eMedNY Subsystem User Manual
Contents
1. nrsnsrrsssssssssassa 29 3 3 1 Summout No Payment Field Descriptions r nnne enne nennen nn enses naar nnns 30 3 4 Section TWO Provider NOLDTICaEIOTI zioni e sus cu cc us cakep 31 3 41 Provider Notification Field DescripLIOFIS DIM BEREIT REDE Ta GU ver Oa EAR UR UM nu 32 3 5 Section Three Claim Detail 33 3 5 1 Claim Detail Page Field Descriptions a 37 3 5 2 Explanation of Claim Detail Columns 37 3 5 3 Subtotals Totals Grand Totals cccceccccssecccceseccccccccceucceccecececsuccecaucececauceeecauececauuececausesecaececaucececaucseecaaececaacececaueeeeaauess 40 3 6 Section Four Financial Transactions and Accounts Receivable esses 41 aK Io I uu s usus 41 3 6 2 Accounts Receivable L 432. REDON James Strong Hipi rius county luin ered aam d ru ms jr tgl l Sn quoil em ered in mas urget imt cd mas Pon DO NOT BARCODE AREA EMELINY HORA 1 11 DOTT CONDO 2 4 1 2 Void A void is submitted to nullify a paid claim A void must be submitted in a new claim form a copy of the original form is unacceptable and all applicable fields must be completed If multiple claim lines originally submitted on the same claim form need to be voided a separate claim form must be submitted for each claim line to be voided A void is identified by the value 8 or X in the A box of field 4 and the claim to be voided is identified by the TCN entered in this field Exhibit 2 4 1 2 1 and Exhibit 2 4 1 2 2 illustrate an example of a claim being voided TCN 082609865432123 was paid on October 1 2008 Later the provider became aware that the patient was covered by other insurance The other insurance was billed and the provider received full payment from that payer Medicaid must be reimbursed by submitting a void to the previously paid claim Exhibit 2 4 1 2 1 shows the claim as it was originally submitted and Exhibit 2 4 1 2 2 shows the claim being submitted as voided PHARMACY Version 2010 01 9 21 2010 Page 11 of 50 CLAIMS SUBMISSION Exhibit 2 4 1 2 1 NYS MEDICAL ASSISTANCE TITLE XIX PHARMACY CLAIM FORM 3 ORLY BE USED TO ADJUST OR VOID A PAID CLAIM cope 4CODE 4
3. Anytown NY 11111 1111 Peter lt Smith um YR 5 amp o a o 1 0 0 T 2 00 2 6 manmi IILPELILI L lolololaloala I814 3 9008191 Mp eee Iw rm seh ee Pa Ed jalal CERTIFICATION ETIA x Tid cere ammi 0 cp d THAT T STATEMENTS GH THE REVERTE BEIDE TO THE BILL WO ARE MADE A PART HEREOF 1 FOR COMPOUND USE ONLY CIRCLE OME UNE MUUBER 12 34 5 e BIGNATLUFRE E IHGREDIENTE James Strong Pacs mul enia county heo uir unies 118 if ema har of Ihe proveer adea enbied un e ueper lan of tha Tom BO NOT r Be AREA DOSAGE FOI AND Dig C TIONS TOTAL INGREDIENT COST COMPOUNDING FEE ALSOUAT CHARGED EMEDN 206303 01 04 1 12 tears VPT f PHARMACY Version 2010 01 9 21 2010 Page 10 of 50 CLAIMS SUBMISSION Exhibit 2 4 1 1 2 NYS MEDICAL ASSISTANCE TITLE XIX PHARMACY CLAIM FORM L PROVIDER ID NUMEA X DATE PILED E ONLY TOBE USED TO ADJUST OR VOID PAID CLAIM kky DAY AA ORAL CLAM ojij 21314 s 3 rum REGFSENT ID MAME 8 DATE OF MATH OTHER _ _ DE eA een pen Last Branden John ELS tH m 111 Park Avenue 01 13 8 1 9 85 8 Anytown NY 11111 1111 P aaa 15 PRESCRIE ORDER TOTALS b CERTIFICATION CERTIFY THAT THE STATEMENTS ON THE REVERSE amp PPLY TO THES BL ANG ARE MADE PART HEREGE FOR COMPOUND USE ONLY CIRCLE CHE LINE NUMBER 12 3 4 8
4. 3 7 Section Five Edit Error Descriptio M u 45 CHIM Si ipi u ve cose nec 46 ADO Bae OS RENI u T DT musun annassa 48 PHARMACY Version 2010 01 9 21 2010 Page 2 of 50 EL CLAIMS SUBMISSION For eMedNY Billing Guideline questions please contact the eMedNY Call Center 1 800 343 9000 PHARMACY Version 2010 01 9 21 2010 Page 3 of 50 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 Pharmacies 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 All Providers General Billing Guideline Information available at www emedny org by clicking on the link to the webpage as follows Information for All Providers PHARMACY Version 2010 01 9 21 2010 Page 4 of 50 SUBMISSION 2 Claims Submission Pharmacies are required to submit most of their claims to NYS Medicaid electronically However certain types of claims are allowed to be submitted in electronic or paper form
5. CLAIMS SUBMISSION 2 3 Claim Form A eMedNY 000301 The eMedNY 000301 claim form is a New York 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 the eMedNY 000301 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 Pharmacy Services Billing Instructions This subsection of the Billing Guidelines covers the specific NYS Medicaid billing requirements for Pharmacies Although the instructions that follow are based on the eMedNY 000301 paper claim form they are also intended as a guideline for electronic billers who should refer to these instructions for finding out what information they need to provide in their claims what codes they need to use etc 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 Claim Form eMedNY 00301 Field Instructions Header Section Fields 1 through 13A The information entered in the Header Section of the claim form fields 1 through 13A must apply to all clai
6. do dud Ea PHARMACY Version 2010 01 9 21 2010 Page 36 of 50 _ REMITTANCE ADVICE 3 5 1 Claim Detail Page Field Descriptions Upper Left Corner Provider s Name Address 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 PHARMACY PROV ID This field will contain the Medicaid Provider ID and the NPI Remittance Number 3 5 2 Explanation of Claim Detail Columns Prescription No Line Number This column indicates the prescription number as it appears on the claim form Item Code This column shows the code that identifies the drug or supply that was dispensed NDC code or HCPCS CODE Quantity The quantity dispensed appears under this column The quantity is indicated with three 3 decimal positions Client Number The client s Medicaid ID number appears 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 under this column PHARMACY Version 2010 01 9 21 2010 Page 37 of 50 ll REMITTANCE ADVICE Service Date This column lists the service date as entered in the claim form TCN The TCN is a un
