Questions and Answers

Claims and Billing

Question Number Question Answer
1 If a patient is dually eligible and a CHHA is billing for both Medicare and Medicaid services, the professional visits will most likely be billed to Medicare which would result in no professional visit for the Medicaid Claim. Will this be acceptable to only have Home Health Aide custodial services on a claim and would a full Medicaid payment result? Yes. A Medicaid episodic claim with no professional visits is possible (as it is under the current FFS billing rules). Only those services which are properly eligible for Medicaid reimbursement may be listed on the Medicaid claim form.
2 Will Interim payment claims require a record 40 with 0023 revenue code and HIPPS code to indicate the billing record´s first visit or SOC? No. An interim payment (50%) is determined based on the values in Field 4 (Type of Bill) on the UB-04. The third digit in Field 4 must be "2" for an interim payment and "9" for a final claim.
3 Will Final Claims require the same matching revenue code and HIPPS code? No. HIPPS codes should continue to be reported in accordance with existing UB-04 requirements. Revenue codes for services provided must be reported in accordance with the new matrix published by the Department. Accurate reporting of these codes and the corresponding number of service units for Medicaid covered services are a key component of the payment determination process. Thus, providers should ensure the revenue codes and corresponding service units are accurately reported on the claim.
4 Will there be an edit to match first visit to Start of Care for an initial episode? For an initial episode, the date of the first Medicaid-eligible visit should be the same as the "Statement Covers Period From" date in field 6 of the UB-04.
5 How should services appear on the claim? All with a charge amount and zero reimbursement amount? Underlying service units must be accurately reported in fields 42-46 of the UB-04. Although the total charges reported for such services will not be used in payment determination, providers should continue to report their usual and customary charges. The underlying services will be utilized, with statewide per unit prices determined and published by the Department, to calculate applicable LUPA or outlier payments. Providers will submit claims for episodic payments based on rate codes determined by the Department which correspond to the case mix that is generated by the Medicaid grouper from the information obtained from patient's OASIS assessments.
6 If final episode value is less than the interim payment (e.g., LUPA episodes), should claim amount be the anticipated takeback amount? The final payment will be determined using the appropriate rate code and the underlying service units reported by revenue code. The final claim should have a claim number (TCN) that matches the interim claim. Based on this match, the interim payment will be voided and the final claim will be paid in full.
7 Medicare Final Claim payments are processed as a takeback of the Interim payment and then a total episode payment after the final claim has been submitted. Will Medicaid processing be the same? Yes.
8 If the final claim results in a LUPA or PEP and the total episode value is less than the Interim payment, how will the payment appear? This will be reported in the same manner as an adjusted claim under the present billing system, showing a "takeback" of the interim claim and full payment of the final claim. The final claim must have a claim number (TCN) that matches the interim claim.
9 If a PEP is identified after final claims remittance is processed how will adjustment to final claim payment be processed? The provider is required to file a revised final claim, which will be considered an adjustment claim. The third digit of the Bill Type must be "9" and the TCN for the previous final claim should be reported. The adjustment claim will be paid in full and the original payment will be voided.

