Health Homes of Upstate New York (HHUNY) Navigating the Waters of Billing
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1 Health Homes of Upstate New York (HHUNY) Navigating the Waters of Billing
2 Agenda Payment Overview Overview of the two channels of agencies and what it means for billing Billing Flow Important Information
3 Payment Overview All payments for Health Home Care Management Services are done on a Per-Member-Per-Month (PMPM) rate individually calculated for each individual served, based on the Minimum Billing Standards The payment received will be a factor of the individual s acuity score, as calculated by NYS Department of Health, and the rate code (Outreach or Enrollment) Each individual enrolled may only be billed at a single rate code for the month An accurate tracking record must be submitted and accepted for all clients for proper Medicaid billing
4 Minimum Billing Standards At least one of the core Health Home services must be provided in given month to be eligible for reimbursement Comprehensive care management Care coordination and health promotion Comprehensive transitional care Individual and family support, Referral to community and social support services Additional information can be found on page of the Provider Manual
5 Channels of Agencies The billing process will differ depending on the type of agency within HHUNY Converting Care Management Agencies continue to bill directly Non-Converting Care Management Agencies will provide information concerning the services provided to HHUNY to direct for billing
6 Converting Agencies Continue to submit bills for services directly to e-medny for care management services The legacy rates will be in effect for converting slots The billing department within the organization will follow up on any denials directly with NYS Once payment is received from NYS, a 3% or 6% administration fee of the claim is due to HHUNY
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8 Important Information The form should be completed for each remittance received from NYS for legacy and expansion slots clients A copy of the remittance should be attached to each summary sheet While your remittance sheet may include individuals that are not with HHUNY, we ask that you still send the remittance It would not be necessary to redact the other client information since the information would remain confidential
9 Payments Payments should be made to: New York Care Coordination Program, Inc Attn: Sarah Larter 1099 Jay Street, Building J Rochester, NY If the information is in electronic format already, it can be sent to HHUNYBilling@ccsi.org, with the check sent to the above noted address
10 Non-Converting Agencies Billing information will flow through HHUNY Spreadsheets will contain records of services for individuals served by your agency The level of detail provided to HHUNY for billing purposes is based on which type of Medicaid the client is in, that is whether or not the client is associated with a Managed Care Organization (MCO) or is Fee For Service
11 Managed Care Organizations HHUNY has contracts with various MCOs in the areas of service Members of a MCO will be assigned to the Care Management Agency (CMA) through the usual assignment or community referral process If a client is enrolled in a MCO at the time of assignment from the Department of Health (DOH), that information will be located on the assignment file It is ultimately the responsibility of the CMA to determine if a client is enrolled under a MCO by using epaces upon initial enrollment and on a monthly basis thereafter
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13 Managed Care Organizations Once HHUNY receives the information in the spreadsheets, we will combine the information to create a billing roster The billing roster is uploaded to the NYS Health Commerce System (HCS) The MCOs will take the information uploaded and link it to the information in the tracking files to create a billing file to send to emedny The MCO will receive the payment directly from emedny, retain a 3% administrative fee, then send the payment to HHUNY. HHUNY will then retain a 3% administrative fee and send the remainder of the payment to the appropriate CMA
14 Fee-for-Service For any client not covered by a Managed Care Organization HHUNY, through use of an outside contractor, will bill emedny for the services performed Because the information submitted will be used to produce an 837i billing file, the information submitted is more extensive
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16 Fee-For-Service HHUNY will consolidate the information collected in the spreadsheets by Health Home and send the information to Beth Platt and Associates, the outside contractor responsible for preparing the billing forms Payments will be made by Medicaid directly to the Health Homes. HHUNY will retain a 6% administrative fee and send the remainder of the payment to the appropriate CMA HHUNY will work with Beth Platt and Associates to process denials, contacting the CMA if additional information is needed
17 Submissions Spreadsheets must be sent via a secure to HHUNYBilling@ccsi.org Billing spreadsheets must be submitted by the 15 th of each month following the month of services If your agency operates in more than one Hub, please submit a unique file for each hub according to the naming convention listed in the detailed instructions
18 Important Information As a reminder, an accurate and accepted tracking record must be on file with the NYS DOH in order to receive payment for services The information submitted in the MCO and FFS spreadsheets must be accurate to ensure proper payment Each record of service should only be submitted once to HHUNY. The CMA should track the submissions to HHUNY to ensure no duplicates have been sent The patient information sent must match the tracking records submitted
19 Important Information Since this Health Homes program is new to all of us, there is a learning curve in place We, as HHUNY, are committed to excellence in what we do, but we know that there is much improvement that can be made on our end as well We are all in this boat together and hopefully we can lend a hand to each other whenever the need arises
20 Resources Health Homes Provider Manual Billing Policy and Guidance: mes/pdfs/health_homes_provider_manual.pdf NYS Department of Health Medicaid Health Homes information: am/medicaid_health_homes/ Denial Code look-up: x.aspx
21 Questions Any billing questions can be directed to: Sarah Larter
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