7. Diseases IC 0 9 Diagnosis Code 424 D0 Code Identifying the diagnosis of the patient NOTE Diagnosis Code can only be reported on NCPDP format Name Ordering Prescribing Provider Field 10B Enter the name of the individual whose name appears as the prescriber on the prescription or fiscal order PROF CD Profession Code Other Referring Ordering Provider Field 11 Leave this field blank Other Referring Ordering Provider ID License Number Field 114A Prescriptions for Restricted Recipients If a restricted recipient was referred by his her primary provider to another provider and this provider is the prescriber orderer enter the recipient s primary provider s NPI in this field The license number of the primary provider is not acceptable in this case Name Other Referring Ordering Provider Field 11B Enter the name of the recipient s primary provider if a provider s NPI has been entered in field 11A Prior Approval Authorization No Field 12 If the provider is billing for a prescription order that requires prior approval or prior authorization enter in this field the prior approval authorization number assigned for the prescription order Line Field 12A Enter the claim line number to which the prior approval authorization entered in field 12 applies If the prior approval authorization number entered in field 12 applies to a claim lines enter an A in this field PHARMACY Version 2010 01 9 21 2010 Pag
8. 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 0581 0 CYCLE 1710 F Fa Fa T INFORMATION SYSTEM TO CITY PHARMACY MEDICAL ASSISTANCE TITLE XIX PROGRAM ETIN 111 FARK AVENUE REMITTANCE STATEMENT FINANCIAL TRANSACTIONS ANYTOWN NEW YORK 11111 PROV ID 00122456 1123456738 REMITTANCE NO Q70806000006 FINANCIAL FISCAL FCN REASON CODE TRANS TYPE DATE AMOUNT 201005056023554 7 RECOUPMENT REASON DESCRIPTION 05 09 10 HH NET FIMANCIAL TRANSACTION AMOUNT 23 25 NUMBER OF FINANCIAL TRANSACTIONS XXX PHARMACY Version 2010 01 9 21 2010 Page 41 of 50 REMITTANCE ADVICE 3 6 1 1 Explanation of Financial Transactions Columns FCN The Financial Control Number FCN 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 al
9. MAY BE SUBJECT TO PENALTIES UNDER LAW FOR IMPROPER USE OR FURTHER DISCLOSURE OF INFORMATION IN THIS COMMUNICATION AND ANY ATTACHMENTS IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR PLEASE IMMEDIATELY NOTIFY NYHIPPADESK QGCSC COM OR CALL 1 800 541 2831 PROVIDERS WHO DO MOT HAVE ACCESS TO E MAIL SHOULD CONTACT 1 800 343 9000 PHARMACY Version 2010 01 9 21 2010 Page 31 of 50 REMITTANCE ADVICE 3 4 1 Provider Notification Field Descriptions Upper Left Corner Provider s Name as recorded in the Medicaid files Upper Right Corner Remittance page number Date on which the remittance advice was issued Cycle Number 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 PHARMACY Version 2010 01 9 21 2010 Page 32 of 50 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 This section may also contain claims that pended previously TO CITY PHARMACY 111 PARK AVENUE AMYTOWNH NEW YORK 11111 PRESCRIF TION NO 267229 4267240 0426722 0042654 ITEM CODE QUANTITY 00173044100 00904191660 00904391660 00002411260 54 000 5 000 5 000 1 000 Exhibit 3 5 1 DICAID PI AGEMENT INFORMATION SYSTEM MEDICAL AS
10. THE CLAIMS FOR THIS REMITTANCE 00127 MEDICARE PAID AMOUNT LESS THAN REASONABLE 00147 SERVICE CODE NOT EQUAL TO 00144 RECIPIENT SEX NOT EQUAL TO FILE 00162 RECIPIENT INELIGIBLE ON DATE OF SERVICE 01154 NOUT SERVICE AUTHORIZATION OM FILE PHARMACY Version 2010 01 9 21 2010 Page 45 of 50 APPENDIX A CLAIM SAMPLES APPENDIX CLAIM SAMPLES The eMedNY Billing Guideline Appendix A Claim Samples contains images of claims with sample data PHARMACY Version 2010 01 9 21 2010 Page 46 of 50 APPENDIX CLAIM SAMPLES Pharmacy Sample Claim NYS MEDICAL ASSISTANCE TITLE XIX PHARMACY CLAIM FORM 1 PROVIDER ID NUMBER 2 DATEFILLED MO DAY 111 Park Avenue 0 4 1 9 1 9 5 3 purse ESTE TIE NAME Anytown NY 11111 Peter Smith 11A OTHER REFERRINSORDERING PROVIDER IDILICENSE NUMBER T unu SUPPLY 25 CASE MGR ID CERTIFICATION AULA THAT THE STATEMENTS THE REVERSE SIDE APPLY TO THIS BILL ARE MADE A PART HEREOF 29 SKGNATURE 31 COUNTY 31 BILLING DATE James Strong emm as ala o7 Payee must enter county wherein signed unless Its fne same as that of the provider address entered In the upper left ofthis form DO NOT WRITE IM BARCODE AREA TOTAL INGREDIENT COST ake EMEDHY 000301 01003 1 11 0071 12503 DISPENSING FEE PHARMACY Version 2010 01 9 21 2010 Page 47 of 50 APPENDIX B CODE SETS APPENDIX B CODE SETS The eMedNY Billing
11. is Pus Sarma as of iter pir tt in thee i tres Tasa GO NOT WRITE EXRCODE AREA EMEDHT 000204 poet 1 11 2078 E203 Recipient ID Number Field 5 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 N numeric character as shown in Exhibit 2 4 1 2 Exhibit 2 4 1 2 MEDICAID NUMBER 1 213415 W PHARMACY Version 2010 01 9 21 2010 Page 13 of 50 SUBMISSION Date of Birth Field 6 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 1 3 Exhibit 2 4 1 3 DATE OF BIRTH Sex Field 7 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 Recipient Other Insurance Code Field 8 If the recipient is exempt from co pay enter the value Z9 in this field For information on co pay exemptions refer to the Policy Guidelines which can be found at www emedny org by clicking on the link to the webpage as follows Pharmacy Manual Recipient Name Field 9 Enter the recipient s last name followed by the first name as
