eMedNY Subsystem User Manual
Contents
1. 27 3 3 Section One Surmmmout NO Payment uuu u uuu 28 3 3 1 Summout No Payment Field Descriptions nennen nennen 29 3 4 Section TWO Provider NotiiCatiON tem T m 30 3 4 1 Provider Notification Field Descriptions 31 3 5 SECTION Whee SP 32 3 5 1 Claim Detail Page Field 9 36 3 5 2 Explanation of Claim Detail Columns a 36 3 5 3 Subtotals Totals Grand Totals a rrarsrnrrsssssssssssssssssssssssssssssssssnsssssssssssssssssssssasssssa 38 3 6 Section Four Financial Transactions and Accounts Receivable 40 3 6 1 M HH 40 2t AC ai AIDC RR UU t m E T 42 3 7 Section Five Edit Error D SCTEIDLIOTI ssseessuxesamivn ves u n NUN T UPS 44 Appendix A Claim 45 HOSPICE Version 2010 01 5 31 2010 Page 2 of 47 EL CLAIMS SUBMISSION Fo2. For NYS Medicaid billing payers are classified into three main categories Medicare Commercial any insurance other than Medicare and Medicaid Medicaid is always the payer of last resort Complete this field in accordance with the following instructions Direct Medicaid Claim No Third Party Involved If Medicaid is the only payer enter the word Medicaid on line A of this field Leave lines B and C blank HOSPICE Version 2010 01 5 31 2010 Page 19 of 47 _ CLAIMS SUBMISSION Medicaid Third Party Other than Medicare Claim If the patient has insurance coverage other than Medicare Enter the name of the Other Insurance Carrier on line A of this field Enter the word Medicaid on line B of this field Leave line C blank NPI Form Locator 56 Enter the provider s 10 digit National Provider Identifier NPI Other Prv ID Other Provider ID Form Locator 57 Leave this field blank Insured s Unique ID Form Locator 60 Enter the patient s ID number Client ID number This information may be obtained from the Client s Patient s Common Benefit ID Card Medicaid Client ID numbers are assigned by the State of New York and are composed of eight characters in the format AANNNNNA where A alpha character and N numeric character For example AB12345C The Medicaid Client ID should be entered on the same line A B or C that matches the line assigned to Medicaid in Form Locators 50 and 57 If the patien
3. 3 6 1 1 Explanation of Financial Transactions Columns FCN The Financial Control Number FCN is a unique identifier assigned to each financial transaction Financial Reason Code This code is for DOH CSC use only it has no relevance to providers It identifies the reason for the recoupment Financial Transaction Type This is the description of the Financial Reason Code For example Third Party Recovery Date The date on which the recoupment was applied Since all the recoupments listed on this page pertain to the current cycle all the recoupments will have the same date Amount The dollar amount corresponding to the particular fiscal transaction This amount is deducted from the provider s total payment for the cycle 3 6 1 2 Explanation of Totals Section The total dollar amount of the financial transactions Net Financial Transaction Amount and the total number of transactions Number of Financial Transactions appear below the last line of the transaction detail list The Net Financial Transaction Amount added to the Claim Detail Grand Total must equal the Medicaid Check or EFT amounts HOSPICE Version 2010 01 5 31 2010 Page 41 of 47 REMITTANCE ADVICE 3 6 2 Accounts Receivable This subsection displays the original amount of each of the outstanding Financial Transactions and their current balance after the cycle recoupments were applied If there are no outstanding negative balances this section is not prod
4. then each service day must be billed separately Hospice Claims for Nursing Home Room and Board Only A separate claim must be completed if the period of service includes therapeutic or hospital leave days NOTES Claims must be submitted within 90 days of the date of service entered in this field unless acceptable circumstances for the delay can be documented Information about billing claims over 90 days or two years from the Date of Service is available in the All Providers General Billing Guideline Information section available at www emedny org by clicking on the link to the webpage as follows Information for All Providers Do not include full days covered by Medicare or other third party insurers as part of the period of service HOSPICE Version 2010 01 5 31 2010 Page 11 of 47 i CLAIMS SUBMISSION Patient Name Form Locator 8 line b Enter the patient s last name followed by the first name This information may be obtained from the Client s Patient s Common Benefit ID Card Birthdate Form Locator 10 Enter the patient s birth date This information may be obtained from the Client s Patient s Common Benefit ID Card The birth date must be in the format MMDDYYYY See the example in Exhibit 2 4 2 6 that follows Exhibit 2 4 2 6 Sex Form Locator 11 Enter for male or for female to indicate the patient s sex This information may be obtained from the Client s Patient s Common Benefit ID Card Adm
5. one is labeled full days and the other is labeled co insurance days The number of days within the reported first FROM service date and the last THROUGH service date appear in the first line under the F sub column The number of full days calculated by the system appears in the second line under the F sub column The number of co insurance days reported on the claim form appears under the C sub column There are no calculated co insurance days Patient Participation Reported Deducted This column shows the patient participation amount NAMI as it was reported first line and as it was deducted second line If no patient participation is applicable this column will show 0 00 amount Other Insurance If applicable the amount paid by the patient s Other Insurance carrier as reported on the claim form is shown under this column If no Other Insurance payment is applicable this column will show 0 00 amount Amount Charged Amount Paid The total charges entered in the claim form appear first under this column If the claim was approved the amount paid appears underneath the charges If the claim has a pend or deny status the amount paid will be zero 0 00 Status This column indicates the status DENY PAID ADJT VOID PEND of the claim line Denied Claims Claims for which payment is denied will be identified by the DENY status A claim may be denied for the following general reasons The service rendered
6. renewal information when their Certification Statement is near expiration Information about these requirements is available at www emedny org by clicking on the link to the webpage as follows Information for All Providers 2 1 Electronic Claims 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 Hospice providers who choose to submit their Medicaid claims electronically are required to use the HIPAA 837 Institutional 8371 transaction Direct billers should also refer to the sources listed below to comply with the NYS Medicaid requirements HIPAA 8371 Implementation Guide IG explains the proper use of the 8371 standards and program specifications This document is available at www wpc edi com hipaa NYS Medicaid 8371 Companion Guide CG is a subset of the IG which provides instructions for the specific requirements of NYS Medicaid for the 8371 This document is available at www emedny org by clicking on the link to the web page as follows Companion Guides and Sample Files NYS Medicaid Technical Supplementary Companion Guide provides technical information needed to successfully transmit and receive electronic data Some of the topics put forth in this CG are testing requirements error repor
