All About Billing. State of New York Office for People with Developmental Disabilities - OPWDD

Transcription

1 All About Billing State of New York Office for People with Developmental Disabilities - OPWDD October 2012

2 Table of Contents Fee-for-Service Services... 1 Three Components of Eligibility Required for Billing... 1 Provider Eligibility... 1 Individual Eligibility... 3 Service Eligibility & Service Authorization... 3 What s Needed for Billing?... 4 Provider Identifiers for Fee-for-Service Services Billed Though emedny... 4 An NPI (National Provider Identification Number) is Required to Bill Certain Services 6 Provider Identifiers for Billing Fee-for-Service Services Billed Through OPWDD s Payment Processing Unit... 6 Service Identifiers (Rate Codes)... 7 Individual Identifiers... 7 What s Needed for Billing - Summary... 7 Critical documents & getting them to the right people... 8 Where to Bill for Services... 8 Services Billed to emedny... 8 Services Billed to OPWDD s Payment Processing Unit... 9 Services billed by Electronic Submission Through One of OPWDD s Web Based Applications... 9 A Shorthand Guide to OPWDD Billing Medicaid Remittance Statements Monitoring Remittance Statements Reading and Interpreting a Medicaid Remittance Statement Early Identification of Medicaid Billing Problems: Unpaid claims A Selection of Important Billing Error Codes and What They Mean Tips For Billing emedny Billing Non-Medicaid Funded Services Identification of Non-Medicaid Billing Problems Tips for Billing OPWDD's Payment Processing Unit...20

3 This manual will provide an overview of what an agency needs to know in order to bill for OPWDD services. There are different rules for billing different services and sometimes different rules for billing the same service for different people. Fee-for-Service Services Fee-for-Service services are those that are reimbursed for each unit of service delivered. These are services that an agency must bill for in order to get paid. Agencies provide services, submit bills, and are paid for services according to the bills submitted. Fee-for-Service services include all services for which an agency receives payment through a price, rate, or fee. They include all HCBS Waiver services, Medicaid Service Coordination (MSC), Intermediate Care Facilities (ICFs), Day Treatment and Article 16 Clinic services. Although agencies have a contract with OPWDD for Options for People Through Services (OPTS) including Enhanced SEMP and Intensive Behavioral (IB) Services contracts, the actual services covered in the contract are paid for on a fee-for-service basis. Fee-for-Service services are different from services reimbursed through a contract; for contract services, an agency receives fixed payments if it provides documentation that it is meeting the agreed upon contract standards. Three Components of Eligibility Required for Billing For an agency to receive payment for a service, regardless of whether the service is a Medicaid or non-medicaid service, the three components of eligibility must be met. These are: The provider must be eligible to deliver the service, The person must be eligible to receive the service, and The service must be authorized by the DDSO/Service Delivery & Integrated Solutions (formerly New York City Regional Office) (Regional Office as of 7/1/12). This means that for any OPWDD service, an agency must have OPWDD authorization to deliver a particular service to a particular person. Provider Eligibility For all OPWDD funded services, an agency must have authorization to provide the specific service before the agency can be paid for that service. For HCBS Waiver services, an agency must complete an HCBS Waiver agreement that is approved by the DDSO/NYC Office (Regional Office as of 7/1/12). In addition, all agencies must receive approval from the Division of Quality Improvement and the Department of Health (DOH) before they can be authorized to provide HCBS Waiver services. June 2012 All About Billing 1

4 Provider Eligibility Billing Identifiers For billing purposes, agency identifiers are assigned to each agency. In order to bill emedny or OPWDD s Payment Processing Unit, an agency must use the correct agency identifier; most agencies have more than one. For services billed through emedny, the agency s identifier is the Provider ID it receives from the Department of Health (DOH). For services billed via vouchers through OPWDD s Payment Processing Unit, the agency s identifier is its New York State Vendor ID. This is a 10 digit number that is assigned by New York State for use in the Statewide Financial System (SFS). It is registered in the OPWDD Tracking and Billing System (TABS) to identify each agency and replaced the Federal Employer Identification Number (FEIN) as of 4/1/2012. For voucher billing, the agency also must include the Provider ID or Price ID. For billing through OPWDD s web based applications, the agency s program code is the identifier for SEMP and Respite. For OPTS, Enhanced SEMP and IB Services, the contract number is the identifier. Thus, the provider service identifiers are as follows: Services Billed Through emedny Services Billed Through OPWDD s Payment Processing Unit Services Billed Through OPWDD s webbased applications OPTS, Enhanced SEMP and IB Services Provider Identifier Provider ID from DOH NYS Vendor ID Agency s program code for SEMP & Respite Contract Number When billing, agencies must use the correct agency identifiers. Getting a Provider ID for billing emedny If an agency will be providing a Medicaid service it has not previously provided, the agency must complete a Provider ID enrollment packet and submit this packet to OPWDD s Bureau of Central Operations. It is extremely important that the enrollment packet be returned promptly to OPWDD so that an agency s billing is not delayed. OPWDD s Central Operations, in turn, submits this packet to the Department of Health (DOH). DOH has up to 90 days to process the enrollment packet. Agencies then receive a letter from the Department of Health notifying them of the Provider ID, locator code and rate code to use for billing Medicaid services. The agency then must register the new Provider ID under its ETIN (Electronic Transmitter Identification Number) with Computer Science Corporation (CSC). If an agency doesn t register a Provider ID, the emedny billing system won t know that the Provider ID is associated with a particular agency and claims will not be processed. The ETIN authorizes an agency to submit claims to emedny for processing and payment. For HCBS Waiver services, the DDSO/NYC Office (Regional Office as of 7/1/12) or Central Office Rate Setting sends the provider a price notification letter that includes pricing details (i.e., Provider ID and/or Price ID, start date, price per unit, number of individuals authorized and units authorized). June 2012 All About Billing 2