12. they appear on the Common Benefit Identification Card PROF Code Profession Code Ordering Prescribing Provider Field 10 Leave this field blank Ordering Prescribing Provider ID License Number Field 10A Prescriptions from Practitioners Enter the NPI of the ordering prescribing provider Prescriptions from Facilities For orders originating in a hospital clinic or other health care facility the following rules apply When a prescription is written by an unlicensed intern or resident the supervising physician s NPI should be entered in this field PHARMACY Version 2010 01 9 21 2010 Page 14 of 50 i CLAIMS SUBMISSION Prescriptions from Physician s Assistants When prescriptions have been written by a Physician s Assistant the supervising physician s NPI should be entered in this field Prescriptions from Nurse Practitioners Licenses issued to Nurse Practitioners certified to write prescriptions have seven characters which includes the letter F followed by six digits For example F012346 Certified Nurse Practitioners with licenses that contain six digits not preceded by the letter F can only write fiscal orders If the prescribing provider is a Nurse Practitioner certified to write prescriptions enter his her NPI in this field NOTE If the NPI of an authorized prescriber is not on the prescription it is the pharmacist s responsibility to obtain it Prescriptions for Restricted Recipients When filling pre
13. 0 05 31 REMITTANCE 070806000006 PROV ID 00123456 1123456 88 00123456 1123456 88 2010 05 31 CITY PHARMAC Y 111 PARK AVENUE AN TOWN NY 11111 YOUR CHECK IS BELOW TO DETACH TEAR ALONG PERFORATED DASHED LINE DOLLARS CENTS DATE REMITTANCE NUMBER PROVIDER ID NO 2010 05 31 070806000006 00123456 1123456789 7 104 88 zs CITY PHARMACY 111PARKAVENUE ANYTOWN NY 11111 NAE DICAI D INFORMATION 6YSTEM MEDICAL ASSISTANCE TITLE XIX PROGRAM CHECKS DRAWN ON J ohn sn Smi th REY HANE M A STATE STREET ALHANT NEW TORS 12207 PHARMACY Version 2010 01 9 21 2010 Page 25 of 50 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 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 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 PHARMACY Version 2010 01 9 21 2010 Page 26 of 50 REMITTANCE ADVICE 3 2
14. 010 01 9 21 2010 Page 39 of 50 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 amp amp amp 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 Adjustments voids combined Pends Paid Denied Net total paid sum of approved adjustments voids and paid original claims Totals by Member ID are provided next to the subtotals for provider type For pharmacies these totals are exactly the same as the subtotals by provider type These subtotals are broken down by amp eeee 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 which include all the provider s service classifications appear on a separate page following the page containing the totals by service classification The grand total is broken down by Adjustments voids combined Pends Paid Deny Net total paid entire remittance PHARMACY Version 2010 01 9 21 2010 Page 40 of 50 REMITTANCE ADVICE 3 6 Section Four Financial Transactions and Accounts
15. 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 the Current Balances listed above PHARMACY Version 2010 01 9 21 2010 Page 44 of 50 REMITTANCE ADVICE 3 7 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 Exhibit 3 7 1 DICAID DATE 053110 CYCLE 1710 F filu B CHE PASE F T k HP ORM ATION awa MEDICAL ASSISTANCE TITLE XIX PROGRAM ETIN TO CITY PHARMACY MITTA ETATEN PHARMACY 111 PARK AVENUE REMITTANCE STATEMENT EDITDESCRIPTIONS ANYTOWN NEW YORK 11111 PROVID Q0122455 1122456789 REMITTANCE NO 0702050000005 THE FOLLOWING 15 DESCRIPTION OF THE EDIT REASON CODES THAT APPEAR ON
16. A pros FIRST John ee DOT o 111 Fark Avenue o a aie ais 6 65 PRIOR APPROCVALALUTHORLIZATION MO e e La ONLY or RE SEE I s re MNT 8 ON THE RIPVERSE SID APPLY TO THIS ane Strong Pay ia usi parlar watai aii Unies il ra hae sagt ds OF the provider pM pepd iri faa upper efr ol his form DO NOT WRITE IN BARCODE AREA EMEDNY 000909 O64 111 0071 125231 PHARMACY Version 2010 01 9 21 2010 Page 12 of 50 CLAIMS SUBMISSION Exhibit 2 4 1 2 2 NYS MEDICAL ASSISTANCE TITLE XIX PHARMACY CLAIM FORM Dassin M lt mor 06 1 23 3 4 sjel 7 8 S mU 0 8 2 8 0 9 8 7 6 5 m RECIPIENT INSURANCE FEUET 111 Park Avenue Al amp 2 3 a e w 6 PRIOR APPROVALIAUTIORIFATION NO j 18 10 t OTHER REFERRE ire W zm NUMBER GC RIP TM S Dy LI PEDE RET LOL SU PLY CUL E LUN xG PE MNSELI MERS Ls an pag EI CLA NSURANCI k RE IM FAIL ORDER MU SuePLY REALL EA CHARGED Ts LI NUMBER 0 1 0 169 16J2J6J613 LC wa TOTALS b CERTIFICATION T I a RENI ial l ml THAT THE STATE UIS ce THREE Sip APPLY TO THES BELL _ ARE MADE A HERED FOR COMPOUND USE ONLY CIRCLE ONE UME NUMBER 1 2 3 Paspea mast enter coanty wherein mayi unies H
17. Guideline Appendix B Code Sets contains a list of SA Exception Codes PHARMACY Version 2010 01 9 21 2010 Page 48 of 50 APPENDIX B CODE SETS SA Exception Codes Code Description Immediate urgent care services rendered in retroactive period Emergency care Client has temporary Medicaid Request from county for second opinion to determine if recipient can work Request for override pending special handling PHARMACY Version 2010 01 9 21 2010 Page 49 of 50 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 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 PHARMACY Version 2010 01 9 21 2010 Page 50 of 50