7. Field Descriptions Upper Left Corner Provider s Name Address Upper Right Corner Remittance page number Date The date on which the remittance advice was issued Cycle number The cycle number should be used when calling the eMedNY Call Center with questions about specific processed claims or payments ETIN not applicable Provider Service Classification NURSING HOME PROV ID This field will contain the Medicaid Provider ID and the NPI Remittance Number 3 5 2 Explanation of Claim Detail Columns Client Name ID Number This column indicates the last name of the patient first line and the Medicaid Client ID second line If an invalid Medicaid Client ID was entered in the claim form the ID will be listed as it was submitted but no name will appear in this column TCN Patient Account Number The TCN first line is a unique identifier assigned to each claim that is processed If a Patient Account Number was entered in the claim form that number up to 20 characters will appear under this column second line Service Dates From Through The first date of service covered by the claim From date appears on the first line the last date of service Through date appears on the second line Rate Code The four digit rate code that was entered in the claim form appears under this column HOSPICE Version 2010 01 5 31 2010 Page 36 of 47 REMITTANCE ADVICE Reported Calculated Days This column has two sub columns
8. files Upper Right Corner Date on which the remittance advice was issued Remittance Number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Medicaid Provider ID NPI Date Provider s Name Address 3 1 2 Medicaid Check Field Descriptions Left Side Table Date on which the check was issued Remittance Nnumber 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 HOSPICE Version 2010 01 5 31 2010 Page 25 of 47 REMITTANCE ADVICE 3 2 Section One EFT Notification For providers who have selected electronic funds transfer or direct deposit an EFT transaction is processed when the provider has claims approved during the cycle and the approved amount is greater than the recoupments if any scheduled for the cycle This section indicates the amount of the EFT Exhibit 3 2 1 TO ABCHOSPICE T DATE 05 31 2010 DI Cc AID REMITTANCE NO 07080600001 PROV ID 00123458 1234587890 MANAGEMENT INFORMATION 001234 6 1234587890 05 31 2010 HOSPICE 123 MAIN ST ANY TOWN 11111 ABC HOSPICE 51452 20 PAYMENT IN AMOUNT WILL BE DEPOSITED VIA ELECTRONICFUNDS TRANSFER HOSPICE Version 2010 01 5 31 2010 Page 26 of 47 REMITTANCE AD
9. 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 the Other Insurance payment for the same type of service This communication should be documented in the client s billing record The provider bills the insurance company and receives a rejection because The service is not covered The deductible has not been met HOSPICE Version 2010 01 5 31 2010 Page 15 of 47 SUBMISSION The provider cannot directly bill the insurance carrier and the policyholder is either unavailable or uncooperative in submitting claims to the insurance company In these cases the LDSS must be notified prior to zero filling The LDSS has subrogation rights enabling it to complete claim forms on behalf of uncooperative policyholders who do not pay the provider for the services The LDSS can direct the insurance company to pay the provider directly for the service whether or not the provider participates with the insurance plan The provider should contact the third party worker in the LDSS whenever he she encounters policyholders who are uncooperative in paying for covered services received by their dependents who are on Medicaid In other cases providers will be instructed to zero fill the Other Insurance payment in the Medicaid claim and the LDSS will retroactiv
10. 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 zip 4 does not match information in the provider s Medicaid file 2 4 2 UB 04 Claim Form Field Instructions Provider Name Address and Telephone Number Form Locator 1 Enter the billing provider s name and address using the following rules for submitting the ZIP code Paper claim submissions Enter the five digit ZIP code or the ZIP plus four Electronic claim submissions Enter the nine digit ZIP code The Locator Code will default to 003 if the nine digit ZIP code does not match information in the provider s Medicaid file NOTE It is the responsibility of the provider to notify Medicaid of any change of address or other pertinent information within 15 days of the change For information on where to direct address change requests please refer to Information for All Providers Inquiry section which can be found at www emedny org by clicking on the link to the webpage as follows Hospice Manual Patient Control Number Form Locator 3a For record keeping purposes the provider may choose to identify a patient by using an account patient control number This field can accommodate up to 30 alphanumeric characters If an account patient control number is indicated on the claim form the first 20 characters will be returned on the paper R
11. 0 digit NPI of the provider is entered in the box labeled NPI After the word QUAL leave the first box blank to indicate the Medicaid Provider ID number of the provider is entered in the field to the right of the qualifier Below the ID numbers enter the name of the RHCF provider See the example in Exhibit 2 4 2 17 Exhibit 2 4 2 17 The patient is a resident of Maple Hill Nursing Home whose NPI numberis 1234567890 73 OTHER NPL 1234567890 QUAL B jJ 4 LAST SMITH FIRST JOHN HOSPICE Version 2010 01 5 31 2010 Page 22 of 47 REMITTANCE ADVICE 3 Explanation of Paper Remittance Advice Sections This Section present a sample of each section of the remittance advice for Hospice providers followed by an explanation of the elements contained in the section The information displayed in the remittance advice samples is for illustration purposes only The following information applies to a remittance advice with the default sort pattern General Remittance Advice Information is available in the All Providers General Billing Guideline Information section available at www emedny org by clicking on the link to the webpage as follows Information for All Providers The remittance advice is composed of five sections Section One may be one of the following Medicaid Check Notice of Electronic Funds Transfer Summout no claims paid Section Two Provider Notification special messages Section Three Clai
