Medicaid New York Billing
New York Medicaid Billing Overview
In Homecare, standard claim processing generates one claim for multiple dates of service and service types for a billing period. For example, to bill a patient for all services provided within one month, one bill is generated. To meet the requirements of New York Medicaid, Allscripts Homecare can generate the individual electronic or hardcopy claims for each billed service.
In Claims>Process>Process a Cycle, the claim summaries are displayed in an one-line mode. When the claims are processed in the Process a Cycle window, the details provided include a bill for each service date and bill rate code. Depending on the window you are accessing, you can view either the claim detail or claim summary information. The electronic billing processing windows (Claims>Process>Late EMC, Claims>Process>Process a Cycle>EMC Review,
Claims>Process>Process a Cycle>Regenerate EMC) display claim detail information.
You can differentiate between the detail and summary view by reviewing the claim start and end dates. If the start and end dates indicate that the service duration exceeds one day, you are viewing the claim summary information. If the start and end dates of the claim are a period of one day, you are viewing the claim detail information.
This functionality applies to the following payers:
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New York Medicaid Traumatic Brain Injury (TBI) – no longer supported as of October, 2011 |
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Late charges are processed as original claims with the type 1, 2, 3, or 4 of the bill position 3. All claim types are processed as original claims with the exception of type 7 and 8 which are processed as a replacement and void respectively. Private duty nursing detail claims are split by date, bill rate code, and the resource who provided the service.
When processing New York Medicaid adjustment claims, void and replacement claims are not generated for the original claim. A void claim is generated for the original detail service and a new original claim – for the adjustment. The claim summary line for the adjusted service displays the from and thru dates of the original billing periods in the Collections/Patient and Collections/Remittance windows. If the multiple adjustment claims are processed, the multiple claim summary lines will be displayed in the Collections/Patient and Collections/Remittance windows for the same date range.
DCN Processing for New York Medicaid Billing
New York Medicaid has specific formatting requirements for the void and adjustment claims. A void is considered a cancelling transaction, and a replacement—an adjustment to the previously submitted claim. For documentation purposes, void and replacement transactions for New York Medicaid will be referred to as adjustment billing.
Payer Claim Document Control Numbers (DCN) are assigned by payers to identify claims processed through the claim system. These numbers are used if an adjustment claim needs to be submitted or if the patient related information in the original claim needs to be corrected. With Allscripts Homecare, you can assign and store this information at the revenue line levels for submitting adjustment claims to meet New York Medicaid's requirements for rebilling and adjustment claim processing.
Adjustment claims are submitted when an agency needs to correct the claim lines submitted in the original claim. New York Medicaid has specific requirements for generating adjustment claims. Only the claims with adjusted (changed or added) claim lines that have the same NY FFS DCN assigned need to be reported to New York Medicaid.
The Electronic Remittance Advice (ERA) files include NY FFS DCN information for each claim transaction which is taken by Allscripts Homecare, and then the NY FFS DCN fields are populated in the application upon processing the ERA file. If this claim is adjusted due to the changes in the associated service, an adjustment claim is generated using the appropriate format including the bill type, adjust, or void code with the NY FFS DCN.
NY FFS DCNs can be applied to the detail items manually in the Collections/Patient and Collections/Remittance windows in Transactions>General or they will be posted as the part of the ERA processing in Transactions>General>ERAs. To store the NY FFS DCN numbers, make the line item active by posting payments for the selected insurance codes in Administration>Financial>Insurance Codes>General.
If you process an ERA file that contains multiple NY FFS DCNs for an Allscripts Homecare claim and the insurance company for the claim is not set up to support the line item payment posting for the insurance codes selected in Administration>Financial>Insurance Codes, the NY FFS DCN numbers are not stored in the application. The payments will be posted to Allscripts Homecare, but the NY FFS DCN information will be displayed as an error on the Detail Errors and Warnings section.
In addition, when storing a NY FFS DCN at the claim line level, claim lines with the same NY FFS DCN number in the ERA file have the same NY FFS DCN in Allscripts Homecare.
Allscripts Homecare can automatically defer adjustment claims when the NY FFS DCNs have not been assigned to the appropriate original claims. When adjustment claims are deferred, the application does not allow submission of the electronic claims until a NY FFS DCN is assigned. You can process the deferred claims in Claims>Process>Late EMC.
