Guide to PC-Based Transactions New York Medicaid Service Authorization (Health Care Services Review and Inquiry)

Transcription

1 Guide to PC-Based Transactions New York Medicaid Service Authorization (Health Care Services Review and Inquiry) Service Authorization: Add v2.2, Cancel v2.2, and Inquiry v2.2 Service Authorization DVS: Add v2.2, Cancel v2.2, and Inquiry v2.2 March 25, 2008 Pub # Emdeon Business Services LLC. All Rights Reserved. Overview 1 About the Transaction 1 Customer Support 2 Values 12 Service Types 12 Requests 3 Transaction Types 3 Search Types 4 Input Prompts 4 Responses 9 About Your Responses 9 Status 9 Input Information 10 Response or (On File) Information 10 Service Authorization 10 Service Auth Event 10 Procedure Codes 11 Error Messages 11

2 Overview About the Transaction The New York Medicaid Service Authorization transactions allow you to add, cancel, or inquire about a Dispensing Validation System (DVS) or non-dvs Service Authorization. Date of Service Restrictions Up to two years in the past. Future dates not allowed. National Provider Identifiers In order for you to use a National Provider Identifier (NPI) as a provider ID, the following conditions must exist: The payer must be ready to accept NPI. Consult our payer lists at for this payer s NPI-readiness status. The provider must have fulfilled all of the payer s NPI registration requirements. Special Considerations DVS transactions are to be used: By a physician, hospital, or clinic when the primary service provided is a diagnostic radiological service. When the provider can submit a stand-alone claim for the radiological service. By a pharmacy when non-dvs non-drug items are being dispensed or when brand-name drugs are dispensed. If the radiological service is ancillary to a service being rendered, the non-dvs transactions are to be used. When using a License Number as a provider identifier for emedny Phase II, the New York State Department of Education (NYSDOH) additionally requires a three-digit Profession Code as a prefix. The codes are a subset of the two-digit Profession Codes assigned by NYSDOH and the Office of the Professions when it issues professional licenses. A leading zero is added to the left to create the NYSDOH three-digit Profession Code, and, for NYS licensed providers, two more zeros must follow between the Profession Code and the License Number. An exception exists for services of a NYS licensed Privileged Nurse Practitioner or Privileged Midwife. In these two cases, a value of 0F must be inserted between the Profession Code and License Number instead of the two zeros. All out-of-state licenses must be formatted with the two-letter State, District of New York Medicaid Service Authorization Overview 1

3 Columbia, or US Territory Code as assigned by the United States Postal Service instead of the 00 or 0F values. For Emdeon products, omit the leading zero of the Profession Code when entering the License Number. The Emdeon system will automatically populate the zero before sending the input information to New York Medicaid s database. The category of inquiry (service type) is used to derive the category of service and Specialty Code, which varies per provider. Note: If you are using Emdeon MAX shell versions prior to 2.3 or Server versions prior to 4.11, you must run this transaction using dialup. Customer Support Emdeon Customer Support customer.service@emdeon.com New York Medicaid Service Authorization Overview 2

4 Requests Transaction Types Service Authorization (Non-DVS) Transactions Service Auth Add: Allows a New York Medicaid non-dvs provider to obtain authorization for a service. Service Auth Cancel: Allows a non-dvs New York Medicaid provider to cancel a service authorization obtained previously. Service Auth Inquiry: Allows a New York Medicaid non-dvs provider to inquire about the status of a service authorization. DVS Service Authorization Transactions DVS transactions are to be used: By a physician, hospital, or clinic when the primary service provided is a diagnostic radiological service. When the provider can submit a stand-alone claim for the radiological service. By a pharmacy when non-dvs non-drug items are being dispensed or when brand-name drugs are dispensed. If the radiological service is ancillary to a service being rendered, the non-dvs transactions are to be used. The following DVS transactions are available: DVS Service Auth Add: Allows a New York Medicaid Dispensing Validation System (DVS) provider to obtain authorization a dispensing service. DVS Service Auth Cancel: Allows a New York Medicaid DVS provider to cancel a dispensing service authorization obtained previously. DVS Service Auth Inquiry: Allows a New York Medicaid DVS provider to inquire about the status of a dispensing service authorization. New York Medicaid Service Authorization Requests 3

