1 Preschool School Supportive Health Services Program SSHSP Transition

1 Preschool/School Supportive Health Services Program (SSHSP) Transition to Direct Medicaid Claiming Training SPRING 2016

2 Agenda • Welcome • 2016 Medicaid Alerts • Advantages of direct claims submission • Options for SSHSP providers • Computer Sciences Corporation Provider Training • Overview of e. PACES • Direct Claiming – resources for troubleshooting • Medicaid Policy Update • More 2016 Medicaid Alerts • Reference and Contact Information

3 New York State Preschool and School Supportive Health Services Program (SSHSP) SSHSP Policy Updates

Medicaid Policy Updates SSHSP Billing Providers to select new process for claim submission during 2016 -17 School Year • School district and county options require careful review ü How to submit claims ü When to transition to a new claiming procedure • Content in presentation is overview, for full information consult Medicaid Alerts and updated information issued from SSHSP Most appropriate billing/claiming solution, and implementation schedule will vary by LEA • Evaluate in-house resources, existing or proposed contract relationships • Current status of claim submission Communicate with fiscal, service delivery, vendor partners involved in claiming to eliminate/minimize interruption in billing/claiming • Initiate planning early on for successful transition • RICs will also track school district and county plans for transition 4

Medicaid Policy Updates Medicaid Alert #16 -02: SSHSP Claim Processing to Change during 2016 -17 School Year ü Medicaid Alert #16 -02 notifies SSHSP providers of the change to direct claiming during the 2016 -17 school year. ü Direct claiming will enable LEAs to submit claims in “real time, ” and not be restricted by the current monthly claiming calendar. ü LEAs will have access to the most current student eligibility information through the Electronic Provider Assisted Claim Entry System (e. PACES). 5

Medicaid Policy Updates Medicaid Alert #16 -03: Transition Schedule and Resources for Direct Billing of SSHSP Claims ü The transition to direct claiming is provided in this Medicaid Alert to assist school districts and counties in this process. ü Prior to transition to direct claiming, providers will have access to: ü Training sessions; ü Opportunities to utilize e. Med. NY’s test environment for trial claim submission; and ü Informational documents to be used as resources - posted on the Medicaid in Education Website http: //www. oms. nysed. gov/medicaid 6

7 New York State Preschool and School Supportive Health Services Program (SSHSP) Training Transition to Direct Medicaid Claiming Advantages of Direct Claiming and Future Claiming Options

8 Current Billing/Claiming Processing LEA School District / County contracted Information System Collect Service Documentation CNYRIC SED-contracted Medicaid Service Bureau Processing Data to CNYRIC “Client Claiming” OR Uploaded File “Integration” DOH- Medicaid Management CNYRICMed Data Entry Software / Programming Extract File e. Med. NY Medicaid Processing Cycle Payment Issued to LEA After March 2017, CNYRIC will no longer serve as a Medicaid Service Bureau Ø CNYRIC processes billing/claiming and submits to MMIS on a monthly calendar Ø All LEAs (except NYC) are presently required to use CNYRIC to process their SSHSP claims Ø LEAs must choose to submit data to CNYRIC either through Integration or Client

Future Billing/Claiming Processing Options During the 2016 -17 school year, SSHSP billing providers must select a new method of transmitting their claims data to e. Med. NY: 1. Submit claims data directly from e. PACES; AND / OR 2. Submit claims data directly from the e. Med. NY e. Xchange – (must first have access to e. PACES); AND / OR 3. Use Medicaid Service Bureau to submit claims to MMIS. Starting this summer, the RIC will inquire what option(s) have been chosen – decisions are expected by January 2017. 9

Advantages of Direct Claims Submission • Direct claiming will enable LEAs to submit for reimbursement in “real time, ” not restricted by the current monthly claiming calendar. Processing of the claim will begin immediately upon submission to e. Med. NY. Direct claiming will enable LEAs to received “real time” claim responses. • Direct submission of claims will allow any necessary action on the part of the LEA to take place timely when or if the claim requires an adjustment. Timely claims processing will result in fewer claims being time barred. Edits and data checks used by CNYRIC to pre-adjudicate claims will no longer prevent a claim from being processed through the MMIS. • LEAs will have access to the most current student eligibility information through the Electronic Provider Assisted Claim Entry System (e. PACES), without lag time for matching student demographic information on a monthly basis. 10