5 Individual Eligibility For an agency to get paid for the delivery of a service to an individual, the individual must be eligible for the service. The individual must be eligible for OPWDD services and the individual s disability must warrant the particular service. The DDSO/NYC Office (Regional Office as of 7/1/12) must also approve the individual for the specific service the agency is providing. For an agency to receive payment for a service billed through emedny, the individual must be enrolled in Medicaid and have active coverage through the correct Medicaid service category. If the billing is for an HCBS service, the individual must also be enrolled in the Waiver. Individual Eligibility Billing Identifiers The individual identifier identifies the person who received the service. When billing emedny, the individual identifier is the individual s Medicaid Client Identification Number (CIN). An agency s billing staff must use the correct CIN for each person when billing emedny. When billing OPWDD s Payment Processing Unit, the individual s identifier is the TABS ID. The TABS ID is a number that identifies a person in OPWDD s Tracking and Billing System (TABS). TABS is OPWDD s statewide database that contains information on voluntary agencies, programs, services and individuals. An agency s billing staff must use the individual s correct TABS ID when billing OPWDD s Payment Processing Unit. Service Eligibility & Service Authorization Before an agency can provide a service to a specific individual, it must be authorized to do so. Nonprofit providers must get approval from the DDSO or NYC Office (Regional Office as of 7/1/12) before they can begin providing specific services to specific individuals. In addition, agencies that wish to provide additional services or expand into new service areas must work through the local DDSO or NYC Office (Regional Office as of 7/1/12) to do so. DDSO/NYC Office (Regional Office as of 7/1/12) staff will have to approve the additional services or the expansion. Agencies cannot begin providing services until they receive written authorization from OPWDD that they have been approved to deliver the new service or additional services. This is true for State Plan services (e.g., MSC), contract services (e.g., Family Support Services and Individual Support Services) and HCBS Waiver services. It is essential that an agency receives the appropriate authorization before providing services. An agency is not entitled to payment if it provides services it has not been authorized to provide. It is understandable that an agency will want to help an individual in need but an agency that extends itself too often by providing services without authorization may end up failing fiscally. Therefore, if an agency determines that an individual is in need of services, the agency should contact the DDSO or NYC Office (Regional Office as of 7/1/12) and follow the appropriate procedures. If an individual has a serious need for services, DDSO/NYC Office staff (Regional Office as of 7/1/12) will do their best to expedite approval for the services. June 2012 All About Billing 3

6 Service Eligibility Billing Identifiers There are identifiers that are used in billing to identify the services provided. These identifiers are called rate codes. When billing, an agency must use a rate code to identify the service provided. What s Needed for Billing? Billing Tools When billing, agencies will need to use the correct Provider, Individual, and Service identifiers. Provider Identifiers for Fee-for-Service Services Billed Through emedny For fee-for-service services billed through emedny, the agency s identifier is the Provider ID it receives from the Department of Health (DOH). There may be a distinct Provider ID for a specific service or there may be one Provider ID which is used for several services. For example, for Hourly Respite (not provided at a Free Standing Respite Center), there is one Provider ID per agency. For Day Habilitation, Prevocational Services and Community Habilitation Phase 1 there is one Provider ID used to bill for all of these services. Effective 11/1/2010, Community Habilitation Phase 1 replaced At Home Residential Habilitation under OPWDD s HCBS Waiver. The same rate codes utilized to bill for At Home Residential Habilitation are being utilized to bill for Community Habilitation Phase 1 as of 11/1/2010. Community Habilitation Phase 1 does not have the requirement that the service start, stop or be delivered in the home of the individual receiving the service. Locator Codes Providers also receive locator codes. Each Provider ID has one or more locator codes associated with it. Each locator code identifies a different level of reimbursement or location of service under a specific Provider ID. For a service like Hourly Respite where there is only one Provider ID, the respite locator code is always 03. If an agency is providing both Day Habilitation and Prevocational services, it will have at least two locator codes, one for Prevocational services and one or more for Day Habilitation (depending on how many types of Day Habilitation it is providing - Group, Group Supplemental, Individual, or Individual Supplemental). Community Habilitation Phase 1 has a locator code associated with each fee region. Fee region 1 is New York City, fee region 2 is Westchester, Putnam, Rockland, Suffolk and Nassau counties and fee region 3 is the rest of the state). Medicaid Service Coordination (MSC) has two locator codes, 03 and 04. Locator code 04 is used for billing services for someone who has met the criteria for a transition payment. An agency may have many Provider IDs and locator codes. It is important that an agency use the correct Provider IDs and locator codes when billing. The list below indicates Provider ID and locator code information specific to each Medicaid service. June 2012 All About Billing 4

