NYEIS Provider Invoicing Information and Frequently Asked Questions

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1 Background Information: NYEIS Provider Invoicing Information and Frequently Asked Questions Invoices Invoices are defined as the master document in which claims are contained for submission and payment. Within the invoice, are claims that contain details for each date a service is provided and within that claim are service lines which supply the details about the procedure(s) performed during the service delivered. Invoices are created for all authorized services, such as occupational therapy, special instruction, respite, transportation, service coordination, and assistive technology devices. Before being able to create an invoice, a provider must have an approved service authorizations that has been accepted by them in order to create a claim for the service delivered. The provider of record is the provider that is assigned the service authorization. The rendering provider is the provider that provides the service to the child/family. Provider Claim Each Invoice can contain one or many provider claims. The provider claim is where the child, rendering provider, service authorization and date of service are captured. Provider claims are at the visit level and only one visit per provider claim is allowed. All provider claims within an invoice must belong to the same provider of record. However, provider claims can be for different children, services or rendering providers. Service Line Procedure Codes (HCPS, CPT, etc.) and their corresponding units are captured at the service line level of an invoice. Only one visit per claim can be captured at the provider claim level in order to allow for reimbursement by commercial insurance at the procedure code level. The process for creating an invoice is the same for either a provider entering an invoice or a municipal financial user entering an invoice that was submitted by a provider into NYEIS. The one difference is the provider entering an invoice will have the provider of record defaulted to themselves. The unique invoice types such as Respite, Transportation and AT Device are typically provided by vendors and not providers. Some vendors may also be state-approved providers. These providers will also need to be entered into NYEIS as vendors in order to be available to select when creating a vendor invoice. Vendors who are not state-approved providers do not have access to NYEIS; therefore, the municipality must enter their invoices into NYEIS. See Unit 10 Municipal Administration in the NYEIS User Manual for further information. Creating Invoices Must a claim for each visit be created separately within an invoice? Yes, a claim for each visit must be created separately within an invoice. If a provider has not accepted a service authorization, can the service authorization be used to create a claim? No, only service authorizations that have been accepted by the provider of record are available for claiming.

2 Must a separate invoice be created for each municipality that a provider bills? Yes, a separate invoice needs to be created for each municipality that the provider intends to bill. The invoice can only include claims for services provided to children associated with the same municipality. It is important that the municipality entered for an invoice match that of the specific child s municipality of residence. Where is the task to accept/reject a service authorization? The task is located in the provider of record s service authorization work queue. Must a provider only create claims for one type of service on an invoice? No, a provider can create claims for more than one type of service on an invoice (e.g., speech, special education, occupational therapy, etc.) Can a provider include claims for many children on one invoice? Yes, a provider can include claims for many children on one invoice. However, the invoice can only include claims for services provided to children associated with the same municipality. Important Note: If a service begins more than thirty days from the date of the IFSP meeting, a task is sent to the provider in NYEIS to record the delay reason documenting why the service began late. The task to the provider to identify a delay reason for the start of services is not generated in NYIES until the provider claims against the service authorization for the first service delivered to the child/family. It is important that provider claims be submitted in NYEIS chronologically, so that a late start of service is not incorrectly identified by NYEIS. In the event that a provider is not a NYEIS user this task would be rerouted to the EIO/D. The reason entered by the provider for the late start of services is then stored on the service authorization in NYEIS. It is strongly recommended that the municipality provide direction to their contracted providers regarding the importance of accurately and promptly completing this task in NYEIS to document the reason(s) for late start of services, as this data will be considered in future years as part of the municipality's local determination. Please see Appendix D in the NYEIS user manual for more information on late services reasons. Claim Status Users with the appropriate access rights can search for claims by Status on the Provider Claim Search page. Draft: Claim has not been submitted for approval and can be edited. Submitted: Claim has been submitted for approval. Submitted for Muni Review: Claim has passed the Invoice rules and has been submitted to the Municipality s Work Queue for review.