11 New York State Preschool and School Supportive Health Services Program (SSHSP) Training Transition to Direct Medicaid Claiming Computer Sciences Corporation

CSC/CSRA - e. Med. NY Ø Responsibilities • Processing Medicaid claims • Provider Manuals • Remittance statements and checks • Electronic Fund Transfer • Billing inquiries & guidelines • Provider training • Electronic Transmitter Identification Numbers (ETIN) • e. PACES (Electronic Provider Assisted Claim Entry System) • Medicaid Eligibility Verification System (MEVS) • Maintain e. Med. NY website 12

e. Med. NY Website – Home Page www. e. Med. NY. org 13

Elements on SSHSP Institutional Claims • Student demographics – Client ID number, DOB, Gender, etc. • Procedure Code (CPT) – 5 digit (Refer to SSHSP Handout #5) • Date of service • Number of units • NPI numbers for: ordering/referring, attending/servicing and billing providers- (Refer to SSHSP Medicaid Alert 14 -01). • Diagnosis code (from ICD-10 for DOS on or after 10/1/15) (Refer to SSHSP Medicaid Alert 14 -02) Previously added by CNYRIC or software: • Revenue code (from NUBC) – 4 digit • Bill Type • Delay reason code • Rate Code – 4 digit (Refer to SSHSP Handout #5) • Procedure code modifier (if applicable) – 2 digit/character (Refer to SSHSP Medicaid Alert 14 -06) 14

15 New York State SSHSP providers must use this select list of Current Procedural Terminology (CPT) codes to bill Medicaid for SSHSP services. This handout contains CPT codes/rate codes for the following SSHSP services that can be billed to Medicaid: SERVICE TYPE CPT Code Rate Code Session Time /Units Payment Rate Psychological Counseling 90832 2008 PSYCHOTHERAPY, 30 MINUTES WITH PATIENT AND/OR FAMILY MEMBER 30 minutes $48. 30 Psychological Counseling 90833 2009 PSYCHOTHERAPY, 30 MINUTES WITH PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICES (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE) 30 minutes $31. 82 Psychological Counseling 90834 2010 PSYCHOTHERAPY, 45 MINUTES WITH PATIENT AND/OR FAMILY MEMBER 45 minutes $61. 83 Psychological Counseling 90836 2011 PSYCHOTHERAPY, 45 MINUTES WITH PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE) 45 minutes $51. 63 DESCRIPTION

EFT / ERA-PDF Remit 16

Claim Submission Methods Ø Electronically – HIPAA Compliant Software (837 Institutional) • e. Med. NY e. Xchange • FTP (File Transfer Protocol) • SOAP (Simple Object Access Protocol) – e. PACES (electronic Provider Assisted Claim Entry System) a free, web-based application – Clearinghouse, Service Bureau/Billing Agency Ø Paper (UB-04 Claim) Additional Information for software vendors and developers - Companion Guides which include NYS Medicaid specific information intended to supplement the instructions published in ASC X 12's Implementation Guides are found at https: //www. emedny. org/HIPAA/5010/transactions/index. aspx 17

Claim Submission Methods (Continued) Ø To send or receive electronic claim information providers need the following: – ETIN (Electronic Transmitter Identification Number) – Certification Statement – updated annually – Trading Partner Agreement – User ID and Password – Electronic Remittance/PDF Remittance Request Form (to receive 835 or PDF remittance) Forms are available at - https: //www. emedny. org/info/Provider. Enrollment 18

ETIN Ø SSHSP may obtain a new ETIN by submitting: Ø PROVIDER ELECTRONIC/PAPER TRANSMITTER IDENTIFICATION NUMBER (ETIN) Ø APPLICATION and CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID Ø SSHSP may be added to an existing ETIN (such as a billing service bureau or clearing house) by submitting a Certification Statement Ø New Service Bureaus will submit the ETIN Certification Statement for New Enrollments Form (EMEDNY 490602) with their enrollment application 19

