New York State Medicaid Update - February 2017 Volume 33 - Number 2

In this issue …

Home Health Care Medicare Maximization Services: New Audits Involving Medicare Demand Billing and Overpayments Involving Dual Eligible Recipients

The Office of the Medicaid Inspector General (OMIG) contracts with the University of Massachusetts Medical School (UMASS) to maximize Medicare reimbursement for dual eligible Medicare/Medicaid recipients who have received home health care services paid by Medicaid. Medicaid is always the payor of last resort. Therefore, when a recipient is eligible for both Medicare and Medicaid, or has other third party insurance benefits, the provider must bill Medicare or the other third party insurance first for covered services prior to submitting a claim to Medicaid.

To ensure Medicaid is the payor of last resort, UMASS identifies home health providers who have not billed Medicare for home health services previously paid by Medicaid, and directs the provider to "demand bill" Medicare for those services. If providers do not comply with this request, they are required to reimburse the Medicaid program for the amount Medicaid paid for these services as required under 18 New York Codes, Rules and Regulations (NYCRR) 540.6 (e).

UMASS also pursues Medicare coverage for claims that were denied payment by Medicare at initial determination and paid by Medicaid. When a provider receives a Medicare payment as a result of a reversed Medicare denial, the provider has received a duplicate payment, which then makes the payment an overpayment. UMASS sends notification letters to the provider who receives the overpayment to inform them that the provider is required to return the Medicare payment to the Medicaid program. If the amount of the Medicare payment is not reimbursed to the Medicaid program, OMIG will pursue recovery of the overpayment.

Effective immediately, providers who are noncompliant with requests to demand bill Medicare or who fail to return identified overpayments will be subject to an audit for recovery of all inappropriate payments. OMIG expects provider compliance with NYS Medicaid program regulations to ensure receipt of proper payments before the timeframes for submission of claims to Medicare are exhausted.

If you have any questions concerning the above information, you may contact the UMass Medicare Appeals Team at 1-866-626-7594.

Safe Discharge Planning Requirement for Individuals Transitioning from Medicaid Fee-for-Service to Managed Care

This update serves as a reminder that Home Care Agency providers must safely discharge Medicaid enrollees who are transitioning from Fee-for-Service (FFS) to Managed Care.

Provider's Role and Responsibility

When an individual is transferring from FFS to any Managed Care Plan in the state, the existing Home Care Agency provider is responsible for adhering to Home Care regulations regarding a safe discharge of services as indicated in Title 10 Section 766.2 of the New York Codes, Rules and Regulations (10 NYCRR 766.2) – entitled, "patient service policies and procedures". See specifically 10 NYCRR 766.2 (a)(8) and (9). According to existing New York State (NYS) Medicaid policy, home care agencies may not stop providing services during the transition from FFS Medicaid to a Managed Care plan.

This policy applies to consumers enrolling in any of the state's Managed Care programs, including but not limited to Managed Long Term Care Partial, Medicaid Advantage Plus, Fully Integrated Duals Advantage (FIDA) and the newly implemented demonstration, Fully Integrated Duals Advantage for Individuals with Developmental Disabilities (FIDA-IDD). 10 Section 766.2 reference:

FIDA-IDD: Overview

FIDA-IDD is a demonstration in NYS for adults with intellectual and developmental disabilities who have Medicare and Medicaid. This demonstration has been implemented through a three-way contract between the NYS Department of Health (DOH), the Centers for Medicare and Medicaid Services (CMS), and Partners Health Plan (PHP).

PHP is the sole plan selected to participate in the FIDA-IDD demonstration. In April 2016, PHP began accepting voluntary enrollments for individuals who are age 21 and older, eligible for Medicare and Medicaid, and who are determined eligible for Intermediate Care Facility/Individuals with Developmental Disabilities (ICF/IDD) level-of-care. The FIDA-IDD program is operating in Bronx, Kings, Nassau, New York, Queens, Richmond, Rockland, Suffolk, and Westchester Counties.

Through FIDA-IDD, existing Medicare and Medicaid benefits will be provided with an integrated benefit design that will include a dedicated interdisciplinary team to address each individual's medical, behavioral, long-term supports and services, and social needs. All individuals enrolled in the FIDA-IDD demonstration receive services through a network of providers contracted with PHP.

Important Contact Information

Managed Care Enrollment Questions: New York Medicaid Choice (NYMC): 1-844-343-2433 (TTY users 1-888-329-1541)

General Questions:

  • MLTC: NYS DOH – Technical Assistance Center: 1-866-712-7197
  • FIDA: SDOH: 1-518-474-6965
  • FIDA-IDD: OPWDD email:
    PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan): 1-855-747-5483

NY Medicaid EHR Incentive Program Update

The New York (NY) Medicaid Electronic Health Records (EHR) Incentive Program provides financial incentives to eligible professionals and hospitals to promote the transition to EHRs. Providers who practice using EHRs are in the forefront of improving quality, reducing costs and addressing health disparities. Since December 2011 over $783 million in incentive funds have been distributed within 24,934 payments to NY State Medicaid providers.


Million Paid

Are you eligible? For more information, visit

MEIPASS Open for 2016 AIU

The NY Medicaid EHR Incentive Program Administrative Support Service (MEIPASS) is now open at: and is accepting attestations for 2016 Adopt, Implement, Upgrade (AIU). The final deadline is to be determined but will be extended beyond 3/31/2017.