3 Approved: Claim has passed the Invoice Rules, been reviewed by the Municipality, and has been approved for payment. Denied: Claim has failed one or more Invoice Rules or was rejected by the Municipality. A Denial Reason is added to the Claim and displays on the Provider Claim Home page. Pending: Claim has violated a billing rule for which an upfront waiver has been denied and is awaiting the submission of a justification from the provider and Approval. Pending-Contract: Claim is awaiting the Provider of record s contract to be approved. The Provider currently has a contract Status of New Contract in Progress. County Provided Service: Municipality was the Provider of Record for an approved Claim. A payment is not created for the Municipality. This Claim will not be included in the County Payment File. Municipal Audit: Claim has been recouped due to Municipal audit. Municipal Audit Processing: Claim has been recouped due to Municipal audit and included on a payment file reducing a payment. Municipal Audit Recovered: Claim has been recouped due to Municipal audit and the net of the provider payment is less than zero. This happens when the total of the provider claim released is less than the recouped claims. SDOH Audit: Claim has been recouped due to an SDOH audit. SDOH Audit Processing: Claim has been recouped due to SDOH audit and included on a payment file reducing a payment. SDOH Audit recovered: Claim has been recouped due to SDOH audit and the net of the provider payment is less than zero. This happens when the total of the provider claim released is less than the recouped claims. SDOH Unqualified Personnel: Claim has been recouped due SDOH determined unqualified personnel on the claim. SDOH Unqualified Personnel Processing: Claim has been recouped due to SDOH Unqualifed Personnel and included on a payment file reducing a payment. SDOH Unqualified Personnel Recovered: Claim has been recouped due to SDOH Unqualified Personnel and the net of the provider payment is less than zero. This happens when the total of the provider claim released is less than the recouped claims. Released: Municipality has released the approved Provider Claim for Payment. Processing: Claim has been included in the Municipal Payment File to Municipal Finance. Paid: Claim has been paid to the Provider. Void: Claim has been voided. Void Processing: Claim has been voided and included on a Provider payment. Void Recovered: Claim has been voided and the Payment containing the credit has been reconciled. Retro/Retro Processing/Retro Paid: Claim has been part of a retroactive reimbursement. Waivers A Waiver is needed if a claim is submitted and it violates a billing rule for which an upfront waiver has been denied and requires the submission of a justification from the provider. A Claim can violate one or more billing rules for which an upfront waiver has been denied and the status of the claim appears as Pending. For each claim in pending status, a task is created for the provider in the Financials Work Queue to provide a justification for each of the billing violations for which an upfront waiver has been denied on the claim. If the

4 provider is not online, the task goes to the municipality s Fiscal Staff Work Queue to obtain the justification from the provider. The provider can view the status of claims, either Submitted for Muni Review, Approved or Denied, by viewing the Claim Homepage. Providers with appropriate access to a child s IFSP Homepage may also click the Waivers link off the navigation bar to view the status of any waivers for that IFSP. Waivers must be approved/rejected by an EIO/D. If co-visits are not authorized will NYEIS allow for two providers to have an overlap in visit times? A brief overlap (up to nine minutes) with two providers is not considered a co-visit and NYEIS will not reject billing. It is considered part of the municipality s oversight role to determine the degree of overlap time that is felt to be acceptable without the authorization of a co-visit. If co-visits are not authorized on the SA in NYEIS and an overlap of more than nine minutes occurs, the claim(s) will be denied. ICD Codes ICD Codes allow the provider to enter the EI Eligible ICD Code and up to three additional ICD Codes. To add data for EI Eligible (ICD) Diagnosis Code field, select the Search icon. EI Eligible Diagnosis (ICD) Code if available may be one or more previously documented automatic eligible ICD Codes in the child s case. If applicable, select the most appropriate code for the service delivered. Click Select link under Action column to identify ICD Code. Create Provider Claim page displays. To add data for the Other Eligible (ICD) Diagnosis Code field, select the Search icon. Other Eligible Diagnosis (ICD) Code if available may be one or more previously documented ICD Codes in the child s case. These codes may have established or contributed to eligibility. If applicable, select the most appropriate code for the service delivered. Click Select link under Action column to identify ICD Code. Create Provider Claim page displays. To add data for the Other Diagnosis Code field, select the Search icon. Type all known information in Search Criteria section. Other Diagnosis (ICD) Code a list of all available ICD Codes. If applicable, select the most appropriate code for the service delivered. Click Search button. Records matching display in Search Results section. To search again, click Reset button. Click Select link under Action column to identify ICD Code. Create Provider Claim page displays. If an appropriate ICD code is not currently available in the EI Eligible Diagnosis (ICD) Code or the Other Eligible (ICD) Diagnosis Code fields and the ICD code will continue to be appropriate for delivery of ongoing services, the provider should contact the municipality and work with them to add the ICD code to the child s case using the Health Assessment link off the Child s Integrated Case Homepage. Adding an ICD code to the Health Assessment will make the ICD code available to select in the Other Eligible (ICD) Diagnosis Code field on every claim created.