5 Search Types In all New York Medicaid DVS and Non-DVS Service Authorization transactions, the following search options are available for locating the patient record: ID Card Swipe the recipient s New York Medicaid hardcard, or enter the full 19-digit number from the front of the recipient s hardcard. Recipient ID/ID Card Serial Number The recipient s 8-digit New York Medicaid number or 13-digit New York Medicaid Access number. The ID card serial number (optional). Input Prompts Prompts are listed in alphabetical order. Prompt names beginning with a symbol (#) are listed first. # Lab Used in: Non-DVS Add, Cancel, and Inquiry transactions. Requirement: For Add and Cancel transactions: This field is optional; however, if the number of labs were entered in the Add transaction, you must enter the same number of labs in the Cancel transaction. For Inquiry transactions: This field is optional, even if number of labs were entered in the corresponding Add transaction. However, if you do enter a number of labs, it must be present in and match the entry in the corresponding Add transaction. The number of lab tests (procedure code S9981) ordered. Note: Use this field if the ordering provider is posting a lab service or if a lab is providing a service. # Prescriptions Used in: Non-DVS Add, Cancel, and Inquiry transactions. Requirement: For Add and Cancel transactions: This field is optional; however, if the number of prescriptions were entered in the Add transaction, you must enter the same number of prescriptions in the Cancel transaction. For Inquiry transactions: This field is optional, even if service units were entered in the corresponding Add transaction. However, if you do enter a number of prescriptions, it must be present in and match the entry in the corresponding Add transaction. The number of prescriptions (procedure code S5000) ordered. Note: Use this field if the ordering provider is posting a pharmacy service or if a pharmacy is dispensing generic or over-the-counter drugs. New York Medicaid Service Authorization Requests 4

6 # Svc Units Used in: Non-DVS Add, Cancel, and Inquiry transactions. Requirement: For Add and Cancel transactions: This field is optional; however, if the number of service units were entered in the Add transaction, you must enter the same number of service units in the Cancel transaction. For Inquiry transactions: This field is optional, even if service units were entered in the corresponding Add transaction. However, if you do enter a number of service units, it must be present in and match the entry in the corresponding Add transaction. The number of service units (procedure code 99212) to be delivered. Note: Use this field if the physician, hospital or clinic is providing a service other than radiology. Access # Used in: All transactions, Recipient ID/ID Card Serial Number searches only. Requirement: Required. The patient s 8-digit New York Medicaid number or 13-digit Access number. Account # Used in: All transactions. Requirement: Optional; not sent to the payer. The patient s account number. For your internal use only (not sent to the payer). Amount Used in: All transactions. Requirement: Optional; not sent to the payer. The amount of the claim. For your internal use only (not sent to the payer). Date Of Service Used in: Non-DVS Add, Cancel, and Inquiry transactions. Requirement: Required. The date to which the authorization pertains, in MMDDYY or MMDDCCYY format. Note: The date of service must be within the past two years and cannot be in the future. ID Card# Used in: All transactions, ID Card searches only. Requirement: Required. The number read from the magnetic stripe of the recipient s New York Medicaid hard card. You can also enter this number manually; it is composed of the 6-digit ISO prefix and the 13-digit Access number printed on the front of the card. New York Medicaid Service Authorization Requests 5