Adjustment Type Codes Used for New York Medicaid
In Administration>Financial>Adjustment Types, you can select to consider an adjustment code a denial, if necessary. A claim considered as a denial is a claim that was not processed for payment due to a reason defined by the payer. Claims that are denied require a new bill to be submitted to the payer for processing. For denied claims, you can suppress the adjustment amount from posting to Allscripts Homecare. Then, the system processes the adjustment reason but does not change the accounts receivable associated with the claim; instead, a zero dollar adjustment is made.
You can also store and select an unlimited number of adjustment reason codes, called Payer Write Off Codes, to associate with the adjustment type codes. The ERA process takes these relationships to determine which adjustment type codes are used to represent payer adjustment reason codes in Allscripts Homecare. If the ERA process cannot find a mapping relationship for an adjustment reason code, the code is included in the Detail Errors and Warnings section as an item that cannot be posted. The 835 transaction contains adjustment reason codes to communicate the reason for partial payment or non-payment. To support the processing of this file in Allscripts Homecare, you can map these codes to the specific adjustment type codes by entering a particular adjustment reason code in the Payer Writeoff Code field in the Adjustment Type window for a particular adjustment type code.
Late Billing Method for New York Medicaid
A late service is a new service date and bill rate code combination that has not been previously billed to New York Medicaid.
The claim generation process determines if any additional services (late charges) or changes to the services (void and replacement) will be included in an existing claim or will be a new claim. When the services belong to a new claim, the process generates a new claim; however, if the services are the part of an existing claim, the process associates these services to that claim using the NY FFS DCN (and payment amounts and adjustment type codes for additional services) to produce a New York Medicaid adjustment claim.
Allscripts Homecare can be set up to automatically defer adjustment claims where the NY FFS DCNs are required but not included in the claim. This setting can be defined in Administration>Financial>Insurance Codes. The deferred claims are handled in Claims>Process>Late EMC. Claims in this window require action to be completed, usually obtaining the NY FFS DCN for the original claim and updating the claim with the NY FFS DCN. Allscripts Homecare checks for updated NY FFS DCN records of these claims. If the NY FFS DCNs have been added to these claims, the claims are added to the ready-to-submit or ready-to-print queues. Claims without NY FFS DCNs added remain deferred.
You can override the deferral of the claims that are missing the NY FFS DCN numbers by clicking the NY FFS DCN Override button in the Generate EMC window. The adjusted services and new services processed in the same cycle are shown in one summary claim. Each detail date and revenue type has the appropriate type of bill based on it being an original or adjusted service.
New York Medicaid Billing Setup Workflow
The changes to the New York Medicaid billing do not affect Hospice (HO) or Personal Care Waiver (PCW) programs. For all other programs, perform the following setup:
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Log in to the Allscripts Homecare Client Support website at http://allscripts.com. |
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Go to Downloads>Billing Templates>Medicaid HIPAA Template Updates>NY and download the appropriate 1.01Q New York Medicaid templates. |
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Ensure the Post to Line Items check box is selected for the New York Medicaid insurance in Administration>Financial>Insurance Codes>General. |
This option should be selected if your agency wants to hold the adjustment claim for which the NY FFS DCN number has not been entered in Allscripts Homecare neither through the Collections/Patient and Collections/Remittance windows nor through the ERA processing.
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For New York Medicaid, select the Defer adjustment claims when NY FFS DCN is not determined for the original claim check box in Administration>Financial>Insurance Codes>EMC. |
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In Administration>Financial>Adjustment Types, perform the following actions: |
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Select for which adjustment type codes to suppress payment amounts in the ERA file. |
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Select which adjustment type codes to consider payer denials in the claim generation process. |
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Click the ellipsis button in the Payer Writeoff Codes column and enter payer adjustment reason codes that apply to each adjustment type code. |
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Recalculate open claims in Administration>Maintenance>Recalculate Claims. You should manually recalculate open claims, so that they are updated to follow the new late billing process. |
New York Medicaid Billing Workflow
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In Transactions>General>Collections/Patient or Transactions>General>Collections/Remittance, do the following actions: |
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Apply the NY FFS DCNs obtained from New York Medicaid to the selected claim line items by clicking the DCN button on the Apply tab. |
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Edit the NY FFS DCNs obtained from New York Medicaid for the selected claim line items by clicking the DCN button on the Edit tab. |
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Regenerate and reproduce claims in Claims>Process>Late EMC. Previously deferred claims that have not been updated with the NY FFS DCNs will remain deferred. |