7 It is important to note that references below to the DDSO s and the NYC Office reflect pre-7/1/2012 OPWDD operations. Restructuring occurred on 7/1/2012 that consolidated the DDSO s into Regional Office Operations. Any changes to pre-7/1/2012 procedures that have, or will come into play will be provided by staff from the Regional Office. For MSC, an agency will have one Provider ID for each MSC contract it holds (i.e., one for the NYC Office and one for each non-new York City DDSO with which it does business). MSC has two locator codes, 03 and 04. Locator code 04 is used for billing services for someone who has met specific criteria for a transitional payment. For Plan of Care Support Services, an agency will have one Price ID for each DDSO/NYC Office (Regional Office as of 7/1/2012); each Price ID has an associated Provider ID and locator code for billing Medicaid. NEW Effective 10/1/2012, changes were implemented to PCSS. The changes will be detailed in a forthcoming Administrative Memorandum (ADM) and Regulations have already been promulgated. The highlights include an initial, increased payment option for individuals new to the service and the availability for individuals to receive four PCSS services in a calendar year. For Supported Employment services, an agency will have a unique Provider ID that is only used for Supported Employment services. Different locator codes may be assigned if the agency provides SEMP in both the Upstate and NYC geographic regions. For IRA Residential Habilitation services, including CRs as of the January 2010 service month, an agency will have a unique Provider ID for its supportive IRAs/CRs and one for its supervised IRAs/CRs. Each Provider ID has only one locator code, 03. NEW Effective 10/1/2012, Community Habilitation Phase 2 was initiated as a new service option under OPWDD s HCBS Waiver. The service will be billed under a provider s IRA Residential Habilitation Provider ID. Eligible agencies will receive notification when Community Habilitation Phase 2 fees are loaded to their provider ID. The changes will be detailed in a forthcoming ADM and Regulations have already been promulgated. For Day Habilitation, Prevocational services, and Community Habilitation Phase 1, an agency will have a unique Provider ID that is used for these services. If an agency is providing both Day Habilitation and Prevocational Services, it will have at least two locator codes. If it is providing different types of Day Habilitation, (group, group supplemental, individual, and individual supplemental), it will have one locator code for each type of day habilitation. For Community Habilitation Phase 1 an agency may have up to three locator codes for service within a specific geographic region of the state. Fee region 1 is New York City, fee region 2 is Westchester, Putnam, Rockland, Suffolk and Nassau counties and fee region 3 is the rest of the state. The locator code used for billing Community Habilitation Phase 1 depends on where an individual receiving service lives. June 2012 All About Billing 5

8 For Respite services, an agency will have a unique Provider ID for Hourly Respite not provided at a Free Standing Respite site. For Hourly Respite provided at a Free Standing Respite site, an agency will have a separate Provider ID for each of its Free Standing Respite sites. Each Provider ID has only one locator code, 03. For Intensive Behavioral Services (IB Services), an agency is reimbursed through an OPTS contract and therefore, does not utilize an emedny provider ID for billing. IB Services are limited at this time and a separate application process was used to determine the agencies authorized to deliver the service. Contact your DDSO (Regional Office as of 7/1/12) for information on IB Services. For other HCBS Waiver services, an agency may have one or more Provider IDs. For Consolidated Supports and Service (CSS) Monthly, the FMS (Fiscal Management Services) will have a unique provider ID for each individual being served. The agency uses locator code 03 when the monthly service standard has been met. For CSS Portal Quarter Hour, the FMS will have one provider ID for all individuals being served. There will be a unique locator code for each individual. The Portal is a limited pilot program. Contact your DDSO (Regional Office as of 7/1/2012) for information on the Portal. An NPI is Required to Bill Certain Services As of 5/23/07, Federal law mandates that agencies include their national provider identification number (NPI) on all billing claims when billing Article 16 clinics, day treatment, Intermediate Care Facilities, Specialty Hospitals, and Care at Home Case Management. Effective September 1, 2008, New York State Medicaid implemented the NPI to process all submitted claims. Effective March 25, 2009, New York State Medicaid discontinued payment of claims that do not contain an appropriate NPI. Effective October 1, 2009, New York State Medicaid converted to an NPI processing system for all claims and non-claims transactions. All such transactions submitted by affected providers must contain an NPI. Providers must include their NPI number on their claims along with their current billing identifiers. Medicare also expects NPI compliant billing. An NPI is not necessary for MSC or HCBS billing. Provider Identifiers for Billing Fee-for-Service Services Billed Through OPWDD s Payment Processing Unit For fee-for-service services billed through OPWDD s Payment Processing Unit, the agency s identifier is its New York State Vendor ID. The New York State Vendor ID ensures that OPWDD is able to correctly identify the agency and thus pay the correct agency. This is a 10 digit number that is assigned by New York State for use in the Statewide Financial System (SFS) to uniquely identify each agency. In June 2012 All About Billing 6

