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eMedNY Subsystem User Manual

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1. 25 3 3 Section One SUMMOUT No Payment uuu gasas 26 3 3 1 Summout No Payment Field Descriptions r aa nennen n enses snae essen 27 3 4 Section TWO drogue 28 3 4 1 Provider Notification Field Descriptions 29 3 5 SECTION Whee pes uu u u u 30 3 5 1 Claim Detail Page Field 34 25 2 Explanation of Claim Detail Columns r r 34 3 5 3 Subtotals Totals Grand 36 3 6 Section Four Financial Transactions and Accounts 38 3 6 1 Financial Transactions eL 38 40 3 7 Section Five Edit Error D SCTEIDLIOTI 42 Appendix A Claim RETI TETTE TTE 43 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 2 of 45 CLAIMS SUBMISSION For eMedNY Billing Guideline questions please contact the eMedNY Call Center 1 800 343 9000 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 3 of 45 ees PURPOSE STATEMENT 1 Purpose Statement The purpose of this document is to assist the prov
2. NM S lt lt lt 3 D x N m x o m gt gt m x OTHER PRX RE d OTHER PROCEDURE OTHER PRO 77 TI CODE ATE CODE ATE piason alas ll LAST 81 CC EM lt mo ow 5 5 04 CMS 145C OME APPROVAL PENDING NATIONAL UNORE LLNS 2132 THE CERTIFICATIONS ON THE REVERSE APPLY THIS BILL ARE MADE PART HEREOF LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 44 of 45 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 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 45 of 45
3. New York State Electronic Medicaid System 0804 Billing Guidelines LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 TT TABLE OF CONTENTS TABLE OF CONTENTS 1 POSE Silo Ir 4 2 Clamis uu MM 5 2 1 Fl CI O C C p uu u 5 2 2 lai u u y ua u uuu 6 2 2 1 General Instructions for Completing Paper 6 2 3 edil E E Z uu c 8 2 4 LLHCSA Services Billing Instructions 8 2 4 1 Instructions for the Submission of Medicare Crossover lt 8 242 08 04 Claim Form Field Instructions U U a T 9 3 Explanation of Paper Remittance Advice Sections nennen nennt snas 21 3 1 Section One NliedicaldChaecku uuu yl M 22 31 1 Maeqicaid Check St b Field ea 23 3 1 2 Medicaid Check Field 5 23 3 2 Section en a e E E a a E 24 3 2 1 EFT Notification Page Field
4. 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 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 23 of 45 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 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 HOME CARE DATE 2010 05 31 D ICAI D REMITTANCE NO 07080600001 PROV ID 00111234 1234557890 ine T 00111234 1234557890 2010 05 31 CITY HOME CARE 111 MAIN STREET ANYTOWN 11111 CITY HOME CARE 51877 11 PAYMENT IH THE ABOVE AMOUNT WILL BE DEPOSITED VIA AN ELECTRONICFUNDS TRANSFER LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 24 of 45 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 Da
5. 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 Exhibit 3 5 1 MANAGEMENT INFORMATION amp YSTEM MEDICAL ASSISTANCE TITLE XIX PROGRAM uir VIRA ME REMITTANCE STATEMENT 111 MAIN STREET AN TTOWN NEW YORK 11111 OFFICE ACCOUNT CLIENT CLIENT DATE OF NUMBER NAME ID SERVICE CODE UNITS CHARGED 1 001234 DOE XX123145xX 07206 000012112 3 2 05 25 10 2810 10 000 187 81 CFIC1 20387 b SAMPLE Xx21455X 0720640000191113 3 2510 2810 8 000 84 38 TOTAL AMOUNT ORIGINAL CLAIMS DENIED 272 19 NUMBER OF CLAIMS HET AMOUNT ADJUSTMENTS DENIED 0 00 NUMBER OF CLAIMS NET AMOUNT VOIDS DENIED 0 00 NUMBER OF CLAIMS NET AMOUNT VOIDS ADJUSTS 0 00 NUMBER OF CLAIMS Fa LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 Page 30 of 45 PAGE 02 DATE 05 31 2010 CYCLE 1710 ETIN HOME HEALTH PROV ID 00111234 1224567890 REMITTANCE 07080500001 LOCATOR CD 003 PAID STATUS ERRORS 0 00 DENY 00162 00131 0 00 DENY 00244 00142 PREVIOUSLY PENDED CLAIM NEW 5 31 2010 REMITTANCE ADVICE Exhibit 3 5 2 PAGE 03 05 31 2010 CYCLE 1710 DICAID MANAGEMENT IRF ORAM ATION Pk w Sa T E F ETIN TO CITY
6. LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 20 of 45 REMITTANCE ADVICE 3 Explanation of Paper Remittance Advice Sections This Section present a sample of each section of the remittance advice for LLHCSA 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 Accounts Receivable cumulative financial information Section Five Edit Error Description LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 Page 21 of 45 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 c
7. 1224567830 REMITTANCE NO O7 02000001 PAID STATUS sa PEND ERRORS 00162 00244 00162 00244 PREVIOUSLY PENDED CLAIM NEW PEND 5 31 2010 REMITTANCE ADVICE Exhibit 3 5 4 DICAID INFORMATION SYSTEM MEDICAL ASSISTANCE TITLE XIX PROGRAM EINE Ur Cllr HOME T ATI HOME HEALT 111 MAIN STREET REMITTANCE STATEMENT GRAND TOTALS ANYTOWN NEW YORK 11111 PROVID 00111234 1234558790 REMITTANCE NO 07080600001 REMITTANCE TOTALS GRAND TOTALS VOIDS ADJUSTS 142 20 NUMBER OF CLAIMS TOTAL PENDS 458 61 NUMBER OF CLAIMS TOTAL 2025 41 NUMBER OF CLAIMS TOTAL DENY 212 13 NUMBER CLAIMS NET TOTAL PAID 1877 11 NUMBER OF CLAIMS Ca LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 33 of 45 _ 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 HOME HEALTH PROV ID This field will contain the Medicaid Provider ID and the NPI Remittance Number 3 5 2 Explanation of Claim Detail Columns Office Account Number If a Patient Office Account Number was entered in the cla
