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eMedNY Subsystem User Manual

1. 42 3 3 Section One Surmmout No Payment uuu u u uu u uu _ _ _ __ 43 3 3 1 Summout No Payment Field Descriptions rr 44 3 4 Section TWO drogue T ______ 45 3 4 1 Provider Notification Field Descriptions r 46 3 5 SECTION Whee DSN uu 47 3 5 1 Claim Detail Page Field 9 51 3 5 2 Explanation or Claim Detail Columns a 51 3 5 3 Subtotals Totals Grand Totals ccceccccsseccccsseccccsccccecccecaucececcuccecnscececauceeecaececaacececausececauececaucececauceeecauecesasececaueeeenauees 54 3 6 Section Four Financial Transactions and Accounts Receivable 55 3 6 1 Financial Transactions ________________________________ _ 55 2t Mb ai g b RR 57 3 7 Section Five Edit Error _____________6_6_ _ _ 6_ 6 59 Appendix Claim SAMI uu TTE 60 PHYSICIAN Version 2010 01 5 31 2010 Page 2 of 79 CLAIMS SUBMISSION Appendix B Code Sets 62 Appe
2. s paypu a i ot 219 ora tas frets ss o isi i o iin CERTE Y THAT THE STATEMENTE THe SIDE APPLY TO THS BILL AMD ARE MADE APART HEREOF 30 EMFLOYERIDENTIRICAT Oa ALE James Strong SOCIAL SECURITY NEER SIGNATURE OF FHS R SUPAR 253 DENTAL CATION NLIUEER PHYSICIAN Version 2010 01 Page 17 of 79 za BANQUNT 3t PHYEICIANG CR SUPPLENS NAME ZF CODE James Strong M D 312 Main Street Anytown New York 11111 TELEPHONE HUBER 5 31 2010 CLAIMS SUBMISSION Exhibit 2 4 2 2 2 ORIGINAL CLAIM REFERENCE NUMBER MEDICAL ASSISTANCE HEALTH INSURANCE ONLY TO BE n USED TO CLAIM FORM TITLE XIX PROGRAM STIvOID PATIENT AND INSURED SUBSCRIBER INFORMATION PAID CLAIM I PATIENTS NUR Fine midi 1 DATE ERTH mie 4 Sheet Cocke 5 ME TERES MEDICARE 1 OCCUPATO OH RELATIONSHIP INSLIELFS E OTHER HEALTH rara cf Peigi cicim WES RELATED T INSURELFS ADDRES S
3. 2a AMOUNT PAL CERTIFY THAT THE STATEMENTS THE APPLY TO THE BLL 30 EMFLO ERIDENTIFLCAT KCN 3t PHYSIO ARS OR SUPPLIERS ADDRESS ZIP CODE E 5 cB NO een James Strong M D NEES 312 Main Street Anytown New York 11111 5L LIATIA 328 MY FEE BEM FRILI TELEPHONE HIER 1 EXT JT WRITE IN THE BEEDNY I2DDDI IPS BODOUNT PHYSICIAN Version 2010 01 5 31 2010 Page 24 of 79 CLAIMS SUBMISSION Name of Facility Where Services Rendered Field 21 This field should be completed when the Place of Service Code entered in Field 248 is 99 Other Unlisted Facility Address of Facility Field 21A This field should be completed when the Place of Service Code entered in Field 248 is 99 Other Unlisted Facility NOTE The address listed in this field does not have to be the facility address It should be the address where the service was rendered Service Provider Name Field 224 If the service was provided by a physician s assistant certified diabetes educator certified asthma educator or a social worker enter his her name in this field Otherwise leave this field blank Prof CD Profession Code Service Provider Field 22B Leave this field blank Identification Number Service Provider Field 22C If the service was provided by a physician s assistant certified diabetes educator certified a
4. CLAIMS SUBMISSION Electronic remittances from Medicaid for crossover claims will be sent to the default ETIN when the default is set to electronic If there is no default ETIN the crossover claims will be reported on a paper remittance The ETIN application is available at www emedny org by clicking on the link to the webpage as follows Provider Enrollment Forms NOTE For crossover claims the Locator Code will default to 003 if the submitted ZIP 4 does not match information in the provider s Medicaid file 2 4 2 eMedNY 150002 Claim Form Field Instructions Header Section Fields 1 through 23B The information entered in the Header Section of the claim form fields 1 through 23B must apply to all claim lines entered in the Encounter Section of the form The following two unnumbered fields should only be used to adjust or void a paid claim Do not write in these fields when preparing an original claim form Adjustment Void Code Upper Right Corner of Form Leave this field blank when submitting an original claim or resubmission of a denied claim If submitting an adjustment replacement to a previously paid claim enter X or the value 7 in the A box If submitting a void to a previously paid claim enter X or the value 8 in the box Original Claim Reference Number Upper Right Corner of Form Leave this field blank when submitting an original claim or resubmission of a denied claim If submitting a
5. Dp EC _ RO a M m Cel eo Far Aare gro Prai rx eu i FS La LT nq TL 2 9 sr sods wz i o is Tu _ Strong MD 312 Main Street New York 11111 PHYSICIAN Version 2010 01 5 31 2010 Page 61 of 79 APPENDIX B CODE SETS APPENDIX B CODE SETS The eMedNY Billing Guideline Appendix B Code Sets contains a list of Place of Service codes SA Exception Codes Specialty Codes Exempted from UT Sterilization Abortion Codes and a list of accepted Unites States Standard Postal Abbreviations PHYSICIAN Version 2010 01 5 31 2010 Page 62 of 79 APPENDIX B CODE SETS Version 2010 01 Description school Homeless shelter Indian health service free standing facility Indian health service provider based facility Tribal 638 free standing facility Tribal 638 provider based facility Doctors office Home Assisted living facility Group home Mobile unit Urgent care facility Inpatient hospital Qutpatient hospital Emergency room hospital Ambulatory surgical center Birthing center Military treatment facility Skilled
6. New York State Electronic Medicaid System 150002 Billing Guidelines 2 PHYSICIAN Version 2010 01 5 31 2010 TT TABLE OF CONTENTS TABLE OF CONTENTS L O 01 2 ____ _____________ 4 eua ____________ ___ 5 2 1 Fl CI O C C p uu u uu uuu 5 2 2 PAPET lai y 6 2 2 1 General Instructions for Completing Paper Claims r 6 2 3 eMedNy lt 150002 Um 8 2 4 Physician Services Billing 5 2 8 2 4 1 Instructions for the Submission of Medicare Crossover 2 nennen rrr nnne nnne 8 2 4 2 eMedNY 150002 Claim Form Field 5 9 3 Explanation of Paper Remittance Advice 5 00 38 3 1 Section One Medicaid MEL M M 39 31 1 Medicaid Check Stub Field DeSSHDEIONS cecus _ ee 40 3 1 2 Medicaid Check Field Descriptions 40 3 2 Section One EFT NOtITICAUOT 41 3 2 1 EFT Notification Page Field
7. Field 24J should containthe Medicare Approved amount andfield 24k should contain the Medicare payment amount Codez Medicare Approved Service Field 24J should containthe Medicare Approved amount andfield 24K should contain the Medicare payment amount Lode 3 Medicare denied payment or did not cover the service Field 24 should containthe amount charged and field 24K should contain 50 00 Code 3 Medicare denied payment did not cover the service Field 24 should containthe amount charged and field 24K should contain 0 00 Code 3 Medicare denied payment did not cover the service Field 24 should containthe amount charged and field 24K should contain 50 00 PHYSICIAN Page 29 of 79 Code 1 Other Insurance involvement Field 24L must be lett blank Code 2 Other Insurance involved Field 24L should containtheamount paid by the other insurance or 0 00 ifthe other insurance did not coverthe service or deniedpayment You mustindicate the two digit insurance code Code3 Indicates patient s participation Field 241 should contain the patient s participation amount If Other Insurance is alsa involved enter thetotal payments in 24L and enter two digit insurance code Code 1 No Other Insurance involvement Field 24L must be left blank Code 2 Other Insurance invalved Field 24L should containtheamount paid by the other insurance 0 00 ifthe other insurance didnot
8. Date of Birth Field 2 Enter the patient s birth date This information may be obtained from the Client s Patient s Common Benefit ID Card The birth date must be in the format MMDDYYYY as shown in Exhibit 2 4 2 1 Exhibit 2 4 2 1 OF BIRTH Patient s Sex Field 5A Place an X in the appropriate box to indicate the patient s sex This information may be obtained from the Client s Patient s Common Benefit ID Card Medicaid Number Field 6A Enter the patient s ID number Client ID number This information may be obtained from the Client s Patient s Common Benefit ID Card Medicaid Client ID numbers are assigned by NYS Medicaid and are composed of 8 characters in the format AANNNNNA where A alpha character and numeric character as shown in Exhibit 2 4 2 2 Exhibit 2 4 2 2 Was Condition Related To Field 10 If applicable place an X in the appropriate box to indicate whether the service rendered to the patient was for a condition resulting from an accident or a crime Select the boxes in accordance with the following Patient s Employment Use this box to indicate Worker s Compensation Leave this box blank if condition is related to patient s employment but not to Worker s Compensation PHYSICIAN Version 2010 01 5 31 2010 Page 19 of 79 CLAIMS SUBMISSION Crime Victim Use this box to indicate that the condition treated was the result of an assault or crime Auto Accide
9. Dp Cocke OCCUPATION CH ZCEDCOL E OTHER HEALTH SUES Cee ae rara Par farm Prraig Zt NAME OF FRG WHERE hama 22 A DAGNOSECRNITURECF LLNESS 015121011 11191910 5 M CONDITIONRELATED TO PATIENT EMPLOTMENT DATE PATIENT RETURN TO ADORESS OF FROLITE POSSIBLE DISABILITY CLAIMS SUBMISSION ORIGINAL CLAIM REFERENCE NUMBER IMSLIRETFS nama Biz z rnama 8 EO CARE MEE BE amp ER OR OCCUPRTION NELIELKE BDOREEZ zm Sime Zip Code OUTSIDE TIRA OFFICE en DIAGNOSIS CODE mmm senes nos anadi inn a iris 0 1 219 0 9 pU PEE fait 25 CERTIFICATION CERTE THAT THE ET ANDARE WADE APART THE APPLY TO THES BILL James Strong SIGHATURE OF FHS GAN OR SUPA 253 IDENTIFICATION Version 2010 01 1816 2 11816 2 EUFLOYERIDENTIRCHTIONN MEER SOGAL SECLRITY im MY FEE Hes PHYSICIAN Page 11 of 79 31 PHACA OA ADDRES James Strong 312 Main
10. NUMBER XX12345X Exhibit 3 5 1 DICAID MANAGEMENT INFORMATION amp YSTEM MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT DATE SERVICE 05 11 10 05 12 10 05 14 10 05 15 10 PROC CODE 208524 91105 20945 TCN 07206 000000227 0 0 07206 000011234 0 0 07206 000013556 0 0 07206 000032456 0 0 DENIED DENIED DENIED 162 20 0 00 0 00 0 00 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS PHYSICIAN Page 47 of 79 UNITS CHARGED 1 000 1 000 1 000 1 000 PAGE 02 05 31 2010 CYCLE 1710 ETIN PRACTITIONER PROV ID 00112233 1123455788 REMITTANCE NO 07080600005 PAID 0 00 0 00 0 00 0 00 STATUS DENY DENY DENY DENY ERRORS 00162 00244 00244 00162 00131 52 80 17 60 14 30 PREVIOUSLY PENDED CLAIM NEWPEND 5 31 2010 REMITTANCE ADVICE Exhibit 3 5 2 TO JAMES deeds M D 100 BROADWA AMYTOUWN NEW YORK 11111 NO M i o Version 2010 01 OFFICE ACCOUNT CLIENT NUMBER NAME CP111111 DOE 222222 SAMPLE Crass EXAMPLE CPAMM SPECIMEN CPTTTTTI STANDARD 555555 MODEL TOTAL AMOUNT ORIGINAL CLAIMS NET AMOUNT ADJUSTMENTS AMOUNT VOIDS NET AMOUNT VOIDS ADJUSTS CLIENT ID NUMBER 123455 XX45675X 07200 200008767 2 22 TON 07206 000033867 22 9 07206 000033067 29 9 07206 000045067 2 2 07206 0000586767 2 2 DATE SERVICE 051110 12 0 0
11. The ETIN and the associated certification qualify the provider to submit claims in both electronic and paper formats Information about these requirements is available at www emedny org by clicking on the link to the webpage as follows Information for Providers 2 2 4 General Instructions for Completing Paper Claims Since the information entered on the claim form is captured via an automated data collection process imaging it is imperative that entries are legible and placed appropriately in the required fields The following guidelines will help ensure the accuracy of the imaging output All information should be typed or printed Alpha characters letters should be capitalized Numbers should be written as close to the example below in Exhibit 2 2 1 1 as possible Exhibit 2 2 1 1 Circles the letter O the number 0 must be closed Avoid unfinished characters See the example in Exhibit 2 2 1 2 Exhibit 2 2 1 2 Written As Intended As Interpreted As 6 6 00 6 6 0 Zero interpreted as six When typing or printing stay within the box provided ensure that no characters letters or numbers touch the claim form lines See the example in Exhibit 2 2 1 3 PHYSICIAN Version 2010 01 5 31 2010 Page 6 of 79 _ CLAIMS SUBMISSION Exhibit 2 2 1 3 Intended As Interpreted As wo interpreted as seven gt hree interpreted as two Characters should not touch e
12. IF YOU HAVE RECEIVED THIS COMMUNICATION IM ERROR PLEASE IMMEDIATELY NOTIFY NYHIPPADESK CSC COM OR CALL 1 800 541 2831 PROVIDERS WHO DO MOT HAVE ACCESS E MAIL SHOULD CONTACT 1 800 343 9000 PHYSICIAN Version 2010 01 5 31 2010 Page 45 of 79 REMITTANCE ADVICE 3 4 1 Provider Notification Field Descriptions Upper Left Corner Provider s Name Address as recorded in the Medicaid files Upper Right Corner Remittance Page Number Date The date on which the remittance advice was issued Cycle Number The cycle number should be used when calling the eMedNY Call Center with questions about specific processed claims or payments ETIN not applicable Name of Section PROVIDER NOTIFICATION PROV ID This field will contain the Medicaid Provider ID and the NPI Remittance Number Center Message Text PHYSICIAN Version 2010 01 5 31 2010 Page 46 of 79 REMITTANCE ADVICE 3 5 Section Three Claim Detail This section provides a listing of all new claims that were processed during the specific cycle plus claims that were previously pended and denied during the specific cycle TO JAMES STRONG M D 100 BROADWAY NEW YORK 11111 LN NO 01 01 01 01 OFFICE ACCOUNT NUMBER 111111 CP222222 CP333333 E CLIENT NAME DOE SAMPLE EXAMPLE SPECIMEN TOTAL AMOUNT ORIGINAL CLAIMS MET AMOUNT ADJUSTMENTS MET AMOUNT VOIDS MET AMOUNT VOIDS ADJUSTS Version 2010 01 CLIENT ID