7 ID Card Serial# Used in: All transactions, Recipient ID/ID Card Serial Number searches only. Requirement: Required only if the authorization is for today s date; otherwise, it is optional. However, if you entered it in an Add or DVS Add transaction, you must enter it in the corresponding Cancel or DVS Cancel transaction. The sequence number from the patient s New York Medicaid hard card. Ordering Prov ID Used in: Add and DVS Add transactions. Requirement: Required if the requesting provider is fulfilling an order (for example, pharmacy or lab). Other providers leave blank. The ordering provider's primary ID; can be MMIS provider ID number, the license number, or NPI. Consult with the payer to determine whether NPI can be used. Note: When using a License Number as a provider identifier for emedny Phase II, the New York State Department of Education (NYSDOH) additionally requires a threedigit Profession Code as a prefix. The codes are a subset of the two-digit Profession Codes assigned by NYSDOH and the Office of the Professions when it issues professional licenses. A leading zero is added to the left to create the NYSDOH threedigit Profession Code, and, for NYS licensed providers, two more zeros must follow between the Profession Code and the License Number. An exception exists for services of a NYS licensed Privileged Nurse Practitioner or Privileged Midwife. In these two cases, a value of 0F must be inserted between the Profession Code and License Number instead of the two zeros. All out-of-state licenses must be formatted with the two-letter State, District of Columbia, or US Territory Code as assigned by the United States Postal Service instead of the 00 or 0F values. For Emdeon products, omit the leading zero of the Profession Code when entering the License Number. The Emdeon system will automatically populate the zero before sending the input information to New York Medicaid s database. Proc Code Used in: DVS Add, DVS Cancel, and DVS Inquiry transactions. Requirement: For DVS Add and DVS Cancel transactions: This field is required. For DVS Inquiry transactions: This field is optional. However, if you do enter a procedure code, it must match the entry in the corresponding DVS Add transaction. The procedure code identifying the dispensed services or drugs provided. For DVS Add and DVS Cancel transactions, additional codes that you may be expected to enter include: To be used by a physician, hospital or clinic when the primary service provided is a diagnostic radiological service. This code should not be used if the radiological service is ancillary to the service being rendered. It should be used only if the provider can submit a stand alone claim for the radiological service To be used by a pharmacy when non-dvs non-drug items are being dispensed. S5001 To be used by a pharmacy when brand-name drugs are dispensed. New York Medicaid Service Authorization Requests 6

8 Proc Code Qualf Used in: DVS Add, DVS Cancel, and DVS Inquiry transactions. Requirement: For DVS Add and DVS Cancel transactions: This field is required. For DVS Inquiry transactions: This field is optional. However, if you do enter a procedure code qualifier, it must match the entry in the corresponding DVS Add transaction. The code qualifier for the procedure code identifying the services or drugs provided (BO = HCFA Common Procedural Coding System or NDC = National Drug Code). Proc Quantity Used in: DVS Add, DVS Cancel, and DVS Inquiry transactions. Requirement: For DVS Add and DVS Cancel transactions: This field is required. For DVS Inquiry transactions: This field is optional. However, if you do enter a procedure quantity, it must match the entry in the corresponding DVS Add transaction. The number of procedures or drugs dispensed. Referring ProvID Used in: Add and DVS Add transactions. Requirement: Required if the patient has been referred to the requesting provider. Other providers leave blank. The ordering provider's primary ID; can be MMIS provider ID number, the license number, or NPI. Consult with the payer to determine whether NPI can be used. Note: When using a License Number as a provider identifier for emedny Phase II, the New York State Department of Education (NYSDOH) additionally requires a threedigit Profession Code as a prefix. The codes are a subset of the two-digit Profession Codes assigned by NYSDOH and the Office of the Professions when it issues professional licenses. A leading zero is added to the left to create the NYSDOH threedigit Profession Code, and, for NYS licensed providers, two more zeros must follow between the Profession Code and the License Number. An exception exists for services of a NYS licensed Privileged Nurse Practitioner or Privileged Midwife. In these two cases, a value of 0F must be inserted between the Profession Code and License Number instead of the two zeros. All out-of-state licenses must be formatted with the two-letter State, District of Columbia, or US Territory Code as assigned by the United States Postal Service instead of the 00 or 0F values. For Emdeon products, omit the leading zero of the Profession Code when entering the License Number. The Emdeon system will automatically populate the zero before sending the input information to New York Medicaid s database. Req Prov ID Used in: All transactions. Requirement: Required. The provider ID of the requesting provider. In order for you to use the National Provider Identifier (NPI), the payer must be ready to accept NPI. Additionally, the payer s NPI registration requirements must be fulfilled. New York Medicaid Service Authorization Requests 7

