| 01 |
Transferred to another HH |
01 |
Transferred |
Member or potential member is working with or wants to work with another Health Home agency |
A transfer to another HH could be due to member choice, ability of a different Health Home to better serve the member or another reason. |
Both |
1/1/2012-current |
| 02 |
Individual opted-out (pre- consent only) |
03 |
Disenrolled |
Individual has voluntarily opted out. Individual does not want to be a Health Home member and receive Health Home services |
To be used for individuals who choose not to enroll into Health Home, as explained in Access to/Sharing of Personal Health Information (PHI) and the Use of Health Home Consents HH0009. |
Outreach |
1/1/2012-current |
| 03 |
Transferred to another CMA |
01 |
Transferred |
Individual is working with another Care Management Agency within the same Health Home |
A transfer to another CMA could be due to member choice, ability of a different CMA to better serve the member, or for another reason. This is not a disenrollment segment end code. |
Both |
1/1/2012-current |
| 04 |
Individual deceased |
03 |
Disenrolled |
HH has been informed that the individual is deceased |
|
Both |
1/1/2012-current |
| 05 |
Individual has a new CIN |
02 |
Administrative Closure |
The individual is assigned a new Medicaid CIN |
If the Medicaid CIN changes for a Health Home enrolled/outreached individual, the segment should be: 1) ended under the old CIN using this reason, 2) the new CIN should be typed in the comments box, and 3) a new segment should be created using the new CIN. |
Both |
1/1/2012-current |
| 06 |
Changed TCM/MATS/COB RA/CIDP slot type |
08 |
Existed in Old System |
Only existed in Old System |
Only existed in Old System |
N/A |
Only existed in Old System |
| 07 |
Closed for Health, welfare and safety concerns for member and/or staff |
03 |
Disenrolled |
Disenrollment due to health, welfare, and safety concerns for member and/or staff (formerly for behavior) |
Member can no longer be disenrolled from HH program for "behavior" or "non-compliance." Behaviors should be addressed by the HH care manager and/or the member's care team following protocols set out in Member Disenrollment From the Health Home Program HH0007. |
Enrollment |
1/1/2012-current |
| 08 |
Member moved out of service county |
03 |
Disenrolled |
Member moved out of service county |
No longer available for use |
Both |
1/1/2012- 10/31/2018 |
| 09 |
Individual moved out of state |
03 |
Disenrolled |
Member moved out of New York State |
|
Both |
1/1/2012-current |
| 10 |
Change in functional eligibility |
08 |
Existed in Old System |
Only existed in Old System |
Only existed in Old System |
N/A |
Only existed in Old System |
| 11 |
Individual incarcerated |
03 |
Disenrolled |
Individual is incarcerated where the length of stay is anticipated to be longer than 6 months |
Individual should be disenrolled as addressed in Continuity of Care and Re-engagement for Enrolled Health Home Members HH0006. |
Both |
1/1/2012-current |
| 12 |
Refused to sign or rescinded consent |
03 |
Disenrolled |
Member refused to sign consent (Segment End Reason currently not used) |
No longer available for use |
Enrollment |
1/1/2012- 10/31/2018 |
| 13 |
Individual is in an inpatient facility |
03 |
Disenrolled |
Member is in an excluded setting and the length of stay is anticipated to be longer than 6 months |
The individual is in an excluded setting such as inpatient, hospitalization, institution or residential facility, nursing home, etc.) as outlined in Continuity of Care and Re-engagement for Enrolled Health Home Members HH0006. |
Both |
1/1/2012-current |
| 14 |
Enrolled Health Home member disengaged from Care Management services |
03 |
Disenrolled |
Member is considered disengaged when diligent and continued search efforts do not result in location of the member |
Member is considered disengaged from care management services when diligent and continued search efforts do not result in location of the member as outlined in Continuity of Care and Re- engagement for Enrolled Health Home Members policy. |
Enrollment |
1/1/2012-current |