9 addition to the New York State Vendor ID, an agency will also need to use the appropriate Provider ID or Price ID assigned to the service being billed. For certain services, such as Agency Sponsored Family Care, an agency receives both a Provider ID and a Price ID. For Assistive Support services, an agency only receives a Price ID. The Provider ID and/or Price ID must be included to ensure the agency receives the correct reimbursement for the service provided. Service Identifiers (Rate Codes) The service identifier is the rate code. Each service has its own rate code(s). For example, beginning with the October 2010 service month (billing date of service 11/1/2010), Medicaid Service Coordination has two rate codes utilized for billing, 5211 and Rate code 5211 is now being utilized to bill for all individuals receiving MSC services, except Willowbrook Class individuals. MSC services provided to Willowbrook Class individuals continue to be billed under rate code 5214, as they always have. Information regarding changes to the MSC program can be found on OPWDD s website at the following link: ice_coordination/redesign_information When billing, agency billing staff must make sure they use the correct rate code. For Day Habilitation services, there are several different rate codes; each rate code is associated with a different type of Day Habilitation (e.g., group, individual, supplemental group or supplemental individual) and for group and group supplemental there are different units (full day or half day) of Day Habilitation. For Hourly Respite, there are two rate codes; one is for Free Standing Respite, where respite is provided at a site-based location and the other is for Respite provided in various locations, such as the individual s home. Individual Identifiers This is the identifier that identifies the person who received the service. For billing emedny, the individual s Medicaid Client Identification Number (CIN) identifies the individual who received the service. An agency s billing staff must use the correct CIN for each person when billing emedny. For billing OPWDD s Payment Processing Unit, the TABS ID identifies the individual who received the service. An agency s billing staff must use the individual s correct TABS ID when billing OPWDD s Payment Processing Unit. What s Needed for Billing - Summary For billing Medicaid services through emedny, an agency needs the correct Provider ID, locator code, rate code, and the individual s Medicaid Client Identification Number (CIN) to bill successfully. June 2012 All About Billing 7

10 For billing OPWDD s Payment Processing Unit, an agency needs the correct NYS Vendor ID, Provider ID or Price ID, rate code and the individual s TABS ID to bill successfully. Critical documents & getting them to the right people Once an agency is approved to provide a service, the agency will receive important fiscal communications from the DDSO or NYC Office (Regional Office as of 7/1/12) and from DOH (Computer Science Corporation (CSC) or emedny) regarding Medicaid billing information. These include information pertaining to the Provider ID associated with a price and an agency s price notification letter. These are critical documents that should be filed and retained. Copies should be sent to the staff persons who handle an agency s pricing, bookkeeping and billing. Where to Bill for Services In order for an agency to get paid for services provided and documented, the agency must know where to bill for services. Where an agency bills can depend on the service provided and on whether the individual is receiving Medicaid or is enrolled in the HCBS Waiver. OPWDD fee-for-service services are either billed to Medicaid via emedny, to OPWDD s Payment Processing Unit or electronically submitted through OPWDD s Web-based applications. Services Billed to emedny For individuals receiving State Plan services, billable services to emedny are: Medicaid Service Coordination (MSC) Intermediate Care Facility (ICF) services Day Treatment services Article 16 Clinic services For individuals enrolled in the HCBS Waiver, billable services to emedny (unless provided through OPTS) are: Residential Habilitation Community Habilitation Phase 1 (effective 11/1/2010) Community Habilitation Phase 2 (effective 10/1/2012) Day Habilitation Prevocational Services Supported Employment (SEMP) Respite Family Education and Training (FET) Plan of Care Support Services (PCSS) Consolidated Support Services (CSS) In order to bill Medicaid services via emedny, agencies must go through DOH s contractor, Computer Science Corporation (CSC). For more information about emedny and epaces (the billing software), agencies can go to or call June 2012 All About Billing 8

11 CSC s helpline at ( ). epaces is the acronym for the Electronic Provider Assisted Claim Entry System, a web-based application which allows providers to create/submit claims and other transactions in HIPAA compliant format. The Health Insurance Portability and Accountability Act (HIPAA) was created to standardize electronic data interchange and to ensure the confidentiality and security of data. Computer Sciences Corporation (CSC) developed this application on behalf of the NYS Department of Health. Services Billed to OPWDD s Payment Processing Unit The following services are billed to OPWDD s Payment Processing Unit: Assistive Supports Those services authorized by the DDSO or NYC Office (Regional Office as of 7/1/12) (including all of the services mentioned on the previous page except SEMP, Respite, and Family Education and Training) for individuals who are not eligible for Medicaid or not enrolled in the HCBS Waiver (State Paid services). Services billed by electronic submission through one of OPWDD s Web based applications The following services are billed through one of OPWDD s Web based applications: All Options for People Through Services (OPTS) services, including Enhanced SEMP and IB Services SEMP provided to individuals not enrolled in the HCBS Waiver and Respite provided to individuals not enrolled in the HCBS Waiver OPWDD encourages providers to record SEMP and Respite services provided to HCBS enrolled individuals in OPWDD s web-based applications and then use the MMIS Billing Advice Reports to submit claims to emedny. The Table that follows, A Shorthand Guide to OPWDD Billing, provides information to help agencies know where to bill June 2012 All About Billing 9