18. LE SPECIMEN FEND FEND FEND SERVICE DATE 001710 ox 15 10 ox zm 10 oxot 10 171 00 00 00 00 00 00 00 20 00 171 00 84 88 240 00 64 88 20 00 171 00 54 85 240 00 64 88 TCN OTZT2 XKXXXXXXIZ27 0 1 Of 2h 2 eS U TZTZ XXXXXXIS 0 1 UTZT2 QOQORORM ID Z 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 NUMBER OF CLAIMS PHARMACY Page 35 of 50 CHARGED PAGE DATE CYCLE 04 05 31 2010 1710 PHARMACY PROVID 00123455 11224557853 REMITTANCE NO 070805000006 FAID 0 00 0 00 0 00 0 00 STATUS PEND PEND PEND PEND 56 00 553 00 20 00 40 00 NEW PEND b od qe ERRORS 00162 00127 00162 00127 01154 01154 PREVIOUSLY PENDED CLAIM 9 21 2010 REMITTANCE ADVICE Exhibit 3 5 4 DICA DATE 0 D DATE o 31710 CYCLE 1710 MANAGEMENT INFORMATION Sys TEM MEDICAL ASSISTANCE TITLE AIA PROGRAM ETIN TO CITY PHARMACY REMITTANCE STATEMENT PHARMACY 111 PARK AVENUE GRAND TOTALS ANYTOWN NEW YORK 11111 PROV ID 00123456 1123456789 REMITTANCE NO 070806000006 REMITTANCE TOTALS GRAND TOTALS YOIDS ADJUSTS 20 00 NUMBER OF CLAIMS 1 TOTAL PENDS 171 00 NUMBER OF CLAIMS TOTAL PAID 84 88 NUMBER OF CLAIMS TOTAL DENY 240 00 NUMBER OF CLAIMS NETTOTAL PAID 64 55 NUMBER OF CLAIMS
19. NT VOIDS ADJUSTS Version 2010 01 CLIENT NAME STANDARD STANDARD STANDARD EXAMPLE EXAMPLE PAID PAID PAID PROV ID 00123455 1123455783 REMITTANCE NO SERVICE DATE TCN CHARGED PAID STATUS ERRORS ONU 10 QOTZbI XXXXXM37 Z 1 100 00 100 00 ONU 10 O TER XXXXQOA37 2 2 10 00 WE ADIT ORIGINAL CLAIM AS PAID 2010 D210 QUr2bI XXXXNIDAZ 0 0 5 31 591 PAID OX 10 10 Q72567 XXXXXIZ250 0 2 28 37 28 3 ONAN O72b67 XXXXXZ253 0 0 50 00 50 00 PAID PREVIOUSLY PENDED CLAIM NEWPEND 584 88 NUMBER OF CLAIMS 3 90 00 NUMBER OF CLAIMS 1 0 00 NUMBER OF CLAIMS 0 20 00 NUMBER OF CLAIMS 1 PHARMACY 9 21 2010 Page 34 of 50 REMITTANCE ADVICE Exhibit 3 5 3 MEDICAL ASSISTANC TO CITY PHARMACY 111 PARK AVENUE ANYTOWN NEW YORK 11111 PRESCRIP TION NO 4267241 4207241 4207242 4207243 ITEM CODE QUANTITY Q0S04331660 5 000 QUS04 331650 5 000 QUS04 331650 5 000 0004391550 5 000 DICAID MAP A CHE IRF OARA TOH Pk FN E TITLE XIX PROGRAM REMITTANCE STATEMENT CLIENT ID NUMBER XX12345X XX34557X XX45678X TOTAL AMOUNT ORIGINAL CLAIMS NET AMOUNT ADJUSTMENTS NET AMOUNT VOIDS NET AMOUNT VOIDS ADJUSTS REMITTANCE TOTALS PHARMACY YOIDS ADJUSTS TOTAL PENDS TOTAL PAID TOTAL DENIED NET TOTAL PAID MEMBER ID 00123455 VOIDS ADJUSTS TOTAL PENDS TOTAL PAID TOTAL DENIED MET TOTAL PAID Version 2010 01 CLIENT NAME DOE SAMPLE EXAMP
20. New York State Electronic Medicaid System eMedNY 000301 Billing Guidelines PHARMACY Version 2010 01 9 21 2010 TT TABLE OF CONTENTS TABLE OF CONTENTS I PURPOSES SUA LINC u 4 TEE o m 5 2 1 monere 5 2 2 PPer lai u cena OE 6 2 2 1 General Instructions for Completing Paper Claims a r 6 2 3 Claim Form A i o G10 0 62 Oh 0S 8 2 4 Pharmacy Services Billing Instructions r nennen nnn ess 8 244 Claim Form eMedNY 00301 Field InstEBCEIODIS seesisssuteaxetekxV aunt HER SERES du SEN nian IMPIUM bai UNS EN FUMUS 8 3 Explanation of Paper Remittance Advice Sections r nnne 24 3 1 Section Medicaid Check MM 25 3 1 1 Medicaid Check Stub Field Descriptions 26 50 2 Medicaid Check Field uuu ul er none ere ee ee ene EO eee 26 3 2 SECtION EFT Notificglioi kL 27 xl EFT Notification Page Field D seriptions Lu LLL 28 3 3 Section One Summout No Payment
21. S WHO ENROLL IM EFT WILL HAVE THEIR MEDICAID PAYMENTS DIRECTLY DEPOSITED INTO THEIR CHECKIMG OR SAVINGS ACCOUNT THE EFT TRANSACTIONS WILL BE INITIATED ON WEDNESDAYS AND DUE TO NORMAL BANKING PROCEDURES THE TRANSFERRED FUNDS MAY NOT BECOME AVAILABLE IM 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 MOT WAIVE THE TWO WEEK LAG FOR MEDICAID DISBURSEMENTS TO EMROLL IM EFT PROVIDERS MUST COMPLETE AN EFT ENROLLMENT FORM THAT CAN BE FOUND AT WWWEMEDNY 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 A MINIMUM TIME OF SIX TO EIGHT WEEKS FOR PROCESSING DURING THIS PERIOD OF TIME YOU SHOULD REVIEW YOUR BANK STATEMENTS AND LOOK FOR AN EFT TRANSACTION IN THE AMOUNT OF 0 01 WHICH CSC WILL SUBMIT ASA TEST YOUR FIRST REAL EFT TRANSACTION WILL TAKE PLACE APPROXIMATELY FOUR TO FIVE WEEKS LATER IF OU HAVE ANY QUESTIONS ABOUT THE EFT PROCESS PLEASE CALL THE EMEDNY 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 USE OF THE SPECIFIC INDIVIDUAL S TO WHOM IT Is ADDRESSED THIS INFORMATION MAY ONLY BE USED OR DISCLOSED IM ACCORDANCE WITH LAW AND YOU
22. SISTANCE TITLE ALA PROGRAM REMITTANCE STATEMENT CLIENT ID NUMBER IHAIA TOTAL AMOUNT ORIGINAL CLAIMS NET AMOUNT ADJUSTMENTS NET AMOUNT VOIDS NET AMOUNT VOIDS ADJUSTS Version 2010 01 CLIENT NAME DOE SAMPLE EXAMPLE SPECIMEN DENIED DENIED DENIED SERVICE DATE 05 01 10 05 15 10 05 25 10 05 01 10 240 00 0 00 0 00 0 00 TCN O7 257 0000005605 0 2 OT 257 000000014 0 1 32 1 T261 XXXXXMB3 7 7 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS PHARMACY Page 33 of 50 CHARGED PAGE 02 05 31 2010 CYCLE 1710 ETIN PHARMACY PROV ID 00123456 1123455783 REMITTANCE O7 0805000006 ERRORS 00162 00162 00142 00144 00142 00144 STATUS DENY DENY DENY DENY PAID 0 00 0 00 0 00 0 00 100 00 50 00 30 00 60 00 PREVIOUSLY PENDED CLAIM NEW PEND 9 21 2010 REMITTANCE ADVICE TO CITY PHARMACY 111 PARK AVENUE AMYTOWNH NEW YORK 11111 FRESCRIP TION NO ITEM CODE QUANTITY 0042663 00002411260 0042663 00002411250 0425722 PEHI O426711 0002411250 0426712 002411250 5 000 5 000 1 000 1 000 1 000 Exhibit 3 5 2 PAGE 3 DATE 05 31 2010 D IC AID CYCLE 1710 MANAGEMENT INFORMATION SYSTEM MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT E e CLIENT ID NUMBER MSO TES POT ESO PAT XXBTGDAX TOTAL AMOUNT ORIGINAL CLAIMS NET AMOUNT ADJUSTMENTS NET AMOUNT VOIDS NET AMOU