| 15 |
Member dissatisfied with services |
03 |
Disenrolled |
Member dissatisfied with services (Segment End Reason currently not used) |
No longer available for use |
Both |
1/1/2012- 10/31/2018 |
| 16 |
Inability to contact/locate individual |
03 |
Disenrolled |
Individual is unreachable during outreach attempts |
See Interim Guidance Addressing Outreach Modification, October 2017. |
Outreach |
1/1/2012-current |
| 17 |
Member not interested in HH services |
03 |
Disenrolled |
Member not interested in services (Segment End Reason currently not used) |
No longer available for use |
Outreach |
1/1/2012- 10/31/2018 |
| 18 |
Member interested in HH at a future date |
03 |
Disenrolled |
For individuals not yet ready for HH services who express future interest |
Individual in outreach is not interested in Health Home services, but indicates that they may be interested in Health Home services in the future. |
Outreach |
1/1/2012-current |
| 19 |
Individual doesn't meet HH eligibility/appro priateness criteria |
03 |
Disenrolled |
Individual does not/no longer meets eligibility criteria required for enrollment/continued enrollment |
Individual does not/no longer meets the eligibility criteria of at least two chronic conditions or one single qualifying condition, and doesn't meet appropriateness criteria, per Member Disenrollment From the Health Home Program policy. |
Both |
1/1/2012-current |
| 20 |
Switched Managed Care Plans |
08 |
Existed in Old System |
Only existed in Old System |
Only existed in Old System |
N/A |
Only existed in Old System |
| 21 |
Member has graduated from HH program |
04 |
Step Down to Lower Level of Care |
Individual can successfully self-manage and monitor their chronic conditions. |
Individual no longer meets the appropriateness criteria, in that they can successfully self-manage and monitor the chronic conditions that made him/her eligible for the Health Home program, as referenced in Member Disenrollment from the Health Home Program policy as described in HH0007. |
Enrollment |
1/1/2012-current |
| 22 |
Transition to FIDA program |
08 |
Existed in Old System |
Only existed in Old System |
Only existed in Old System |
N/A |
Only existed in Old System |
| 23 |
Member disenrolled |
03 |
Disenrolled |
Member disenrolled (Segment End Reason currently not used) |
No longer available for use |
Enrollment |
1/1/2012- 10/31/2018 |
| 24 |
Individual is not/no longer eligible for Medicaid |
03 |
Disenrolled |
Individual no longer qualifies or meets eligibility requirements for Medicaid. |
This code should be used only when appropriate measures have been initiated to reinstate benefits, as noted in Member Disenrollment from the Health Home Program policy. |
Both |
1/1/2012-current |
| 25 |
Individual moved from Outreach to Enrollment |
02 |
Administrative Closure |
System generated – When an enrollment segment is created prior to the end of an outreach segment the system will automatically end date the outreach segment on the last day of the month prior to the start date of the enrollment segment using this reason code. User selected – When user ends an outreach segment because the individual has been found during outreach. |
When user selected, end outreach segment when individual is found and eligible for Health Home services and begin enrollment segment. |
Outreach |
1/1/2012-current |
| 26 |
No resources that speak the member's primary language |
08 |
Existed in Old System |
Only existed in Old System |
Only existed in Old System |
N/A |
Only existed in Old System |
| 27 |
Member not eligible for HH program |
03 |
Disenrolled |
Member not eligible for HH program (Segment End Reason currently not used) |
No longer available for use |
Both |
1/1/2012- 10/31/2018 |
| 28 |
Health Home change MMIS Provider ID |
02 |
Administrative Closure |
CMA or HH MMIS ID changes within MAPP HHTS |
This code is used to indicate that the individual's segment is ended under the old ID and will be started under the new ID with no loss to Health Home services for the individual. |
Both |
1/1/2012-current |
| 29 |
Member withdrew consent to enroll |
03 |