8. Advice Using an account patient control number can be helpful for locating accounts when there is a question on patient identification LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 9 of 45 SUBMISSION Type of Bill Form Locator 4 Completion of this field is required for all provider types All entries in this field must contain three digits Each digit identifies a different category as follows 1st Digit Type of Facility 2nd Digit Bill Classification 3rd Digit Frequency Type of Facility Enter the value 3 Home Health as the first digit of this field as seen in Exhibit 2 4 2 1 The source of this code is the UB 04 Manual Form Locator 4 Type of Facility category Exhibit 2 4 2 1 Bill Classification Enter the value Z Other as the second digit of this field as in Exhibit 2 4 2 2 The source of this code is the UB 04 Manual Form Locator 4 Bill Classification Except Clinics and Special Facilities category Exhibit 2 4 2 2 Frequency Adjustment Void Code New York State Medicaid uses the third position of this field on y to identify whether the claim is an original a replacement adjustment or a void If submitting an original claim enter the value 0 in the third position of this field as in Exhibit 2 4 2 3 Exhibit 2 4 2 3 If submitting an adjustment replacement to a previously paid claim enter the value 7 in the third position
9. Claim Samples contains images of claims with sample data LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 43 of 45 APPENDIX A CLAIM SAMPLES LLHCSA UB 04 Sample Claim APPROVED OMB A 0938 0279 City Home Care 7 AB123467 A TYPE OF BILL 111 Main Street x ws T own 11111 Spio f STATEMENT COVERS PERIOD yt 5 FED TAX NO a EH z 04012007 04302007 5 PATIENTNAME SMITH WILLIAM ADMISSION CONDITION CODES 29 ACDT 12 DATE 13HR 14 TYPE 15 SRC 21 22 23 24 25 STATE LL IL I IL I II 31 OCCURRENCE CURRENCE EE OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN OCCURRENCE SPAN CODE DATE COD E DATE CODE DATE CODE DATE CODE FROM THROUGH DE FROM THROUGH VALUE CODES 40 VALUE CODES 44 VALUE CODES AMOUNT CODE AMOUNT CODE AMOUNT 00 00 42REVC 43 DESCRIPTION 44 HCPCS RATE HIPPS CODE 45 SERV DATE 04022007 0240 04252007 4 5 f 1f 18 19 20 21 22 c a FOXAES nb A Blue Cross B Medicaid 58 INSURED S NAME 59 60 INSURED S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO 12345 63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME SPATIENTADDRESS a il ti G NS
10. SUBMIT AS A TEST YOUR FIRST REAL EFT TRANSACTIOM WILL TAKE PLACE APPROXIMATELY FOUR TO FIVE WEEKS LATER IF YOU HAVE ANY QUESTIONS ABOUT THE EFT PROCESS PLEASE CALL THE EMEDN CALL CENTER AT 1 800 343 9000 NOTICE THIS COMMUNICATION AND ANY ATTACHMENTS MAY CONTAIN INFORMATION THAT IS PRIVILEGED AND CONFIDENTIAL UNDER STATE AND FEDERAL LAW AND IS INTENDED ONLY FOR THE USE OF THE SPECIFIC INDIVIDUAL S TO WHOM IT 15 ADDRESSED THIS INFORMATION MAY ONLY BE USED OR DISCLOSED IN ACCORDANCE WITH LAW AMD YOU BE SUBJECT TO PENALTIES UNDER LAW FOR IMPROPER USE OR FURTHER DISCLOSURE OF INFORMATION IM THIS COMMUNICATION AND ANY ATTACHMENTS IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR PLEASE IMMEDIATELY NOTIFY NYHIPPADESK CSC COM OR CALL 1 800 541 2831 PROVIDERS WHO DO NOT HAVE ACCESS E MAIL SHOULD CONTACT 1 800 343 9000 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 28 of 45 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 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 29 of 45
11. 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 zip 4 does not match information in the provider s Medicaid file 2 4 2 UB 04 Claim Form Field Instructions Provider Name Address and Telephone Number Form Locator 1 Enter the billing provider s name and address 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 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 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 Limited License Home Care LLHCSA Manual Patient Control Number Form Locator 3a For record keeping purposes the provider may choose to identify a patient by using an account patient control number This field can accommodate up to 30 alphanumeric characters If an account patient control number is indicated on the claim form the first 20 characters will be returned on the paper Remittance
12. be submitted to NYS Medicaid The UB 04 manual is available at www nubc org Form Locators in this manual for which no instruction has been provided have no Medicaid application These Form Locators are ignored when the claim is processed 2 4 LLHCSA Services Billing Instructions This subsection of the Billing Guidelines covers the specific NYS Medicaid billing requirements for LLHCSA providers Although the instructions that follow are based on the UB 04 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 claims 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 Medica