12. 444 6 05 05 10 i345 1945 PREVIOUSLY PENDED CLAIM NEW TOTAL AMOUNT ORIGINAL CLAIMS PAID 1551 24 NUMBER OF CLAIMS 5 HET AMOUNT ADJUSTMENTS FAID 83 04 NUMBER OF CLAIMS 1 NET AMOUNT VOIDS FAID 0 00 NUMBER OF CLAIMS 0 HET AMOUNT VOIDS ADJUSTS 83 04 NUMBER OF CLAIMS 1 HOSPICE Version 2010 01 5 31 2010 Page 33 of 47 REMITTANCE ADVICE Exhibit 3 5 3 04 DATE 053710 CYCLE 1710 EDICAID INFORMATION amp GY STEM ETIN TO ABC HOSPICE MEDICAL ASSISTANCE TITLE XIX PROGRAM NURSING HOME 123 MAIN STREET T PROV ID 00123455 1224557890 ANYTOWN NEW YORK 11111 REMITTANCE STATEMENT REMITTANCE NO 07080500001 211154 PATIENT OTHER AMOUNT v EE s FUL WS SERVICE RATE n DAYS O PARTICIPATION INSURANCE CHARGED PATIENT ACCOUNT DATES Oa Op Po ar ee FROM CODE DAYS PAYMENT REPORTED AMOUNT NUMBER FROM DAYSPAYMENT BEPORTED THRU a DEDUCTED SAMPLE 07206 000000112 3 20 05 02710 0 0 00 0 00 0 00 387 81 PEND 0016200571 XX12345X 00987 8 05 06 10 2 00 0 00 EXAMPLE 07206 111 2 050210 0 0 00 0 00 0 00 381 81 01131 AXBTSSQX CFIC1 00678 3 on 10 0 00 0 00 CLIENT NAME ID NUMBER STATUS ERRORS i ET Lal PREVIOUSLY CLAIM NEW TOTAL AMOUNT ORIGINAL CLAIMS PEND 779 62 NUMBER OF CLAIMS NET A
13. E m gt p G H 68 CODE ECI RST FIRST THE CERTIFICATIONS ON THE REVERSE APPLY TOTHIS ARE MADE PART HEREOF 5 31 2010 EMEDNY INFORMATION eMedNY is the name of the electronic New York State Medicaid system The eMedNY system allows New York Medicaid providers to submit claims and receive payments for Medicaid covered services provided to eligible clients eMedNY offers several innovative technical and architectural features facilitating the adjudication and payment of claims and providing extensive support and convenience for its users CSC is the eMedNY contractor and is responsible for its operation The information contained within this document was created in concert by eMedNY DOH and eMedNY CSC More information about eMedNY can be found at www emedny org HOSPICE Version 2010 01 5 31 2010 Page 47 of 47
14. ENY 0 00 01023 01035 0 00 DENY 01023 PREVIOUSLY PENDED CLAIM NEW 5 31 2010 REMITTANCE ADVICE Exhibit 3 5 2 PAGE 03 DATE 05 31 10 D ICAID CYCLE 1710 INFORMATION Sar S TEM ETIN TO ABC HOSPICE MEDICAL ASSISTANCE TITLE XIX PROGRAM NURSING HOME 122 MAIN STREET REMITTANCE STATEMENT PROV ID O0122456 1234567290 ANYTOWN NEW YORK 11111 REMITTANCE NO 07080500001 RATE CALCED FATIENT OTHER AMOUNT PARTICIPATION INSURANCE CHARGED _ USES CODE AMOUNT STATUS ERRORS G DEDUCTED FAID 0 48781 0 00 0 00 JBT 81 PAID 0 00 387 81 9 387 41 0 00 0 00 387 81 0 00 381 81 0 44781 0 00 0 00 187 81 PAID 000 3B7 81 0 187 81 0 00 000 38181 0 00 387 81 0 257 81 0 00 287 81 ADJT ORIGINAL CLAIM 0 00 387 81 PAID 05 11 2040 0 ZUB TI 000 0 00 238 TT ADJT 0 00 238 77 FULL DAYS CO INSURANCE DAYS FAYMENT SERVICE PATIENT ACCOUNT DATES zoNUNBEP NUMBER FROM THRU SAMPLE 27206 000000012 323 08702710 XX12 45X 1 00987 5 05 05 10 EXAMPLE Q0720 amp 000900111 1 0 05702710 XX57890X CPIC1 00678 9 05 06 10 MODEL 07206 000232456 0 0 05 02 10 3945 XXSS7EBP 1 00543 5 05 05 10 SPECIMEN 07206 004445656 0 0 05 02 10 3945 XXS7554X 1 00321 5 05 05 10 STANDARD 0 07206 007776546 01 05 02 40 3945 XXTeS4iX EPIDTD0555 5 05 06 10 DOE 07206 00777554520 2 05 02 10 3945 XXE5432X 1 1 00
15. HOSPICE Version 2010 01 5 31 2010 Page 31 of 47 REMITTANCE ADVICE 3 5 Section Three Claim Detail This section provides a listing of all new claims that were processed during the specific cycle plus claims that were previously pended and denied during the specific cycle This section may also contain claims that pended previously TO ABC HOSPICE 123 MAIN STREET ANYTOWN NEW YORK 11111 REFTED DAYS CN SERVIGE PATIENT ACCOUNT OATES NUMBER FROM THRU O02 10 10 O02 10 ioe 10 RATE CODE CLIENT NAME ID NUMBER Q7206 000000112 3 0 3945 0 1 00987 6 Q7206 000000111 1 0 1 00678 9 SAMPLE EXAMPLE XXb7 EX 3945 775 62 0 00 0 00 0 00 DENIED DENIED DENIED TOTAL AMOUNT ORIGIMAL CLAIMS AMOUNT ADJUSTMENTS AMOUNT VOIDS AMOUNT VOIDS ADJUSTS Version 2010 01 Exhibit 3 5 1 DICAID Pul AGEMENT TIM w T E FN MEDICAL ASSISTANCE TITLE PROGRAM REMITTANCE STATEMENT PATIENT PARTICIPATION REPORTED DEDUCTED 0 00 FULL DAYS CO INSURANCE DAYS PAYMENT 2 00 0 00 0 00 0 00 0 00 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS HOSPICE Page 32 of 47 INSURANCE PAGE DATE CYCLE 02 05 31 10 1710 NURSING PROV ID 01224567 1234567890 REMITTANCE NO 07080600001 AMOUNT CHARGED AMOUNT PAID 387 81 0 00 387 81 0 00 OTHER STATUS ERRORS D
16. MOUNT ADJUSTMENTS 0 00 HUMBER OF CLAIMS NET AMOUNT VOIDS 0 00 NUMBER OF CLAIMS NET AMOUNT VOIDS ADJUSTS 0 00 NUMBER OF CLAIMS 5 NURSING HOME VOIDS ADJUSTS 83 04 NUMBER OF CLAIMS TOTAL PENDS 775 62 NUMBER OF CLAIMS TOTAL PAID 1551 24 NUMBER OF CLAIMS TOTAL DENY 77 62 NUMBER OF CLAIMS TOTAL PAID 1452 20 HUMBER OF CLAIMS n racn pa MEMBER ID 12345678 VOIDS ADJUSTS 59 04 HUMBER OF CLAIMS TOTAL 5 77 62 NUMBER OF CLAIMS TOTAL PAID 1551 24 NUMBER OF CLAIMS TOTAL DENY 774 62 NUMBER OF CLAIMS NETTOTAL PAID 1452 20 NUMBER OF CLAIMS cn p HOSPICE Version 2010 01 5 31 2010 Page 34 of 47 REMITTANCE ADVICE Exhibit 3 5 4 DICAID EY SS T E MEDICAL ASSISTANCE TITLE XIX PROGRAM ABC HDSFICE 123 MAIN STREET REMITTANCE STATEMENT ANYTOWN NEW YORK 11111 REMITTANCE TOTALS GRAND TOTALS VOIDS ADJUSTS 83 04 NUMBER OF CLAIMS TOTAL PENDS 19 62 NUMBER OF CLAIMS TOTAL PAID 1551 24 NUMBER OF CLAIMS TOTAL DENY 75 62 NUMBER OF CLAIMS NET TOTAL PAID 1452 20 NUMBER OF CLAIMS HOSPICE Version 2010 01 Page 35 of 47 FAGE 05 DATE 05 31 10 CYCLE 1710 ETIN NURSING HOME GRAND TOTALS PROVID 00123456 1234567890 REMITTANCE NO 07080600001 ra BRI 5 31 2010 REMITTANCE ADVICE 3 5 1 Claim Detail Page
17. MS SUBMISSION The TCN must be entered in the line A B or C that matches the line assigned to Medicaid in Form Locators 50 and 57 If the TCN is entered in lines B or C the word NONE must be written on the line s above the TCN line Adjustments An adjustment is submitted to correct one or more fields of a previously paid claim Any field except the Provider ID number or the Patient s Medicaid ID number can be adjusted The adjustment must be submitted in a new claim form copy of the original form is unacceptable and all applicable fields must be completed An adjustment is identified by the value 7 in the third position of Form Locator 4 Type of Bill and the claim to be adjusted is identified by the TCN entered in this field Form Locator 64 Adjustments cause the correction of the adjusted information in the claim history records as well as the cancellation of the original claim payment and the re pricing of the claim based on the adjusted information Voids A void is submitted to nullify a paid claim The void must be submitted in a new claim form copy of the original form is unacceptable and all applicable fields must be completed A void is identified by the value 8 in the third position of Form Locator 4 Type of Bill and the claim to be voided is identified by the TCN entered in this field Form Locator 64 Voids cause the cancellation of the original claim history records and payment Untitled Principal Diagnosis Co