13. Street Z M York 11111 5 31 2010 CLAIMS SUBMISSION Exhibit 2 4 2 1 2 MEDICAL ASSISTANCE HEALTH INSURANCE ORIGINAL CLAIM REFERENCE NUMBER CLAIM FORM TITLE XIX PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION LEATENTS MARS er cu ix 1 DATE z ce JANE SMITH XPASTENTZ Ze Sue Iip Cooke ITERE EER MEDICARE NUMER PRIWATE EC FATEHTIREPLOYER OCCUPATION OF SCHOOL amp EMPLOYER OR OGCURATION LOTR EE HEALTH ISSUANCE CO Ae rara ci Pica Par liar arc sce arc rarir uniber Waly 3uq oogwg Td LS LON 15 FIRST CONSULTED TH AAG PATIENT FOR COMOT ION SAME OR SMLAR FNPT XL NATIONAL PROS GIDE 1 OF FATT WHERE SERVICES RENDERED M afar aiia ADDRES OF WAS LEORA ORE WORK FERFORIUET OUTSIDE TOUR OFFICE CEPR Ene PROF ENTFERNEN MEE 0 1 219 0 9 it 913161019 1115 010 02 to CERTIFICATION LOCEPT ASSIGNMENT CH 28 PAC CERTF Y THAT THE STATEMENTS ON THE IDE APPLY TO THE BILL AND ARE MADE A PART KL EMFPLO YERIDENTIFICAT CHA 3t PHY elc BM OR SLIEPLERPES ADDRESS ZIP CODE James Strong BOCAL SEGUATY MEER Jam
14. claim to deny Also the persons completing the form should check to see that all five copies are legible Each required field or blank must be completed in order to ensure payment fa woman is not currently Medicaid eligible at the time she signs the 1055 3134 or LDSS 3134 S form but becomes eligible prior to the procedure and if she is 21 years of age when the form was signed the 30 day waiting period starts from the date the LDSS form was signed regardless of the date the woman becomes Medicaid eligible A sample Sterilization Consent Form and step by step instructions follow on the next pages PHYSICIAN Version 2010 01 5 31 2010 Page 67 of 79 LDSS 3134 2 01 STERILIZATION CONSENT FORM HOSPITAL CLINIC NOTICE APPENDIX C STERILIZATION CONSENT FORM CHART NO RECIPIENT ID NO YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS m CONSENT TO STERILIZATION m have asked for and received information about sterilization from 2 When asked for the doctor or clinic information was told that the decision to be sterilized is completely up to me was told that could decide not to be sterilized If decide not to be sterilized my decision will not affect my right to future care or treatment 1 will not lose any help or benefits from programs receivi
15. claims and providing extensive support and convenience for its users CSC is the eMedNY contractor and is responsible for its operation The information contained within this document was created in concert by eMedNY DOH and eMedNY CSC More information about eMedNY can be found at www emedny org PHYSICIAN Version 2010 01 5 31 2010 Page 79 of 79
16. coverthe service or denied payment You must indicate the two digit insurance code Code 3 Indicates patient s the patient s participation amount If Other Insurance is also involved enterthe total payments 241 and enter the two digit insurance cade Code 1 Mo Other Insurance involvement Field 241 must be left blank 2 Other Insurance involved Field 241 Should containthe amount paid by the other insurance 0 00 ifthe other insurance did not coverthe service or denied payment You must indicate the two digit insurance code Code 3 Indicates patient s participation Field 24L should contain the patient s participation amount If Other Insurance is also involved enterthe total payments 241 and enter the two digit insurance code 5 31 2010 CLAIMS SUBMISSION Encounter Section Fields 24A to 240 The claim form can accommodate up to seven encounters with a single patient plus a block of encounters in a hospital setting if all the information in the Header Section of the claim Fields 1 23B applies to all the encounters The following instructions apply to drug code claims only NDC in field 20 and the associated information in fields 20A through 20C must correspond directly to information on the first line of fields 24A through 241 Only the first line of fields 24A through 241 may be used for drug code billing Only one drug code claim may be submitted per 1
17. not obtained because the hysterectomy was performed in a life threatening emergency in which prior acknowledgment was not possible check this box and briefly describe the nature of the emergency This waiver may apply to cases in which the woman was not a Medicaid recipient at the time the hysterectomy was performed Field 13 If the patient s Acknowledgment was not obtained because she was not a Medicaid recipient at the time a hysterectomy was performed but the performing surgeon did inform her before the procedure that the hysterectomy would make her permanently incapable of reproducing check this box Field 14 The surgeon who performed the hysterectomy must sign the form to certify that the procedure was for medical necessity and not primarily or secondarily for family planning purposes and that one of the conditions indicated in Fields 11 12 and 13 existed PHYSICIAN Version 2010 01 5 31 2010 Page 77 of 79 e KNOWLEDGEMENT OF RECEIPT OF HYSTERECTOMY INFO FORM Field 15 Enter the date of the surgeon s signature PHYSICIAN Version 2010 01 5 31 2010 Page 78 of 79 EMEDNY INFORMATION eMedNY is the name of the electronic New York State Medicaid system The eMedNY system allows New York Medicaid providers to submit claims and receive payments for Medicaid covered services provided to eligible clients eMedNY offers several innovative technical and architectural features facilitating the adjudication and payment of
18. prescribed Periodic examinations associated with a contraceptive method Visits during which sterilization or other methods of birth control are discussed Sterilization procedures This field must always be completed Place an X in the YES box if all services being claimed are family planning services Place an X in the NO box if at least one of the services being claimed is not a family planning service If some of the services being claimed but not all are related to Family Planning place the modifier FP in the two digit space following the procedure code in Field 24D to designate those specific procedures which are family planning services PHYSICIAN Version 2010 01 5 31 2010 Page 26 of 79 CLAIMS SUBMISSION Prior Approval Number Field 23A If the provider is billing for a service that requires Prior Approval Prior Authorization enter in this field the 11 digit prior approval number assigned for this service by the appropriate agency of the New York State Department of Health If several service dates and or procedures need to be claimed and they are covered by different prior approvals a separate claim form has to be submitted for each prior approval NOTES For information regarding how to obtain Prior Approval Prior Authorization for specific services please refer to Information for Providers Inquiry section on the web page for this manual which can be found at www emedny org by clicking o
19. sterilization procedure Field 8 The patient must sign the form PHYSICIAN Version 2010 01 5 31 2010 Page 69 of 79 APPENDIX STERILIZATION CONSENT FORM Field 9 Enter the date of patient s signature This is the date on which the consent was obtained The sterilization procedure must be performed no less than 30 days nor more than 180 days from this date except in instances of premature delivery 23 or emergency abdominal surgery 24 25 when at least 72 hours three days must have elapsed Field 10 Completion of the race and ethnicity designation is optional Interpreter s Statement Field 11 If the person to be sterilized does not understand the language of the consent form the services of an interpreter will be required Enter the language employed Field 12 The interpreter must sign and date the form Statement of Person Obtaining Consent Field 13 Enter the patient s name Field 14 Enter the name of the sterilization operation Field 15 The person who obtained consent from the patient must sign and date the form If the sterilization is to be performed in New York City this person cannot be the operating physician 26 Field 16 Enter the name of the facility with which the person who obtained the consent is associated This may be a clinic hospital Midwife s or physician s office Field 17 Enter the address of the facility PHYSICIAN Version 2010 01 5 31 2010 Page 70 of
20. the Current Balances listed above PHYSICIAN Version 2010 01 5 31 2010 Page 58 of 79 REMITTANCE ADVICE 3 Section Five Edit Error Description The last section of the Remittance Advice features the description of each of the edit codes including approved codes failed by the claims listed in Section Three TO JAMES STRONG M D 100 BROADWAY ANY TOWN NEW YORK 11111 MEDICAL ASSISTANC Exhibit 3 7 1 DICAID MAM I FOAMS TOM fre T E FN E TITLE ALA PROGRAM REMITTANCE STATEMENT PAGE DATE 05 31 10 CYCLE 1710 ETIN PRACTITIONER EDIT DESCRIPTIONS PROV ID 00112233 1123456789 REMITTANCE 070806000065 THE FOLLOWING 15 DESCRIPTION OF THE EDIT REASON CODES THAT APPEAR ON THE CLAIMS FOR THIS REMITTANCE 00131 PROVIDER NOT APPROVED FOR SERVICE 00142 SERVICE CODE NOT EQUAL PA 00162 RECIPIENT INELIGIBLE ON DATE OF SERVICE 00244 PANOT OR REMOVED FROM FILE Version 2010 01 PHYSICIAN Page 59 of 79 5 31 2010 APPENDIX A CLAIM SAMPLES APPENDIX A CLAIM SAMPLES The eMedNY Billing Guideline Appendix A Claim Samples contains an image of a claim with sample data PHYSICIAN Version 2010 01 5 31 2010 Page 60 of 79 APPENDIX CLAIM SAMPLE MEDICAL ASSISTANCE HEALTH INSURANCE ONLY TO BE CLAIM FORM TITLE XIX PROGRAM PATIENT AND IN SU RED SUBSCRIBER INFORMATION L ESTE m oUm TE CUT UE JANE SMITH ESTES SCORES
21. the patient is covered by other insurance and the insurance carrier s paid for the service add the Other Insurance payment to the Patient Participation amount and enter the sum in this field If the other insurance carrier denied payment enter 0 00 in field 24L Proof of denial of payment must be maintained in the patient s billing record Zeroes must also be entered in this field if any of the following situations apply Prior to billing the insurance company the provider knows that the service will not be covered because The provider has had a previous denial for payment for the service from the particular insurance policy However the provider should be aware that the service should be billed if the insurance policy changes Proof of denials must be maintained in the patient s billing record Prior claims denied due to deductibles not being met are not to be counted as denials for subsequent billings n very limited situations the Local Department of Social Services LDSS has advised the provider to zero fill other insurance payment for same type of service This communication should be documented in the patient s billing record The provider bills the insurance company and receives a rejection because service is not covered or The deductible has not been met The provider cannot directly bill the insurance carrier and the policyholder is either unavailable to or uncooperative in submitting claims t
22. 31 2010 D REMITTANCE NO 07080600006 PROVID 00112233 1 123456789 BLA Pd MEM T INFORMATION SYSTEM PAYMENT WILL BE RECEIVED THIS CYCLE SEE REMITTANCE FOR DETAILS JAMES STRONG M D 100 BROADWAY ANY TOWN 11111 PHYSICIAN Version 2010 01 Page 43 of 79 5 31 2010 ADVICE 3 3 1 Summout No Payment Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Date The date on which the remittance advice was issued Remittance Number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Notification that no payment was made for the cycle no claims were approved Provider s Name Address PHYSICIAN Version 2010 01 5 31 2010 Page 44 of 79 REMITTANCE ADVICE 3 4 Section Two Provider Notification This section is used to communicate important messages to providers Exhibit 3 4 1 PAGE 01 DICAID s MEDICAL ASSISTAMCE TITLE XIX PROGRAM TO JAMES STRONG M D s Ni 100 BROADWAY PROVIDER NOTIFICATION ANYTOWNM NEW YORK 11111 PROV ID 0011225371 123456879 REMITTANCE NO 7080600006 REMITTAMCE ADVICE MESSAGE TEXT ELECTRONIC FUNDS TRANSFER EFT FOR PROVIDER PAYMENTS IS NOW AVAILABLE PROVIDERS WHO ENROLL EFT WILL HAVE THEIR MEDICAID PAYMENTS DIRECTLY DEPOSITED IMTO THEIR CHECKING OR SAVINGS ACCOUNT THEEFT TRANSACTIONS WILL BE INITIATED
23. 5 05 10 EUST MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT PROC CODE 911 99441 99111 88281 CYCLE HU 25571 2 1123456769 23 05 31 2010 1710 REMITTANCE 07 UNITS CHARGED FAD 1 000 1 000 1 000 1 000 1 000 1 000 147 40 NUMBER CLAIMS 3 60 NUMBER OF CLAIMS FAID 0 20 NUMBER OF CLAIMS 36 gt NUMBER OF CLAIMS PHYSICIAN Page 48 of 79 14 30 4 9 52 80 17 60 14 39 14 22 14 30 ax 17 60 14 00 STATUS AID FAID AD ADJT ADJT ERRORS IGINAL CLAIM FAID 05 74 10 oc Slat CLAIM 5 31 2010 REMITTANCE ADVICE Exhibit 3 5 3 JAMES STRONG 100 BROADWAY ANYTOWN NEW YORK 11111 DICAID FUTT IN FORMATION F MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT PAGE 04 DATE CYCLE 1710 ETIN PRACTITIONER 05 31 2010 PROV ID Q0112233 1123456873 LN NO 01 02 OFFICE ACCOUNT NUMBER CP111111 CF331333 CP444444 NAME DOE SAMPLE EXAMPLE SPECIMEN CLIENT ID NUMBER TCN UT 206 000033467 0 0 07206 000033468 0 0 UT 206 XXX 35565 0 0 UT 206 XXXI335560 0 0 DATE OF SERVICE 08 11 10 08 12 10 08 14 10 05 15 10 PROC CODE 30828 50514 91105 91105 1 000 1 000 1 000 1 000 59 30 71 04 14 30 14 32 UNITS CHARGED P
