR HOSPITAL BASED ORDERED AMBULATORY Version 2010 01 11 18 2010 Page 20 of 74 CLAIMS SUBMISSION DX Code Field 19D Leave this field blank Drug

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