ETIN Certification Statement • ETIN Certification Statement must be Notarized. • ETIN must be recertified annually to send or receive electronic transactions. Electronic Remittance Advice (ERA) 835 or PDF remit and Electronic Fund Transfer (EFT) required for recertification. 20

Provider Electronic/Paper Transmitter Identification Number (ETIN) Application 21 • Used by provider(not service bureau) to obtain an ETIN • Submit at least one notarized Certification Statement with this form before an ETIN can be issued.

Self-Help 22

Enrollment • Provider must obtain or be added to an ETIN number • Primary Administrator requests TOKEN number by contacting e. Med. NY Call Center at 800 -343 -9000 with the following: • • Provider NPI / MMIS ID Email Address ETIN Contact Information • Series of emails and online steps to complete the e. PACES enrollment process • e. PACES Enrollment Reference sheet is available at https: //www. emedny. org/HIPAA/Quick. Ref. Docs/e. PACESEnrollment_Overview. pdf 23

Training 24 • e. Med. NY Call Center available to assist with provider questions – 800 -343 -9000 • e. Med. NY Provider Services Regional Representatives available throughout state – to request training contact the e. Med. NY Call Center. • Seminars and Webinars available on e. Med. NY Training page at https: //www. emedny. org/training/index. aspx

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Home Screen • • • 26 Web-based application Role-based security Submit claims Check claim status Verify eligibility Obtain DVS and Prior Approvals

Support Files and User Admin • User Administration – Add new users and update their access to e. PACES functions • Provider and Other Payer - Create lists of providers and payers to be included on claims and other e. PACES transactions. • Submitter Information – shows the ETIN under which the e. PACES transactions are being submitted 27

User Administration • In order to access the e. PACES program, every user must have an individual User ID and Password. • The User ID and program privileges are created and maintained by the System Administrator. • The System Administrator may add new users, review and edit privileges of existing users, change passwords, unlock existing user accounts and inactivate existing users. 28

Adding A New User After clicking on “Add New User”, enter the user’s information: 29

Adding A New User (Cont) e. PACES will generate a user name and temporary password for the new user 30

Adding A New User (Cont) The e. PACES program will then ask if the user will have administrator privileges: • If yes, then the user will be set up as an alternate administrator • If no, each user’s privileges can be edited 31

Provider Support File • Select “Add New Provider” to create a list of attending/servicing, referring providers. Enter Name or NPI • Edit and Delete icons can used to modify the list. 32

Other Payer Support File • Select “Add New Payer” • Enter Medicare in Other Payer Name and select Medicare Part B payer in “Claim filing Indicator” • Click submit. You will be returned to the main page 33

Adding Other Payers To add a new payer to the system: 1. Click the “Add New Payer” button 2. Enter the organization or Payer Name 3. Select the appropriate claim filing indicator 4. Click submit. You will be returned to the main page 34

Submitter Information The submitter function allows the TSN/ETIN enrolled in e. PACES to be viewed for reference. 35

36 Medicaid Eligibility Verification System - MEVS Ø Methods for checking eligibility • e. PACES: Free Internet based application • Audio Response Unit: (touch-tone telephone method) 1 -800 -997 -1111 • Alternate access: Batch and Real-time 270/271 Eligibility Inquiry & Response Eligibility verification is necessary to avoid risk of receiving no payment

MEVS / DVS Provider Manual 37

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Timely Claiming Submission for SSHSP Providers • Effective December 1, 2013, New York State adjusted the claiming window for SSHSP claims to 12 months following the date of service. • SSHSP claims submitted more than 90 days after the date of service must include a valid delay reason code (3) on the claim in order to be processed. • Important: Do not include a delay reason code (3) on the claim if it is not over 90 days. The claim will deny. • New York State Medicaid does not planning on changing the 12 -month claiming policy at this time. 49