13. 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 e Circles the letter O the number 0 must be closed Avoid unfinished characters See the example in Exhibit 2 2 1 2 e Exhibit 2 2 1 2 Written As Intended As Interpreted As j felele 6 00 6 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 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 6 of 45 _ CLAIMS SUBMISSION Exhibit 2 2 1 3 Intended As Interpreted As lwointerpreted as seven 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 Entry cannot be 23 illegible interpreted properly Donot 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 highlighter
14. of this field as in Exhibit 2 4 2 4 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 10 of 45 CLAIMS SUBMISSION Exhibit 2 4 2 4 If submitting a void to a previously paid claim enter the value 8 in the third position of this field as in Exhibit 2 4 2 5 Exhibit 2 4 2 5 Statement Covers Period From Through Form Locator 6 Enter the date s of service claimed in accordance with the instructions provided below When billing for one date of service enter the date in the FROM box The THROUGH box may contain the same date or may be left blank When billing for multiple dates of service enter the first service date of the billing period in the FROM box and the last service date in the THROUGH box The FROM THROUGH dates must be in the same calendar month Instructions for billing multiple dates of service are provided below in Form Locators 42 47 When billing for monthly rates only one date of service can be billed per claim form Enter the date in the FROM box The THROUGH box may contain the same date or may be left blank Dates must be entered in the format MMDDYYYY NOTES The provider s paper remittance statement will only contain the date of service in the FROM box with the total number of units for the sum of all dates of service reported below Providers who receive an electronic 835 remittance will receive only the claim level dates of service from and t
15. that sanctions and or legal action can be brought against the patient or absent parent LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 15 of 45 CLAIMS SUBMISSION The provider is instructed to zero fill by the LDSS for circumstances not listed above The example in Exhibit 2 4 2 9 illustrates a correct Other Insurance Payment entry Exhibit 2 4 2 9 39 VALUE CODES CODE AMOUNT a wo Patient Participation Spend Down Value Code 31 Some patients of the Home Health services do not become eligible for Medicaid until they pay an overage or monthly amount spend down toward the cost of their medical care Value Code If applicable enter Code 31 to indicate that the patient s spend down participation is entered under Amount Value Amount Enter the spend down amount paid by the patient The example in Exhibit 2 4 2 10 illustrates a correct Patient Participation entry Exhibit 2 4 2 10 39 VALUE CODES CODE AMOUNT 100 00 Rev Cd Revenue Code Form Locator 42 Revenue Codes identify specific accommodations ancillary services or billing calculations NYS Medicaid uses Revenue Codes to report the following information Total Amount Charged Units LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 16 of 45 CLAIMS SUBMISSION Total Amount Charged Use Revenue Code 0001 to indicate that total charges for the se
16. the provider s 10 digit National Provider Identifier NPI Other Prv ID Other Provider ID Form Locator 57 Leave this field blank Insured s Unique ID Form Locator 60 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 the State of New York and are composed of eight characters in the format AANNNNNA where A alpha character and N numeric character For example AB12345C The Medicaid Client ID should be entered on the same line A B or C that matches the line assigned to Medicaid in Form Locators 50 and 57 If the patient s Medicaid Client ID number is entered on lines B or C the lines above the Medicaid ID number must contain either the patient s ID for the other payer s or the word NONE Treatment Authorization Codes Form Locator 63 All LLHCSA services require Prior Approval Enter in this field the eleven digit Prior Approval number issued by the appropriate agency in the county of fiscal responsibility The Prior Approval number must be entered in the same line A B or C that matches the line assigned to Medicaid in Form Locators 50 and 57 If the Prior Approval number is entered on lines B or C the word NONE must be written on the line s above the Prior Approval line For information regarding how to obtain Prior Approval Authorization for specific services refer to the Policy Guidel