For episodic CHHA claims, the number "7" in the Bill Type will no longer be used to indicate an adjustment claim.
10 If additional services are billed after final claim is paid and the additional services result in an adjustment to final payment (outlier condition or changing a LUPA to a non LUPA) how will payment be adjusted? Would it be a takeback and new payment? Or just an additional payment? Provider will file an adjusted final claim. The adjusted claim will be paid in full and the previous claim payment will be voided (shown as a takeback).
11 Should claims for non-episodic programs (LTHHCP, NFP, etc.) be submitted on a separate claim file than episodic claims? If so, will remittances be separated also? Consistent with current fee-for-service billing rules, different programs must be billed on separate claims. Therefore, non-CHHA programs must continue to be billed on separate claims.
12 Would PERS (Personal Emergency Response System) and Telehealth be part of the episodic payment? As an existing CHHA service, Telehealth is included in the episodic payment. PERS is not a CHHA covered service.
13 In regard to timely filing, would the requirement be to bill within 90 days of the start of the episode, the end of the episode, or specific to service dates? Bills should be submitted within 90 days from the end of the episode.
14 How would DENIALS be handled for both visits as well as episodes? Claims will be rejected if inaccurate information is transmitted. Billing edits are applicable to ensure that all underlying service units (e.g., visits, hours) are reported under proper revenue codes, and dates of service must be within the episodic service period. Edits are in place to ensure proper rate codes are utilized. For example, rate code age category will be edited against Medicaid system patient age as of the episode end date.
15 Is there a code similar to the OASIS matching key that is placed on Medicare claims? If not, then how would the scores that were used for the calculation be included on the bill? There is no "matching key" like Medicare. Instead, a new occurrence code of 50 has been established on the UB-04 for assessment date, for tracking/audit purposes. The bill should be submitted with the rate code that corresponds to the case mix as determined by the Medicaid grouper which uses data from the patient's OASIS assessment.
16 How would the services provided to the patient (nursing visits, home health aide hours, etc.) be reported on the claim form? The agency will report all Medicaid eligible services in UB-04 fields 42-46, using revenue codes provided by the Department. An interim claim must include at least one eligible service and the final claims should include all eligible services, including any listed on the interim claim.
17 What is the impact to secondary claims? Medicare/Medicaid dually eligible patients? Medicare crossover claims will not be part of the episodic payment system, but will continue to be processed in the same manner as they were under the fee-for-service system. For dually eligible patients, maximizing third party liability coverage is still a necessary component of the Medicaid billing system. Only services determined and verifiable by the agency as eligible for Medicaid (and not otherwise covered) can be included on an episodic claim.
18 Explain how the calculated classification code will look; and how is it represented on the claim? Rate codes will be utilized to bill for payment. These rate codes will correspond to the patient case mix as determined by the Medicaid grouper which uses data from the patient's OASIS assessment.
19 Will the services require authorization and would the authorization number be required on the claim? Service authorization requirements will be consistent with existing requirements (e.g., physician order, medical record, etc.)
20 When will the 5010 companion guide that reflects changes due to the PPS Reimbursement model be published? There will be no updates to the 5010 companion guide. Detailed billing guidelines will be published by the Department.
21 Are Interim and Final payments equal for all episodes? 50/50? Would it be different for the first billing cycle, compared to subsequent billing cycles? Interim payments for all episodes are calculated as 50% of the total episodic rate, assuming no adjustment for LUPA, PEP, or outliers. Final payments are 100% of the actual amount due.
22 Is the rate code based on the patient's age at the beginning of the episode, start of care, or the end of the billing episode? The billed rate code must be consistent with the patient's age as of the "Through" date on the claim. In some cases, this will require using a different rate code on the interim and final claims.
23 Is a 329 claim considered an adjustment claim? Only if it includes the TCN of the claim being adjusted.
24 If the TCN number from the Interim payment is reported on the final claim, what field on the UB04 is it reported in, and what segment in the 837I? For 837I, the TCN is reported in the REF02 segment of the 2300 loop, with an F8 qualifier in the REF01 segment. For UB04, Form locator 64, data element is "Document Control Number (DCN)."
25 If a claim if filed which covers parts of three calendar months, and the patient lacked eligibility during one of those months, will the entire claim be denied, or will partial reimbursement occur? The entire claim will be denied.
26 When we submit an Interim Claim, coverage is established for that month, but when we bill final payment 2 months later, if there is no coverage is the final payment pended? Yes. Final claim will be pended for Edit 00162 (RECIPIENT INELIGIBLE ON SERVICE DATE).
27 What occurs if an interim payment is made but a final claim is not submitted by the provider? The interim payment is voided 120 days after the original adjudication date (on remittance advice) if a final claim with the TCN of the interim claim is not received. (This will be increased to 150 days after April 1, 2012).
28 Rate Codes are reported in fields 39-41 - is there a revenue code for the rate code? Should there be a price attached to the rate code? If so, would this be the 50%? There will be no changes to ePACES as a result of the Episodic Payment System. Providers who need guidance on using ePACES to submit episodic claims should contact Computer Sciences Corp. at 800-343-9000.
29 Will there be changes to the Epaces system (screens/entering claims/adjustments)? There will be no changes to ePACES as a result of the Episodic Payment System. Providers who need guidance on using ePACES to submit episodic claims should contact Computer Sciences Corp. at 800-343-9000.
30 If the episodic rates change in the middle of the episode, will reimbursement be based on the rates in effect at the beginning or end of the episode? Rates in effect at the beginning of the episode will apply.
31 Are non-covered charges to be reported on the final claim? Non-covered charges may be reported at the discretion of the provider. They will have no impact on the claim payment amount.
32 When billing Medicare the rate code takes on the first visit date - is this true for NYS Medicaid or does the rate code not have a date? There is no date directly associated with the rate code.
33 Our Home Health staff does Maternal Child Health visits - would these visits also have to be episodic billing? If the patient listed on the claim is 18 or older, episodic billing will be required. However, because federal regulations do not require an OASIS assessment for maternity patients, a special rate code (4920) has been created for maternity patients for whom no OASIS has been completed. Rate code 4920 will have the same Case Mix Index and Outlier Threshold as the lowest acuity group in the 108 OASIS-based rate codes (4810).