18. New York State Electronic Medicaid System B04 Billing Guidelines HOSPICE Version 2010 01 5 31 2010 TT TABLE OF CONTENTS TABLE OF CONTENTS TL Purpose CRON CUR E E RUDI 4 2 Clamis uu uu u 5 2 1 Fl CI O NG C p uu u uu uuu 5 2 2 s u ua u uuu 6 2 2 1 General Instructions for Completing Paper 6 2 3 044 UIN O E EE o 8 2 4 Hospice Services Billing 5 8 2 4 1 Instructions for the Submission of Medicare Crossover nnn nnne ener nns 8 2 4 2 UB 04 Claim Form Field Instructions Ua Ino Esa ORI E RUa RS u UN CU UE ed 9 3 Explanation of Paper Remittance Advice 5 23 3 1 Section One IVICCIC AICO CMM 24 31 1 Medicaid Check St b Field DeSeHpDEIONS a E ee 25 3 1 2 Medicaid Check Field Descriptions 25 3 2 BECTON TREE 26 3 2 1 EFT Notification Page Field
19. RNAME 51 HEALTHPLAN ID S A Blue Cross E Medicaid 58 INSURED S 59 50 INSURED S UNIQUE ID A None AB12345C 63 TREATMENT AUTHORIZATION CODES ER PROCEDURE j a CODE 80 REMARKS Version 2010 01 T Maple Avenue TPATIENTADDRESS 19 20 E m ot 4 y 2 O CQ d G N C G d N L b OTHER PROCEDURE CONDITION CODES 21 22 23 CODE DATE CODE DATE CODE DATE CODE FROM 42 REV CD 43 DESCRIPTION 44 HCPCS RATE HIPPS CODE 61 GROUP NAME 64 DOCUMENT CONTROL NUMBER ES ES L M I N M N DATE OCEDURE DATE HOSPICE Page 46 of 47 j ASG 2 x 57 PRV ID somer DN wei 1234567890 tast SMIT First JOHN 79 OTHER APPENDIX A CLAIM SAMPLES APPROVED OMB NO 0938 0279 PAT CNTL 1224567 4 OF BILL 6 STATEMENT COVERS PERIOD 3 FED TAX NO FROM THROUGH 04012007 04302007 Eu lb loe s ERE 25 26 27 28 STATE L OCCURRENCE SPAN VALUE CODES 55 OCCURRENCE SPAN 7 CODE FROM THROUGH 40 VALUE CODES 41 VALUE CODES CODE AMOUNT CODE AMOUNT 10 11 12 13 14 15 16 1f 18 19 20 21 22 23 OQ O m gt 62 INSURANCE GROUP NO m x 65 EMPLOYER NAM
20. URING THIS PERIOD OF TIME YOU SHOULD REVIEW YOUR BANK STATEMENTS AND LOOK FOR AN EFT TRANSACTION IN THE AMOUNT OF 0 01 WHICH CSC WILL SUBMIT AS TEST YOUR FIRST REAL EFT TRANSACTION WILL TAKE PLACE APPROAIMATELY FOUR TO FIVE WEEKS LATER IF YOU HAVE ANY QUESTIONS ABOUT THE EFT PROCESS PLEASE CALL THE EMEDNY CALL CENTER AT 1 800 343 8000 NOTICE THIS COMMUNICATION AND ANY ATTACHMENTS MAY CONTAIN INFORMATION THAT 15 PRIVILEGED AND CONFIDENTIAL UNDER STATE AND FEDERAL LAW AND 15 INTENDED ONLY FOR THE USE OF THE SPECIFIC INDIVIDUAL S TO WHOM IT Is ADDRESSED THIS INFORMATION MAY ONLY BE USED OR DISCLOSED IN ACCORDANCE WITH LAW AND YOU MAY BE SUBJECT TO PENALTIES UNDER LAW FOR IMPROPER USE OR FURTHER DISCLOSURE OF INFORMATION IN THIS COMMUNICATION AND ANY ATTACHMENTS IF YOU HAVE RECEIVED THIS COMMUNICATION ERROR PLEASE IMMEDIATELY NOTIFY NYHIPPADESKi CSC COM OR CALL 1 800 541 2831 PROVIDERS WHO DO HAVE ACCESS E MAIL SHOULD CONTACT 1 800 343 9000 HOSPICE Version 2010 01 5 31 2010 Page 30 of 47 REMITTANCE ADVICE 3 4 1 Provider Notification Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Remittance page number Date on which the remittance advice was issued Cycle Number ETIN not applicable Name of section PROVIDER NOTIFICATION PROV ID This field will contain the Medicaid Provider ID and the NPI Remittance Number Center Message text
21. VICE 3 2 1 EFT Notification Page Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Date on which the remittance advice was issued Remittance Number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Medicaid Provider ID NPI Date Provider s Name Address Provider s Name Amount transferred to the provider s account This amount must equal the Net Total Paid Amount under the Grand Total subsection plus the total sum of the Financial Transaction section HOSPICE Version 2010 01 5 31 2010 Page 27 of 47 REMITTANCE ADVICE 3 3 Section One Summout No Payment A summout is produced when the provider has no positive total payment for the cycle and therefore there is no disbursement of moneys Exhibit 3 3 1 TO ABC HOSPICE DATE 05 31 2010 REMITTANCE NO 07080600001 D ICAI D PROV ID 001234 6 1234567890 BLA M AGE EM T INFORMATION SYSTEM HO PAYMENT WILL BE RECEIVED THIS CYCLE SEE REMITTANCE FOR DETAILS ABC HOSPICE 123 MAIN ST ANYT OWN 11111 HOSPICE Version 2010 01 Page 28 of 47 5 31 2010 REMITTANCE ADVICE 3 3 1 Summout No Payment Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Date on which the remittance advice was issued Remittance Number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Notifica
22. aid for the specific service classification Grand Totals for the entire provider remittance advice which include all the provider s service classifications appear on a separate page following the page containing the totals by service classification The grand total is broken down by Adjustments voids combined Pends Paid Deny Net total paid entire remittance HOSPICE Version 2010 01 5 31 2010 Page 39 of 47 REMITTANCE ADVICE 3 6 Section Four Financial Transactions and Accounts Receivable This section has two subsections Financial Transactions Accounts Receivable 3 6 1 Financial Transactions The Financial Transactions subsection lists all the recoupments that were applied to the provider during the specific cycle If there is no recoupment activity this subsection is not produced Exhibit 3 6 1 1 oF m DICAID A m Lj P CR 1 TA T EE Lu ee TO ELA MR EE MEDICAL ASSISTANCE TITLE XIX PROGRAM ze 3 Laco Pb TS I RANSAC TIONS ANYTOWN NEW YORK 11111 REMITTANCE STATEMENT PROV ID 00122456 1224557830 REMITTANCE 8 FINANCIAL FISCAL FCN REASON CODE TRANS TYPE DATE AMOUNT 35547 RECOUPMENT REASON DESCRIPTION O05 09 10 5 NET FINANCIAL AMOUNT 255 25 NUMBER OF FINANCIAL TRANSACTIONS HOSPICE Version 2010 01 5 31 2010 Page 40 of 47 REMITTANCE ADVICE
23. aims 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 anytime afterwards that a new location is added Value Code Code 61 should be used to indicate that a Locator Code is entered under Amount Value Amount Entry must be three digits and must be placed to the left of the dollars cents delimiter Locator codes 001 and 002 are for administrative use only and are not to be entered in this field The entry may be 003 or a higher locator code Enter the locator code that corresponds to the address where the service was performed The example in Exhibit 2 4 2 7 illustrates a correct Locator Code entry Exhibit 2 4 2 7 39 VALUE CODES CODE AMOUNT 21 s HOSPICE Version 2010 01 5 31 2010 Page 13 of 47 CLAIMS SUBMISSION 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 Hospice Manual Rate Code Value Code 24 Rates are established by the Department of Health and other State agencies At the time of enrollment in Medicaid providers receive notification of the rate codes and rate amounts assigned to their ca
24. bmitted when approval for a budget change has been received from the LDSS Other Insurance Payment Value Code A3 or B3 If the patient has insurance other than Medicare it is the responsibility of the provider to determine whether the service being billed for is covered by the patient s Other Insurance carrier If the service is covered or if the provider does not know if the service is covered the provider must first submit a claim to the Other Insurance carrier as Medicaid is always the payer of last resort Value Code If applicable code A3 or B3 should be used to indicate that the amount paid by an insurance carrier other than Medicare is entered under Amount The line A or B assigned to the Insurance Carrier in Form Locator 50 determines the choice of codes or B3 Value Amount Enter the actual amount paid by the other insurance carrier If the other insurance carrier denied payment enter 0 00 Proof of denial of payment must be maintained in the patient s billing record Zeroes must also be entered in this field if any of the following situations apply Priorto 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