9 Service Type Used in: All transactions. Requirement: Requirement is based on the provider s classification with New York Medicaid. Clinic providers must enter a taxonomy code or a service type or both, depending on the applicable specialty code. If you were required to enter a taxonomy code in the Add transaction, you must also enter it in the corresponding Cancel or Inquiry transaction. The type of service to which the transaction pertains. The service type is used to derive the category of service and Specialty Code, which varies per provider. See Service Types on page 12 for a list of possible values. Taxonomy Code Used in: All transactions. Requirement: Requirement is based on the provider s classification with New York Medicaid. Clinic providers must enter a taxonomy code or a service type or both, depending on the applicable specialty code. If you were required to enter a taxonomy code in the Add transaction, you must also enter it in the corresponding Cancel or Inquiry transaction. The requesting provider s taxonomy code. New York Medicaid Service Authorization Requests 8

10 Responses About Your Responses All of the items described in the following response explanation may not appear in every response. Payers typically return only the information that is applicable to your query. If the payer does not return a particular piece or section of information in a specific response, the headings for that information will not print. Items will shift position to fill the vacancy. Your username appears in the upper left corner of the response. See your product User s Guide for information about creating usernames. Additional Reference Document More information about your response can be found in the Dictionary-of-Transaction- Error-Messages.pdf a complete dictionary of error messages. This document is available on your installation CD, and on the Web at: Note: The above document is in Portable Document Format (.pdf). You must have the Adobe Acrobat Reader to view this document. If you do not have the Reader, you can download it for free at Status Closed Emdeon received a valid response. Read your response for clarification. Retry Emdeon did not receive a valid response. Read the message in the response for clarification. Error A communications-related error or error of greater severity occurred. Read the message in the response for clarification. New York Medicaid Service Authorization Responses 9

11 Input Information The Input Information section (or the labeled fields in the Input/Response Information section) shows the information you entered in your inquiry. Response or (On File) Information No response data will appear in this section. Service Authorization The Service Authorization section includes: - Transaction reference number. - Status of the transaction: Add Successful Add Pending Add Modified - Error condition associated with the rejection of the requesting provider. Up to three possible reject reasons can appear. - Follow-up action message for the preceding reject reason. Up to three follow-up action messages can appear, one for each reject reason. - Patient s New York Medicaid U.S. Healthcare member ID number. - Patient s birth date. - Co-payment exemption message, when the patient is copay-exempt. - Error condition associated with the rejection of the patient. Up to three possible reject reasons can occur. - Follow-up action message for the preceding reject reason. Up to three follow-up action messages can appear, one for each reject reason. Service Auth Event The Service Auth Event section includes: - Provider ID number of the ordering provider for the service authorization or inquiry. - Provider ID number of the referring provider for the service authorization or inquiry. - Error condition associated with the rejection of the service provider. Up to three possible reject reasons can occur. - Follow-up action message for the preceding reject reason. Up to three follow-up action messages can appear, one for each reject reason. New York Medicaid Service Authorization Responses 10

