Stop Loss FAQs

Table of Contents

Q. One of the least common mistake states: claims submitted using the first of the month as the date of service are denied as a duplicate claim. Does this apply to the CSC (eMedNY) file or the new electronic claim submission file in the column titled "ADMIT DATE"?

A. The comment refers to the CSC or eMedNY file. Capitation payments, which are automated, are paid and go out on the first of the month. When the first of the month is used as the date of service on a Stop Loss claim, the eMedNY system interprets the Stop Loss claim as a duplicate and will deny it with system edit 00705 or 00727.

Q. What is a REMIT statement? Is this the 837 file received from CSC?

A. The REMIT statement is also referred to as the 837 file.

Q. When Rates Change do we have to resubmit?

A. Historically, Stop Loss has always waited until the appropriate rates for a specific time period were published before processing claims.

Between the lag time of submitting claims and the time required to access and adjudicate claims by Stop Loss, reimbursements were usually based on the latest rate available at the time of payment.

Because claims were reviewed and processed off-line, the only portion of the claims available for review electronically were the recalculated payments for the entire claim recorded in eMedNY. We had no process to do a mass adjustment other than a total resubmission of the claim as an adjustment.

With the implementation of claim documentation being submitted electronically, it will be possible at some point in the future to have a record of all claims paid for a specific rate code, time period and facility. With that information, it will be possible to do a mass adjustment for all claims affected by a rate change. Until that point in time, the only way to process a claim with a rate adjustment would be to resubmit the claim to eMedNY and Stop Loss as an adjustment to a previously paid claim.

Please keep in mind that post payment audits that change the charges and payments on hospital stays that have been previously submitted to Stop Loss should be resubmitted as adjustments to the previously paid claim.

Q. Do we void or rebill claims that require changes and have not been adjudicated?

Once a claim is pending there is nothing that allows the provider to cancel or void it.

If a claim has been submitted and requires changes, a Plan can wait until the claim is adjudicated and then file an adjusted claim or it can submit a new claim that includes the changes.

If you are submitting multiple claims for the same charges/dates of service, please notify Stop Loss with an e-mail to stop.loss@health.ny.gov.

Q. How Do We Handle Out of State Claims?

A. Calculating an out of state Inlier

Case payment rate upstate hospital (upstate teaching or non-teaching {rate code 2953}) × SIW + Capital per discharge (Rate code 2990) = Inlier reimbursement

Case payment rate downstate hospital (downstate teaching or non-teaching {rate code 2953}) × SIW + Capital per discharge (Rate code 2990) = Inlier reimbursement