Timely Claim Submission • Initially submit claims within 90 days of the date of service to be valid and enforceable, unless the claim is delayed due to circumstances outside the control of the provider. • Claims submitted after 90 days must be submitted within 30 days from the time submission came within the control of the provider. • If a claim is returned to a provider due to data insufficiency or claiming errors (rejected or denied), it must be corrected and resubmitted within 60 days of the date of notification to the provider. • In addition, paid claims requiring correction or resubmission must be submitted as adjustments to the paid claim within 60 days of the date of notification. • In most cases adjustments, rather than voids, must be billed to correct a paid claim. • Claims not correctly resubmitted within 60 days, or those continuing to not be payable after the second resubmission, are neither valid nor enforceable. https: //www. emedny. org/Provider. Manuals/All. Providers/PDFS/Information_for_All_Providers. General_Billing. pdf 50

Timely Submission (Continued) Ø 90 -Day Indicator for Electronic Claims (HIPAA Compliant) 1 = Proof of eligibility unknown or unavailable 2 = Litigation 3 = Authorized delays 4 = Delay in certifying provider 6 = Delay in supplying custom made appliances * 7 = Third party processing delay 8 = Delay in eligibility determination 9 = Original claim rejected or denied due to a reason unrelated to the billing limitation rules 10 = Administration delay in the prior authorization process 11 = Other (IPRO denial reversal, interrupted maternity care & adjustments of paid claims) 15 = Natural Disaster * e. Med. NY will deny code 6 51

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56 To Zero-fill Medicare info – • Other Payer Name - Select Medicare from list (or if Medicare Managed Care, select the name of the other payer) • Payer Sequence Number -Select Primary • Total Non-Covered Amount - Enter claim charged amount • Enter all other asterisked fields

To Zero-fill Medicare info – Relationship – Select Self Payer Type – Select MB (or If this is a Medicare Managed Care , enter Payer Type - 16) Assignment of Benefits - Select YES Release of Information - Pick an entry of Y or I from the drop down list. 57

58 SSHSP Revenue code is 0240

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Claim Submission ØClaim Adjudication Cycle • Monday 6: 00 PM cut-off time • Check & Remit prepared the following Monday (PDF Remit also available in e. Med. NY e. Xchange) • Checks & Paper remits are mailed 2 weeks and 2 days from check date • Electronic Funds Transfer (EFT) - funds are available 2 weeks and 2 days from check date 69

Claim Submission / Status Ø Claim Status • Can be viewed on e. PACES “View Previously Submitted Claims” or • 277 CA file – notification of claim acceptance ‒ Pre-adjudication Edits / Rejected Claims (crosswalk available for interpreting codes) ‒ REJECTED CLAIMS DO NOT APPEAR ON REMIT • Remittance - notification of claim adjudication ‒ Remittance Formats: Paper, PDF or Electronic 835 ‒ Claim status - PAID, DENY, PEND, ADJ, Void (If 835 electronic remit – pends appear on 835 Supplemental file) ‒ Edits/error codes returned – Use EEKB (Edit/Error Knowledge Base) on www. emedny. org to assist in interpreting 70

Website – Pre-Adjudication Editing ØSeveral claim edits previously reported on remittances are now moved to the pre-adjudication process. üExamples: client ID invalid, Dx code invalid, procedure code invalid ØNYS Medicaid Pre-Adjudication Crosswalk for Health Care Claims lists pre-adjudication edits and is posted at www. emedny. org under e. Med. NYHIPAASUPPORT, 5010 Crosswalks. Ø Providers MUST correct and resubmit rejected claims as these are not reflected in a remittance advice. 71

Sample Paper/PDF Remittance Advice 72

Edit Error Knowledge Base (EEKB) 73

Edit Error Knowledge Base (EEKB) 74

e. Med. NY exchange R 141081111111. 1914. 00. PDF 75 4/18/2014 3: 36 AM • e. Med. NY e. Xchange – a web-based access method to send and receive HIPAA-compliant transactions • Requires e. PACES enrollment and login. The e. PACES User ID and password are also used for e. Xchange access. • Software needed to create files to send to e. Med. NY and to interpret the files received from e. Med. NY. (exception to this is PDF remittances that need no special software to interpret)