5 CPT Codes It is the provider's responsibility to ensure that the appropriate HCPCS/CPT codes for each procedure they perform during an early intervention service visit are reported on claims for reimbursement. Providers should select the codes that most accurately describe the service(s) provided/technique(s) used with the child and/or family during the session. The Bureau of Early Intervention (BEI) cannot advise you as to which HCPCS/CPT codes should be used. The codes must be provided by the early intervention professionals delivering the service. It is the provider's responsibility to ensure that HCPCS/CPT codes for each procedure they perform during an early intervention service visit are reported on claims for reimbursement. The HCPCS/CPT codes reported must be appropriate for the ICD diagnoses associated with the child. A good resource for identifying applicable HCPCS/CPT codes is the AMA website at: which contains information regarding coding, as well as a search feature that you can use to look up both Level I and Level II HCPCS codes. At the webpage provided above, look for the option that reads CPT Code/Relative Value Search. You will be able to search by code or by keyword. Currently in New York State, all early intervention services, including services provided by special educators, are included in the State Medicaid Plan. The EIP adheres to Medicaid standards for billing and documentation. Medicaid is enforcing a requirement for Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes to be provided on claims for all services. Providers are responsible for supplying accurate coding information and for providing the code that best describes the procedure performed during the session they are billing. Medicaid and EIP guidance require that the HCPCS/CPT code which is appropriate to describe the activity/technique being performed with the child and/or taught to the family must be submitted as part of the EIP provider's documentation to support billing to third party payors, including Medicaid and commercial insurance. Please refer to Memorandum Guidance on Claiming Commercial Insurance for Early Intervention Services, specifically question 12, for additional information. The AMA website at: contains information regarding coding, as well as a search feature that providers can use to look up both Level I and Level II HCPCS codes. A list of CPT codes is available in a drop-down menu in NYEIS. Should you find that the most appropriate and current code identifying the service provided is not available as a choice in the menu, a request can be made to the NYEIS helpdesk to have the code added. Service Coordination Claims Please see the targeted resource Service Coordination Claims on the CMA NYEIS informational webpage. Invoice Status Every Invoice has an assigned status depending on where an invoice is in the process. Prior to being submitted, an invoice is considered Draft, after submission it is considered Submitted. Once the invoice is submitted and processed, the user can view the status for the Invoice which will display as Submitted for Muni Review. Once the municipality has reviewed each claim, the Invoice is considered Fully Adjudicated, meaning a decision has been made on each claim. An Invoice will be Partially Adjudicated if the municipality completed their review and any claim is pended awaiting a waiver decision.

6 Submitting Invoices A user with appropriate access rights can submit an invoice which will process using the Nightly Batch process overnight. All claims in the invoice will run through the NYEIS invoice business rules to determine for each claim whether it passes the rules and is approved, fails the rules and is denied, or is pending indicating the claim violates a billing rule for which an upfront waiver has been denied and requires the submission of a justification from the provider. A municipal user with appropriate access rights will see the results of this process as a task in the Municipal Invoice Review work queue. The invoice will display the status of submitted for muni review until the review is complete. The municipality has 90 days to review the claims that passed the NYEIS invoice business rules in the invoice. During this time period, the Municipality Fiscal user can do the following: Reject the claims and enter a reason from a drop down and enter a comment. Once the user has finished reviewing the invoice, they can select Review Complete. For all claims not rejected, the system treats the claims as approved by the municipality and starts the batches for 3 rd Party claiming based on the child s insurance coverage. At anytime during the review period, the user can select Review Complete which will approve all claims and start the batches for 3 rd party claiming. If the user chooses not to review, then after 90 days the task is closed and all claims in the invoice will begin the 3 rd party claiming process. If the municipality has finished reviewing the invoice, the user can view the status for the invoice which will display Fully Adjudicated if all the Claims are either approved or denied or Partially Adjudicated. If any of the Claims are pended (i.e., violates a billing rule for which an upfront waiver has been denied and requires the submission of a justification from the provider, or if there is a provider contractual issue) the invoice status will be partially adjudicated. As part of the nightly batch process, if any approved claim is determined to be the first service delivered on a service authorization and the date of service is greater than 30 days from the Authorizing IFSP, a task is generated to the providers Service Authorization Work Queue to supply a late reason. See Appendix D in the NYEIS UM for a listing of late reasons. If the provider wants to correct the denied/rejected claim and submit it to NYEIS, the claim must be added to a new invoice with the corrected information and submitted. It is recommended that information on the original claim to be included in the comments section of any claim that is created as a resubmission of a claim that was initially denied/rejected (e.g., claim # of the originally denied claim, nature of the error made in the initial submission, etc.) Editing Invoices When can invoice data be edited? Invoice data can only be edited if the Status of the invoice is Draft. Draft is defined as an invoice that has not been submitted in the overnight batch process.

7 Voiding Claims A claim cannot be voided if the claim has a Status of Draft. A claim can only be voided if it has been submitted. Please be aware that voiding a claim will void the claim and all service lines attached. If a correction to a claim in draft status is needed, a user can delete the claim from the invoice. After a claim is voided, the next payment batch to a provider will be reduced by the amount of the void. Payment reductions can be seen on the Payment Summary Detail List page with the amount in the Credit column. For each Claim on an invoice that is voided, NYEIS checks if any 3 rd party reimbursement has started. If a void occurs on a claim that has been submitted for reimbursement to commercial insurance or Medicaid, a credit is sent to the 3 rd Party, if the 3 rd Party pays the claim. If the voided claim is part of a State Voucher, a credit is created and goes into the next state voucher. If a claim is voided prior to being released for payment, the claim will not be included in the list of claims that can be released. The voided claim will not be part of the county payment file.