25. de Form Locator 67A Q Hospice Services Leave these fields blank Hospice Claiming Nursing Home Room and Board This field must be completed upon admission of a patient if there is any change in the diagnosis including a diagnosis change for a patient on bed reservation and when a patient is discharged Leave blank if the entry in Form Locator 17 Patient Status indicates that the patient is still a patient or is on therapeutic leave Using the nternational Classification of Diseases Ninth Edition Clinical Modification ICD 9 CM coding system enter the appropriate code that describes the main condition or symptom of the patient The ICD 9 CM code must be entered exactly as it is listed in the manual The remaining Form Locators labeled A Q may be used to indicate secondary diagnosis information See the example in Exhibit 2 4 2 16 Exhibit 2 4 2 16 HOSPICE Version 2010 01 5 31 2010 Page 21 of 47 CLAIMS SUBMISSION NOTE Three digit and four digit diagnosis codes will be accepted only when the category has no subcategories Other Form Locator 78 Hospices need to complete this field only when the patient is a resident of a residential health care facility RHCF otherwise leave this field blank If applicable enter the NPI number of the RHCF in which the patient resides Instructions for Entering the RHCF NPI Enter the code DN in the unlabeled field between the words OTHER and NPI to indicate the 1
26. e that it be legible and placed appropriately in the required fields The following guidelines will help ensure the accuracy of the imaging output information should be typed or printed Alpha characters letters should be capitalized Numbers should be written as close to the example below in Exhibit 2 2 1 1 as possible Exhibit 2 2 1 1 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 Zero interpreted as six When typing or printing stay within the box provided ensure that no characters letters or numbers touch the claim form lines See the example in Exhibit 2 2 1 3 HOSPICE Version 2010 01 5 31 2010 Page 6 of 47 _ CLAIMS SUBMISSION Exhibit 2 2 1 3 Intended As Interpreted As lwointerpreted as seven hree interpreted as two Characters should not touch each other as seen in Exhibit 2 2 1 4 Exhibit 2 2 1 4 Written As Intended As Interpreted As Entry cannot be 23 illegible interpreted properly not write between lines Donot 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 writin
27. ely 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 The example in Exhibit 2 4 2 10 illustrates a correct Other Insurance Payment entry Exhibit 2 4 2 10 39 VALUE CODES CODE AMOUNT fe mn Medicaid Covered Days Value Code 80 Value Code Code 80 should be used to indicate the total number of days that are covered by Medicaid If only co insurance days are claimed do not report code 80 Value Amount Enter the actual amount of days covered by Medicaid The sum of Medicaid Full covered days Medicaid non covered days and Medicare co insurance days must correspond to the Statement Covers Period in Form Locator 6 and should not reflect the day of discharge The Covered Days must be entered to the left of the dollars cents delimiter The example in Exhibit 2 4 2 11 illustrates a correct Medicaid Covered Days entry HOSPICE Version 2010 01 5 31 2010 Page 16 of 47 CLAIMS SUBMISSION Exhibit 2 4 2 11 CODES CODE AMOUNT Medicaid Non Covered Days Value Code 81 Value Code Code 81 should be used to indicate the total number of full days that are not reimbursable by Medicaid or any other third party Thi
28. emittance Advice Using an account patient control number can be helpful for locating accounts when there is a question on patient identification HOSPICE Version 2010 01 5 31 2010 Page 9 of 47 CLAIMS SUBMISSION Type of Bill Form Locator 4 Completion of this field is required for all provider types All entries in this field must contain three digits Each digit identifies a different category as follows 1st Type of Facility 2nd Digit Bill Classification 3rd Digit Frequency Type of Facility Enter the value 8 as the first digit of this field as seen in Exhibit 2 4 2 1 The source of this code is the UB 04 Manual Form Locator 4 Type of Facility category Exhibit 2 4 2 1 Bill Classification Non hospital based hospices must use the value 1 as the second digit of this field Please refer to the UB 04 Manual Form Locator 4 Bill Classification Special Facilities Only Hospital based hospices must use the value 2 as the second digit of this field Please refer to the UB 04 Manual Form Locator 4 Bill Classification Special Facilities Only See Exhibit 2 4 2 2 for an example of the proper position for these entries Exhibit 2 4 2 2 Frequency Adjustment Void Code New York State Medicaid uses the third position of this field on y to identify whether the claim is an original a replacement adjustment or a void If submitting an original claim enter the value 0 in the third po
29. g 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 Do write or use staples on the bar code area The address for submitting claim forms is COMPUTER SCIENCES CORPORATION P O Box 4601 Rensselaer NY 12144 4601 HOSPICE Version 2010 01 5 31 2010 Page 7 of 47 i CLAIMS SUBMISSION 2 33 UB 04 Claim Form To view a sample Hospice UB 04 claim form see Appendix A The displayed claim form is a sample and the information it contains is for illustration purposes only The UB 04 CMS 1450 is a CMS standard form therefore CSC does not supply it The form can be obtained from any of the national suppliers The UB 04 Manual National Uniform Billing Data Element Specifications as Developed by the National Uniform Billing Committee Current Revision should be used in conjunction with this Pr
30. h the information on the claim After manual review is completed a match is found in the Medicaid files or the recycling time expires pended claims may be approved for payment or denied A new pend is signified by two asterisks A previously pended claim is signified by one asterisk Errors For claims with a DENY or PEND status this column indicates the NYS Medicaid edit error numeric code s that caused the claim to deny or pend Some edit codes may also be indicated for a PAID claim These are approved edits which identify certain errors found in the claim and that do not prevent the claim from being approved Up to twenty five 25 edit codes including approved edits may be listed for each claim Edit code definitions will be listed on a separate page of the remittance advice at the end of the claim detail section 3 5 3 Subtotals Totals Grand Totals Subtotals of dollar amounts and number of claims are provided as follows Subtotals by claim status appear at the end of the claim listing for each status The subtotals are broken down by Original claims Adjustments Voids Adjustments voids combined HOSPICE Version 2010 01 5 31 2010 Page 38 of 47 REMITTANCE ADVICE Totals by service classification and by member ID are provided next to the subtotals for service classification locator code These totals are broken down by Adjustments voids combined Pends Paid Deny eeee Net total p