  • Downstate facilities are providers located in areas that surround NYC- in New Jersey, the counties of Sussex, Passaic, Bergin, Hudson, Essex, Union, Middlesex and Monmouth. In Connecticut it applies to Fairfield and Litchfield and in Pennsylvania, the county of Pike. Rates for facilities in these areas should be taken from "downstate" rates. All other areas fall under "upstate" rates. The case payment rate chart for out of state facilities contains a list of more than 1,000 out of state hospitals. If you match the case payment rate from the facility to the above rate chart, you can determine whether the facility is an upstate or downstate teaching/non-teaching facility.
  • For HCO calculations, use the HCO thresholds found in the Cost outlier tables on the NYS DOH website. Make sure they are date appropriate for the claim discharge date. The WEF column on the out of state rate sheet corresponds to the Institution specific adjustment factor (ISAF) - column 5 on the NYS inpatient rate sheet. The WEF value should be used on Line 18 on the high cost outlier page of the claims calculation when calculating out of state rates.
  • Out of state hospital APR-DRG rate chart
  • Please remember to check HCS weekly to ensure important documentation and information is retrieved before the 14-day expiration, which includes Payment/Failure summaries, Aged Inventory notifications, documentation requests, Stop Loss inquiries and plan inquiry responses that include PHI, etc.
  • The preferred naming convention of .txt files is rate code/year/date of submission (2299_2020_12172021). Anything additional can be added as a suffix, e.g., adj, resubmission, v2, etc.
  • Plans can include up to 50 CINs maximum per .txt file.
  • High-Cost Outlier (HCO) should only be indicated on .txt files if the Plan paid as HCO and the HCO threshold has been met.
  • The preferred naming convention of HCO supporting .pdf documents is CIN, year, date of submission (ABXXXXXC_2022_120122).
  • Check permanent placement status to determine recipient eligibility before including stay on rate code 2297 .txt files for calendar year services through 12/31/21. 
  • Encounters must include an admission and discharge date, and they should be within the statement header dates of the bill.
  • Remember that an Encounter being "accepted" does not guarantee payment of a Stop Loss claim since the system does not know what type of benefit you will be billing at a future date (Example:  incorrect invoice type code, incorrect category of service code and surs category of service code).
  • If a plan incurs additional expenses during a benefit year where a reimbursement has already occurred, then an Adjustment/Replacement claim must be entered into ePaces against the paid TCN to pend, awaiting adjudication.  All stays for the member must be submitted to Stop Loss as a .txt file in order for the system to retract the original payment and adjudicate the higher dollar amount.
  • Always check for the latest updates to the billed Benefit Year APR-DRG and Exempt Rates on the DOH website at the following location: APR-DRG and Exempt Rates for Medicaid Fee-for-Service and Medicaid Fee-For-Service and Medicaid Managed Care (ny.gov)
  • Plans can request an ongoing inventory of pended claims directly from eMedNY using the link provided to the form. The Plans are NPI exempt and would use their Provider Medicaid ID (MMIS) number for each Provider Name (one per plan Medicaid and HARP). This form can be found on the eMedNY.org site under Provider Enrollment and then Provider Maintenance Forms. The Plan chooses how often you would like to receive the report.
    703101_PNDCLMFORM_PENDED_CLaIM_RECYCLE_REQUEST_FORM.pdf (emedny.org)
  • Plans cannot repeat admit dates for stays or Encounters. If it is a concurrent, episodic stay for BH, billed as intermittent, then the day following the previous week's "discharge" date is the new "admission" date for the next week. If the disposition code is 30, Medicaid pays for that "discharge" date since it is not really the discharge date and is an ongoing stay. The Plan should enter a total amount paid for each stay.
  • Electronic flat files are processed via auto calculating processing methods, matching the calculation methods found in the work sheets online at the Rate Schedules/ Rate Appeals location (see link) for Inlier, Transfer, High Cost Outlier, and Exempt per diem. It is titled the DOH Medicaid FFS and HMO Claims Payment Calculation. It pulls together the DRG/SOI and SIW, and adds the HCRA tax for NY facilities that is entered from the published rate schedules.
  • The DRG derived from the Encounter submitted through APD is what Is used to price each stay. Exempt stays are paid per diem from those rate schedules. The coding on the flat file should match the Encounter data for accurate anticipation of reimbursement by the plan.
  • Paper is only utilized for the special cases approved by Stop Loss, and management, to be priced manually if there is no Encounter on file but there is a pending claim in eMedNY. Each stay for each case is manually grouped using the 3M grouper and then entered into an electronic calculation sheet for total net amount due.
  • https://www.health.ny.gov/facilities/hospital/reimbursement/apr-drg/rates/ffs/2020/
  • Plans should ensure the same ICD 10 codes (diagnosis and procedure) are entered on the Encounter and submitted .txt file. Since the grouping is developed by 3M using clinical logic, if a claim does not group to an APR-DRG as the Plan expects it to group, the Plan will need to contact 3M to discuss the grouping logic. If 3M determines, based on their clinical review, that the grouping should be revised, the Stop Loss Unit requests the Plan submit an e-mail to hospffunit@health.ny.gov informing the Department about the grouping logic discussion with 3M and the outcome for informational purposes.
  • For grouping purposes on Encounter, drugs are included under the ICD 10 procedure codes for IV Administration of a drug. The way an Inpatient facility bill is processed and paid by the FFS hospital unit is different than how Stop Loss processes the end payment. The Stop Loss Unit does not process by individual REV codes or procedure codes, only the Stop Loss Inpatient Rate Code against the APR DRG that was grouped in the Encounter.
  • From time to time, the Plans may have a member who was admitted in a Benefit Year and not discharged until after a two-year timeframe. In these cases, the Plan needs to make sure an Encounter is on file for the stay. If the claim submission is denied for timely filing (Edit 01292), the Plan will have to send a waiver request to the Two-Year Unit and copy the Stop Loss Unit on all correspondence.
Q. What is a plan´s responsibility for inpatient hospital discharges when an enrollee changes plans in the middle of the inpatient hospital stay? Who is responsible financially for the discharge and how is it determined?

A. The new plan is not liable for cost of a hospital stay for a Medicaid Managed Care (MMC) enrollee who is admitted to the hospital prior to the effective date of enrollment; unless the patient is:

  1. Transferred to another hospital.
  2. Unit 5 transferred from acute setting to a per diem setting such as psych/rehab or detox.
  3. Any time the case payment (usually DRG/AP/APR) changes from cost basis to a per diem basis.
  4. From a per diem rate to another per diem rate (detox to rehab for example).

Once the patient meets one of the four conditions above, the new plan picks up.