12 A Shorthand Guide to OPWDD Billing If the service delivered is: Service Coordination Ask: Does the individual have Medicaid Coverage? If YES, bill emedny for Medicaid Service Coordination. If NO, bill OPWDD s Payment Processing Unit for State Paid Service Coordination. If the service delivered is one of the following: Residential Habilitation (non-opts) Day Habilitation (non-opts) Prevocational Services (non-opts) Community Habilitation Phase 1 (non-opts) Community Habilitation Phase 2 Family Education & Training Plan of Care Support Services Consolidated Supports & Services (CSS)* Ask: Is the individual enrolled in the HCBS Waiver? If YES, bill emedny for appropriate HCBS Waiver Service. If NO, bill OPWDD s Payment Processing Unit for appropriate State Paid Service. *A CSS budget may include costs that are billed to emedny and costs that are billed to the Payment Processing Unit. If the service delivered is either: Respite (non-opts) or Supported Employment (non-opts) Ask: Is the individual enrolled in the HCBS Waiver? If YES, bill emedny for appropriate HCBS Waiver Service (recommend service recording through Web Based Service Application first) If NO, record services in OPWDD s Web-based Service Application. OPWDD processes the payment through the Office of the State Comptroller (OSC). If the service delivered is under the OPTS program, is Enhanced SEMP or IB Services: Bill by recording services in OPWDD s Web-based Service Application; June OPWDD 2012 processes the payment through All About OSC. Billing 10

13 If the service delivered is an Assistive Support: Bill OPWDD s Payment Processing Unit. If there are room and board, property and/or land costs associated with certain services: IRA Supplement (the IRA supplement comprises costs associated with an individual s room and board that are not covered by the individual s Social Security Income) Community Habilitation Phase 2 (models the IRA supplement as individuals receiving the service remain enrolled in the Supervised IRA/CR) IRA or Day Habilitation Land Costs Free-Standing Respite Property Costs OPTS Property and Equipment Costs No Billing Needed - OPWDD automatically generates these payments monthly. If there is a price change due to changes in property/land costs, OPWDD will periodically review an agency s payment history and make retroactive adjustments. Price Changes If the price for a service changes, an agency does not need to re-bill. Price changes are handled in the following ways: For Services Originally Billed to emedny: An adjustment will automatically be recalculated and if additional reimbursement is due, it will be sent to the provider shortly after the provider has been notified of the price change. If a provider has been overpaid, future payments will be adjusted to recover the excess reimbursement. For Services Originally Billed to OPWDD s Web-based Service Application: An adjustment will automatically be recalculated and if additional reimbursement is due, it will be sent to the provider shortly after the provider has been notified of the price change. If a provider has been overpaid, future payments will be adjusted to recover the excess reimbursement. For Services Originally Billed to OPWDD s Payment Processing Unit: Periodically, OPWDD staff reconcile all price changes and if additional reimbursement is due, it is sent to providers. If a provider has been overpaid, future payments will be adjusted to recover the excess reimbursement.. June 2012 All About Billing 11

14 Match the billing process with the service a) OPWDD Payment Processing Unit b) emedny c) Web-Based Billing 1. Individual enrolled in the HCBS Waiver receiving Day Habilitation 2. Individual enrolled in the HCBS Waiver receiving Day Habilitation through OPTS 3. Individual not enrolled in the HCBS Waiver receiving Community Habilitation Phase 1 Services 4. Individual not enrolled in the HCBS Waiver receiving respite. 5. Individual with Medicaid not enrolled in the HCBS Waiver and receiving Medicaid Service Coordination. Answers: 1b; 2c; 3a; 4c; 5b; June 2012 All About Billing 12

15 Medicaid Remittance Statements The remittance statement identifies each claim submitted by an agency s billing department and specifies: If the claim was paid How much was paid A reason if a claim was not paid A claim will either be paid, pended or denied. A claim will be pended if further review is necessary to determine whether the claim can be paid. A claim will be denied for many reasons (e.g., the individual was not Medicaid enrolled); some of these will be discussed in this section. Monitoring Remittance Statements Nonprofit agencies should develop procedures for monitoring remittance statements that allow agencies to: Ensure that remittance statements are easily accessible so that a history of paid claims can be easily obtained. Compare the actual revenue received with anticipated revenue: Agencies should be able to project how much income their claims will generate and carefully compare expected payments with actual payments for each remittance statement.. Agencies should make sure that they have staff available to read and understand remittance statements. Agency staff should: a. Review remittance statements as soon as they are received and identify claims that were denied or pended and any irregularities (e.g., revenue was less than expected) and bring these to the Executive Director s attention when necessary. b. Understand the codes that the state uses to deny or pend claims so they can promptly address problems. c. Correct problems if claims were denied or pended. If your agency is unable to determine the appropriate resolution for denied or pended claims, OPWDD may be contacted to provide assistance. Providers are also encouraged to visit the emedny website ( or contact the CSC Call Center at (800) with questions related to denied or pended claims. Reading and Interpreting a Medicaid Remittance Statement Monitoring Medicaid Revenue: Price Sheets (or rate or fee sheets) indicate how much revenue an agency will receive for each unit billed. Based on the number of services an agency anticipates providing, agency staff can estimate how much revenue the agency will receive over a period of time. For example, an agency has a family care residential habilitation price of $80 and anticipates providing 30 units a month. The agency would anticipate $2,400 of revenue per month ($80 x 30). June 2012 All About Billing 13

