Medicaid New York Episodic Payment System Workflow

EPS Setup Workflow

Note: To work with the EPS functionality, make sure all the needed privileges have been granted by the Allscripts Homecare administrator.

The following items must be set up to receive EPS reimbursement:

>	Insurance Codes – General Tab

Set up the EPS payer with the insurance type as K: Medicaid or C: Commercial and 
the P: Episodic (EPS and PPS) mode. For K: Medicaid, select the state as NY: New York.

>	Insurance Codes – Episodic Parameters Tab or Insurance Companies – Plans Tab

Define the episodic parameters, which are used to calculate the EEP and possible adjustments. 
Note: This tab is available for the payers with the P: Episodic (EPS and PPS) mode.

>	NY CHHA EPS HHRG Case Mix Window

Define the HHRG parameters. The Case Mix value is used for the EEP calculation. The Outlier threshold is used at the end of the episode to determine if an episode qualifies as Outlier. These values are predefined.

>	Billing Rates – Rates Tab

EPS requires using revenue codes for services to be included in the Final claim along with the current HCPCS codes. Use the same billing rates as for the FFS model and add the new NYMA insurance code with the correct values. When adding a rate, select * (all) and * (all others) under the CBSA/MSA and U. R. (Urban or Rural) columns.
Important: Do not set up billing rates for supplies and any discipline not covered by NYMA CHHA program.

EPS Patient Information

After you have set up the insurance code, episodic parameters, Case Mixes, and billing rates, define EPS information for a patient.

Payers

Add the EPS payer for a patient in the Pay Source section and define it as primary or eligible in the Pay Control section (in Patient>General>Payers).

OASIS

To reimburse under EPS, a patient must have a valid OASIS assessment within the last 60 days from the beginning of the episode. After completing OASIS, the Scores - NYMA EPS section of the Scores dialog shows EPS OASIS values.
Note: For maternity cases, you can complete the OASIS or use MCNO: Maternity Case - No OASIS for EPS HHRG on the EPS Information tab.

EPS Information

The EPS Information tab (in Patient>General>Admissions & Status) shows the data taken from the OASIS with RFA 1, 3, 4, or 5 to create the episode. The status line for a new episode is added in the last five days of the current episode. On this tab, you can view the EPS episodes date ranges.

Note: The start date of the initial EPS episode is the date of the first billable service for a patient. The first episode and all subsequent episodes follow the 60-day ranges.

Spend Down

If needed, use the Liability Spend Down functionality on the first day of the episode or the first day of the month. The period for which a patient pays the Spend Down amount must be set to Month in the Per field. For more information about liability, see Pay Control – Liability Tab.

For the patients using Spend Down, the following conditions apply:

•	An episode begins when the cost of provided services is enough to apply Spend Down.

•	If a patient is discharged, the episode ends on the date of the last visit in the month where Spend Down was applied. If some services are provided in the last month where Spend Down was not applied, you need to reassign these services to another payer (for example, to SelfPay).

•	If the cost of provided services is too low to apply Spend Down for any month in the episode, the episode ends on the last day of the month where Spend Down is covered. In this case, you can change the patient's payer to a non-EPS payer.

For more information, see Spend Down on Claims.

You may also review the New York Medicaid Episodic Payment System – Spend Down Workflow.

EPS Readmissions

Except those patients who were discharged with the Transfer Out status, for readmissions that occur within 60 days of the same episode, the episode continues in the new admission if the following conditions are met:

>	Patient has NY EPS payer in both admissions.

>	Patient has NY EPS payer in the previous admission and primary PPS payer (EPS as eligible payer) in the new admission without the episodes synchronization activated (applies to Dual Eligibility Episodes).

EPS Claims

Interim and Final Claims

All episodes begin with the same EEP (Expected Episode Payment) amount calculation and are adjusted at the end of the episode based on services provided or discharge status. The following EPS payments are provided:

>	Interim payment – Calculated at the beginning of the episode as 50% of the Base Price adjusted according to the beneficiary's health condition and regional wage index.

>	Final payment – Calculated at the end of the episode as an adjustment to the Interim claim and the Final claim. The cost is calculated to determine if the episode qualifies as one of the following:

•	LUPA (Low Utilization Payment Adjustments) – If the cost of the services provided is less than the LUPA Threshold amount.

•	Full – If the cost based on the services provided is less than the Outlier Threshold amount of the appropriate Case Mix and more than LUPA Threshold amount.

•	PEP (Partial Episode Payment) – Episode is PEP in the following situations:

•

Patient is discharged to another CHHA or LTC agency causing the shortened episode. Thus, the agency pays for the days from the first billable visit to the last billable visit provided (patient's status code type must be F (Final discharge) and the Transfer Out check box must be selected in Administration>General>Patient Status Codes).

•	Payer was changed and the NY EPS payer is not active in the Pay Control section.

•	Episode is synchronized and lasts less that 60 days.

•	Outlier – If the cost based on the services provided exceeds the Outlier Threshold amount of the appropriate Case Mix.

•	Outlier PEP – If the episode meets the criteria for both Outlier and PEP adjustment types.

Spend Down on Claims

Spend Down for the first portion of the episode is deducted from the total actual net amount of the Interim claim and reported with the value code of "22". Spend Down for the whole episode is reported on the Final claim.

For multiple episodes within one month, Spend Down is subtracted from the first episode only. However, if Spend Down for the last month of the previous episode is not fully subtracted, then the remaining amount will be subtracted from the next episode within the same month.

To check whether Spend Down is met for the Interim and Final claims, you can use the Episodic Claims subreport of the Claim Alerts report. If Spend Down is not met, you can use the Batch Insurance Reassignment Windowand change the payer as needed.

Dual Eligibility Episodes

According to NYMA, a patient can receive Medicare and Medicaid services concurrently. Thus, a patient may have two episodic calculations. You may use the option to synchronize episodes for an insurance code and, if needed, override it for a particular patient. For details, see Insurance Codes – Episodic Parameters Tab. You can use split billing rules for dual eligibility episodes, if needed.

Voiding and Replacing Episodic Claims

EPS claims are automatically voided and, if applicable, replaced when the episode dates are changed (for example, due to admission date, discharge date, or payer change). All other voids and replacements should be manually generated through Episodic Claims Void and Replace Window (for example, if you change the rates or the Generate Final Claim Only setting for the insurance).

If you change the Synchronize with Existing Episodes setting for the insurance code or plan levels, run the Recalculate Claims function to update open claims.
Note: Any closed claims will be voided and replaced.

Claim Form

Only those services which are properly billable to Medicaid may be listed on the UB-04 claim form.

The claims that are older than 90 days based on the claim end date are marked with a default reason code of "7". If needed, you can specify any other reason code in the Over 90 Day Indicator field in Claims>Process>Annotate Claims. Also, you can use the New York Medicaid EMC 90-Day Indicator Update Utility to update these reason codes as needed.

EPS Reports

The following reports are supported for the EPS payers:

Reports>Episodic

>	Episodic ATB at 100% Report

>	Episodic Cost Reimbursement – Services Report

>	Episodic Cost Reimbursement – Services and Supplies Report

>	Diagnosis Profit and Loss Report

>	Episode Detail Report

>	Episodic Revenue Recognition Report

Reports>Financial

>	ATB by Date Provided Report

>	Collections Journal Report

>	Discipline Visit Analysis Report

>	Patient Statement Report

>	Revenue and Expense Report

>	Claim Alerts Report

For general information about EPS reports, see Episodic Reports Overview.