Disenrolled |
Member chooses to disenroll from the Health Home program. |
This code is used when the member chooses to disenroll from the Health Home program, as noted in Member Disenrollment From the Health Home Program policy. |
Enrollment |
1/1/2012-current |
| 30 |
Hiatus to Closed |
07 |
System Generated |
For use when an outreach segment switches from hiatus to closed. This is a system generated End Date Reason |
System generated end reason |
Outreach |
1/1/2012-current |
| 31 |
Active to Hiatus |
07 |
System Generated |
For use when an outreach segment switches from active to hiatus. This is a system generated End Date Reason |
System generated end reason |
Outreach |
1/1/2012-current |
| 32 |
Provider closed |
02 |
Administrative Closure |
For use when HH or CMA closes business and member is transferred to another HH and/or CMA |
Use when a Health Home or CMA closes business and member must be transferred to new Health Home and/or CMA. |
Both |
1/1/2012-current |
| 33 |
Merger |
02 |
Administrative Closure |
For use in the instance of a merger between two HH or CMAs |
This is used in the instance of a merger between two Health Homes or CMAs. Notification of Change Form is used to inform the NYS Department of Health of any changes made to Health Home from originally approved Health Home application and designation letter. |
Both |
1/1/2012-current |
| 34 |
Provider ID changed |
02 |
Administrative Closure |
For use when a provider ID is changed (Segment End Date Reason currently not used) |
No longer available for use |
Both |
1/1/2012- 10/31/2018 |
| 35 |
Member refused consent |
03 |
Disenrolled |
For use when a member refused to sign consent (Segment End Date Reason currently not used) |
No longer available for use |
Enrollment |
1/1/2012- 10/31/2018 |
| 36 |
Enrollment Requested to be Deleted |
08 |
Existed in Old System |
Only existed in Old System |
Only existed in Old System |
N/A |
Only existed in Old System |
| 37 |
Outreach Requested to be Deleted |
08 |
Existed in Old System |
Only existed in Old System |
Only existed in Old System |
N/A |
Only existed in Old System |
| 38 |
Active to Closed |
07 |
System Generated |
For use when an outreach segment switches from active to closed. This is a system generated End Date Reason |
System Generated end reason |
Outreach |
1/1/2012-current |
| 39 |
Segment pended |
06 |
Pended |
For use when a segment is pended |
For use when a segment is pended |
Both |
1/1/2012-current |
| 40 |
Pended segment closed |
03 |
Disenrolled |
For use when a pended segment is closed |
No longer available for use |
Both |
1/1/2012- 4/20/2016 |
| 41 |
Coverage not compatible |
03 |
Disenrolled |
Individual's Medicaid coverage is not compatible with HH |
See Guide to Coverage Codes and Health Home Services for examples of Medicaid coverage that is not compatible with the Health Home program. |
Both |
11/1/2018- current |
| 42 |
Program not compatible |
03 |
Disenrolled |
Individual chooses to move to another program not compatible with HH program |
Individual chooses to move to another program not compatible with Health Home program or individual is found to be currently enrolled in non- compatible program. See the Guide to Restriction Exception (RE) Codes and Health Home Services for examples of programs that are not compatible with the Health Home program. |
Both |
11/1/2018- current |
| 43 |
Individual moved between HHSC and HHSA |
01 |
Transferred |
When a member who previously received services as a child transitions to adult, or an adult transitions back to a HHSC |
An individual previously receiving Health Home services as a child or adult is transitioned to the other program based on individual preferences or age (i.e. child in HHSC services transitions to adult HH services). |
Both |
11/1/2018- current |
| 44 |
Segment Correction |
02 |
Administrative Closure |
For use only if directed by DOH in order for HH RE codes to be correctly attributed to the member |
Only use if directed by DOH - This code should be used when it is necessary to end a segment and create a new one in order for Health Home RE codes to be correctly attributed to the member. |