31. here the revenue code appears The number of units entered in this field must match the entry in Form Locators 39 41 Value Code 80 Covered Days If Revenue Code 0183 Therapeutic Leave was used in Form Locator 42 enter the total number of Therapeutic Leave days on the same line where the revenue code appears The number of therapeutic days must match the entry in Form Locators 39 41 Value Code 80 Covered Days Total Charges Form Locator 47 Enter the total amount charged for the service s rendered on the lines corresponding to Revenue Code 0001 in Form Locator 42 total charges for all lines billed and for any other Revenue Code individual charges for that one line Both sections of the field dollars and cents must be completed if the charges contain no cents enter 00 in the cents box See Exhibit 2 4 2 14 for an example Exhibit 2 4 2 14 3000 00 If Therapeutic Leave or Hospital Leave units were entered in Form Locator 46 enter the charges for that line in this field as well See Exhibit 2 4 2 15 for an example Exhibit 2 4 2 15 d REV CD 45 DESCRIPTION dd HCPCS RATE HIPPS CODE 45 SERV DATE 45 SERV UNITS dr TOTAL CHARGES 45 NON COVERED CHARGES DN 1500 00 1600 M Payer Name Form Locator 50 A B C This field identifies the payer s responsible for the claim payment The field lines A B and C are devised to indicate primary A secondary B and tertiary C responsibility for claim payment
32. ice features the description of each of the edit codes including approved codes failed by the claims listed in Section Three ABC HOSPICE 123 MAIN STREET AMYTOWNM NEW YORK 11111 Exhibit 3 7 1 DICAID IPIE forse MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT PAGE DATE 05 31 10 CYCLE 1710 ETIN NURSING HOME EDIT DESCRIPTIONS PROV ID 00123455 1234557830 REMITTANCE NO THE FOLLOWING 15 A DESCRIPTION OF THE EDIT REASON CODES THAT APPEAR ON THE CLAIMS FOR THIS REMITTANCE 00162 RECIPIENT IMELIGIBLE FOR DATE OF SERVICE Qu371 RECIPIENT NOT OM LONG TERM CAE FILE 010231 HOSPITAL LEAVE NOT SEPARATE LINE 01035 STAUS DISCHARGED DESTINATION PROVIDER BLANK 01131 MEDICAID NOT ALLOWED UNTIL MEDICARE 15 MAXIMIZED Version 2010 01 HOSPICE Page 44 of 47 5 31 2010 APPENDIX A CLAIM SAMPLES APPENDIX A CLAIM SAMPLES The eMedNY Billing Guideline Appendix A Claim Samples contains images of claims with sample data HOSPICE Version 2010 01 5 31 2010 Page 45 of 47 Hospice UB 04 Claim Sample 1 Anytown Hospice Anytown NY 11111 1111 5 PATIENTNAME a SMITH WILLIAM ADMISSION 12 DATE 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT 18 04191940 az 31 OCCURRENCE OCCURRENCE OCCURRENCE 34 OCCURRENCE CODE DATE b 20 21 22 23 PAGE CREATION DATE 50 PAYE
33. is not covered by the New York State Medicaid Program The claim is a duplicate of a prior paid claim The required Prior Approval has not been obtained Information entered in the claim form is invalid or logically inconsistent Approved Claims Approved claims will be identified by the statuses PAID ADJT adjustment or VOID Paid Claims The status PAID refers to original claims that have been approved HOSPICE Version 2010 01 5 31 2010 Page 37 of 47 REMITTANCE ADVICE Adjustments The status ADJT refers to a claim submitted in replacement of a paid claim with the purpose of changing one or more fields An adjustment has two components the credit transaction previously paid claim and the debit transaction adjusted claim Voids The status VOID refers to a claim submitted with the purpose of canceling a previously paid claim A void lists the credit transaction previously paid claim only Pending Claims Claims that 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 match found the Medicaid files for certain information submitted on the claim for example Patient ID Prior Approval Service Authorization These claims are recycled for a period of time during which the Medicaid files may be updated to matc
34. ission Form Locators 12 15 Leave all fields blank Stat Patient Status Form Locator 17 This field is used to indicate the specific condition or status of the patient as of the last date of service indicated in Form Locator 6 Select the appropriate code except for codes 43 and 65 from the UB 04 Manual Condition Codes Form Locators18 28 Leave all fields blank Occurrence Code Date Form Locators 31 34 Leave all fields blank Occurrence Code Span Form Locators 35 36 Leave all fields blank HOSPICE Version 2010 01 5 31 2010 Page 12 of 47 i CLAIMS SUBMISSION Value Codes Form Locators 39 41 NYS Medicaid uses Value Codes to report the following information Locator Code required see notes for conditions Rate Code required Patient Participation only if applicable Other Insurance Payment only if applicable Medicaid Covered Days only if applicable Medicaid Non Covered Days only if applicable eec eco cc Medicare Co Insurance Days only if applicable Value Codes have two components Code and Amount The Code component is used to indicate the type of information reported The Amount component is used to enter the information itself Both components are required for each entry Locator Code Value Code 61 For electronic claims leave this field blank The Locator Code will be defaulted to 003 if the nine digit ZIP Code submitted on the claim does not match what is on file For paper cl
35. m Detail Section Four Financial Transactions recoupments Accounts Receivable cumulative financial information Section Five Edit Error Description HOSPICE Version 2010 01 5 31 2010 Page 23 of 47 REMITTANCE ADVICE 3 1 Section One Medicaid Check For providers who have selected to be paid by check a Medicaid check is issued when the provider has claims approved for the cycle and the approved amount is greater than the recoupments if any scheduled for the cycle This section contains the check stub and the actual Medicaid check payment Exhibit 3 1 1 DICAID MAM aoe PT INFORMATION GYSTEM TO ABC HOSPICE DATE 2010 05 31 REMITTANCE NO 07080600001 PROV ID 00123456 123456 890 00123456 123456 890 2010 05 31 ABC HOSPICE 123 MAIN ST ANY TOWN NY 11111 YOUR CHECK 15 BELOW TO DETACH TEAR ALONG PERFORATED DASHED LIME PROVIDER ID HO DOLLARS CENTS NUMBER 2010 05 31 07080600001 00123456 1234567890 00 WD AFTER So DAYS Te ABC HOSPICE c 123 MAIN ST D CAI D ANY TOWN NY 11111 EA T INFORMATION 6YSTEM MEDICAL ASSISTANCE TITLE XIX PROGRAM CHECKS DRAWN John Smith KEY BANK N A 60 STATE STREET ALBANY Naw YORK 12207 U rre xu HOSPICE Version 2010 01 5 31 2010 Page 24 of 47 REMITTANCE ADVICE 3 1 1 Medicaid Check Stub Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid
36. ovider Billing Guideline as a reference guide for the preparation of claims to be submitted to NYS Medicaid The UB 04 manual is available at www nubc org Form Locators in this manual for which no instruction has been provided have no Medicaid application These Form Locators are ignored when the claim is processed 2 4 Hospice Services Billing Instructions This subsection of the Billing Guidelines covers the specific NYS Medicaid billing requirements for Hospice providers Although the instructions that follow are based on the UB 04 paper claim form they are also intended as a guideline for electronic billers to find out what information they need to provide in their claims in addition to the HIPAA Companion Guides which are available at www emedny org by clicking on the link to the webpage as follows eMedNY Companion Guides and Sample Files It is important that providers adhere to the instructions outlined below Claims that do not conform to the eMedNY requirements as described throughout this document may be rejected pended or denied 2 4 1 Instructions for the Submission of Medicare Crossover Claims This subsection is intended to familiarize the provider with the submission of crossover claims Providers can bill claims for Medicare Medicaid patients to Medicare Medicare will then reimburse its portion to the provider and the provider s Medicare remittance will indicate that the claim will be crossed over to Medicaid Claims for se
37. r eMedNY Billing Guideline questions please contact the eMedNY Call Center 1 800 343 9000 HOSPICE Version 2010 01 5 31 2010 Page 3 of 47 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 Hospice 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 Providers HOSPICE Version 2010 01 5 31 2010 Page 4 of 47 CLAIMS SUBMISSION 2 Claims Submission Hospice providers can submit their claims to NYS Medicaid in electronic or paper formats Providers are required to submit an Electronic Paper Transmitter Identification Number ETIN Application and Certification Statement before submitting claims to NYS Medicaid Certification Statements remain in effect and apply to all claims until superseded by another properly executed Certification Statement Providers will be asked to update their Certification Statement on an annual basis Providers will be provided with
38. rvices 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 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 HOSPICE Version 2010 01 5 31 2010 Page 8 of 47 CLAIMS SUBMISSION If a separate claim is submitted directly by the provider to Medicaid for a dual eligible recipient and the claim is paid before the Medicare crossover claim both claims will be paid The eMedNY system automatically voids the provider submitted claim in this scenario Providers may submit adjustments to Medicaid for their crossover claims because they are processed as a regular adjustment Electronic remittances from Medicaid for crossover claims will be sent to the default ETIN when the default is set to electronic If there is no default ETIN the crossover claims will be reported on a paper
39. s NYS Medicaid uses Revenue Codes to identify the following information Total Charges Title XIX Days Hospital Leave Title XIX Days Therapeutic Leave Total Charges Use Revenue Code 0001 to indicate that total charges are entered in Form Locator 47 Hospital Leave Only When Billing for Nursing Home Room and Board The patient was hospitalized during the billing period and bed retention was involved If bed retention for hospitalization was not involved hospital leave is not applicable If applicable use Revenue Code 0185 to indicate that the number of Hospital Leave days is entered in Form Locator 46 Hospital Leave must not be claimed together with regular billing these claims must be submitted on a separate form Therapeutic Leave Only When Billing for Nursing Home Room and Board These are overnight absences that include leave for personal reasons or to participate in medically acceptable therapeutic or rehabilitative plans of care If applicable use Revenue Code 0183 to indicate that the number of Therapeutic Leave days is entered in Form Locator 46 Therapeutic Leave must not be claimed together with regular billing these claims must be submitted on a separate form HOSPICE Version 2010 01 5 31 2010 Page 18 of 47 CLAIMS SUBMISSION Serv Units Form Locator 46 If Revenue Code 0185 Hospital Leave was used in Form Locator 42 enter the total number of Hospital Leave days on the same line w
40. s does not include full days covered by Medicare or other third party insurers Value Amount Enter the actual amount of days non covered by Medicaid The sum of Medicaid Full covered days Medicaid non covered days and Medicare co insurance days must correspond to the Statement Covers Period in Form Locator 6 and should not reflect the day of discharge The Non Covered Days must be entered to the left of the dollars cents delimiter The example in Exhibit 2 4 2 12 illustrates a correct Medicaid Non Covered Days entry Exhibit 2 4 2 12 39 VALUE CODES CODE AMOUNT a Medicare Co Insurance Days Value Code 82 Value Code Code 82 should be used to indicate the total number of Medicare co insurance days claimed during the service period Value Amount Enter the actual number of Medicare co insurance days The sum of Medicaid Full covered days Medicaid non covered days and Medicare co insurance days must correspond to the Statement Covers Period in Form Locator 6 and should not reflect the day of discharge The Co Insurance Days must be entered to the left of the dollars cents delimiter HOSPICE Version 2010 01 5 31 2010 Page 17 of 47 CLAIMS SUBMISSION The example in Exhibit 2 4 2 13 illustrates a correct Medicare Co Insurance Days entry Exhibit 2 4 2 13 39 VALUE CODES Rev Cd Revenue Code Form Locator 42 Revenue Codes identify specific accommodations ancillary services or billing calculation
41. sition of this field as in Exhibit 2 4 2 3 Exhibit 2 4 2 3 HOSPICE Version 2010 01 5 31 2010 Page 10 of 47 CLAIMS SUBMISSION If submitting an adjustment replacement to a previously paid claim enter the value 7 in the third position of this field as in Exhibit 2 4 2 4 Exhibit 2 4 2 4 If submitting a void to a previously paid claim enter the value 8 in the third position of this field as in Exhibit 2 4 2 5 Exhibit 2 4 2 5 Statement Covers Period From Through Form Locator 6 Enter the date s of service claimed in accordance with the instructions provided below When billing for one date of service enter the date in the FROM box The THROUGH box may contain the same date or may be left blank When billing for multiple consecutive dates of service enter the first service date of the billing period in the FROM box and the last service date in the THROUGH box The FROM THROUGH dates must be in the same calendar month Instructions for billing multiple dates of service are provided below in Form Locators 42 47 Dates must be entered in the format MMDDYYYY Non Occupant Care In order to properly identify each date of service the FROM and THROUGH dates must be inclusive All services included in the FROM and THROUGH fields must indicate the same number of hours and must be for consecutive days within the same month If services rendered do not have a consistent number of hours scheduled for any given period