23. Schedules available at www emedny org by clicking on the link to the webpage as follows Pharmacy Manual NOTES Quantities with decimals should not be rounded off When completing this field enter only the appropriate numbers do not enter a quantity abbreviation e g 4 mLs Days Supply Field 19 Enter the number of days for which the quantity supplied should last as written on the prescription order Exhibit 2 4 1 6 shows an example of a proper entry of a 30 day supply Exhibit 2 4 1 6 If the prescription order directs the patient to take when necessary enter 180 in this field as shown in Exhibit 2 4 1 7 Exhibit 2 4 1 7 New Refill Number Field 20 Original Prescription Order Enter O in this field PHARMACY Version 2010 01 9 21 2010 Page 19 of 50 CLAIMS SUBMISSION Refill Indicate the number of the refill For example enter 1 for first refill Enter 5 for fifth refill Enteral Formula Prior authorizations for enteral formula are issued based on times approved rather than refills When billing for enteral formula products enter 0 in this field always Number of Refills Authorized Field 20A Enter the number of refills indicated on the prescription order form for the particular drug supply This number of refills may not exceed 5 If no refills are indicated on the prescription or if billing for enteral formula enter 0 in this field Brand Necessary Field 21 If the p
24. 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 approved 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 CITY PHARMACY DATE 2010 05 31 D CAI D REMIT T ANGE NO 070605000006 PROV ID 00123458 1123456789 MAN INFORMATION SYSTEM 001234561 123456709 2010 05 31 CITY PHARMACY 111 PARK AVENUE ANYT OWN HY 11111 CITY PHARMACY 104 88 PAYMENT IN THE ABOVE AMOUNT WILL BE DEPOSITED VIA AN ELECTRONIC FUNDS TRANSFER PHARMACY Version 2010 01 9 21 2010 Page 27 of 50 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 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 PHARMACY Version 2010 01 9 21 2010 Page 28 of 50 REMITTANCE ADVICE 3 3 Section One Summout No Payment A summout is produced when the p
25. aid 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 No 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 payment 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 PHARMACY Version 2
26. ats Examples of these types of claims are claims requiring attachments such as manufacturers invoices for manual review and pricing and claims exempt from the Drug Utilization Review DUR requirement Providers are required to submit an Electronic Paper Transmitter Identification Number ETIN Application and 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 Pharmacies are required to use the HIPAA compliant National Council for Prescription Drugs Program NCPDP 5 1 electronic format Direct billers should also refer to the sources listed below to comply with the NYS Medicaid requirements NCPDP Standard Version 5 1 Implementation Guide explain
27. circumstances not listed above Leave this field blank if the recipient has no other insurance coverage PHARMACY Version 2010 01 9 21 2010 Page 21 of 50 CLAIMS SUBMISSION NOTE It is the responsibility of the provider to determine whether the patient is covered by other insurance and whether the insurance carrier 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 submit a claim to the other insurance carrier prior to billing Medicaid as Medicaid is the payer of last resort Pharmacy Claim Form Certification Section Fields 29 to 31 Signature Field 29 The provider or an 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 County Field 30 Enter the name of the county wherein the claim form is signed The county may be left blank only when the provider s address entered in Field 1 is within the county wherein the claim form is signed Date Field 31 Enter the date on which the provider or an authorized representative of the dental provider 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 cla
28. ction of the remittance advice for Pharmacy providers 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 applies to a remittance advice with the default sort pattern General Remittance Advice Information is available in the All Providers General Billing Guideline Information section available at www emedny org by clicking on the link to the webpage as follows Information for All 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 6 Accounts Receivable cumulative financial information Section Five Edit Error Description PHARMACY Version 2010 01 Page 24 of 50 9 21 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 DIC AID MAM AGEMENT INFORMATION SYSTEM TO CITY PHARMACY DATE 201
29. e 16 of 50 CLAIMS SUBMISSION Prior Approval Authorization No Field 13 If a prior approval authorization number different from the one entered in field 12 applies to another claim line in the same claim form enter the other prior approval authorization number in this field Line Field 13 Enter the claim line number to which the prior approval authorization entered in field 13 applies NOTES For information regarding how to obtain Prior Approval Prior Authorization for specific services please refer to the Information for All Providers Inquiry section on the web page for this manual For information on how to submit a DVS transaction please refer to the MEVS Manual available at www emedny org by clicking on the link to the webpage as follows Provider Manuals For information regarding procedures that require prior approval please consult the Procedure Codes and Fee Schedules for this manual Allitems listed above are available at www emedny org by clicking on the link to the webpage as follows Pharmacy Manual Encounter Section Fields 15 to 24 Prescription Order Number Field 15 Enter the pharmacy prescription order number in this field Date Ordered Field 16 Enter the original date on which the prescription order was written as it appears on the prescription order note signed by the prescribing ordering provider The date should be entered in the format MM DD YY For example if a drug was original