12 Procedure Codes The Procedure Codes section can occur up to 12 times. Includes: - NYDOH certification number for the authorization. This field may also contain text that further describes the authorization. - Certification action for this procedure. - Reject reason associated with the rejection of the procedure. - Up to five procedure codes associated with the certification ID. - Number of the preceding procedure requested or authorized. - Starting and ending dates of the procedure. - Additional NYDOH certification number for the authorization. This field may also contain text that further describes the authorization. - Certification action for this procedure. - Reject reason associated with the rejection of the procedure. - Service/Taxonomy classification for the type of service performed (see Service Types on page 12). - Starting date of the service. - Error condition associated with the rejection of the service. Up to three possible reject reasons can appear. - Follow-up action message for the preceding reject reason. Up to three follow-up action messages can appear, one for each reject reason. Error Messages Transaction-related error messages begin with CL, HT, RH, or another alphabetic prefix, followed by a number and a line or so of text. Messages are self-explanatory. For a comprehensive description of all error messages, see the document Dictionary of Transaction Error Messages. This document is available on your installation CD, and on the Web at: New York Medicaid Service Authorization Responses 11

13 Values Service Types The payer can return any of the service types listed below. Abbreviation Description Code Abortion Abortion 84 Acupuncture Acupuncture 64 Adjunctive Dntl Svcs Adjunctive Dental Services 28 AIDS AIDS 85 Air Transportation Air Transportation 57 Alcoholism Alcoholism AJ Allergy Testing Allergy Testing 79 Alternate Method Dial Alternate Method Dialysis 15 Anesth Anesthesia 7 Anesthesiologist Anesthesiologist 97 ASC Facility Ambulatory Service Center Facility 13 Audiology Exam Audiology Exam 71 Blood Charges Blood Charges 10 Brand Name Rx Drg Brand Name Prescription Drug 91 Cabulance Cabulance 58 Cancer Cancer 87 Cardiac Cardiac BL Cardiac Rehab Cardiac Rehabilitation BG CH Chemotherapy 78 Chiropractic Chiropractic 33 Chiropractic Office Visits Chiropractic Office Visits 34 Cognitive Thrpy Cognitive Therapy BD Consultation Consultation 3 CRD Equipment Chronic Renal Disease (CRD) Equipment 16 Day Care (PC) Day Care (Psychiatric) BC Dial Dialysis 76 DME Purchase Durable Medical Equipment Purchase 12 New York Medicaid Service Authorization Values 12

14 Abbreviation Description Code DME Rent Durable Medical Equipment Rental 18 Dntl Accident Dental Accident 37 Dntl Care Dental Care 35 Dntl Crowns Dental Crowns 36 Donor Procedures Donor Procedures 63 Drg Addiction Drug Addiction AK Dx Dntl Diagnostic Dental 23 Dx Lab Diagnostic Lab 5 Dx Medical Diagnostic Medical 73 Dx X-Ray Diagnostic X-Ray 4 Emergency Svcs Emergency Services 86 Endocrine Endocrine BP Endodontics Endodontics 26 Experimental Drg Thrpy Experimental Drug Therapy AR Eye Eye BR FP Family Planning 82 Frames Frames AM Free Standing Rx Drg Free Standing Prescription Drug 89 General Benefits General Benefits 60 Generic Rx Drg Generic Prescription Drug 92 GI Gastrointestinal BN Health Bene Plan Cvg Health Benefit Plan Coverage 30 HH Rxs Home Health Prescriptions 43 HH Visits Home Health Visits 44 HHC Home Health Care 42 Hosp Hospital 47 Hosp Ambulatory Surg Hospital Ambulatory Surgical 53 Hosp Emergency Accident Hosp Emergency Medical Hospital Emergency Accident 51 Hospital Emergency Medical 52 Hosp IP Hospital Inpatient 48 Hosp OP Hospital Outpatient 50 Hosp Room/Board Hospital Room and Board 49 Hspc Hospice 45 Immunizations Immunizations 80 Independent Medical Eval Independent Medical Evaluation BA Infertility Infertility 83 Inhalation Thrpy Inhalation Therapy 72 New York Medicaid Service Authorization Values 13