16 The remittance statement can be used as a tool to monitor an agency s actual revenue received from emedny. In this example, if the monthly income is less than the $2,400 projected, agency staff should investigate. Possible reasons that projected revenue differs from actual revenue include: Some individuals required fewer services than originally planned. Some individuals no longer require services (e.g., they moved). (If so, the agency may wish to contact the DDSO/NYC Office (Regional Office as of 7/1/12) and inquire about providing services to a new individual.) Staff did not deliver services they had planned to provide or failed to report and document services delivered. TIP: An agency should have a reporting system in place so that an agency s billing office can communicate actual revenue to the agency s fiscal department on a routine basis. This mechanism will give an agency a fiscal status report for its Medicaid funded services. This report should be used by administrative staff to examine who is getting services, whether services are being delivered as expected, and/or whether there are changes in the roster of individuals enrolled for services. Early Identification of Medicaid Billing Problems: Unpaid claims It s important for agency staff to identify early any claims that were denied. This allows the agency to address problems before it experiences cash flow issues. Below are some common reasons for unpaid claims: The agency used the wrong billing code, wrong Provider ID and/or rate code. The recipient exception code (R/E code) has not been appropriately entered on the individual Medicaid file. Recipient exception codes are special codes that OPWDD staff must enter to ensure an agency can bill particular services. An agency must provide OPWDD with service authorization information that is individual-specific so that OPWDD enters the correct codes. The agency can contact its local RSFO staff to correct this problem. The agency did not submit its claim within the specified time period. Medicaid has very strict guidelines for timely submission of claims. Billings should be submitted within 90 days of the date the service was provided. If more than 90 days have passed, the agency must use a 90 day indicator code (for electronic claims) or include a 90 day letter (for paper claims). If more than two years have passed, it is extremely difficult for an agency to get paid for an initial claim. The emedny website ( has detailed information on time frames for submission of claims to Medicaid that all providers should be familiar. IMPORTANT - Beginning in May 2012, new edits are being phased in to verify the validity of Delay Reason Codes reported on both original and adjustments to paid claims. It is extremely important that agency s submit claims within 90 days and for instances that require use of a valid Delay Reason Code The individual who received the service has no Medicaid coverage. It is important to ensure that individuals retain their Medicaid coverage. An agency s billing staff should carefully review remittance statements and follow up immediately on denied claims. If an agency has been unsuccessful in resolving a denied June 2012 All About Billing 14

17 claim, OPWDD can help an agency find out why the claims were denied. Agency staff should be prepared to explain steps taken to resolve denied claims when contacting OPWDD for assistance. A Selection of Important Billing Error Codes and What They Mean When a claim submitted by an agency is denied or pended, the agency will receive an error code with a short explanation. The explanation provided by emedny for these error codes can be confusing. For example, error reason code reads recipient not on restricted recipient file and error reason code reads claim provider not equal restriction recipient file provider. Neither of these explanations gives a provider a clear understanding of what billing mistake was made. Below are plain English explanations for these common error codes and information on what provider staff can do to resolve the billing problem. Error Reason Code 00162: Recipient ineligible on date of service. Claims fail this edit when an individual did not have active Medicaid coverage on the date of the service billed. It may mean the individual s Medicaid case has been closed, that the individual s Medicaid coverage needs to be recertified, or that a spend down has not been met. The individual s service coordinator, the individual and/or his/her family should be contacted to resolve the Medicaid coverage issue. Error Reason Code 01319: Recipient Exception invalid for Home and Community Based Services Waiver. Claims fail this edit when an OPWDD HCBS Waiver service is billed for a Medicaid eligible consumer who is not enrolled in the HCBS Waiver. If an agency receives this error code, the agency should check to see if there is a Notice of Decision (NOD) approving HCBS enrollment for the individual. If a NOD is not on file for the individual, the agency should contact the local OPWDD DDSO HCBS Waiver Coordinator to resolve the HCBS enrollment issue. If a NOD approving HCBS enrollment is on file, the agency should contact the local OPWDD RSFO to request that the HCBS Recipient Exception (R/E) code 46 be entered into the Medicaid system. The RSFO is responsible for putting R/E codes that allow payment of HCBS services into the emedny system. Agency staff can call the RSFO if assistance is needed to resolve these types of billing issues. A listing of the RSFO s and contact information is available at the following link - The next three edits apply to OPWDD MSC and Supervised IRA (and Supervised CR as of January 2010) and Community Habilitation Phase 2 programs (effective 10/1/12). Error Reason Code 01338: Recipient not on restricted recipient file. Agencies providing Medicaid service coordination, IRA/CR Residential Habilitation or Community Habilitation Phase 2 may receive this code as an explanation for a denied claim. June 2012 All About Billing 15