Service Bureaus - Enrollment • Regulations at 18 NYCRR, Section 504. 9 - Service bureaus, billing services and electronic media billers • Persons submitting claims, verifying client eligibility or obtaining service authorizations for or on behalf of providers • Must enroll if submitting claims on behalf of more than one SSHSP Provider 76

Service Bureaus - Enrollment 77

OPRA SSHSP must ensure that: • Individuals who order/prescribe/refer/attend (OPRA) services payable by the feefor-service Medicaid Program must be enrolled in the fee-for-service Medicaid Program. • e. Med. NY provides the OPRA Search Tool to determine if a provider is already enrolled • If a provider is not enrolled, they would need to enroll in Medicaid via https: //www. emedny. org/info/Provider. Enrollment/index. aspx 78

OPRA Search Tool 79

Enter Facility Practitioner NPI Attending Practitioners included on claims submitted by the SSHSP, need to be affiliated with that SSHSP Provider. 80

Reference and Contact Information for e. Med. NY Øe. Med. NY Website • www. emedny. org Ø e. PACES Claim Quick Reference Guides • https: //www. emedny. org/selfhelp/e. PACES/PDFS/5010_e. PACES_Institutional_Cla im_Reference_Guide. pdf Øe. Med. NY Call Center • 800 -343 -9000 81

82 Resources: References/Links • Provider Enrollment (as a Medicaid Service Bureau) information is available through e. Med. NY. ü The link to e. Med. NY’s Provider Enrollment section is: https: //www. emedny. org/info/Provider. Enrollment/index. aspx ü Then click on “Service Bureau” on the menu on the right, which will bring you to this page: https: //www. emedny. org/info/Provider. Enrollment/svcbur/index. aspx ü The link to the instructions for completing the NY Medicaid enrollment form to become a Service Bureau is: https: //www. emedny. org/info/Provider. Enrollment/Provider. Maint. Forms/414401_SBINST_Service. Bureau Enrl. Inst. pdf

83 New York State Preschool and School Supportive Health Services Program (SSHSP) Upcoming Medicaid Alerts

Medicaid Policy Updates Medicaid Alert #16 -XX: Expanded Medicaid Eligibility Data Affecting Identification and Matching of Students, and Submission of SSHSP Claims • Matching of Students: • School districts and counties will need to compare the new eligibility data with existing service records to determine whethere is potential for additional Medicaid claiming. • Submission of SSHSP Claims: • The SSHSP claiming window will be temporarily extended from 11. 5 months to 18 months to allow retroactive claiming for all services that were ordered, delivered, and documented in accordance with applicable laws, regulations and policies. • Note: This includes, but is not limited to, parental consent as required by the Individuals with Disabilities Education Act (IDEA) and the Family Educational Rights and Privacy Act (FERPA) 84

Medicaid Policy Updates Medicaid Alert #16 -XX: Record Keeping Requirements for Special Transportation Services Provided by Contracted Entities (Ambulette, Taxi/Livery providers) • Medicaid Alert #16 -05 provides clarification to SSHSP providers regarding the recently published, December 2015 Medicaid Update articles about requirements for documentation of transportation services. • For dates or services on and after, July 1, 2016 all SSHSP providers that contract with an Ambulette and/or a Taxi/Livery company (contracted entity) to provide special transportation services must ensure that the driver of the ambulette, taxi or livery includes in the transportation log his/her full printed name and signature attesting that the referenced trip was completed. • New record keeping requirements apply to all vehicles, including buses, that are under contract to provide special transportation services. 85

86 Reference and State Contacts • NYS DOH - SSHSP Medicaid Policy and Medicaid Claiming Questions • DOH 518 -473 -2160 • DOH SSHSP Mailbox: SSHSP@health. ny. gov • SED - Medicaid in Education • SED 518 -474 -7116 • medined@nysed. gov • e. Med. NY • • CSC 1 -800 -343 -9000 www. emedny. org