30. he UT Program please refer to Information for All Providers General Policy which can be found at www emedny org by clicking on the link to the webpage as follows Pharmacy Manual If not applicable leave this field blank Adjustment Void Code Field 4 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 V box NOTE Fields 4 and 4A should only be used to adjust or void a paid claim Do not write in these fields when preparing an original claim form Original Claim Reference Number Field 4A Leave this field blank when submitting an original claim or resubmission of a denied claim If submitting an adjustment or a void enter the appropriate Transaction Control Number TCN in this field A TCN isa 16 digit identifier that is assigned to each claim and listed in the Remittance Advice NOTE Fields 4 and 4A should only be used to adjust or void a paid claim Do not write in these fields when preparing an original claim form 2 4 1 1 Adjustment An adjustment is submitted to correct one or more fields of a previously paid claim Any field except the Provider ID Number or the Patient s Medicaid ID Number can be adjusted The adjustment must be submitted in a new claim form a copy of the original form is unacceptable and all applicable fields must be completed If multiple claim lines originally submitted
31. ims 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 Pharmacy Manual For Compound Use Only Field 35 Electronic Claims NCPDP 5 1 Please refer to the Procedure Codes which can be found at www emedny org by clicking on the link to the webpage as follows Pharmacy Manual Paper Claims Ingredients Indicate each ingredient as specified on the prescription on a separate line Indicate the manufacturer s name Quantity Enter the metric quantity of each ingredient Price Enter the cost of each ingredient PHARMACY Version 2010 01 9 21 2010 Page 22 of 50 _ CLAIMS SUBMISSION Dosage Form and Directions Indicate the form of the final preparation i e cream capsules ointment etc Also state the physician s directions in this box Total Ingredient Cost Enter the total cost of the compound prescription Compounding Fee Enter the fee for compounding a prescription Dispensing Fee Enter the fee for dispensing a prescription Amount Charged Enter the total amount charge Also be sure to enter this total amount in field 22 on the appropriate claim line PHARMACY Version 2010 01 9 21 2010 Page 23 of 50 ADVICE 3 Explanation of Paper Remittance Advice Sections This Section present a sample of each se
32. ique identifier assigned to each claim that is processed 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 a 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 e Information entered in the claim form is invalid or logically inconsistent Approved Claims Approved claims will be identified by the statuses PAID ADJT adjustment or VOID 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 PHARMACY Version 2010 01 9 21 2010 Page 38 of 50 oe ees seem tance ADVICE Voids The status VOID refers to a claim submitted with the purpose of canceling a previously p
33. l 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 PHARMACY Version 2010 01 9 21 2010 Page 42 of 50 REMITTANCE ADVICE 3 6 2 Accounts Receivable This subsection 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 ACCME F T In FOAM ATOM bre T E Fi TO CITY PHARMACY 111 PARK AVENUE ANYTOWN NEW YORK 11111 REMITTANCE STATEMENT REASON CODE DESCRIPTION ORIG BAL CURR BAL SHOOK SXXX XX TOTAL AMOUNT DUE THE STATE XXX XX PHARMACY Version 2010 01 Page 43 of 50 MEDICAL ASSISTANCE TITLE XIX PROGRAM RECOUP AMT PAGE 08 DATE 05 31 10 CYCLE 1710 ETIN ACCOUNTS RECEIVABLE PROV ID 00123455 1123456783 REMITTANCE NO 9 21 2010 REMITTANCE ADVICE 3 6 2
34. ld be 60 Allliquid preparations that are dispensed in unbroken bottles must be billed for the same number of units mls indicated on the label e g Cough Preparation 472 8 mls bottle is billed as a quantity of 472 8 All reconstituted medications must be expressed in terms of milliliters Oral penicillin s and penicillin derivatives are priced by the number of mls dispensed e g Ampicillin Suspension 5 ml 125 mg 100 ml is billed as a quantity of 100 PHARMACY Version 2010 01 9 21 2010 Page 18 of 50 CLAIMS SUBMISSION Powders for rectal administration are priced by the number of mls dispensed e g Cortenema 100mg 60nml is billed as a quantity of 60 Alllegend drugs are billed by the appropriate unit e g Caps Tabs Packets Suppositories etc with the following exceptions Ampules are billed in ml units e g Lasix Ampules 20 mg cc five 2 ml ampules are billed as a quantity of 10 Vials are billed as number of ml e g Demerol 100mg ml one 20 ml vial is billed as a quantity of 20 For birth control pills and OTC drugs please carefully comply with the instructions that follow Birth control pills are billed as tablet units e g Ovral 21 is billed as a quantity of 21 Over the counter OTC drugs are billed in the same manner as legend drugs For medical surgical supplies please refer to the Procedure Codes and the Fee