24. 5 through 34 must apply to all claim lines entered in the Encounter Section of the form PHYSICIAN Version 2010 01 5 31 2010 Page 34 of 79 CLAIMS SUBMISSION Certification Signature of Physician or Supplier Field 25 The billing provider or authorized representative must sign the claim form Rubber stamp signatures are not acceptable Please note that the certification statement is on the back of the form Provider Identification Number Field 25A Enter the provider s 10 digit National Provider Identifier NPI Medicaid Group Identification Number Field 25B For a Group Practice enter the NPI assigned to the group in this field A claim should be submitted under the Group ID only if payment for the service s being claimed is to be made to the group In such case the NPI of the group member that rendered the service must be entered in field 25A For a Shared Health Facility enter the NPI assigned to the facility If the provider or the service s rendered is not associated with a Group Practice or a Shared Health Facility leave this field blank Locator Code Field 250 For electronic claims leave this field blank For paper claims enter the locator code assigned by NYS Medicaid Locator codes are assigned to the provider for each service address registered at the time of enrollment in the Medicaid program or at any time afterwards that a new location is added Enter the locator code that corresponds to the add
25. 50002 claim form however other procedures may be billed on the same claim Date of Service Field 24A Enter the date on which the service was rendered in the format MM DD YY NOTE A service date must be entered for each procedure code listed Place of Service Field 24B This two digit code indicates the type of location where the service was rendered Please note that place of service code is different from locator code Select the appropriate codes from Appendix B Code Sets NOTE If code 99 Other Unlisted Facility is entered in this field for any claim line the exact address where the procedure was performed must be entered in fields 21 and 21A Procedure Code Field 24C This code identifies the type of service that was rendered to the patient Enter the appropriate five character procedure code in this field NOTE Procedure codes definitions prior approval requirements if applicable fees etc are available at www emedny org by clicking on the link to the webpage as follows Physician Manual PHYSICIAN Version 2010 01 5 31 2010 Page 30 of 79 CLAIMS SUBMISSION MOD Modifier Fields 24D 24E 24F and 24G Under certain circumstances the procedure code must be expanded by a two digit modifier to further explain or define the nature of the procedure If the Procedure Code requires the addition of modifiers enter one or more up to four modifiers in these fields Special Instructions for Claiming Medicar
26. 79 APPENDIX C STERILIZATION CONSENT FORM Physician s Statement The physician should complete and date this form after the sterilization procedure is performed Field 18 Enter the patient s name Field 19 Enter the date the sterilization procedure was performed Field 20 Enter the name of the sterilization procedure Instructions for Use of Alternative Final Paragraphs If the sterilization was performed at least 30 days from the date of consent 9 then cross out the second paragraph and sign 26 and date the consent form If less than 30 days but more than 72 hours has elapsed from the date of consent as a consequence of either premature delivery or emergency abdominal surgery proceed as follows Field 21 Specify the type of operation Field 22 Select one of the check boxes as necessary Field 23 If the sterilization was scheduled to be performed in conjunction with delivery but the delivery was premature occurring within the 30 day waiting period check box one 22 and enter the expected date of delivery 23 Field 24 If the patient was scheduled to be sterilized but within the 30 day waiting period required emergency abdominal surgery and the sterilization was performed at that time then check box two 22 and describe the circumstances 25 Field 25 Describe the circumstances of the emergency abdominal surgery PHYSICIAN Version 2010 01 5 31 2010 Page 71 of 79 APPENDIX C STERILIZATIO
27. AID 0 00 0 00 0 00 0 00 PEND TOTAL AMOUNT ORIGINAL CLAIMS NET AMOUNT ADJUSTMENTS NET AMOUNT VOIDS NET AMOUNT VOIDS ADJUSTS REMITTANCE TOTALS PRACTITIONER YOIDS ADJUSTS TOTAL PENDS TOTAL PAID TOTAL DENIED NET TOTAL PAID MEMBER 00112233 YOIDS ADJUSTS TOTAL PENDS TOTAL FAID TOTAL DENIED NET TOTAL PAID Version 2010 01 168 34 0 00 0 00 0 00 3 60 168 54 147 47 152 20 143 80 3 60 168 94 147 40 162 20 143 80 NUMBER CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS PHYSICIAN Page 49 of 79 Eo dm REMITTANCE NO 07020500000 STATUS PEND PEND PEND PEND ERRORS 00162 00162 00142 00131 PREVIOUSLY CLAIM HEW PEND 5 31 2010 Exhibit 3 5 4 DICAID DATE 05340 CYCLE 1710 INFORMATION MEDICAL ASSISTANCE TITLE XIX PROGRAM ETIN TO JAMES STRONG MITTANCE STATEMENT PRACTITIONER 100 BROADWAY REMITTANCE STATEMENT GRAND TOTALS ANYTOWN NEW YORK 11111 PROV ID 00112233 1123456789 REMITTANCE NO 07080600006 REMITTANCE TOTALS GRAND TOTALS VOIDS ADJUSTS 3 60 NUMBER OF CLAIMS TOTAL FENDS 168 94 NUMBER OF CLAIMS TOTAL PAID 147 40 NUMBER OF CLAIM
28. ART H MUST BE COMPLETED Part i RECIPIENT S ACKNOWLEDGEMENT STATEMENT AMD SURGEON S CERTIFICATION RECIPIENT S ACKNOWLEDGEMENT STATEMENT It has been explained ta __3 that the hysterectomy to be performed on me will RECIPIEMT make itimpoassible formeto become pregnant orbear children understandthat a hysterectomy is a permanent operation Thereasonforperfonningthe hysterectomy andthe discomforts risks and benefits associated withthe hysterectomy have been explained to and all my questions have been answered to my satisfaction prior to the surgery 4 RECIPIENT OR REPRESENTATIVE 5 DATE 5 INTER PRETER S SIGNATURE If required SIGNATURE x X SURGEON S CERTIFICATION The hysterectomy to be performedfor the above mentioned recipientis solely for medical indications The hysterectomy is not primarily or secondarily for family planning reasons that for rendering the recipient permanently incapable of reproducing Part 11 WAIVER OF ACKNOWLEDGEMENT AND SURGEON S CERTIFICATION The hysterectomy performed on 10 was solely for medical reasons The RECIPIENT hysterectomy was not primarily secondarily forfamil y planningreas ons that 15 forrendering the recipient permanently incapable of reproducing didnot obtain amp cknowledgement of Receipt of Hysterectomy information from her and have her complete Part of this form because please check the appropriate statement and describe the circum
29. E TRANS TYPE DATE AMOUNT 10006022004 T XXX RECOUPMENT REASON DESCRIPTION 05 09 10 5 NET FINANCIAL TRANSACTION AMOUNT 553 35 NUMBER OF FIMANCIAL TRANSACTIONS PHYSICIAN Version 2010 01 5 31 2010 Page 55 of 79 REMITTANCE ADVICE 3 6 1 1 Explanation of Financial Transactions Columns FCN This is a unique identifier assigned to each financial transaction Financial Reason Code This code is for DOH CSC use only it has no relevance to providers It identifies the reason for the recoupment Financial Transaction Type This is the description of the Financial Reason Code For example Third Party Recovery Date The date on which the recoupment was applied Since all the recoupments listed on this page pertain to the current cycle all the recoupments will have the same date Amount The dollar amount corresponding to the particular fiscal transaction This amount is deducted from the provider s total payment for the cycle 3 6 1 2 Explanation of Totals Section The total dollar amount of the financial transactions Net Financial Transaction Amount and the total number of transactions Number of Financial Transactions appear below the last line of the transaction detail list The Net Financial Transaction Amount added to the Claim Detail Grand Total must equal the Medicaid Check or EFT amounts PHYSICIAN Version 2010 01 5 31 2010 Page 56 of 79 REMITTANCE ADVICE 3 6 2 Accounts Receivable This subsection
30. EMITTANCE NUMBER PROVIDER ID HO 2010 05 31 07080600006 00112233 1123456789 VOID AFTER 50 DAYS JAMES STRONG M D 100 BROADWAY DICAID ANYTOWN NY 11111 MANAGEMEN IN FORAM ATION MEDICAL ASSISTANCE TITLE PROGRAM John Smi th CHECKS DRAWN ON KEY BANK 50 STATE STREET ALBANY NEW YORK 12207 PHYSICIAN Version 2010 01 5 31 2010 Page 39 of 79 REMITTANCE ADVICE 3 1 1 Medicaid Check Stub Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Date The date on which the remittance advice was issued Remittance Number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Medicaid Provider ID NPI Date Provider s Name Address 3 1 2 Medicaid Check Field Descriptions Left Side Table Date The date on which the check was issued Remittance Number Provider ID No This field will contain the Medicaid Provider ID and the NPI Provider s Name Address Right Side Dollar Amount This amount must equal the Net Total Paid Amount under the Grand Total subsection plus the total sum of the Financial Transaction section PHYSICIAN Version 2010 01 5 31 2010 Page 40 of 79 REMITTANCE ADVICE 3 2 Section One EFT Notification For providers who have selected electronic funds transfer or direct deposit an EFT transaction is processed when the provider has claims approved during the cycle and the appr
31. HOM RELATED TO HL IMELIBELDKE ADDRES mee Simba Zn Godel 22 LABORATORY WORM FERFORIUED OUTSIDE YOUR OFFICE BABQUNT PED 31 EMFLOYERIDENTIFECAT KON H PHYSICA SUPPLE HAIE ZIP CODE James Strong M D 312 Main Street Anytown New York 11111 EXT PHYSICIAN Page 15 of 79 5 31 2010 CLAIMS SUBMISSION 2 4 2 2 Void A void is submitted to nullify a individual claim lines originally submitted on the same document record and sharing the same TCN When submitting a void please follow the instructions below The void must be submitted a new claim form copy of the original form is unacceptable The void must contain all the claim lines to be cancelled and all applicable fields must be completed Voids cause the cancellation of the original TCN history records and payment Exhibit 2 4 2 2 1 and Exhibit 2 4 2 2 2 illustrate an example of a claim being voided TCN 090410123456789 contained two claim lines which were paid on January 29 2009 Later the provider became aware that the patient had other insurance coverage The other insurance was billed and the provider was paid in full for all the services Medicaid must be reimbursed by submitting a void for the two claim lines paid in the specific TCN Exhibit 2 4 2 2 1 shows the claim as it was originally submitted and Exhibit 2 4 2 2 2 shows the claim being submit
32. Leave the last row of Fields 24H 24J 24K 24 blank Consecutive Billing Section Fields 24M to 240 This section may be used for block billing consecutive visits within the SAME MONTH YEAR made to a patient in a hospital inpatient status Inpatient Hospital Visit From Through Dates Field 24M In the FROM box enter the date of the first hospital visit in the format MM DD YY In the THROUGH box enter the date of the last hospital visit in the format MM DD YY Proc Code Procedure Code Field 24N If dates were entered in 24M enter the appropriate five character procedure code for the visit Block billing may be used with the following procedure codes 90238 90240 through 90282 94997 99231 through 99233 99296 through 99297 99433 eec ec cce MOD Modifier Field 240 If the procedure code entered in 24N requires the addition of a modifier to further define the procedure enter the modifier in this field NOTE The last row of Fields 24H 24J 24K and 24L must be used to enter the appropriate information to complete the block billing of Inpatient Hospital Visits For Fields 24J 24K and 24L enter the total Charges Medicare Approved Amount Medicare Paid Amount or Other Insurance Paid Amount that results from multiplying the amount for each individual visit times the number of days entered in field 24M Trailer Section Fields 25 through 34 The information entered in the Trailer Section of the claim form fields 2
33. N CONSENT FORM Field 26 The physician who performed the sterilization must sign and date the form The date of the physician s signature should indicate that the physician s statement was signed after the procedure was performed that is on the day of or a day subsequent to the sterilization For Sterilizations Performed In New York City New York City local law requires the presence of a witness chosen by the patient when the patient consents to sterilization In addition upon admission for sterilization in New York City the patient is required to review his her decision to be sterilized and to reaffirm that decision in writing Witness Certification Field 27 Enter the name of the witness to the consent to sterilization Field 28 Enter the date the witness observed the consent to sterilization This date will be the same date of consent to sterilization 9 Field 29 Enter the patient s name Field 30 The witness must sign the form Field 31 Enter the title if any of the witness Field 32 Enter the date of witness s signature Reaffirmation Field 33 The patient must sign the form PHYSICIAN Version 2010 01 5 31 2010 Page 72 of 79 APPENDIX C STERILIZATION CONSENT FORM Field 34 Enter the date of the patient s signature This date should be shortly prior to or same as date of sterilization in field 19 Field 35 The witness must sign the form for reaffirmation This witness need not be the sam