17. HOME CARE MED ICAL ASSISTANCE TITLE XIX PROGRAM HOME HEALTH 111 STREET PROV ID 00111224 1224557820 ANYTOWN NEW YORK 1111 REMITTANCE STATEMENT REMITTANCE 07080600001 OFFICE ACCOUNT CLIENT CLIENT DATE OF RATE NUMBER NAME ID TCN SERVICE CODE UNITS CHARGED PAID STATUS ERRORS 1 001234 DOE XX12345X O7205 0000041122 2 A 2810 8 000 30020 30020 PAI 1 00387 5 SAMPLE XX234556X O7205 000445113 0 2 2810 5 000 18841 18841 PAI CPICT 44444 6 EXAMPLE XX34557X 0720500455302 0527 1 2810 8 000 30020 300 20 1 1 666666 SPECIMEN XX45678X 07206 00044566302 0522 1 2810 800 30020 300 20 CPIC1 33233 6 STANDARD XX55789X Q7206 000447654 0 2 Q5 22 1 2810 8 000 30020 300 20 CPIC1 55555 5 MODEL XX67890X Q7206 000465553 01 2 05 25 1 2810 7 000 186 10 18610 PAI CPIC1 77777 5 DOE 07205 000455557 0 2 05 25 71 2810 800 30020 30020 1 11111 6 SAMPLE XX98755X 27224 00054444402 OSOS 2810 5 000 150 39 150290 ADJ 1 999995 EXAMPLE XXB7654X 07205 000455477 0 2 0505 1 2810 800 30020 300 20 ORIGINAL CLAIM PAID 05 24 2010 PREVIOUSLY PENDED CLAIM NEW TOTAL AMOUNT ORIGINAL CLAIMS FAID 2026 41 NUMBER OF CLAIMS NET AMOUNT ADJUSTMENTS PAID 43 30 NUMBER OF CLAIMS NET AMOUNT VOIDS PAID 0 00 NUMBER OF CLAIMS AMOUNT VOIDS ADJUSTS 143 30 NUMBER CLAIMS LIMITED LICENSED
18. HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 31 of 45 REMITTANCE ADVICE TO CITY HOME CARE 111 MAIN STREET ANYTOWN NEW YORK 11111 OFFICE ACCOUNT CLIENT CLIEMT NUMBER NAME ID CPIC 1 200125 DOE XX12345X 00987 SAMPLE XX23455X TOTAL AMOUNT ORIGINAL CLAIMS NET AMOUNT ADJUSTMENTS NET AMOUNT VOIDS NET AMOUNT VOIDS ADJUSTS REMITTANCE TOTALS HOME HEALTH VOIDS ADJUSTS TOTAL PENDS TOTAL PAID TOTAL DENIED NET TOTAL PAID MEMBER ID 0011123 VOIDS ADJUSTS TOTAL PENDS TOTAL PAID TOTAL DENY NETTOTAL PAID LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 FEND FEND FEND Exhibit 3 5 3 DICAID MANAGEMENT INFORMATION SYSTEM MEDICAL ASSISTANCE TITLE ALA PROGRAM REMITTANCE STATEMENT DATE OF SERVICE Oo 10 RATE CODE 2810 2810 OF 20 4 1 12 3 2 OT 206 XX0445113 3 1 UNITS 8 000 5 000 188 41 488 61 0 00 0 00 0 00 NUMBER OF CLAIMS NUMBER OF CLAIMS 0 NUMBER OF CLAIMS 0 NUMBER OF CLAIMS 0 00 0 00 0 00 775 62 0 00 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS 143 32 488 61 2026 41 272 19 1877 11 NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS NUMBER OF CLAIMS po bi p RO Page 32 of 45 CHARGED 300 20 PAGE 24 DATE 05 31 2010 CYCLE 1710 HOME HEALTH PROV ID Q0111224
19. LUE CODES Medicare Information See Value Codes Below If the patient is also a Medicare beneficiary it is the responsibility of the provider to determine whether the service being billed for is covered by the patient s Medicare coverage 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 Value Code lf applicable enter the appropriate code from the UB 04 manual Form Locator 39 41 to indicate that one or more of the following items is entered under Amount Medicare Deductible 1 Medicare Co insurance A2or B2 Medicare Co payment A7or B7 Enter code A3 or B3 to indicate that the Medicare Payment is entered under Amount NOTE The line A or B assigned to Medicare in Form Locator 50 determines the choice of codes AX or BX Value Amount Enter the corresponding amount for each value code entered Enter the amount that Medicare actually paid for the service If Medicare denied payment or if the provider knows that the service would not be covered by Medicare or has received a previous denial of payment for the same service enter 0 00 Proof of denial of payment must be maintained in the patient s billing record LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 14 of 45 CLAIMS SUBMISSION Other Insurance Payment
20. TLE XIX PROGRAM EN ie ae RIA 3 Ici NAW IM MAN c ELICIT I ANYTOWN NEW YORK 11111 REMITTANCE STATEMENT PROV ID 9911 1224 1224567850 REMITTANCE NO 07080600001 FINANCIAL FISCAL FCN REASON CODE TRANS TYPE DATE AMOUNT 2007 0500023554 T XXX RECOUPMENT REASON DESCRIPTION 0 08 10 25 52 NET FINANCIAL AMOUNT 5 95 NUMBER OF FINANCIAL TRANSACTIONS LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 38 of 45 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 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 tra
21. Value Code A3 or B3 If the patient has insurance other than Medicare it is the responsibility of the provider to determine whether the service being billed for is covered by the patient s Other Insurance carrier 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 the Other Insurance carrier as Medicaid is always the payer of last resort Value Code If applicable code A3 or B3 should be used to indicate that the amount paid by an insurance carrier other than Medicare is entered under Amount The line A or B assigned to the Insurance Carrier in Form Locator 50 determines the choice of codes A3 or B3 Value Amount Enter the actual amount paid by the other insurance carrier If the other insurance carrier denied payment enter 0 00 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 subs