Enrollment |
11/1/2018- current |
| 45 |
Member Re-engaged |
02 |
Administrative Closure |
For use when a member is re-engaged in HH services when in a pended segment. |
This code should be used when ending a pended segment because the member is re-engaging in health home services and a new segment should be created. |
Enrollment |
7/1/2019-current |
| 46 |
Transitioned to PCMH or other Healthcare Provider Care Management |
04 |
Step Down to Lower Level of Care |
Member is transitioning to PCMH or other Healthcare Provider Care Management services |
This code should be used when a member is stepping down to PCMH or other Healthcare Provider Care Management Services as described in HH0007. |
Enrollment |
12/1/2020-current |
| 47 |
Transitioned to MCO or MLTC Care Management |
04 |
Step Down to Lower Level of Care |
Member is transitioning to MCO or MLTC Care Management services |
This code should be used when a member is stepping down to MCO or MLTC Care Management Services as described in HH0007. |
Enrollment |
12/1/2020-current |
| 49 |
Transitioned to Standard HHCM |
04 |
Step Down to Lower Level of Care |
Member is transitioning to Standard HHCM services |
This code should be used when a member is stepping down to Standard HHCM services as described in HH0007. |
Enrollment |
12/1/2020-current |
| 50 |
Transitioned to ACT Team |
05 |
Step Up to Higher Level of Care |
Member is transitioning to the ACT Team services |
This code should be used when a member is stepping up to the ACT Team as described in HH0007. |
Both |
11/1/2021-current |
| 51 |
Transitioned to HH+ for AOT |
05 |
Step Up to Higher Level of Care |
Member is transitioning to HH+ for AOT services |
This code should be used when a member is stepping up to HH+ for AOT for a more intensive level of HHCM as described in HH0007. |
Both |
11/1/2021-current |
| 52 |
Transitioned to HH+ for HIV |
05 |
Step Up to Higher Level of Care |
Member is transitioning to HH+ for HIV services |
This code should be used when a member is stepping up to HH+ for HIV services for a more intensive level of HHCM with as described in HH0007. |
Both |
11/1/2021-current |
| 53 |
Transitioned to HH+ for SMI |
05 |
Step Up to Higher Level of Care |
Member is transitioning to HH+ for SMI services |
This code should be used when a member is stepping up to HH+ for SMI services for a more intensive level of HHCM as described in HH0007. |
Both |
11/1/2021-current |
| 54 |
Transferred to a CCO/HH |
01 |
Transferred |
Member is transitioning to a CCO/HH |
This code should be used for a member transferring to the CCO Health Home program. |
Both |
11/1/2021-current |
| 55 |
No longer HCBS eligible |
03 |
Disenrolled |
Member is no longer HCBS eligible |
This code should be used when a member is disenrolling because they are no longer HCBS eligible. |
Both |
11/1/2021- 8/8/2022 |
| 56 |
Disenrolled from HH and HCBS |
03 |
Disenrolled |
Member is disenrolled from Health Home services and HCBS services. |
This code is available for Child segments only. |
Enrollment |
7/27/2022-current |
| 57 |
Disenrolled from HH only, continue HCBS |
03 |
Disenrolled |
Member is disenrolled from Health Home services but continues in HCBS. |
This code is available for Child segments only. |
Enrollment |
7/27/2022-current |
| 58 |
Member Re-engaged |
02 |
Administrative Closure |
For use when a member is re-engaged in HH services when in a pended segment. |
This code should be used when ending a pended segment because the member is re-engaging in health home services and a new segment should be created. |
Enrollment |
3/26/2023-current |
| 98 |
Invalid end date reason at conversion |
07 |
System Generated |
Invalid end date reason at conversion. This is a system generated End Date Reason |
System Generated end reason |
Both |
1/1/2012-current |
| 99 |
Other |
09 |
DOH Only |
Reason not listed. Comments related to end reason must be included. This can only be used by DOH. |
"Other" cannot be used by Health Homes – For DOH Only. Reach out to DOH if you are unable to find the appropriate code. |
Both |
1/1/2012-current |