34. Pediatrics Pediatrics Cardiology Pediatrics Hematology Oncology Pediatrics Surgery Pediatrics Nephrology Pediatrics Neonatal Perinatal Medicine Pediatrics Endocrinology Pediatrics Pulmonology Preferred Physicians and Children Program Moms Medicaid Obstetrical amp Maternal Service Program Pediatrics Pediatric Critical Care Moms Health Supportive Services Directly Observed Therapy Physician Child Psychology Psychiatry Child Neurology Psychiatry and Neurology Clozapine Case Manager Therapeutic Radiology Managed Care Physician Enhanced Fee Primary Care Services CHAP Child Health Assurance Program PHYSICIAN 5 31 2010 Page 64 of 79 APPENDIX B CODE SETS sterilization Abortion Codes Code Description Induced Abortion Dangerto the woman s life Induced Abortion Physical health damage to the woman B C Induced Abortion Victim of rape or incest D Induced Abortion Medically necessary Induced Abortion Elective i e not considered medically necessary by the attending physician provision of elective abortions 15 restricted to New York City recipients Procedure performed for the purpose of sterilization PHYSICIAN Version 2010 01 5 31 2010 Page 65 of 79 State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois lowa Indiana Kansas Kentucky Lou
35. S TOTAL DENY 162 20 NUMBER OF CLAIMS NETTOTAL PAID 143 80 NUMBER OF CLAIMS PHYSICIAN Version 2010 01 5 31 2010 Page 50 of 79 _ REMITTANCE ADVICE 3 5 1 Claim Detail Page Field Descriptions Upper Left Corner Provider s Name Address 5 recorded in the Medicaid files Upper Right Corner Remittance Page Number Date The date on which the remittance advice was issued Cycle Number The cycle number should be used when calling the eMedNY Call Center with questions about specific processed claims or payments ETIN not applicable Provider Service Classification PRACTITIONER PROV ID This field will contain the Medicaid Provider ID and the Remittance Number 3 5 2 Explanation of Claim Detail Columns LN NO Line Number This column indicates the line number of each claim as it appears on the claim form Office Account Number If a Patient Office Account Number was entered in the claim form that number up to 20 characters will appear under this column Client Name This column indicates the last name of the patient If an invalid Medicaid Client ID was entered in the claim form the ID will be listed as it was submitted but no name will appear in this column Client ID Number The patient s Medicaid ID number appears under this column PHYSICIAN Version 2010 01 5 31 2010 Page 51 of 79 ees sere tance ADVICE TCN The TCN is a unique identifier assigned to each claim that is processed If m
36. TH FART HEREC XL BIPLOWER DEAT A 3t PHYSIC ARS OF SUPPLIERS MALE ADDRESS ZIP James Strong Mr James Strong M D IL 312 Main Street deat York 11111 XM FEE BEEN FID EXT 32 PATIEMPE PHYSICIAN Version 2010 01 5 31 2010 Page 14 of 79 MEDICAL ASSISTANCE HEALTH INSURANCE CLAIM FORM TITLE XIX PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION I ESTISP T S Arr 5 RE 4 5 ADDRESS Sue Do __ SCS OTHER HEALTH Brit aT Fur har sce ane rarr Number Waly LON PATIENTS OF AUTHOR HGH IFE 1 amp FIRST OMALT 1 PATENT FOR CONDITION SANE OF SMLAREUETONE 21 OF FALCRLITE WHERE SERVICES RENDERED V oher honaw aria CERTIFICATION CERTIFY THAT THE STATEMENTS ON THE FEVEFEE SIDE APPLY TO TH S HILL AND ARE MADE APART HEREOF James Strong SIGNATURE OF FHS GAA OR ELIPRUL ER PRONTDER NLIUEER 32 AGGOUNT Version 2010 01 CLAIMS SUBMISSION Exhibit 2 4 2 1 4 ORIGINAL CLAIM REFERENCE NUMBER MEDICARE PRIVATE WEBS T
37. WEDNESDAYS AND DUE TO NORMAL BANKING PROCEDURES THE TRANSFERRED FUNDS MAY NOT BECOME AVAILABLE IN THE PROVIDER S CHOSEN ACCOUNT FOR UP TO 48 HOURS AFTER TRANSFER PLEASE CONTACT YOUR BANKING INSTITUTION REGARDING THE AVAILABILITY OF FUNDS PLEASE NOTE THAT EFT DOES NOT WAIVE THE TWO WEEK LAG FOR MEDICAID DISBURSEMENTS TO ENROLL IM EFT PROVIDERS MUST COMPLETE AN EFT ENROLLMENT FORM THAT FOUND AT WWW EMEDNY ORG CLICK ON PROVIDER ENROLLMENT FORMS WHICH CAN BE FOUND INTHE FEATURED LINKS SECTION DETAILED INSTRUCTIONS WILL ALSO BE FOUND THERE AFTER SENDING THE EFT ENROLLMENT FORM TO CSC PLEASE ALLOW MINIMUM TIME OF SIX TO EIGHT WEEKS FOR PROCESSING DURING THIS PERIOD OF TIME YOU SHOULD REVIEW YOUR BANK STATEMENTS AMD LOOK FOR EFT TRANSACTION IN THE AMOUNT OF 0 01 WHICH CSC WILL SUBMIT AS TEST YOUR FIRST REAL EFT TRANSACTION WILL TAKE PLACE APPROXIMATELY FOUR TO FIVE WEEKS LATER IF YOU HAVE ANY QUESTIONS ABOUT THE EFT PROCESS PLEASE CALL THE CALL CENTER AT 1 800 343 8000 NOTICE THIS COMMUNICATION AND ANY ATTACHMENTS MAY CONTAIN INFORMATION THAT 15 PRIVILEGED AND CONFIDENTIAL UNDER STATE AMD FEDERAL LAW AND IS INTENDED ONLY FOR THE THE SPECIFIC INDIVIDUAL S TO WHOM IT 15 ADDRESSED THIS INFORMATION MAY ONLY BE USED OR DISCLOSED IM ACCORDANCE WITH LAW AND YOU MAY BE SUBJECT TO PENALTIES UNDER LAWFOR IMPROPER USE OR FURTHER DISCLOSURE OF INFORMATION IM THIS COMMUNICATION AND ANY ATTACHMENTS
38. ach other as seen in Exhibit 2 2 1 4 Exhibit 2 2 1 4 Written As Intended As Interpreted As gt Entry cannot be 23 illegible interpreted properly Do not write between lines Do not use arrows or quotation marks to duplicate information Do not use the dollar sign 5 to indicate dollar amounts do not use commas to separate thousands For example three thousand should be entered as 3000 not as 3 000 For writing it is best to use a felt tip pen with a fine point Avoid ballpoint pens that skip do not use pencils highlighters or markers Only blue or black ink is acceptable If filling in information through a computer ensure that all information is aligned properly and that the printer ink is dark enough to provide clear legibility e Do not submit claim forms with corrections such as information written over correction fluid or crossed out information If mistakes are made a new form should be used Separate forms using perforations do not cut the edges Do not fold the claim forms Do not use adhesive labels for example for address do not place stickers on the form ee cc Do not write or use staples on the bar code area The address for submitting claim forms is COMPUTER SCIENCES CORPORATION P O Box 4601 Rensselaer NY 12144 4601 PHYSICIAN Version 2010 01 5 31 2010 Page 7 of 79 CLAIMS SUBMISSION 2 3 eMedNY 150002 Claim Form The 150002 form 15 New Yo
39. ay be left blank Instructions for Anesthesia Claims Only For anesthesia each interval of 15 minutes of anesthesia time equals one unit The total number of anesthesia units are computed as follows Determine the number of 15 minute intervals the total time that anesthesia was being administered Add to that result the anesthesia basic value for the procedure PHYSICIAN Version 2010 01 5 31 2010 Page 31 of 79 CLAIMS SUBMISSION Charges Field 24 This field must contain either the Amount Charged or the Medicare Approved Amount Amount Charged When Box M in field 23B has an entry value of 1 or 3 enter the amount charged in this field The Amount Charged may not exceed the provider s customary charge for the procedure Medicare Approved Amount When Box M in field 23B has an entry value of 2 Enter the Medicare Approved Amount in field 24J The Medicare Approved amount is determined as follows If billing for the Medicare deductible the Medicare Approved amount should equal the Deductible amount claimed which must not exceed the established amount for the year in which the service was rendered If billing for the Medicare coinsurance the Medicare Approved amount should equal the sum of the amount paid by Medicare plus the Medicare co insurance amount plus the Medicare deductible amount if any The entries in field 23B Payment Source Code determine the entries in field s 24J 24K and 241 Fie
40. displays the original amount of each of the outstanding Financial Transactions and their current balance after the cycle recoupments were applied If there are no outstanding negative balances this section is not produced Exhibit 3 6 2 1 DICAID MAM ACME INFORMATION SYSTEM TO JAMES STRONG 100 BROADWAY ANYTOWN NEW YORK 11111 MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT ORIG BAL REASON CODE DESCRIPTION in TOTAL AMOUNT DUE THE STATE XXX PHYSICIAN Version 2010 01 Page 57 of 79 Of DATE 05 31 10 CYCLE 1710 ETIN ACCOUNTS RECEIVABLE PROV ID Q01122733 1123455783 REMITTANCE O7 020500005 5 31 2010 REMITTANCE ADVICE 3 6 2 1 Explanation of Accounts Receivable Columns If a provider has negative balances of different types or negative balances created at different times each negative balance will be listed in a different line Reason Code Description This is the description of the Financial Reason Code For example Third Party Recovery Original Balance The original amount or starting balance for any particular financial reason Current Balance The current amount owed to Medicaid after the cycle recoupments if any were applied This balance may be equal to or less than the original balance Recoupment Amount The deduction recoupment scheduled for each cycle Total Amount Due the State This amount is the sum of all
41. e refer to the Policy Guidelines on the web page for this manual which can be found at www emedny org by clicking on the link to the webpage as follows Physician Manual Status Code Field 22E Leave this field blank Possible Disability Field 22F Place an X in the Y box for YES or an in the box for NO to indicate whether the service was for treatment of a condition which appeared to be of a disabling nature the inability to engage in any substantial or gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months EPSDT C THP Field 22G This field must be completed if the physician bills for a periodic health supervision well care examination for a patient under 21 years of age whether billing a Preventive Medicine Procedure Code or a Visit Code with a well care diagnosis If applicable place an X in the Y box for YES Family Planning Field 22H Medical family planning services include diagnosis treatment drugs supplies and related counseling which are furnished or prescribed by or are under the supervision of a physician or nurse practitioner The services include but are not limited to Physician clinic or hospital visits during which birth control pills contraceptive devices or other contraceptive methods are either provided during the visit or
42. e Deductible When billing for the Medicare deductible modifier 027 must be used in conjunction with the Procedure Code for which the deductible is applicable Do not enter the U2 modifier if billing for Medicare coinsurance NOTE Modifier values and their definitions can be found on the web page for this manual under Procedure Codes and Fee Schedule which can be found at www emedny org by clicking on the link to the webpage as follows Physician Manual Diagnosis Code Field 24H Using the International Classification of Diseases Ninth Edition Clinical Modification ICD 9 CM coding system enter the appropriate code which describes the main condition or symptom of the patient The ICD 9 CM code must be entered exactly as it is listed in the manual in the correct spaces of this field and in relation to the decimal point Proper entry of an IDC 9 CM Diagnosis Code is shown in Exhibit 2 4 2 9 Exhibit 2 4 2 9 4H DIAGNOSIS CODE 2 6 8 0 NOTE three digit Diagnosis Code no entry following the decimal point will only be accepted when the Diagnosis Code has no subcategories Otherwise Diagnosis Codes with subcategories MUST be entered with the subcategories indicated after the decimal point Days or Units Field 241 If a procedure was performed and approved by Medicare more than one time on the same date of service enter the number of times in this field If the procedure was performed only one time this field m
43. e person whose signature appears in field 30 Field 36 Enter the date of witness s signature PHYSICIAN Version 2010 01 5 31 2010 Page 73 of 79 KNOWLEDGEMENT OF RECEIPT OF HYSTERECTOMY INFO FORM APPENDIX D ACKNOWLEDGMENT OF RECEIPT OF HYSTERECTOMY INFORMATION FORM LDSS 3113 An Acknowledgment of Receipt of Hysterectomy Information Form LDSS 3113 must be completed for each hysterectomy procedure other form can be used in place of the LDSS 3113 A supply of these forms available in English and in Spanish can be obtained from the New York State Department of Health s website by clicking on the link to the webpage as follows Local Districts Social Service Forms Claims for hysterectomy procedures must be submitted on paper forms and a copy of the completed and signed LDSS 3113 must be attached to the claim When completing the LDSS 3113 please follow the guidelines below Becertain that the form is completed so it can be read easily An illegible or altered form is unacceptable will cause a paper claim to deny Each required field or blank must be completed in order to ensure payment A sample Hysterectomy Consent Form and step by step instructions follow on the next pages PHYSICIAN Version 2010 01 5 31 2010 Page 74 of 79 KNOWLEDGEMENT OF RECEIPT OF HYSTERECTOMY INFO FORM D55 3113 Rev 4 84 ACKNOWLEDGEMENT OF RECEIPT OF HYSTERECTOMY INFORMATION NYS MEDICAID PROGRAM EITHER PART I OR P