Preparing to Attest

Questions? Contact NY Medicaid EHR Incentive Program Support at

New Informational Website

In December 2016, the NY Medicaid EHR Incentive Program launched a new informational website. The new website includes detailed program information on all of the prior and current Meaningful Use (MU) stages, program requirements, guidance for the public health reporting objective, and also has a more comprehensive section for post-payment audit guidance. Please visit the new website

Public Health Reporting Objective Update

The NYS Department of Health (NYSDOH) is now collecting syndromic surveillance data from Eligible Professionals (EPs) working at NYS certified urgent care centers, located outside the five boroughs of New York City. EPs who work in an urgent care center are encouraged to update their registration of intent to say "yes" they intend to submit electronic syndromic surveillance data to the NYSDOH in the Meaningful Use Registration for Public Health (MURPH) System. Active engagement with the NYSDOH to syndromic surveillance data can count as meeting the syndromic surveillance reporting measure for the NY Medicaid EHR Incentive Program. For more details, please see the Public Health Reporting website at:

Need Assistance?

In addition to the NY Medicaid EHR Incentive Program Support Team, who can be reached via phone at 877-646-5410 or via email at, there are two Regional Extension Centers (RECs) available to assist you. EPs in New York City can contact NYC REACH at 347-396-4888 or EPs outside of New York City can contact NYeC at 646-619-6400 or

Coverage of Medical Language Services in Hospital Inpatient Settings

As a result of recently adopted regulation Title 10 NYCRR, Part 86-1.45 and the approval of State Plan Amendment (SPA) 12-028 by CMS, reimbursement is now available for language assistant services provided in hospital inpatient settings, retroactive to September 1, 2012.

Inpatient medical language assistant services will also be reimbursed by Medicaid Managed Care plans in accordance with rates established in provider agreements or out of network providers at negotiated rates.

To qualify, the service must be provided by an independent third party, a dedicated hospital employee or a third party vendor (e.g., telephonic interpretation service) whose sole function is to provide interpretation services for individuals with limited English proficiency and communication services for people who are deaf and hard of hearing. The need for this service must also be documented in the medical record.

Billing Guidance

The New York State Department of Health has implemented discrete rate code 2572 for hospitals to bill for inpatient medical language assistant services, if provided, in addition to their existing inpatient rates of payment. The rate of payment will be set at $11.00 for one unit of service up to a maximum of two billable units of service per patient per day. One unit of service is defined as an encounter up to and including 22 minutes and the second unit is the minutes thereafter. Each claim must include Healthcare Common Procedure Coding System (HCPCS) procedure code T1013 (sign language and oral interpretation) in addition to the units of service. The claim for inpatient language assistance shall only be submitted subsequent to adjudication of the corresponding inpatient claim (i.e. 2946, 2852, etc.) or it will deny.

If a provider submits a claim, at this time, with a date of service that is greater than the 90-day initial claim filing requirement, the provider may use Delay Reason Code 3 (Authorization Delays). Authorization to use Delay Reason Code 3 for this purpose will expire 60 days from the date providers are notified that rate code 2572 has been established on their provider file. Providers will be expected to file all claims based on timely claim submission requirements after this 60-day period. In addition, all claims over two years old must be submitted in accordance with current Medicaid policy. The General billing manual is provided at:

Medicare/Medicaid Eligible Providers

For claims in which the recipient has Medicare coverage and Medicare does not cover the service will report the Claim Adjustment Reason Code(s) (CARC) to indicate that a prior payer has paid zero.

Any questions regarding this information should be directed to

Certified Home Health Agencies Episodic Payment System Notification of Provider Overpayments

A review of the Certified Home Health Agencies (CHHA) Episodic Payment System (EPS) has found Medicaid overpayments were made to a number of CHHA providers. These identified overpayments included but are not limited to the following:

  1. Payment for full episodic payment instead of pro-rated episodic payment when the recipient was transferred into a Managed Long Term Care Plan within 60 days of episode;
  2. Payment for multiple episodic payments within 60 days of episode;
  3. Payment to two separate CHHA providers for the same recipient within 60 days of episode.

The review also revealed situations where erroneous discharge codes were used by a CHHA in providing multiple episodes to the same patient, or an erroneous discharge code used for a patient who was discharged to a managed long term care plan. These types of errors are clearly within the control of the billing CHHA to submit correctly and in accordance with the Billing Guidelines dated April 9, 2013, posted on the NYS DOH website at:

Additionally, there were instances where providers created a new episode apparently based on a change in rate code (due to a new Outcome and Assessment Information Set [OASIS], or a change in age group). Such a situation should not trigger a new episode. The CHHA should still bill a full 60-day episode, where applicable. In accordance with previously published billing guidance (, the rate code should be based on the most recent OASIS assessment available as of the start date of the episode (or within 5 days after the start date), and the age group must match the patient's age on the "through" date of the claim.

To minimize future billing errors that could result in similar overpayments, all CHHA providers should check their billing systems to ensure that they are in full compliance with the above-noted billing requirements for partial episodes.

NYS DOH will continue to monitor these billings and provide updated billing guidance as necessary. The NYS Office of the Medicaid Inspector General will seek to recover all inappropriate payments made to providers.

Any questions regarding CHHA rates, CHHA billing and other CHHA related issues can be sent via email to

The Medicaid Update is a monthly publication of the New York State Department of Health.

Andrew M. Cuomo
State of New York

Howard A. Zucker, M.D., J.D.
New York State Department of Health

Jason A. Helgerson
Medicaid Director
Office of Health Insurance Programs