22. 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 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 41 of 45 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 Exhibit 3 7 1 CYCLE 1710 s MENT ln FORTIN Ta Rz MEDICAL ASSISTANCE TITLE XIX PROGRAM ETIN TO CITY HOME CARE REMITTANCE STATEMENT HOME HEALTH yc ANYTOWNM NEW YORK 11111 FROVID 00111234 122455 78532 REMITTANCE O7 020500001 THE FOLLOWING IS A DESCRIPTION OF THE EDIT REASON CODES THAT APPEAR ON THE CLAIMS FOR THIS REMITTANCE 00131 THIRD PARTY INDICATED OTHER INSURANCE PAD BLANK 00142 RECIPIENT TEAR OF BIRTH DIFFERS FROM FILE 00162 RECIPIENT INELIGIBLE ON DATE OF SERVICE 00244 PANOT ON FILE LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 42 of 45 APPENDIX A CLAIM SAMPLES APPENDIX A CLAIM SAMPLES The eMedNY Billing Guideline Appendix A
23. d for services rendered in 1 hour and 30 minutes 5 units would be used used for services rendered in 1 hours and 10 minutes 4 unit would be used for services rendered in 1 hour and 5 minutes If a Nurse or Personal Care Aide renders fewer hours of service than that for which prior approval has been received report the actual number of hours in this field NOTE If the Service Units field is blank payment will be made for one unit of service Total Charges Form Locator 47 Enter the total amount charged for the service s rendered on the lines corresponding to Revenue Code 0001 in Form Locator 42 total charges for all lines billed and for any other Revenue Code individual charges for that one line Both sections of the field dollars and cents must be completed if the charges contain no cents enter 00 in the cents box See Exhibit 2 4 2 11 for an example LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 17 of 45 CLAIMS SUBMISSION Exhibit 2 4 2 11 42 m GD 43 DESCRIPTION 44 HOPS RATE HIPPS COCE 45 SERI DATE 45 SERI UNITS qTOTALOHARGES 48 NON COWEFED CHARGES LH 302007 If billing for multiple units the total charges should equal the number of units entered Form Locator 46 multiplied by the rate amount If no units were reported in Form Locator 46 the total charges should equal the rate amount Payer Name Form Locator 50 A B C This field identifies t
24. equent billings n very limited situations the Local Department of Social Services LDSS has advised the provider to zero fill the Other Insurance payment for the same type of service This communication should be documented in the client s billing record The provider bills the insurance company and receives a rejection because service is not covered The deductible has not been met The provider cannot directly bill the insurance carrier and the policyholder is either unavailable or uncooperative in submitting claims to the insurance company In these cases the LDSS must be notified prior to zero filling The 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 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 LDSS whenever he she encounters policyholders who are uncooperative in paying for covered services received by their dependents who are on Medicaid In other cases providers 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 The LDSS must be notified so
25. he 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 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 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 35 of 45 REMITTANCE ADVICE 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 tha
26. he payer s responsible for the claim payment The field lines A B and C are devised to indicate primary A secondary B and tertiary C responsibility for claim payment For NYS Medicaid billing payers are classified into three main categories Medicare Commercial any insurance other than Medicare and Medicaid Medicaid is always the payer of last resort Complete this field in accordance with the following instructions Direct Medicaid Claim If Medicaid is the only payer enter the word Medicaid on line A of this field Leave lines B and C blank Medicare Medicaid Claim If the patient has Medicare coverage Enter the word Medicare on line A of this field Enter the word Medicaid on line B of this field Leave line C blank Commercial Insurance Medicaid Claim If the patient has insurance coverage other than Medicare Enter the name of the Insurance Carrier on line A of this field Enter the word Medicaid on line of this field Leave line C blank Medicare Commercial Medicaid Claim If the patient is covered by Medicare and one or more commercial insurance carriers Enter the word Medicare on line A of this field Enter the name of the Other Insurance Carrier on line B of this field Enter the word Medicaid on line C of this field LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 Page 18 of 45 5 31 2010 CLAIMS SUBMISSION NPI Form Locator 56 Enter