44. edicaid in electronic or paper formats Providers are required to submit an Electronic Paper Transmitter Identification Number ETIN Application anda Certification Statement before submitting claims to NYS Medicaid Certification Statements remain in effect and apply to all claims until superseded by another properly executed Certification Statement Providers will be asked to update their Certification Statement on an annual basis Providers will be provided with renewal information when their Certification Statement is near expiration Information about these requirements is available at www emedny org by clicking on the link to the webpage as follows Information for All Providers 2 1 Electronic Claims Pursuant to the Health Insurance Portability and Accountability Act HIPAA Public Law 104 191 which was signed into law August 12 1996 the NYS Medicaid Program adopted the HIPAA compliant transactions as the sole acceptable format for electronic claim submission effective November 2003 Physicians who choose to submit their Medicaid claims electronically are required to use the HIPAA 837 Professional 837P transaction Direct billers should refer to the sources listed below to comply with the NYS Medicaid requirements HIPAA 837P Implementation Guide IG explains the proper use of the 837P standards and program specifications This document is available at www wpc edi com hipaa 5 Medicaid 837P Companion Guide is a sub
45. equences of the procedure Instructions for use of alternative final paragraphs Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the individual s signature on the consent form In those cases the second paragraph below must be used Cross out the paragraph which is not used 1 At least thirty days have passed between the date of the individual s signature on this consent form and the date sterilization was performed This sterilization was preformed less than 30 days but more than 72 hours after the date of the individual s signature on this consent form because of the following circumstances check applicable and fill in information requested 22 the 2 Lj 1 Premature delivery Individual s expected date of delivery 23 Lj 2 Emergency abdominal surgery 24 describe circumstances 25 Physician Date THE FOLLOWING MUST BE COMPLETED FOR STERILIZATIONS PERFORMED IN NEW YORK CITY WITNESS CERTIFICATION do certify that on 28 I was present while the counselor read and explained the consent 9 and saw the patient sign the consent form in his her handwriting patient s name SIGNATURE OF WITNESS 30 REAFFIRMATION to be signed by the patient on admission for Sterilization TITLE DATE I certify that have carefully considered all the information advice and explanatio
46. es Strong SIGHATURE OF GAA OR SUCFLIER PROVIDER DENTAGATION NIE 312 Main Street Anytown New York 11111 EXT LUNT PHYSICIAN Version 2010 01 5 31 2010 Page 12 of 79 SUBMISSION Adjustment to Cancel One or More Claims Originally Submitted on the Same Document Record TCN An adjustment should be submitted to cancel or void one or more individual claim lines that were originally submitted on the same document record and share the same TCN The following instructions must be followed The adjustment must be submitted in a new claim form copy of the original form is unacceptable The adjustment must contain all claim lines submitted in the original document all claim lines with the same TCN except for the claim s line s to be voided these claim lines must be omitted in the adjustment All applicable fields must be completed The adjustment will cause the cancellation of the omitted individual claim lines from the TCN history records as well as the cancellation of the original TCN payment and the re pricing of the new TCN Adjustment based on the adjusted information Exhibit 2 4 2 1 3 and Exhibit 2 4 2 1 4 illustrate an example of a claim with an adjustment being made to cancel a line on submitted on the claim TCN 0902901234567890 contained three individual claim lines which were paid on January 29 2009 Later it was determined that one of the claims was incorrectly billed since the se
47. he patient was not a Medicaid recipient on the day the hysterectomy was performed Field 3 Enter the recipient s name Field 4 The recipient or her representative must sign the form Field 5 Enter the date of signature Field 6 If applicable the interpreter must sign the form Field 7 If applicable enter the date of interpreter s signature PHYSICIAN Version 2010 01 Page 76 of 79 5 31 2010 ACKNOWLEDGEMENT OF RECEIPT OF HYSTERECTOMY INFO FORM Field 8 The surgeon who performed or will perform the hysterectomy must sign the form to certify that the procedure was for medical necessity and not primarily for family planning purposes Field 9 Enter the date of the surgeon s signature Part II Waiver of Acknowledgement The surgeon who performs the hysterectomy must complete this Part of the claim form if Part I the recipient s Acknowledgment Statement has not been completed for one of the reasons noted above This part need not be completed before the hysterectomy is performed Field 10 Enter the recipient s name Field 11 If the recipient s acknowledgment was not obtained because she was sterile prior to performance of the hysterectomy check this box and briefly describe the cause of sterility e g postmenopausal This waiver may apply to cases in which the woman was not a Medicaid recipient at the time the hysterectomy was performed Field 12 If the recipient s Acknowledgment was
48. imba Code Par Mare arc arc Peier orar PATIEHT E EMFLOYIMENT Waly 3u oogvg 1d LS LON ALT SOO DENT 15 FIRST OMALT 11 HAS PATENT EMERGENCY Tr DATE PATENT FOR CONDITION SAME OF SMLAR RETURN TO WORK 21 OF WHERE RENDERED hawa o area E LABORA ORT WORK FERFORIUETD OUTSIDE TIR OFFICE ERE 2E PROF 220 IDENTIFICATION NUMEER OSAST Z3 PRIOR SPPEOMBL NIER Ir I 1313 010 0 1 2 9 0 9 118141618 141i 010 0 0 0 0 1 1219 0 9 SAR I 1 11010 010 25 CERTIFICATION CERTIFY THAT THE STATEMENTS THE APPLY TO THE BILL ANO ARIE FART HEREOF XL EMFLOYERIDENTIFLCAT KHN NLIUEET 3t PHYSIO SMS OR SLIEFLIERES ADDRESS ZIP CODE James Strong James Strong M D SIGNATURE OF FHS GaN RAPAE 258 PROVIDER DENTIR CATION 312 Main Street Anytown New York 11111 FEE HS EEN TELEPHONE HIES BOCOUNT NUM REFERRING ORDERING FANDER PR E D LICENSE HIES PHYSICIAN Version 2010 01 5 31 2010 Page 18 of 79 SUBMISSION Patient s Name Field 1 Enter the patient s first name followed by the last name This information may be obtained from the Client s Patient s Common Benefit ID Card
49. ims for Medicare Medicaid patients to Medicare Medicare will then reimburse its portion to the provider and the provider s Medicare remittance will indicate that the claim will be crossed over to Medicaid Claims for services not covered by Medicare should continue to be submitted directly to Medicaid as policy allows Also Medicare Part C Medicare Managed Care and Medicare Part D claims are not part of this process Providers are urged to review their Medicare remittances for crossovers beginning December 1 2009 to determine whether their claims have been crossed over to Medicaid for processing Any claim that was indicated by Medicare as a crossover should not be submitted to Medicaid as a separate claim If the Medicare remittance does not indicate that the claim has been crossed over to Medicaid the provider should submit the claim directly to Medicaid Claims that are denied by Medicare will not be crossed over Medicaid will deny claims that are crossed over without a Patient Responsibility If a separate claim is submitted directly by the provider to Medicaid for a dual eligible recipient and the claim is paid before the Medicare crossover claim both claims will be paid The eMedNY system automatically voids the provider submitted claim in this scenario Providers may submit adjustments to Medicaid for their crossover claims because they are processed as a regular adjustment PHYSICIAN Version 2010 01 5 31 2010 Page 8 of 79
50. ing provider in this field PHYSICIAN Version 2010 01 5 31 2010 Page 20 of 79 _ CLAIMS SUBMISSION Surgical Assistance If the claim is for surgical assistance services the primary surgeon s name must be entered in this field If no order or referral is involved or the claim is not for surgical assistance leave thisfield blank Address or Signature SHF Only Field 19A If services were rendered in a Shared Health Facility and the patient was referred for treatment or a specialty consultation by another Medicaid provider in the same Shared Health Facility obtain the referring ordering provider s signature in this field If not applicable leave blank Prof CD Professional Code Ordering Referring Provider Field 19B Leave this field blank Identification Number Ordering Referring Provider Field 19C This field must be completed when the claim involves any of the following Ordered Procedure Referred Service Surgical Assistance Ordered Procedures If the service was ordered by another provider see field 19 for the list of ordered procedures enter the ordering provider s National Provider ID NPI in this field Referred Service If the patient was referred for treatment by another physician enter the referring provider s NPI in this field A facility ID cannot be used for the referring ordering provider In those instances where an order or referral was made by a facility the NPI of the practitione
51. isiana Maine Maryland Massachusetts Michigan Minnesota State Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico North Carolina Morth Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin American Territories American Samoa Canal Zone Guam Puerto Rico Trust Territories Virgin Islands NOTE Required only when reporting out of state license numbers PHYSICIAN Version 2010 01 Page 66 of 79 APPENDIX CODE SETS 5 31 2010 APPENDIX C STERILIZATION CONSENT FORM APPENDIX C STERILIZATION CONSENT FORM LDSS 3134 A Sterilization Consent Form LDSS 3134 must be completed for each sterilization procedure No other form can be used in place of the LDSS 3134 A supply of these forms available in English and in Spanish LDSS 3134 S can be obtained from the New York State Department of Health s website by clicking on the link to the webpage as follows Local Districts Social Service Forms Claims for sterilization procedures must be submitted on paper and a copy of the completed and signed Sterilization Consent Form LDSS 3134 or LDSS 3134 S must be attached to the claim When completing the DSS 3134 please follow the guidelines below Becertain that the form is completed so it can be read easily An illegible or altered form is unacceptable will cause a paper
52. ithdrawn at any time and that he she will not lose any health services or any benefits provided by Federal funds To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent He She knowlingly and voluntarily requested to be sterilized and appears to understand the nature and consequence of the procedure Before signed the A Signature of person obtaining Date Facilit 17 Address m PHYSICIAN S STATEMENT m Shortly before performed a sterilization operation of individual to be sterilized Date of sterilization 20 explained to him her the Operation nature of the sterilization operation 21 Specify type of operation fact that it is intended to be a final irreversible procedure and the discomforts risks and benefits associated with it counseled the individual to be sterilized that alternative methods of birth control are available which are temporary explained that sterilization is different because it is permanent informed the individual to be sterilized that his her consent can be withdrawn at any time and that he she will not lose any health services or benefits provided by Federal funds To the best of my knowledge and belief the individual to be sterilized is a least 21 years old and appears mentally competent He She knowingly and voluntarily requested to be sterilized and appeared to understand the nature and cons
53. jects funded by that Department but only for determining if Federal laws were observed I have received of this form 8 9 Signature Month Day Year You are requested to supply the following information but it is not required LO My consent Date Race and ethnicity designation please check 01 American Indian or Alaska Native O 4 Hispanic 2 Asian or Pacific Islander 5 White not of Hispanic origin Black not of Hispanic origin m INTERPRETER S STATEMENT If an interpreter is provided to assist the individual to be sterilized I have translated the information and advice presented orally to the individual to be sterilized by the person obtaining this consent have also read him her the consent form in 11 language and explained its contents to him her To the best of my knowledge and belief he she understood this explanation i Interpreter Date m STATEMENT OF PERSON OBTAINING CONSENTE L3 Name of Individual consent form explained to him her the nature of the sterilization operation 14 the fact that it is intended to be a final and irreversible procedure and the discomforts risks and benefits associated with it counseled the individual to be sterilized that alternative methods of birth control are available which are temporary explained that sterilization is different because it is permanent informed the individual to be sterilized that his her consent can be w