18 MSC - Claims fail this edit when an MSC service is billed for an individual without the Recipient Exception (R/E) code 35 attached to his/her Medicaid eligibility record. This R/E code indicates that the individual is authorized to receive MSC. If the agency has documentation on file that the individual is authorized to receive MSC, agency staff should contact OPWDD s Central Operations staff to request that the R/E code 35 be entered into emedny. Central Operations staff can be reached at (518) IRA/CR - A claim for supervised IRA/CR services will also hit this edit if the individual does not have the recipient exception (R/E) code 49 (the R/E 49 code indicates the individual is authorized to receive supervised IRA/CR services) attached to his/her Medicaid eligibility record. If the agency has been approved to provide the service, staff should contact the local RSFO to request that the R/E code 49 be put up on emedny. Community Habilitation Phase 2 A claim for Community Habilitation (CH) Phase 2 services will also hit this edit if the individual does not have the recipient exception (R/E) code 47 (the R/E 47 code indicates the individual is authorized to receive CH Phase 2 services) attached to his/her Medicaid eligibility record. If the agency has been approved to provide the service, staff should contact the local RSFO to request that the R/E code 49 be put up on emedny. Individuals receiving CH Phase 2 services, remain enrolled in a Supervised IRA/CR program, but only R/E code 47 is needed on file to claim for the service. If the agency doesn t have any documentation on file showing that the individual has been approved for MSC, supervised IRA/CR or CH Phase 2 services, agency staff should contact the local OPWDD DDSO (Regional Office as of 7/1/12) to resolve the enrollment issue. Error Reason Code Recipient not authorized for MSC/IRA on date of service. MSC - Claims fail this edit when an MSC service is billed for an individual and the recipient exception (R/E) code 35 which authorizes MSC services was not in effect on the date the service was billed. Agency staff should check agency records to confirm the individual was authorized by OPWDD to receive MSC services on the date the service was billed. If the agency has documentation that the individual was authorized to receive MSC services on that date, the provider agency should contact OPWDD s Central Operations staff for help resolving the problem. IRA/CR - A supervised IRA/CR claim will fail this edit when a supervised IRA/CR service is billed for an individual and the R/E code 49 authorizing supervised IRA/CR services was not in effect on the date the service was billed. Agency staff should check agency records to confirm the individual was authorized by OPWDD to receive supervised IRA/CR services on the date the service was billed. If the agency has documentation that the individual was authorized to receive supervised IRA/CR services on that date, agency staff should contact the local RSFO to resolve the problem. June 2012 All About Billing 16

19 Community Habilitation Phase 2 - A claim for CH Phase 2 services will fail this edit when a service is billed for an individual and the R/E code 47 authorizing CH Phase 2 services was not in effect on the date the service was billed. Agency staff should check agency records to confirm the individual was authorized by OPWDD to receive CH Phase 2 services on the date the service was billed. If the agency has documentation that the individual was authorized to receive supervised CH Phase 2 services on that date, agency staff should contact the local RSFO to resolve the problem. If the agency doesn t have any documentation on file showing that the individual has been approved for MSC, supervised IRA/CR or CH Phase 2 services, agency staff should contact the local OPWDD DDSO (Regional Office as of 7/1/12) to resolve the enrollment issue. Error Reason Code 01340: Claim provider not equal restriction recipient file provider. Claims fail this edit when an MSC, supervised IRA/CR or CH Phase 2 service is billed and the recipient exception (R/E) code 35 for MSC, R/E code 49 for supervised IRA/CR, or R/E code 47 for Ch Phase 2 indicates another vendor is authorized to provide the service to the individual. If an agency received this error code, agency staff should check agency records to confirm the agency was authorized to provide the service to the individual for the dates the service was billed. If the agency was authorized to provide the service to the individual, agency staff should contact OPWDD Central Operations staff at (518) if the claim denied is for MSC or the local RSFO if the claim denied is for supervised IRAs/CRs or CH Phase 2. If the agency was not authorized to provide the service, the agency should contact the DDSO (Regional Office as of 7/1/12). Tips For Billing emedny 1. Agencies should ensure that program staff quickly report services to the billing office. There is a 90-day time limit between the service delivery date and when claims can be submitted. If claims are submitted after the 90 days, an agency must provide justification for why the 90 days were exceeded. Late reporting can lead to lost revenue. New emedny billing edits are being implemented that will verify the validity of certain delay codes utilized for billing, so it is extremely important that claims are submitted as soon as possible. 2. Agencies should bill as quickly as possible, as soon after the service is delivered (and documented) to increase cash flow. 3. Agencies should be knowledgeable about Medicaid billing rules (e.g., the 90 day billing rule and the 2 year billing rule). For example, it is extremely difficult to receive payment for a service provided if two or more years have passed. In addition, DOH has recently implemented system edits to enforce appropriate use of delay indicator codes for claims over 90 days old. Submit claims ASAP! June 2012 All About Billing 17