For all other episodic billing rate codes, the Medicaid claim form must include Occurrence Code 50 and this code must be used to report the most recent assessment date prior to, or coincident with, the start date of the episode. Occurrence Code 50 will not be required for Rate Code 4920, which can be used only for maternity patients.

Providers may, at their discretion, complete an OASIS assessment for a maternity patient and use a different rate code as applicable.

Consistent with federal rules, maternity patients are defined as: patients who are currently or were recently pregnant and are receiving treatment as a direct result of such pregnancy.
34 In field 46 on the UB-04 should the service units be reported as visits, hours, etc.? Please refer to the "Billing Guidelines" document.
35 If a patient is not eligible for Medicaid at the beginning of an episode that is already being billed to Medicare, but becomes eligible for Medicaid after the start of the episode, how is payment processed? The Medicaid episode cannot start until the patient is eligible for Medicaid and a Medicaid eligible service is provided.
36 In the event the patient is discharged prior to the end of an episode and the episode is going to be PEPPED, and if the discharge occurs prior to the patient's DOB, then will DOH adjust the rate accordingly? It is the provider's responsibility to assure that the billed rate code is consistent with the patient's age on the end date of the episode (the "through" date on the claim).
37 If a Medicaid episode is started due to a billable visit being in the agency's system, and after creating the episode and billing, a visit prior to the episode start date is released from suspense or appears due to late visit entry, can agencies void the original episode and start anew with the new first billable visit? The provider has the ability to submit an adjusted interim claim and an adjusted final claim, as well as the ability to void a prior claim. The new submitted claim would reflect the corrected dates.
38 If there are assessment response changes after the Interim Claim is submitted and the Final Claim has a different CMG code, will this be accepted by Medicaid? Which group will be paid for the final payment, the first one submitted or the one on the final claim? There is no requirement that the Interim Claim and Final Claim have the same rate code. The billed rate code must be based on an OASIS assessment which occurs on or before the start date of the episode, but not more than 60 days prior to the start date.
39 Does the EPS have the concept of a 'Known LUPA' or 'No RAP LUPA'? That is, episodes the agency knows will be a LUPA are billed using a Final Claim only, no RAP submitted. The provider is not required to submit an Interim claim. If the Final Claim does not match up with an Interim Claim, the entire Final Claim will be paid (if approved for payment by eMedNY).
40 How should supplies be reported or entered within the NY EPS claim? There will be no change in Medicaid policy regarding supplies which may be billed by a CHHA. Supplies must be billed on a separate claim, not on the episodic claim.
41 For dually eligible cases where Medicare is being billed and Medicaid billing is now applicable, do providers need to submit the existing OASIS submitted to Medicare with the new Medicaid episodic billing or will Medicaid electronically access that information from the Medicare system? The Medicaid episodic payment system has no data link to OASIS information from Medicare. Providers will not submit OASIS data to the Department; Medicaid billing will be determined by the provider utilizing the rate code generated by applying the OASIS assessment information to the Medicaid grouper logic. As noted in the answer to a previous question, a new occurrence code of 50 has been established on the UB-04 claim for assessment date, that will provide the audit/tracking link to the OASIS assessment data the provider utilized for Medicaid billing.
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