54. l form is unacceptable The adjustment must contain all claim lines originally submitted the same document record all claim lines with the same TCN and all applicable fields must be completed with the necessary changes The adjustment will cause the correction of the adjusted information in the TCN history records as well as the cancellation of the original TCN payment and the re pricing of the TCN based on the adjusted information Exhibit 2 4 2 1 1 and Exhibit 2 4 2 1 2 illustrate an example of a claim with an adjustment being made to change information submitted on the claim TCN 0904101234567890 is shared by three individual claim lines This was paid on February 10 2009 After receiving payment the provider determines that the service date of one of the claim line records is incorrect An adjustment must be submitted to correct the records Exhibit 2 4 2 1 1 shows the claim as it was originally submitted and Exhibit 2 4 2 1 2 shows the claim as it appears after the adjustment has been made PHYSICIAN Version 2010 01 5 31 2010 Page 10 of 79 Exhibit 2 4 2 1 1 MEDICAL ASSISTANCE HEALTH INSURANCE CLAIM FORM TITLE XIX PROGRAM PATIENT AND INSURED SUB SCRIBER INFORMATION LPATENT NUR 5 8 miiir inr JANE SMITH c lt m m ca m gt A HAS PATIENT SAME OR 3MLAREUPTONS OFLA OCDE ADDRES Zum Simip
55. ld 24J must never be left blank or contain zeroes the responsibility of the provider to determine whether Medicare covers the service being billed for If the service is covered or if the provider does not know if the service is covered the provider must first submit a claim to Medicare as Medicaid is always the payer of last resort Unlabeled Field 24K This field is used to indicate the Medicare Paid Amount and must be completed if Box M in field 23B has an entry value of 2 or 3 Box 2 When billing for the Medicare deductible enter 0 00 in this field When billing for the Medicare coinsurance enter the Medicare Paid amount as the sum of the actual Medicare paid amount and the Medicare deductible if any Box 3 Enter 0 00 in this field to indicate that Medicare denied payment or did not cover the service If none of the above situations are applicable leave this field blank PHYSICIAN Version 2010 01 5 31 2010 Page 32 of 79 SUBMISSION Unlabeled Field 241 This field must be completed when Box O in field 23B has an entry value of 2 or 3 When Box O has an entry value of 2 enter the other insurance payment in this field If more than one insurance carrier contributes to payment of the claim add the payment amounts and enter the total amount paid by all other insurance carriers in this field When Box has entry value of 3 enter the Patient Participation amount If
56. le Medicaid is responsible for reimbursing the Medicare deductible and or full or partial coinsurance PHYSICIAN Version 2010 01 5 31 2010 Page 27 of 79 SUBMISSION Patient has Medicare Part B Medicare denied payment Source Code Indicator 3 This code indicates that Medicare denied payment or did not cover the service billed Box O Box O is used to indicate whether the patient has insurance coverage other than Medicare or Medicaid or whether the patient is responsible for a pre determined amount of his her medical expenses The values entered in this box define the nature of the amount entered in field 24L Enter the appropriate indicator from the following list Other Insurance involvement Source Code Indicator 1 This code indicates that the patient does not have other insurance coverage Patient has Other Insurance coverage Source Code Indicator 2 This code indicates that the patient has other insurance regardless of the fact that the insurance carrier s paid or denied payment or that the service was covered or not by the other insurance When the value 2 is entered in Box O the two character code that identifies the other insurance carrier must be entered in the space following Box O If more than one insurance carrier is involved enter the code of the insurance carrier who paid the largest amount For the appropriate Other Insurance codes refer to Information for All Provider
57. n adjustment or a void enter the appropriate Transaction Control Number TCN in this field A TCN is a 16 digit identifier that is assigned to each claim document or electronic record regardless of the number of individual claim lines service date procedure combinations submitted in the document or record For example a document record containing a single service date procedure combination will be assigned a unique single TCN a document record containing five service date procedure combinations will be assigned a unique single TCN which will be shared by all the individual claim lines submitted under that document record 2 4 2 1 Adjustment An adjustment may be submitted to accomplish any of the following purposes To change information contained one or more claims submitted on a previously paid cancel one more claim lines submitted a previously paid except if the contained one single claim line or if all the claim lines contained in the TCN are to be voided PHYSICIAN Version 2010 01 5 31 2010 Page 9 of 79 SUBMISSION Adjustment to Change Information If an adjustment is submitted to correct information on one or more claim lines sharing the same follow the instructions below Provider ID number the Group ID number and the Patient s Medicaid ID number must not be adjusted The adjustment must be submitted in a new claim form copy of the origina
58. n the link to the webpage as follows Physician Manual For information on how to complete the prior approval form please refer to the Prior Approval Guidelines for this manua which can be found at www emedny org by clicking on the link to the webpage as follows Physician Manual For information regarding procedures that require prior approval please consult the Procedure Codes and Fee Schedules which be found on the web page for this manual which be found at www emedny org by clicking on the link to the webpage as follows Physician Manual Payment Source Code Box M and Box 0 Field 23B This field has two components Box M and Box O as shown in Exhibit 2 4 2 7 below Exhibit 2 4 2 7 238 PAYM TI SOURCE CO Mi O Both boxes need to be filled as follows Box M The values entered in this box define the nature of the amounts entered in fields 24J and 24K Box M is used to indicate whether the patient is covered by Medicare and whether Medicare approved or denied payment Enter the appropriate numeric indicator from the following list No Medicare involvement Source Code Indicator 1 This code indicates that the patient does not have Medicare coverage Patient has Medicare Part B Medicare approved the service Source Code Indicator 2 This code indicates that the service is covered by Medicare and that Medicare approved the service and either made a payment or paid 0 00 due to a deductib
59. ndix C Sterilization Consent Form 1055 3134 0 000 0 6 0 67 Sterilization Consent Form 1055 3134 3134 S 69 Appendix D Acknowledgment of Receipt of Hysterectomy Information Form LDSS 3113 74 Acknowledgement Receipt of Hysterectomy Information Form 1055 3113 Instructions 76 For eMedNY Billing Guideline questions please contact the eMedNY Call Center 1 800 343 9000 PHYSICIAN Version 2010 01 5 31 2010 Page 3 of 79 ees PURPOSE STATEMENT 1 Purpose Statement The purpose of this document is to assist the provider community in understanding and complying with the New York State Medicaid NYS Medicaid requirements and expectations for Billing and submitting claims Interpreting and using the information returned in the Medicaid Remittance Advice This document is customized for Physicians and should be used by the provider as an instructional as well as a reference tool For providers new to NYS Medicaid it is required to read the Providers General Billing Guideline Information available at www emedny org by clicking on the link to the webpage as follows Information for Providers PHYSICIAN Version 2010 01 5 31 2010 Page 4 of 79 ExL Lt e LLIO SUBMISSION 2 Claims Submission Physicians can submit their claims to NYS M
60. ng Federal funds such as A F D C or Medicaid that am now getting or for which 1 may become eligible UNDERSTAND THAT THE STERILIZATION MUST CONSIDERED PERMANENT AND NOT REVERSIBLE HAVE DECIDED THAT DO NOT WANT TO BECOME PREGNANT BEAR CHILDREN OR FATHER CHILDREN I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father a child in the future 1 have rejected these alternatives and chosen to be sterilized understand that will be sterilized by an operation know as c 28 The discomforts risks and benefits associated with the operation have been explained to me my questions have been answered to my satisfaction understand that the operation will not be done until at least thirty days after sign this form understand that can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs am at least 21 years of age and was born on l 5 free will to be sterilized by 4 Month Day Year hereby consent of my own 6 Doctor by a method called 7 expires 180 days from the date of my signature below also consent to the release of this form and other medical records about the operation to Representatives of the Department of Health Education and VVelfare or Employees of programs or pro
61. ns given to me at the time originally signed the consent form I have decided that still want to be sterilized by the procedure noted in the original consent form and hereby affirm that decision SIGNATURE OF PATIENT 33 DISTRIBUTION 1 Medical Record File 2 Hospital Claim SIGNATURE OF WITNESS x 3 Surgeon Claim 4 Anesthesiologist Claim 5 Patient PHYSICIAN Version 2010 01 5 31 2010 Page 68 of 79 APPENDIX C STERILIZATION CONSENT FORM STERILIZATION CONSENT FORM LDSS 3134 AND 3134 S INSTRUCTIONS Patient Identification Field 1 Enter the patient s name Medicaid ID number and chart number name of hospital or clinic is optional Consent to Sterilization Field 2 Enter the name of the individual doctor or clinic obtaining consent If the sterilization is to be performed in New York City the physician who performs the sterilization 26 cannot obtain the consent Field 3 Enter the name of sterilization procedure to be performed Field 4 Enter the patient s date of birth Check to see that the patient is at least 21 years old If the patient is not 21 on the date consent is given 9 Medicaid will not pay for the sterilization Field 5 Enter the patient s name Field 6 Enter the name of doctor who will probably perform the sterilization It is understood that this might not be the doctor who eventually performs the sterilization 26 Field 7 Enter the name of
62. nt Use this box to indicate Automobile No Fault Leave this box blank if condition is related to an auto accident other than no fault or if no fault benefits are exhausted Other Liability Use this box to indicate that the condition was related to an accident related injury of a different nature from those indicated above If the condition being treated is not related to any of these situations leave these boxes blank Emergency Related Field 16A Enter an X in the Yes box only when the condition being treated is related to an emergency the patient requires immediate intervention as a result of severe life threatening or potentially disabling condition otherwise leave this field blank Name of Referring Physician or Other Source Field 19 This field should be completed only when claiming the following Ordered Procedure Referred Service Surgical Assistance Ordered Procedures If claiming any of the procedures listed below the name of the ordering provider must be entered in this field If the procedures were performed by the billing physician the billing physician s name should be entered in this field All Radiology Procedures Cardiac Fluoroscopy Echocardiography Non invasive Vascular Diagnostic Studies Consultations Note Consultation codes must not be claimed for a physician s own patient Referred Service If the patient was referred by another provider enter the name of the referr
63. nt or denied A new pend is signified by two asterisks A previously pended claim is signified by one asterisk Errors For claims with a DENY or PEND status this column indicates the NYS Medicaid edit error numeric code s that caused the claim to deny or pend Some edit codes may also be indicated for a PAID claim These are approved edits which identify certain errors found in the claim and that do not prevent the claim from being approved Up to twenty five 25 edit codes including approved edits may be listed for each claim Edit code definitions will be listed on a separate page of the remittance advice at the end of the claim detail section PHYSICIAN Version 2010 01 5 31 2010 Page 53 of 79 REMITTANCE ADVICE 3 5 3 Subtotals Totals Grand Totals Subtotals of dollar amounts and number of claims are provided as follows Subtotals by claim status appear at the end of the claim listing for each status The subtotals are broken down by s fhe Original claims Adjustments Voids Adjustments voids combined Subtotals by provider type are provided at the end of the claim detail listing These subtotals are broken down by e e eee Adjustments voids combined Pends Paid Deny Net total paid for the specific service classification Totals by member ID are provided next to the subtotals for provider type For individual practitioners these totals exactly the same as the subtotals by