27. hrough as reported on the incoming claim transaction Claims must be submitted within 90 days of the date of service entered in this field unless acceptable circumstances for the delay can be documented Information about billing claims over 90 days or two years from the Date of Service 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 Patient Name Form Locator 8 line b Enter the patient s last name followed by the first name This information may be obtained from the Client s Patient s Common Benefit ID Card LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 11 of 45 CLAIMS SUBMISSION Birthdate Form Locator 10 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 See the example in Exhibit 2 4 2 6 that follows Exhibit 2 4 2 6 Sex Form Locator 11 Enter for male or for female to indicate the patient s sex This information may be obtained from the Client s Patient s Common Benefit ID Card Admission Form Locators 12 15 Leave all fields blank Stat Patient Status Form Locator 17 Leave this field blank Condition Codes Form Locators18 28 Leave all fields blank Occurrence Code Date Form Locat
28. id 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 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 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 8 of 45 CLAIMS SUBMISSION 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 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
29. ider 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 LLHCSA providers 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 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 4 of 45 SUBMISSION 2 Claims Submission LLHCSA providers can submit their claims to NYS Medicaid in electronic or paper formats 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 Inf
30. ied by the TCN entered in this field Form Locator 64 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 Voids A void is submitted to nullify a paid claim The void must be submitted in a new claim form copy of the original form is unacceptable and all applicable fields must be completed A void is identified by the value 8 in the third position of Form Locator 4 Type of Bill and the claim to be voided is identified by the TCN entered in this field Form Locator 64 Voids cause the cancellation of the original claim history records and payment Untitled Principal Diagnosis Code Form Locator 67 Using the International Classification of Diseases Ninth Edition Clinical Modification ICD 9 CM coding system enter the appropriate code that describes the main condition or symptom of the patient as indicated in the service order form Only designated OMH diagnosis codes will be accepted The ICD 9 CM code must be entered exactly as it is listed in the manual See the example in Exhibit 2 4 2 12 The remaining Form Locators labeled A Q may be used to indicate secondary diagnosis information Exhibit 2 4 2 12 NOTE Three digit and four digit diagnosis codes will be accepted only when the category has no subcategories Other Form Locator 78 Leave this field blank
31. im 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 The patient s Medicaid ID number appears under this column TCN The TCN is a unique identifier assigned to each claim that is processed If multiple claim lines are submitted on the same claim form all the lines are assigned the same TCN LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 34 of 45 7 REMITTANCE ADVICE 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 Rate Code The four digit rate 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 Home Health 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 The total charges entered in the claim form appear under this column Paid If the claim was approved the amount paid appears under this column If t
32. ine section located at www emedny org by clicking on the link to the webpage as follows Limited License Home Care LLHCSA Manual Document Control Number Form Locators 64 A B C Leave this field blank when submitting an original claim or a resubmission of a denied claim If submitting an Adjustment Replacement or a Void to a previously paid claim this field must be used to enter the Transaction Control Number TCN assigned to the claim to be adjusted or voided The TCN is the claim identifier and is listed in the Remittance Advice If a TCN is entered in this field the third position of Form Locator 4 Type of Bill must be 7 or 8 The TCN must be entered in the line A B or C that matches the line assigned to Medicaid in Form Locators 50 and 57 If the TCN is entered in lines B or C the word NONE must be written on the line s above the TCN line LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 19 of 45 _ CLAIMS SUBMISSION Adjustments 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 copy of the original form is unacceptable and all applicable fields must be completed An adjustment is identified by the value 7 in the third position of Form Locator 4 Type of Bill and the claim to be adjusted is identif