20 4. Agency staff should review details of ALL remittance statements look at the amount PAID, not just at the Status to ensure the expected payment was received! The status indicates whether the service billed was paid, pended, or denied. A pended claim is one that is still under review. 5. Agency staff should follow-up immediately on DENIED claims get help early there are time limits on an agency s ability to resolve problems. 6. Agencies should consider ELECTRONIC BILLING it is faster than paper billing and makes it easier to track and project revenue. 7. Agencies should retain a copy of ALL letters received from the DOH. 8. Agencies should send copies of DOH letters to staff responsible for billing. 9. Agencies should promptly respond to all annual certification statements for billing (electronic and paper) from DOH. An agency must complete a certification form annually attesting that the claims it submits for payment are true and valid and that the agency has documentation to substantiate that the services were provided. Without a current certification form, an agency s billing will be jeopardized. 10. When an agency obtains a new Provider ID, the agency must register the new Provider ID under its ETIN (Electronic Transmitter Identification Number) to ensure that claims are processed. If an agency doesn t register its Provider ID, the Computer Science Corporation (CSC) billing system won t know that the Provider ID is associated with a particular agency and the claim will not be processed. 11. See Useful Links for Billing Information that was included with the training materials for information on billing emedny. Billing Non-Medicaid Funded Services Billing Services to the Payment Processing Unit Nonprofit agency providers bill the Payment Processing Unit for certain non-medicaid funded services: Voucher Billing: For certain services, agencies submit vouchers to OPWDD s Payment Processing Unit. For these services, the agency s voucher must include the agency s New York State Vendor ID, the Provider ID/Price ID to identify the service, and the individual s TABS ID. Agencies must use vouchers for the following services: State Paid services: These include all Medicaid services provided to individuals without Medicaid coverage or who are not enrolled in the HCBS Waiver if the service is a Waiver service. For example, services provided to an individual who June 2012 All About Billing 18

21 lives in an IRA but doesn t qualify for Medicaid would be billed to the Payment Processing Unit. It is OPWDD s policy that an individual wishing to receive an OPWDD Medicaid service must file for and pursue Medicaid enrollment. In addition, if a person wants to receive an OPWDD HCBS Waiver service, the person is expected to meet the qualifications for HCBS Waiver enrollment. OPWDD has issued regulations that govern liability for services. Information on the liability regulations can be found on OPWDD s website at the following link - Assistive Supports: These are non-medicaid services that are authorized by DDSO/NYC Office (Regional Office as of 7/1/12) staff and require Central Office approval. State Paid Portion of the Consolidated Supports and Services budget: The agency sends in a billing form and voucher for each service month in which reimbursement is owed. Note that there is a separate billing form for the Portal pilot program. CSS Monthly and Portal Services may not be submitted on a voucher with other state paid services. Note that there are different Billing Forms to use depending on the services billed, and in some cases, the time period when the services were provided. When submitting vouchers, it s important that the correct Billing Forms are used. Billing Forms are available through OPWDD s website. See TIPS for Billing OPWDD s Payment Processing Unit on page 20. Web Based Billing: The Payment Processing Unit also processes payments for services billed through internet based applications. The provider enters service information into the internet based application and the Payment Processing Unit processes payments. The following services are billed through internet based applications: All services provided through OPTS, including Enhanced SEMP and IB Services Respite and Supported Employment services (SEMP) provided to individuals who are not enrolled in the HCBS Waiver. Agencies are expected to access the web applications for payments, exception and billing advice reports. Agencies should review the reports promptly and address any exceptions identified. Non-Billed Payments: In addition, the Payment Processing Unit processes some payments that don t require the agency to submit vouchers. These include the following: Property reimbursement for Free Standing Respite. This is paid out monthly regardless of whether the agency bills any Free Standing Respite service. Each month, the agency receives 1/12 of the total property costs. June 2012 All About Billing 19

22 IRA/CR Room & Board Supplements and land based costs. These are paid based on a provider s billings of the IRA/CR Residential Habilitation units. Billing Rules: Currently, OPWDD s Payment Processing Unit expects claims to be submitted within 2 years of service delivery and requires claims submitted after the 2 year service period to have a letter of explanation for the late billing. OPWDD may or may not make payment on a late billing but will make this determination based on the reason for the late billing. IMPORTANT There will be changes to the amount of time that providers have to submit services for payment to OPWDD s Payment Processing Unit. Allowable timeframes have not yet been finalized, but it is likely that providers will have approximately three months from the conclusion of a service month to submit state paid billing forms for payment. OPWDD s Payment Processing Unit also expects that services recorded through OPWDD s internet based applications be submitted within the specified timeframes of web screen availability. IMPORTANT - Effective June 8, 2012, availability of calendars for recording SEMP services was reduced. At the start of a month until the first payment run in the month, rosters for the two months prior, plus the roster for the current month will be available for service recording. Once the first SEMP payment run occurs in a month, only rosters for the current and prior month will be available for service recording. Best Practice record service provided in prior month in current month (e.g. May services in June). IMPORTANT Effective September 13, 2012 availability of calendars for recording Respite and OPTS services was reduced. At the start of a month until the first payment run in the month, rosters for the two months prior, plus the roster for the current month will be available for service recording. Once the first Respite/OPTS payment run occurs in a month, only rosters for the current and prior month will be available for service recording. Web recording Best Practice record service provided in prior month in current month (e.g., August services in September). Identification of Non-Medicaid Billing Problems For billing submitted via a voucher to OPWDD s Payment Processing Unit, a letter is sent to the agency if an adjustment is made to the voucher or if an agency s voucher is rejected in whole. OPWDD does NOT issue remittance statements for voucher claims. The OPWDD Payment Processing Unit can be contacted if assistance is needed with OPWDD billing for state paid services - (518) Tips for Billing OPWDD s Payment Processing Unit Claims should be submitted on the 1st of the month (or later) following the month of service delivery. June 2012 All About Billing 20