64. ntered in the claim form is invalid or logically inconsistent Approved Claims Approved claims will be identified by the statuses PA D ADJT adjustment or VOID PHYSICIAN Version 2010 01 5 31 2010 Page 52 of 79 REMITTANCE ADVICE Paid Claims The status PAID refers to original claims that have been approved Adjustments The status ADJT refers to a claim submitted in replacement of a paid claim with the purpose of changing one or more fields An adjustment has two components the credit transaction previously paid claim and the debit transaction adjusted claim Voids The status VOID refers to a claim submitted with the purpose of canceling a previously paid claim A void lists the credit transaction previously paid claim only Pending Claims Claims that require further review or recycling will be identified by the PEND status The following are examples of circumstances that commonly cause claims to be pended New York State Medical Review required Procedure requires manual pricing match found in the Medicaid files for certain information submitted on the claim for example Patient ID Prior Approval Service Authorization These claims are recycled for a period of time during which the Medicaid files may be updated to match the information on the claim After manual review is completed a match is found in the Medicaid files or the recycling time expires pended claims may be approved for payme
65. nursing facility Nursing facility Custodial care facility Hospice Ambulance land Ambulance air or water Independent clinic Federally qualified health center Inpatient psychiatric facility Psychiatric facility partial hospitalization Community mental health center Intermediate care facility mentally retarded Residential substance abuse treatment facility Psychiatric residential treatment center Non residential substance abuse treatment facility Mass immunization center Comprehensive inpatient rehabilitation facility Comprehensive outpatient rehabilitation facility End stage renal disease treatment facility state local public health clinic Rural health clinic Independent laboratory Other unlisted facility PHYSICIAN Page 63 of 79 5 31 2010 APPENDIX CODE SETS Cn Description Immediate urgent care services rendered in retroactive period Emergency care Glienthas temporary Medicaid Request from county for second opinion to determine If recipient can work Request for override pending special handling Note Code 7 must be used when billing for a physician service with a specialty exempted from the Utilization Threshold Program Exempt specialties are listed below Specialty Codes Exem ted from Utilization Thresholds Code 020 150 151 152 153 154 155 156 15 158 158 161 168 186 181 182 183 196 205 241 249 270 Version 2010 01 Description Anesthesiology
66. o the insurance company In these cases the LDSS must be notified prior to zero filling LDSS has subrogation rights enabling them to complete claim forms on behalf of uncooperative policyholders who do not pay the provider for the services The LDSS office can direct the insurance company to pay the provider directly for the service whether or not the provider participates with the insurance plan The provider should contact the third party worker in the local social services office whenever he she encounters policyholders who are uncooperative in paying for covered services received by their dependents who are on Medicaid In other cases the provider will be instructed to zero fill the Other Insurance Payment in the Medicaid claim and the LDSS will retroactively pursue the third party resource The patient or an absent parent collects the insurance benefits and fails to submit payment to the provider LDSS must be notified so that sanctions and or legal action can be brought against the patient or absent parent The provider is instructed to zero fill by the LDSS for circumstances not listed above PHYSICIAN Version 2010 01 5 31 2010 Page 33 of 79 CLAIMS SUBMISSION If none of the above situations are applicable leave this field blank NOTES tis the responsibility of the provider to determine whether the patient s Other Insurance carrier covers the service being billed for as Medicaid is always the payer of last resort
67. ogram which can be found at www emedny org by clicking on the link to the webpage as follows Physician Manual If not applicable leave this field blank County of Submittal Unnumbered Field Enter the name of the county wherein the claim form is signed The County may be left blank on y when the provider s address is within the county wherein the claim form is signed Date Signed Field 25E Enter the date on which the provider or an authorized representative signed the claim form The date should be in the format MM DD YY NOTE In accordance with New York State regulations claims must be submitted within 90 days of the Date of Service unless acceptable circumstances for the delay can be documented For more information about billing claims over 90 days or two years from the Date of Service refer to Information for All Providers General Billing section which can be found at www emedny org by clicking on the link to the webpage as follows Physician Manual Physician s or Supplier s Name Address Zip Code Field 31 Enter the provider s name and correspondence address using the following rules for submitting the ZIP code Paper claim submissions Enter the 5 digit ZIP code or the ZIP plus four Electronic claim submissions Enter the 9 digit ZIP code The Locator Code will default to 003 if the nine digit ZIP code does not match information in the provider s Medicaid file NOTE It is the responsibility of the provider
68. oved amount is greater than the recoupments if any scheduled for the cycle This section indicates the amount of the EFT Exhibit 3 2 1 TO JAMES STRONG MD DATE 2010 05 31 Al D REMITTANCE NO 07080600008 PROVID 00112233 1123456879 BLA M C3 E INE P IN FORI 00112233 1123456879 2010 05 31 JAMES STRONG M D 100 BROADWAY 11111 JAMES STRONG M D 5143 80 PAYMENT IM THE ABOVE AMOUNT WILL DEPOSITED VIA AN ELECTRONIC FUNDS TRANSFER PHYSICIAN Version 2010 01 5 31 2010 Page 41 of 79 REMITTANCE ADVICE 3 2 1 EFT Notification Page Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Date The date on which the remittance advice was issued Remittance Number PROV ID This field will contain the Medicaid Provider ID and the NPI Center Medicaid Provider ID NPI Date Provider s Name Address Provider s Name Amount transferred to the provider s account This amount must equal the Net Total Paid Amount under the Grand Total subsection plus the total sum of the Financial Transaction section PHYSICIAN Version 2010 01 5 31 2010 Page 42 of 79 REMITTANCE ADVICE 3 3 Section One Summout No Payment A summout is produced when the provider has no positive total payment for the cycle and therefore there is no disbursement of moneys Exhibit 3 3 1 TO JAMES STRONG M D DATE 05
69. pplies to a remittance advice with the default sort pattern General Remittance Advice Information is available in the Providers General Billing Guideline Information section available at www emedny org by clicking on the link to the webpage as follows Information for Providers The remittance advice is composed of five sections Section One may be one of the following Medicaid Check Notice of Electronic Funds Transfer Summout no claims paid Section Two Provider Notification special messages Section Three Claim Detail Section Four Financial Transactions recoupments Accounts Receivable cumulative financial information Section Five Edit Error Description PHYSICIAN Version 2010 01 Page 38 of 79 5 31 2010 REMITTANCE ADVICE 3 1 Section One Medicaid Check For providers who have selected to be paid by check a Medicaid check is issued when the provider has claims approved for the cycle and the approved amount is greater than the recoupments if any scheduled for the cycle This section contains the check stub and the actual Medicaid check payment Exhibit 3 1 1 DICAID MAM ACE NE PIT INFORMATION SYSTEM JAMES STRONG M D DATE 2010 05 31 REMITTANCE NO 07080600006 PROV ID 00112233 1123456789 00112233 1123456789 2010 05 31 JAMES STRONG M D 100 BROADWAY ANYTOWN 11111 YOUR CHECK 15 BELOW DETACH TEAR ALONG PERFORATED DASHED LIME DATE R
70. printed decimal point must be rewritten in blue or black ink when entering a value in this field The claim will not process correctly if the decimal is not entered in blue or black ink Exhibit 2 4 2 6 contains a sample of how a drug code would be submitted along with another service provided on the same day PHYSICIAN Version 2010 01 5 31 2010 Page 23 of 79 CLAIMS SUBMISSION Exhibit 2 4 2 6 MEDICAL ASSISTANCE HEALTH INSURANCE IOmwtYToBE eee CLAIM FORM TITLE XIX PROGRAM Fisco PATIENT AMD INSURED SUBSCRIBER INFORMATION 1 NUR pz 2 DATE FERTH Ahh INSLISETFS nama nied JANE SMITH 0121210 1191910 XPATENTZ ADDRES Cy Ip Coca 5 IME PATIENPE SEX ED CARE NS 1 EC PATENTTREEPLOYEH CICCUPATION SCEDOL PATIEMPS RELATIOMEHEP 8 IMSLIELFS EUPLOFER OR E OTHER HEALTH SULA E COVERAGE Rrisr rare n WE GIAO t T ADDRESS Sires Sate Cade Par harm arc ccn arc Peicyer Prrsig rarr i ratar Waly LON 1 PATIENT EVER HAD SAME OF SIMLAR SHTIMES 21 OF WHERE SERES RENDERED her homa o area ADDRESS OF FROLITY 22 LAHAT ORT LUTE OFFICE 220 DENTIA 23 DBGNOSZORNIUBEGOFLLMEZS 914161110
71. provider type For practitioner groups this subtotal category refers to the specific member of the group who provided the services These subtotals are broken down by W e eee Adjustments voids combined Pends Paid Deny Net total paid sum of approved adjustments voids and paid original claims Grand Totals for the entire provider remittance advice appear on a separate page following the page containing the totals by provider type and member ID The grand total is broken down by he Adjustments voids combined Pends Paid Deny Net total paid entire remittance PHYSICIAN Version 2010 01 5 31 2010 Page 54 of 79 REMITTANCE ADVICE 3 6 Section Four Financial Transactions and Accounts Receivable This section has two subsections Financial Transactions Accounts Receivable 3 6 1 Financial Transactions The Financial Transactions subsection lists all the recoupments that were applied to the provider during the specific cycle If there is no recoupment activity this subsection is not produced Exhibit 3 6 1 1 DICAID DATE 05 DATE 05 31 10 CYCLE 1710 MAM JAMES STRONG MEDICAL ASSISTAMCE TITLE XIX PROGRAM ETIN 10900 BROADWAY I FINANCIAL TRANSACTIONS ANYTOWN NEW YORK 11111 REMITTANCE STATEMENT PROVID O0112233 11234565785 REMITTANCE NO FINANCIAL FISCAL FON REASON COD
72. r at the facility must be used When providing services to a patient who is restricted to a primary physician or facility the NPI of the patient s primary physician must be entered in this field The license number of the primary physician is not acceptable in this case If a patient is restricted to a facility the NPI of the practitioner in the facility the patient is restricted to must be entered The ID of the facility cannot be used Surgical Assistance If the claim is for surgical assistance services the NPI of the primary operating physician must be entered in this field If no order or referral is involved or the claim is not from an assistant surgeon leave this field blank PHYSICIAN Version 2010 01 5 31 2010 Page 21 of 79 CLAIMS SUBMISSION DX Code Field 19D Leave this field blank Drug Claims Section Fields 20 to 20C The following instructions apply to drug code claims only The NDCin field 20 and the associated information in fields 20A through 20C must correspond directly to information on the first line of fields 24A through 24L Only the first line of fields 24A through 24L may be used for drug code billing Only one drug code claim may be submitted per 150002 claim form however other procedures may be billed on the same claim NDC National Drug Code Field 20 National Drug Code is a unique code that identifies a drug labeler vendor product and trade package size Enter the NDC as an 11 digit seq
73. ress where the service was performed Locator codes 001 and 002 are for administrative use only and are not entered in this field If the provider renders services at one location only enter locator code 003 If the provider renders service to Medicaid patients at more than one location the entry may be 003 or a higher locator code NOTE The provider is reminded of the obligation to notify Medicaid of all service locations as well as changes to any of them For information on where to direct locator code updates please refer to Information for Providers Inquiry section located at www emedny org by clicking on the link to the webpage as follows Physician Manual SA EXCP Code Service Authorization Exception Code Field 25D If it was necessary to provide a service covered under the Utilization Threshold UT program and service authorization SA could not be obtained enter the SA exception code that best describes the reason for the exception For valid SA exception codes please refer to Appendix B Code Sets NOTE If the services being claimed require a specialty that is exempted from the Utilization Threshold program see list of exempted specialties in Appendix A Codes the value 7 must be entered in this field PHYSICIAN Version 2010 01 5 31 2010 Page 35 of 79 CLAIMS SUBMISSION For more information on the UT Program please refer to Information for All Providers General Policy subsection Utilization Threshold Pr