42. t information and communication specifications This document is available at www emedny org by clicking on the link to the web page as follows Companion Guides and Sample Files Further information about electronic claim pre requirements is available at www emedny org by clicking on the link to the webpage as follows Information for All Providers HOSPICE Version 2010 01 5 31 2010 Page 5 of 47 _ CLAIMS SUBMISSION 2 2 Paper Claims Hospice providers who choose to submit their claims on paper forms must use the Centers for Medicare and Medicaid Services CMS standard UB 04 claim form To view a sample Hospice UB 04 claim form see Appendix A The displayed claim form is a sample and the information it contains is for illustration purposes only An Electronic Transmission Identification Number ETIN and a Certification Statement are required to submit paper claims Providers who have a valid ETIN for the submission of electronic claims do not need an additional ETIN for paper submissions The ETIN and the associated certification qualify the provider to submit claims in both electronic and paper formats Information about these requirements is available at www emedny org by clicking on the link to the webpage as follows Information for All Providers 2 2 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 imperativ
43. t s Medicaid Client ID number is entered on lines B or C the lines above the Medicaid ID number must contain either the patient s ID for the other payer s or the word NONE Treatment Authorization Codes Form Locator 63 If the service requires Prior Approval enter the 11 digit Prior Approval Number here The Prior Approval Number must be entered on the line A B or C that corresponds to the line assigned to Medicaid in Form Locators 50 and 57 If the Prior Approval number is entered on lines B or C the word NONE must be written on the line s above the Prior Approval line Leave this field blank if the service does not require Prior Approval Note For information regarding how to obtain Prior Approval Authorization for specific services refer to the Policy Guidelines section located at www emedny org by clicking on the link to the webpage as follows Hospice Manual Document Control Number Form Locators 64 A B C Leave this field blank when submitting an original claim or a resubmission of a denied claim If submitting an Adjustment Replacement or a Void to a previously paid claim this field must be used to enter the Transaction Control Number TCN assigned to the claim to be adjusted or voided The TCN is the claim identifier and is listed in the Remittance Advice If a TCN is entered in this field the third position of Form Locator 4 Type of Bill must be 7 or 8 HOSPICE Version 2010 01 5 31 2010 Page 20 of 47 i CLAI
44. tegory of service Any time that rate codes or amounts change providers also receive notification from the Department of Health Value Code Code 24 should be used to indicate that a rate code is entered under Amount Value Amount Enter the rate code that applies to the service rendered The four digit rate code must be entered to the left of the dollars cents delimiter The example in Exhibit 2 4 2 8 illustrates a correct rate code entry Exhibit 2 4 2 8 39 VALUE CODES CODE AMOUNT In order for claims to be processed correctly it is essential that the correct Rate Code be used for each patient Patient Participation NAMI Value Code 23 Value Code Code 23 should be used to indicate that the patient s Net Available Monthly Income NAMI amount is entered under Amount Value Amount Enter the NAMI amount approved by the local Social Services agency as the patient s monthly budget In cases where the patient s budget has increased the new amount rather than the current budgeted amount should be entered If billing occurs more than once a month enter the full NAMI amount on the first claim submitted for the month as illustratedin Exhibit 2 4 2 9 HOSPICE Version 2010 01 5 31 2010 Page 14 of 47 _ CLAIMS SUBMISSION Exhibit 2 4 2 9 99 CODES CODE AMOUNT 450 00 NOTE For retroactive NAMI changes an adjustment to the previously paid claim needs to be submitted These adjustments can only be su
45. tion that no payment was made for the cycle no claims were approved Provider Name and Address HOSPICE Version 2010 01 5 31 2010 Page 29 of 47 REMITTANCE ADVICE 3 4 Section Two Provider Notification This section is used to communicate important messages to providers Exhibit 3 4 1 FAGE 01 DIC AID DATE 05 31 10 MSABENENT overen COME TO ABC HOSPICE ETIN 123 MAIN STREET PROVIDER NOTIFICATION ANYTOWN NEW YORK 11111 PROV ID 00123456 1234567890 REMITTANCE 07080500001 REMITTANCE ADVICE MESSAGE TEXT ELECTROMIC FUNDS TRANSFER EFT FOR PROVIDER PAYMENTS 15 AVAILABLE PROVIDERS WHO ENROLL IM EFT WILL HAVE THEIR MEDICAID PAYMENTS DIRECTLY DEPOSITED INTO THEIR CHECKING OR SAVINGS ACCOUNT THEEFT TRANSACTIONS WILL BE INITIATED ON WEDNESDAYS AND DUE TO NORMAL BANKING PROCEDURES THE TRANSFERRED FUNDS MAY NOT BECOME AVAILABLE IN THE PROVIDER S CHOSEN ACCOUNT FOR UP TO 48 HOURS AFTER TRANSFER PLEASE CONTACT YOUR BANKING INSTITUTION REGARDING THE AVAILABILITY OF FUNDS PLEASE NOTE THAT EFT DOES NOT WAIVE THE TWO WEEK LAG FOR MEDICAID DISBURSEMENTS TO ENROLL IM EFT PROVIDERS MUST COMPLETE AN EFT ENROLLMENT FORM THAT FOUND AT WWW ORG CLICK ON PROVIDER ENROLLMENT FORMS WHICH CAN BE FOUND IN THE FEATURED LINKS SECTION DETAILED INSTRUCTIONS WILL ALSO BE FOUND THERE AFTER SENDING THE EFT ENROLLMENT FORM TO CSC PLEASE ALLOW MINIMUM TIME OF SIX TO EIGHT WEEKS FOR PROCESSING D
46. uced Exhibit 3 6 2 1 DICAID W CHE PA E TO ABC HOSPICE __ AS INFORMATION amp YSTEM 122 MAIN STREET MEDICAL ASSISTANCE TITLE XIX PROGRAM ANY TOWN NEW YORK 11111 REMITTANCE STATEMENT REASON CODE DESCRIFTION PREV BAL CURR BAL RECOUP AMT TOTAL AMOUNT DUE THE STATE HOSPICE Version 2010 01 Page 42 of 47 PAGE 02 DATE 05 31 10 CYCLE 1710 ETIN ACCOUNTS RECEIVABLE PROV ID 00123456 1234567890 REMITTANCE 07080600001 5 31 2010 REMITTANCE ADVICE 3 6 2 1 Explanation of Accounts Receivable Columns If a provider has negative balances of different types or negative balances created at different times each negative balance will be listed in a different line Reason Code Description This is the description of the Financial Reason Code For example Third Party Recovery Original Balance The original amount or starting balance for any particular financial reason Current Balance The current amount owed to Medicaid after the cycle recoupments if any were applied This balance may be equal to or less than the original balance Recoupment Amount The deduction recoupment scheduled for each cycle Total Amount Due the State This amount is the sum of all the Current Balances listed above HOSPICE Version 2010 01 5 31 2010 Page 43 of 47 REMITTANCE ADVICE 3 Section Five Edit Error Description The last section of the Remittance Adv
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