33. is field The entry may be 003 or a higher locator code Enter the locator code that corresponds to the address where the service was performed The example in Exhibit 2 4 2 7 illustrates a correct Locator Code entry Exhibit 2 4 2 7 39 VALUE CODES CODE AMOUNT 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 All Providers Inquiry section located at www emedny org by clicking on the link to the webpage as follows Limited License Home Care LLHCSA Manual Rate Code Value Code 24 Rates are established by the Department of Health and other State agencies At the time of enrollment in Medicaid providers receive notification of the rate codes and rate amounts assigned to their category of service Any time that rate codes or amounts change providers also receive notification from the Department of Health Value Code Code 24 should be used to indicate that a rate code is entered under Amount LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 13 of 45 CLAIMS SUBMISSION Value Amount Enter the rate code that applies to the service rendered The four digit rate code must be entered to the left of the dollars cents delimiter The example in Exhibit 2 4 2 8 illustrates a correct rate code entry Exhibit 2 4 2 8 39 WA
34. ms Adjustments Voids Adjustments voids combined eee LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 36 of 45 REMITTANCE ADVICE Totals by service classification and by member ID are provided next to the subtotals for service classification locator code These totals are broken down by Adjustments voids combined Pends Paid Deny eeee Net total paid for the specific service classification 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 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 37 of 45 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 PAGE EDICAID BAE CYCLE 1710 uw IB FORMATION Bre T E Fi TO pu dri MEDICAL ASSISTANCE TI
35. nsaction detail list The Net Financial Transaction Amount added to the Claim Detail Grand Total must equal the Medicaid Check or EFT amounts LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 39 of 45 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 MAN AGEMENT lI FOAM ATION MEDICAL ASSISTANCE TITLE AIA PROGRAM REMITTANCE STATEMENT TO CITY HOME CARE 111 MAIN STREET ANYTOWN NEW YORK 11111 REASON CODE DESCRIPTION ORIG BAL CURR BAL RECOUP AMT TOTAL AMOUNT DUE THE STATE XXX X5 FAGE 05 DATE 05 31 10 CYCLE 1710 ETIN ACCOUNTS RECEIVABLE PROV ID 0011123412455 7830 REMITTANCE LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 Page 40 of 45 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
36. on 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 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 5 of 45 _ CLAIMS SUBMISSION 2 2 Paper Claims LLHCSA providers who choose to submit their claims on paper forms must use the Centers for Medicare and Medicaid Services CMS standard UB 04 claim form To view a sample LLHCSA UB 04 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 Providers 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
37. ormation 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 LLHCSA providers who choose to submit their Medicaid claims electronically are required to use the HIPAA 837 Institutional 8371 transaction Direct billers should also refer to the sources listed below to comply with the NYS Medicaid requirements HIPAA 8371 Implementation Guide IG explains the proper use of the 8371 standards and program specifications This document is available at www wpc edi com hipaa NYS Medicaid 8371 Companion Guide CG is a subset of the IG which provides instructions for the specific requirements of NYS Medicaid for the 8371 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 informati
38. ors 31 34 Leave all fields blank Value Codes Form Locators 39 41 NYS Medicaid uses Value Codes to report the following information Locator Code required see note for conditions Rate Code required Medicare Information only if applicable Other Insurance Payment only if applicable eec Patient Participation Spend down only if applicable Value Codes have two components Code and Amount The Code component is used to indicate the type of information reported The Amount component is used to enter the information itself Both components are required for each entry LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 12 of 45 CLAIMS SUBMISSION Locator Code Value Code 61 For electronic claims leave this field blank The Locator Code will be defaulted to 003 if the nine digit ZIP Code submitted on the claim does not match what is on file 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 anytime afterwards that a new location is added Value Code Code 61 should be used to indicate that a Locator Code is entered under Amount Value Amount Entry must be three digits and must be placed to the left of the dollars cents delimiter Locator codes 001 and 002 are for administrative use only and are not to be entered in th