74. rk State Medicaid form that can be obtained through the financial contractor CSC To order the forms please contact the eMedNY call center at 1 800 343 9000 To view a sample Physican eMedNY 150002 claim form see Appendix A The displayed claim form is a sample and the information it contains is for illustration purposes only Shaded fields are not required to be completed unless noted otherwise Therefore shaded fields that are not required to be completed in any circumstance are not listed in the instructions that follow 2 4 Physician Services Billing Instructions This subsection of the Billing Guidelines covers the specific NYS Medicaid billing requirements for Physicians Although the instructions that follow are based on the eMedNY 150002 paper claim form they are also intended as a guideline for electronic billers to find out what information they need to provide in their claims in addition to the HIPAA Companion Guides which are available at www emedny org by clicking on the link to the webpage as follows eMedNY Companion Guides and Sample Files It is important that providers adhere to the instructions outlined below Claims that do not conform to the eMedNY requirements as described throughout this document may be rejected pended or denied 2 4 1 Instructions for the Submission of Medicare Crossover Claims This subsection is intended to familiarize the provider with the submission of crossover claims Providers can bill cla
75. rvice was never rendered The claim line for that service must be cancelled to reimburse Medicaid for the overpayment An adjustment should be submitted Exhibit 2 4 2 1 3 shows the claim as it was originally submitted and Exhibit 2 4 2 1 4 shows the claim as it appears after the adjustment has been made PHYSICIAN Version 2010 01 5 31 2010 Page 13 of 79 CLAIMS SUBMISSION Exhibit 2 4 2 1 3 MEDICAL ASSISTANCE HEALTH INSURANCE ussassuss CLAIM FORM TITLE XIX PROGRAM PATIENT AND INSURED SUBSCRIBER INFORMATION L ESTISN T S irr JANE SMITH PATENTS Zee Dp Coke 5 MARED TES MEDICARE MER PRIVATE INZLIEZNCE NLIUEER EC FATEHTI OCCUPATION OF SCHOOL PATIENPS RELATIONSHIP amp IMNELIRELFZ EPLER OR LOTR EA HEALTH COVERAGE Eris rara Price Par Farne arc Prrsig ix rara uniber Waly LON DATE OF ONSET FIRET CONBULTED PATENT 18 DATES OF DIEABILIT Y OF CONDITION FOR CONDITION SANE OF SIMLAR SMP TORS TENTO W TOTM 2 NAME OF WHERE SERVICES RENDERED har Ban hama ara ba 213 SDDRESS OF FACLITY Z2 Wee LABORA WORM PERFORMED OUTSIDE TAR OFFICE SERWICEFROMIDER SSE CERTIFY THAT THE STATEMENTS ON THE REVEREE SDE APPLY TO
76. s Third Party Information which can be found at www emedny org by clicking on the link to the webpage as follows Physician Manual Patient Participation Source Code Indicator 3 This code indicates that the patient has incurred a pre determined amount of medical expenses which qualify him her to become eligible for Medicaid Exhibit 2 4 2 8 provides a full illustration of how to complete field 23B and the relationship between this field and fields 24J 24K and 24L PHYSICIAN Version 2010 01 5 31 2010 Page 28 of 79 CLAIMS SUBMISSION 238 PAYM I SOURCE CO 1 4 23 SOURCE 4 2 238 SOURCE CO 4 3 238 PAYM I SOURCE CO 2 7 238 SOURCE CO 2 238 SOURCE CO 2 0 gt 238 SOURCE CO 238 SOURCE CO 2 23B PAYM T SOURCE CO 29 Version 2010 01 Exhibit 2 4 2 8 Code 1 Mo Medicare involvement Field 24J should contain the amount charged andfield 24K must be left blank Code 1 Mo Medicare involvement Field 24J should contain the amount charged andfield 24K must be left blank Code 1 Medicare involvement Field 24J should contain the amount charged andfield 24K must be left blank Codez Medicare Approved Service Field 24J should containthe Medicare Approved amount andfield 24K should containthe Medicare payment amount Codez Medicare Approved Service
77. set of the IG which provides specific instructions on the NYS Medicaid requirements for the 837P transaction This document is available at www emedny org by clicking on the link to the web page as follows eMedNY Companion Guides and Sample Files 5 Medicaid Technical Supplementary Companion Guide provides technical information needed to successfully transmit and receive electronic data Some of the topics put forth in this CG are testing requirements error report information and communication specifications This document is available at www emedny org by clicking on the link to the web page as follows eMedNY Companion Guides and Sample Files Further information about electronic claim pre requirements is available at www emedny org by clicking on the link to the webpage as follows Information for Providers PHYSICIAN Version 2010 01 5 31 2010 Page 5 of 79 _ CLAIMS SUBMISSION 2 2 Paper Claims Physicians who choose to submit their claims on paper forms must use the New York State eMedNY 150002 claim form To view a sample eMedNY 150002 claim form see Appendix A below The displayed claim form is a sample and the information it contains is for illustration purposes only An Electronic Transmission Identification Number ETIN and a Certification Statement are required to submit paper claims Providers who have a valid ETIN for the submission of electronic claims do not need an additional ETIN for paper submissions
78. stances where indicated She was sterile priorto the hysterectomy briefly describethe cause of sterility The hysterectomy was performed in life threatening emergency in which prior acknowledgement was not possible briefly describe the nature of the emergency Shewas a Medicaid recipient at the time the hysterectomy was performed buti did inform her prior to surgery that the procedure would make her permanently incapable of reproducing 15 DATE DISTRIBUTION File patients medical record hospital submit with claim for payment surgeon and anesthesiologist submit with claims for payment patient PHYSICIAN Version 2010 01 5 31 2010 Page 75 of 79 ACKNOWLEDGEMENT OF RECEIPT HYSTERECTOMY INFO FORM ACKNOWLEDGEMENT RECEIPT OF HYSTERECTOMY INFORMATION FORM 1055 3113 INSTRUCTIONS Either Part or Part must be completed depending on the circumstances of the operation In all cases Fields 1 and 2 must be completed Field 1 Enter the recipient s Medicaid ID number Field 2 Enter the surgeon s name Part I Recipient s Acknowledgement Statement and Surgeon s Certification This part must be signed and dated by the recipient or her representative unless one of the following situations exists recipient was sterile prior to performance of the hysterectomy hysterectomy was performed in a life threatening emergency in which prior acknowledgment was not possible or T
79. sthma educator or by a social worker enter the service provider s NPI in this field Otherwise leave this field blank Sterilization Abortion Code Field 22D If applicable enter the appropriate code to indicate whether the service being claimed was related to an induced abortion or sterilization The abortion sterilization codes can be found in Appendix B Code Sets If the procedure is unrelated to abortion sterilization leave this field blank If a code is entered in this field it must be applicable to all procedures listed on the claim Procedures that are not related to abortion or sterilization must be submitted on separate claim form s When billing for procedures performed for the purpose of sterilization Code F a completed Sterilization Consent Form LDSS 3134 is required and must be attached to the paper claim form see Appendix C This type of claim must be submitted on paper with the LDSS 3134 form attached to it NOTES The following medical procedures not induced abortions therefore when billing for these procedures leave this field blank Spontaneous abortion miscarriage Termination of ectopic pregnancy PHYSICIAN Version 2010 01 5 31 2010 Page 25 of 79 CLAIMS SUBMISSION Drugs devices to prevent implantation of the fertilized ovum Menstrual extraction Medicaid does not reimburse providers for hysterectomies performed for the purpose of sterilization Pleas
80. ted as voided PHYSICIAN Version 2010 01 5 31 2010 Page 16 of 79 Exhibit 2 4 2 2 1 MEDICAL ASSISTANCE HEALTH INSURANCE ONLY TO BE A CD USED TO CLAIM FORM TITLE XIX PROGRAM UsmDTO D r PATIENT AND INSURED SUBSCRIBER INFORMATION 1 Tix E ROBERT JOHNSON 4 155 Zw Cuy Simin E EC PATRHTAREPLITEH OCCUPATION CH ZCEDCOL RELATIONSHIP UE CHLO LOTR Ee HEALTH SUS E COEP A ari Par sr Score PURGE i carm e e d gt m m e m m m T HAS PATIENT m EMERGENGOY tr DATE PATIENT SAME OR RELATED RETURN ACER 21 NAME OF WHERE SENES REMOGRED afar Ran home orig OF FACULTY MNE OF CD CLAIMS SUBMISSION ORKSINAL CLAIM REFERENCE NUMBER 3 NEURELFS nama missis hib iz nama B MEDICARE PRIVATE TE IMSURELFS ADDRES Oby Habe Code NTIRCHTIONNUMEER OUTEDE YOUR OF ic D D espa L maa a p paka Q 2 fait
81. to notify Medicaid of any change of address or other pertinent information within 15 days of the change For information on where to direct address change requests please refer to Information for All Providers Inquiry section which can be found at www emedny org by clicking on the link to the webpage as follows Physician Manual Patient s Account Number Field 32 For record keeping purposes the provider may choose to identify a patient by using an office account number This field can accommodate up to 20 alphanumeric characters If an office account number is indicated on the claim form it will be returned on the Remittance Advice Using an Office Account Number can be helpful for locating accounts when there is a question on patient identification Other Referring Ordering Provider ID License Number Field 33 Leave this field blank PHYSICIAN Version 2010 01 5 31 2010 Page 36 of 79 CLAIMS SUBMISSION Prof CD Profession Code Other Referring Ordering Provider Field 34 Leave this field blank PHYSICIAN Version 2010 01 5 31 2010 Page 37 of 79 REMITTANCE ADVICE 3 Explanation of Paper Remittance Advice Sections This Section presents samples of each section of the Chiropractors Portable X Ray Supplier s remittance advice followed by an explanation of the elements contained in the section The information displayed in the remittance advice samples is for illustration purposes only The following information a
82. uence of numbers Do not use spaces hyphens or other punctuation marks in this field NOTE Providers must pay particular attention to placement of zeroes because the labeler of a particular drug package may have omitted preceding leading zeros in any one of the NDC segments The provider must enter the required leading zeros within the affected segment See Exhibit 2 4 2 3 for examples of the NDC and leading zero placement Exhibit 2 4 2 3 Package NDC Number Correct Leading Zero NDC Field Example Configuration Placementfor 5 4 2 11 XXXX XXXX XX 5 4 2 XXXXX XXX xX 5 4 2 5 4 PHYSICIAN Version 2010 01 5 31 2010 Page 22 of 79 CLAIMS SUBMISSION Unit Field 20A Use one of the following when completing this entry UN Unit F2 International Unit GR Gram ML Milliliter Quantity Field 20B Enter the numeric quantity administered to the client Report the quantity in relation to the decimal point as shown in Exhibit 2 4 2 4 NOTE The preprinted decimal point must be rewritten in blue or black ink when entering a value in this field The claim will not process correctly if the decimal is not entered in blue or black ink Exhibit 2 4 2 4 208 QUANTIT Ye E Cost Field 20C Enter based on price per unit e g if administering 0 150 grams GM enter the cost of only one gram or unit as shown in Exhibit 2 4 2 5 Exhibit 2 4 2 5 NOTE The pre
83. ultiple claim lines are submitted on the same claim form all the lines are assigned the same TCN Date of Service The first date of service From date entered in the claim appears under this column If a date different from the From date was entered in the Through date box that date is not returned in the Remittance Advice Procedure Code The five digit procedure code that was entered in the claim form appears under this column Units The total number of units of service for the specific claim appears under this column The units are indicated with three 3 decimal positions Since Physicians must only report whole units of service the decimal positions will always be 000 For example 3 units will be indicated as 3 000 Charged This column lists either the amount the provider charged for the claim or the Medicare Approved amount if applicable Paid If the claim was approved the amount paid appears under this column If the claim has pend or deny status the amount paid will be zero 0 00 Status This column indicates the status DENY PAID ADJT VOID PEND of the claim line Denied Claims Claims for which payment is denied will be identified by the DENY status A claim may be denied for the following general reasons The service rendered is not covered by the New York State Medicaid Program The claim is a duplicate of a prior paid claim The required Prior Approval has not been obtained eee Information e

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