15 Abbreviation Description Code Invasive Procs Invasive Procedures BS IVF In vitro Fertilization 61 Lenses Lenses AO Licensed Ambulance Licensed Ambulance 59 LTC Long Term Care 54 Lymphatic Lymphatic BM Mail Order Rx Drg Mail Order Prescription Drug 90 Major Medical Major Medical 55 Massage Thrpy Massage Therapy BE Maternity Maternity 69 Med Care Medical Care 1 Medically Related Transportation Medically Related Transportation 56 MFP Maxillofacial Prosthetics 27 MRI/CAT Scan MRI/CAT Scan 62 Neuro Neurology BQ Newborn Care Newborn Care 65 Nonmedically Necessary Physical Nonmedically Necessary Physical Nursery Nursery BI Oral Surg Oral Surgery 40 Orthodontics Orthodontics 38 Orthopedic Orthopedic BK OT Occupational Therapy AD Other Medcl Other Medical 9 Otological Exam Otological Exam 77 Pa Pathology 66 PC Psychiatric A4 PC IP Psychiatric Inpatient A7 PC OP Psychiatric Outpatient A8 PC Room/Board Psychiatric Room and Board A5 Peds Pediatric BH Periodontics Periodontics 24 Pharm Pharmacy 88 Physical Medicine Physical Medicine AE Plan Waiting Period Plan Waiting Period 32 Pneumonia Vaccine Pneumonia Vaccine 19 Podiatry Podiatry 93 AQ New York Medicaid Service Authorization Values 14

16 Abbreviation Description Code Podiatry Nursing Home Visits Podiatry Nursing Home Visits 95 Podiatry Office Visits Podiatry Office Visits 94 Pre-Admin Testing Pre Admission Testing 17 Private Duty Nursing Private Duty Nursing 74 Professional (PHY) Professional (Physician) 96 Professional (PHY) Visit Home Professional (PHY) Visit IP Professional (PHY) Visit Nursing Home Professional (PHY) Visit Office Professional (PHY) Visit OP Professional (PHY) Visit SNF Professional (Physician) Visit Home Professional (Physician) Visit Inpatient 99 Professional (Physician) Visit Nursing Home Professional (Physician) Visit Office 98 Professional (Physician) Visit Outpatient Professional (Physician) Visit Skilled Nursing Facility Prosthetic Device Prosthetic Device 75 Prosthodontics Prosthodontics 39 Prtl Hospitalization (PC) Partial Hospitalization (Psychiatric) BB Psychotherapy Psychotherapy A6 Pulmonary Rehab Pulmonary Rehabilitation BF Radiation Thrpy Radiation Therapy 6 Rehab Rehabilitation A9 Rehab IP Rehabilitation Inpatient AB Rehab OP Rehabilitation Outpatient AC Rehab Room/Board Rehabilitation Room and Board AA Renal Supplies in the Home Renal Supplies in the Home 14 Respite Care Respite Care 46 Restorative Restorative 25 Routine (Preventive) Dntl Routine (Preventive) Dental 41 Routine Exam Routine Exam AN Routine Physical Routine Physical 81 SA Substance Abuse AI Second Surg Opinion Second Surgical Opinion 20 Skilled Nursing Care Skilled Nursing Care AG Skilled Nursing Care Room and Board Skilled Nursing Care Room and Board Skin Skin BJ Smoking Cessation Smoking Cessation 67 A3 A1 A0 A2 AH New York Medicaid Service Authorization Values 15

17 Abbreviation Description Code Social Work Social Work 22 Spch Thrpy Speech Therapy AF Surg Surgical 2 Surg Asstnce Surgical Assistance 8 Third Surg Opinion Third Surgical Opinion 21 Transplants Transplants 70 Used DME Used Durable Medical Equipment 11 Vision (Optometry) Vision (Optometry) AL Well Baby Care Well Baby Care 68 New York Medicaid Service Authorization Values 16