CHHA Episodic Multi - Provider Billing Guidance

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December 5, 2019

Dear Administrator:

This letter provides you with information on new edits which have been added to the eMedNY system. As the result of an Office of State Controller review the following Certified Home Health Agency – Episodic Payment System edits were recommended and have now been included in the eMedNY Billing system.

Edit #1: Deny any billed episode during any portion of which the patient was enrolled in a managed care plan.

If a provider bills for the period March 15 – May 14, but the patient was enrolled in a managed care plan on May 1, the claim would be denied. If resubmitted with an end date of April 30, the claim would be paid.

The system will check for any managed care enrollment between the begin Date–of Service (DOS) and the end DOS (inclusive of both dates). If an enrollment is found, the claim will be denied. This denial is irrespective of any discharge code the provider may code on the claim. The provider needs to put an allowable end date on the claim.

Edit #2: Deny any billed episode if the start date of that episode is within 60 days of the start date of a prior episode billed by the same provider.

The provider needs to adjust the first claim to include the services from the second claim. If the end date of the second claim is more 60 days after the start date of the first claim, the provider will need to resubmit the second claim using a start date that is at least 60 days after the start date of the first claim.

Edit #3: If a provider bills an episode with a start date between the start and end date of an episode billed by a different provider, the episode with the earlier start date should deny.

In most cases, the claim with the earlier start date will already have been submitted and paid. That first claim needs to have the funds recovered and then the provider needs to rebill with the correct end date (which should be provided in the detail accompanying the denial).

If you have any questions concerning the forgoing, please email CHHA­ and Russ Smith with respond.


Laura Rosenthal
Bureau of Residential Health Care Reimbursement
Division of Finance and Rate Setting
Office of Health Insurance Program