35. ly prescribed for a patient on 04 03 10 and is being refilled on 05 03 10 enter 04 03 10 in Field 16 PHARMACY Version 2010 01 9 21 2010 Page 17 of 50 SUBMISSION Drug Supply Code Field 17 For Prescription Drugs Enter in this field the National Drug Code NDC of the drug displayed on the package For OTC Drugs Bill using the 11 digit NDC code NOTE Do not use the UPC code found on packaging For Supplies Leave the first four spaces of this field blank Enter the five character code from the Procedure Code and Fee Schedule Section in the next five spaces and leave the next two spaces of this field blank unless a modifier is required When a modifier is required enter the two character modifier in the last two spaces of this field See exhibit 2 4 1 5 for an example of proper entry for Medical Surgical supply items Exhibit 2 4 1 5 Procedure Code and Fee Schedule available e at www emedny org by clicking on the link to the webpage as follows Pharmacy Manual Quantity Dispensed Field 18 To determine units pricing use the rules that follow Legend Drugs When applicable units must be expressed in the metric system Examples Apint bottle of a liquid is billed as milliliters and the quantity supplied should be 473 A2o0z bottle of a liquid is billed as milliliters and the quantity supplied should be 60 A202 unit of a solid or semi solid is billed as grams and the quantity supplied shou
36. m lines entered in the Encounter Section of the form Provider ID Number Field 1 Enter the provider s 10 digit National Provider Identifier NPI name and address in this field using the following rules for submitting the ZIP code Paper claim submissions Enter the five digit ZIP code or the ZIP plus four Electronic claim submissions Enter the nine digit ZIP code NOTE It is the responsibility of the provider 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 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 Pharmacy Manual Date Filled Field 2 Enter the date on which the prescription order is filled in the format MM DD YY See Exhibit 2 4 1 1 for an example PHARMACY Version 2010 01 9 21 2010 Page 8 of 50 CLAIMS SUBMISSION Exhibit 2 4 1 1 2 DATE FILLED MO DAY YR SA EXCP Code Service Authorization Exception Code Field 3 For Dental Clinic Claims Only 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 For more information on t
37. on the same claim form need to be adjusted a separate claim form must be submitted for each claim line to PHARMACY Version 2010 01 9 21 2010 Page 9 of 50 CLAIMS SUBMISSION be adjusted An adjustment is identified by the value 7 or X in the A box of field 4 and the claim to be adjusted is identified by the TCN entered in this field Adjustments cause the correction of the adjusted information in the claim history records as well as the cancellation of the original claim payment and the re pricing of the claim based on the adjusted information Exhibit 2 4 1 1 1 and Exhibit 2 4 1 1 2 illustrate an example of a claim with an adjustment being made TCN 0826019876543200 is shared by three individual claim lines TCN 0826067890123456 was paid on October 1 2008 After receiving payment the provider determines that an incorrect item code has been reported An adjustment must be submitted to correct the claim records Exhibit 2 4 1 1 1 shows the claim as it was originally submitted and Exhibit 2 4 1 1 2 shows the claim as it appears after the adjustment has been made Exhibit 2 4 1 1 1 NYS MEDICAL ASSISTANCE TITLE XIX PHARMACY CLAIM FORM PROVIDER ID HUMBER eR RR ORIGINAL CLAIM MAEIBER o 1 213 4 sj 9 5 i DATE OF BIRTH Bm MAME RECIPIENT Peres FRET John i Park Aven mamam jun ere PUE cac 111 Park Avenue 1 2 4 5 l oja 2 9 1ls 5 5 PRICE APPROVALIAUTHORIZATION NO Ln
38. r the Medicare co pay amount for this drug supply Otherwise leave this field blank PHARMACY Version 2010 01 9 21 2010 Page 20 of 50 SUBMISSION Medicare Paid Field 23C If applicable enter the amount actually paid by Medicare for the drug supply If Medicare denies payment enter 0 00 in this field Otherwise leave this field blank Other Insurance Paid Field 24 This field must be completed if the patient is covered by insurance other than Medicare If applicable enter the amount actually paid by the other insurance carrier in this field If the other insurance carrier denied payment enter 0 00 in this field 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 Priorto billing the insurance company the provider knows that the service will not be covered because The provider has had a previous denial of 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 providers to zero fill other insurance payment for the same type of
39. rescription form indicates DAW in the Dispense As Written box and the ordering prescribing provider wrote brand necessary or brand medically necessary in their own handwriting on the face of the order prescription place an X on Y for Yes in the proper field to indicate the brand drug was dispensed This indicator will cause the claim to be paid at the EAC price when multiple source generic drugs affected by Upper Payment Limits are available Otherwise place an X on N for No Amount Charged Field 22 Enter the total amount charged for each service rendered The amount must not exceed the provider s usual and customary charge Medicare Co Insurance Field 23 If applicable enter the Medicare co insurance amount for this drug supply NOTES Fields 23 23A 23B and 23C are only applicable if the recipient is also a Medicare beneficiary 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 Ifthe provider knows that the service rendered is not covered by Medicare enter zero in field 23C Medicare Deductible Field 23A If applicable enter the Medicare deductible amount for this drug supply Otherwise leave this field blank Medicare Co Pay Field 23B If applicable ente