39. rovider Notification This section is used to communicate important messages to providers Exhibit 3 4 1 PAGE 01 DICAID DATE 05 31 10 k CYCLE 1740 PORATION EYETEM MEDICAL ASSISTANCE TITLE XIX PROGRAM TO CITY HOME CARE REMITTANCE STATEMENT ETIN 111 STREET PROVIDER NOTIFICATION ANYTOWN NEW YORK 11111 PROVID 00111234 1234567890 REMITTANCE NO 07080600001 REMITTANCE ADVICE MESSAGE TEXT ELECTRONIC FUNDS TRANSFER EFT FOR PROVIDER PAYMENTS IS NOW AVAILABLE PROVIDERS WHO ENROLL IM EFT WILL HAVE THEIR MEDICAID PAYMENTS DIRECTLY DEPOSITED INTO THEIR CHECKING OR SAVINGS ACCOUNT THEEFT 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 IMSTITUTIOM 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 CANBE FOUND AT WWW CLICK ON PROVIDER ENROLLMENT FORMS WHICH CAN BE FOUND IM THE FEATURED LINKS SECTION DETAILED INSTRUCTIONS WILL ALSO BE FOUND THERE AFTER SENDING THE EFT ENROLLMENT FORM TO CSC PLEASE ALLOW A MINIMUM TIME OF SIA TO EIGHT WEEKS FOR PROCESSING DURING THIS PERIOD OF TIME YOU SHOULD REVIEW YOUR BANK STATEMENTS AND LOOK FOR AN EFT TRANSACTION IM THE AMOUNT OF 50 01 WHICH CSC WILL
40. rvices being claimed in the form are entered in Form Locator 47 Units Use an appropriate Revenue Code from the UB 04 manual to indicate that the units of service are entered in Form Locator 46 NOTE If the number of service lines dates of service exceed the number of lines that can be accommodated on a single UB 04 form another claim form must be entirely completed Medicaid cannot process additional claim lines without all the required information Each claim form will be processed as a unique claim document and must contain only one Total Charges 0001 Revenue Code Multi paged documents cannot be accepted Serv Date Form Locator 45 Enter the service date corresponding to each iteration of a revenue code other than 0001 The dates entered here must be contained within the billing period FROM THROUGH in Form Locator 6 Serv Units Form Locator 46 If billing for more than one unit of service enter the number of units on the same line where a Revenue Code other than Revenue Code 0001 was entered in Form Locator 42 For determining the number of units follow the guidelines below All LLHCSA rate codes are based on 15 minute rates Enter in this field the number of 15 minute intervals that reflect the total time of LLHCSA services provided The service units must be reported as full units only Partial units of service duration of less than 15 minutes must be rounded to the nearest quarter hour For example 6 units would be use
41. s 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 Do not write or use staples the bar code area The address for submitting claim forms is COMPUTER SCIENCES CORPORATION P O Box 4601 Rensselaer NY 12144 4601 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 7 of 45 CLAIMS SUBMISSION 2 3 UB 04 Claim Form To view a sample LLHCSA UB 04 claim form see Appendix A The displayed claim form is a sample and the information it contains is for illustration purposes only The UB 04 CMS 1450 is a CMS standard form therefore CSC does not supply it The form can be obtained from any of the national suppliers The UB 04 Manual National Uniform Billing Data Element Specifications as Developed by the National Uniform Billing Committee Current Revision should be used in conjunction with this Provider Billing Guideline as a reference guide for the preparation of claims to
42. t commonly cause claims to be pended New York State Medical Review required Procedure requires manual pricing No match found 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 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 Original clai
43. te 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 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 25 of 45 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 CITY HOME CARE DATE 05 31 2010 rn REMITTANCE NO 07080800001 D PROV ID 00111234 1234567890 MANAGEMENT INFORMATION SYSTEM NO PAYMENT WILL BE RECEIVED THIS CYCLE SEE REMITTANCE FOR DETAILS CITY HOME CARE 111 MAIN ST ANY TOWN 11111 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 26 of 45 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 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 27 of 45 REMITTANCE ADVICE 3 4 Section Two P
44. ycle 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 INFORMATION Gd TEM TO CITY HOME CARE DATE 2010 05 31 REMITTANCE NO 07080600001 PROV ID 00111234 1234567890 00111234 1234567890 2010 05 31 CITY HOME CARE 111 MAIN ST ANYTOWN NY 11111 YOUR CHE CK IS BELOW TO DETACH TEAR ALONG PERFORATED DASHED LINE PROVIDER ID NO 2010 05 31 7080600 00111234 1234567890 cmm ATEM BA CITY HOME CARE d 111 ST DICA ANYTOWN 11111 DICA ID MEDICAL ASSISTANCE TITLE XIX PROGRAM CHECKS DRAWN ON J ohn Smi th an BANK SQ STATS ALBANY NEN YORK 12207 LIMITED LICENSED HOME CARE SERVICES AGENCY LLHCSA Version 2010 01 5 31 2010 Page 22 of 45 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

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