40. rovider has no positive total payment for the cycle and therefore there is no disbursement of moneys Exhibit 3 3 1 TO ABC PHARMACY 05 31 2010 D ICAI D REMITTANCE NO 070605000008 PROV ID 00123456 1123456789 MANAGEMEN iINFORMATIC H EYSTE NO PAYMENT WILL BE RECEIVED THIS CYCLE SEE REMITTANCE FOR DETAILS CITY PHARMACY 111 PARK AVENUE ANYT OWN HY 11111 PHARMACY Version 2010 01 9 21 2010 Page 29 of 50 REMITTANCE 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 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 Name and Address PHARMACY Version 2010 01 9 21 2010 Page 30 of 50 REMITTANCE ADVICE 3 4 Section Two Provider Notification This section is used to communicate important messages to providers Exhibit 3 4 1 FAGE 01 2 DATE 05 31 10 DICAID CYCLE 1710 k IAF O RA TION Ea T E FN MEDICAL ASSISTANCE TITLE XIX PROGRAM REMITTANCE STATEMENT TO CITY PHARMACY ETIN 111 PARK AVENUE PROVIDER MOTIFICATION ANY TOWN NEW YORK 11111 PROV ID 00123456H123456789 REMITTANCE NO 070806000006 REMITTANCE ADVICE MESSAGE TEXT ELECTRONIC FUNDS TRANSFER EFT FOR PROVIDER PAYMENTS IS NOW AVAILABLE PROVIDER
41. s lwointerpreted as seven hree interpreted as two Characters should not touch each other as seen in Exhibit 2 2 1 4 Exhibit 2 2 1 4 Written As Intended As Interpreted As EI Pes Entry cannot be 23 illegible interpreted properly Do not write between lines Donotuse arrows or quotation marks to duplicate information Donotuse 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 Forwriting 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 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 notfold the claim forms Donot use adhesive labels for example for address do not place stickers on the form 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 PHARMACY Version 2010 01 9 21 2010 Page 7 of 50
42. s the proper use of the standards and program specifications This document is available at www ncpdp org NYS Medicaid NCPDP 5 1 Request and Response Companion Guides CGs provide instructions for the specific requirements of NYS Medicaid for the NCPDP 5 1 This document is available at www emedny org by clicking on the link to the web page as follows Companion Guides and Sample Files NYS 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 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 All Providers PHARMACY Version 2010 01 9 21 2010 Page 5 of 50 _ CLAIMS SUBMISSION 2 2 Paper Claims For paper submissions Pharmacies must use the New York State eMedNY 000301 claim form Pharmacy Claim Form To view the eMedNY 000301 claim form see Appendix A 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 Provider
43. s who have a valid ETIN for the submission of electronic claims do not need an additional ETIN for paper submissions 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 All 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 it be legible and placed appropriately in the required fields The following guidelines will help ensure the accuracy of the imaging output Allinformation 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 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 00 16 y 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 PHARMACY Version 2010 01 9 21 2010 Page 6 of 50 _ CLAIMS SUBMISSION Exhibit 2 2 1 3 Intended As Interpreted A
44. scriptions orders for a recipient who is restricted to a primary provider physician clinic podiatrist or dentist and the primary provider is the prescribing ordering provider the NPI of this provider must be entered in this field If the restricted recipient was referred by his her primary provider to another provider and the referred provider is the ordering prescribing provider the pharmacy provider must enter the referred provider s NPI in this field The primary provider s NPI must be entered in field 11A DIAGNOSIS CODE New York Medicaid policy requires the prescriber to provide a valid diagnosis code on all fiscal orders for durable medical equipments prosthetics orthotics and supplies DMEPOS A valid diagnosis code is a minimum requirement for all DMEPOS fiscal orders The diagnosis code must be submitted on all NCPDP pharmacy DMEPOS claims The diagnosis code on the fiscal order must match the diagnosis code reported on the claim Providers that bill using the 837 form should already be submitting the diagnosis code on all DMEPOS claims Exhibit 2 4 1 4 contains the NCPDP 5 1 fields utilized to report diagnosis code PHARMACY Version 2010 01 9 21 2010 Page 15 of 50 CLAIMS SUBMISSION Exhibit 2 4 1 4 Diagnosis Code Count 481 VE Countof diagnosis occurrences 1 5 Diagnosis Codes may be sent Diagnosis Code Qualifier 482 WE Code qualifying the Diagnosis Code sent 1 International Classification of
45. service This communication should be documented in the patient s billing record The provider bills the insurance company and receives a rejection because The 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 to the insurance company In these cases the LDSS must be notified prior to zero filling LDSS has subrogation rights enabling it 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 recipient or an absent parent collects the insurance benefits and fails to submit payment to the provider The LDSS must be notified so that sanctions and or legal action can be brought against the recipient or absent parent The provider is instructed to zero fill by the LDSS for
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