Q. What elements are used to verify an original and an adjustment Stop Loss claim?

A. The following are requirements necessary for all submissions and/or processing of claim types defined by rate codes; 2299 (IP), 2295 (MH), 2297 (RHCF), and 2296 (SNP):

  • The requirement of the Transaction Control Number (TCN) of the claim being replaced if submitting an adjustment claim. This field is column J of the electronic file specifications. This is the adjustment/replacement TCN of the claim being replaced ending with a "2," not the TCN of the claim being replaced.
  • Plans are required to have a corresponding encounter in the MEDS system for every discharge submitted for every claim excluding rate code 2297 (RHCF). Failure to do so may result in claim denial or underpayment. Plans are allowed to submit missing encounters and having verified encounter presence in the MEDS system, may submit claim adjustments for processing.
  • Encounters must have discharge dates for each stay as this date drives the payment for General Inpatient stays. This is imperative for intermittent billing since these dates are within the statement header dates and are billed as individual stays. Each "stay" must have its own encounter with an Admit and Discharge date. Examples of intermittent billing are Specialty Hospitals and some Inpatient Psych/Substance Abuse rehabilitation facilities.
  • The diagnoses and procedure codes on all encounters submitted by plans to the MEDS system must correspond to the claims submitted to the Stop Loss unit. Failure to do so may result in claim denial or underpayment. Plans are allowed to resubmit encounters and having verified encounter presence in the MEDS system, may submit claim adjustments for processing.
  • Plans must include a copy of the total charges and documentation as to how the payment was applied or your plan´s grouper calculation indicating that the claim paid as an HCO. This documentation should be in the form of a PDF version of the UB-04 CMS-1450 or 837I and accompany the .txt file submission.
  • The Hospital Medicaid MMIS ID, NPI and the Hospital Name must be included in all claims submitted by plans.
  • Plans are required to follow the format indicated in the electronic file specification. Additional columns should only be added after the last column.
  • The adjustment submission should include all the stays as if it was a new submission, and not just the additional or revised stays. The system will retract the original payment and calculate the new, all inclusive, rates. As stated above, the encounter must match this new submission's additional/revised stay(s) for General Inpatient and Inpatient Psychiatric claims.
Q. NPI vs. MMIS - which do I use?

A. Both the NPI and the MMIS number are required. If there is discrepancy between the NPI and the MMIS, Stop Loss will use the NPI to identify the provider. This does not imply that you can eliminate the MMIS from our claim submission. If you do, the claim will fail and will be returned to you for resubmission.

  • If an MMIS is unavailable, please use the generic MMIS. Per the eMedNY Provider Manual/Managed Care MEDSIII - Data Element Dictionary, the MMIS for OON or OOS Inpatient is 01666086.
Q. What file format or specifications do I use for submitting claims to Stop Loss for HARP members?

A. The file specifications have not changed. Use the same import file specificationsas you use for all your Stop Loss claims.

Q. What part of a member stay is the responsibility of the plan and what part is the responsibility of Stop Loss?

A. Effective January 1, 2016 statewide for all individuals for whom psychiatric inpatient and/or Substance Use Disorder (SUD) inpatient services are a covered service, the psychiatric inpatient Stop Loss and SUD inpatient Stop Loss provisions will change.

This change will be phased in and fully realized in three years. The parameters of the Stop Loss program responsibility are clearly outlined in the:

Q. How are claims over $700,000 calculated for Stop Loss?

A. Stop loss claims over $700,000 are calculated as outlined below. This illustration is color-coded and uses fictitious data.

TCN CIN Discharge Date DOH Calc DRG Total Plan ChargeÚ Total DOH CalcÚ ClaimTotal Threshold Copay Total Claim Charge Total Due Plan
12345678910110 AB12340C 7/9/2025 662.2 6,877.28 6,877.28          
12345678910110 AB12340C 7/18/2025 662.3 11,890.50 11,890.50          
12345678910110 AB12340C 7/30/2025 662.3 10,821.18 10,821.18          
12345678910110 AB12340C 8/6/2025 662.2 6,877.28 6,877.28          
12345678910110 AB12340C 8/10/2025 662.1 5,259.67 5,259.67          
12345678910110 AB12340C 8/15/2025 662.2 7,090.25 7,090.25          
12345678910110 AB12340C 8/17/2025 662.2 7,777.23 7,777.23          
12345678910110 AB12340C 8/23/2025 662.2 6,702.03 6,702.03   Where is the surcharge?  
12345678910110 AB12340C 8/26/2025 662.3 12,048.95 12,048.95          
12345678910110 AB12340C 8/31/2025 662.2 6,825.83 6,825.83   * The 7.04% surcharge was added in to the Plan charge and in this case DOH paid the same amount to the Plan that the Plan paid
12345678910110 AB12340C 9/15/2025 662.1 4,950.05 4,950.05  
12345678910110 AB12340C 9/10/2025 662.3 12,048.95 12,048.95  
12345678910110 AB12340C 9/26/2025 662.3 10,975.08 10,975.08          
12345678910110 AB12340C 9/21/2025 662.3 12,048.95 12,048.95          
12345678910110 AB12340C 10/13/2025 662.3 10,975.08 10,975.08          
12345678910110 AB12340C 10/7/2025 662.3 12,048.95 12,048.95          
12345678910110 AB12340C 10/29/2025 662.2 4,954.89 4,954.89          
12345678910110 AB12340C 10/28/2025 662.3 12,048.95 12,048.95          
12345678910110 AB12340C 11/5/2025 662.2 7,289.46 7,289.46          
12345678910110 AB12340C 11/2/2025 662.3 8,376.11 8,376.11          
12345678910110 AB12340C 11/12/2025 662.3 10,975.08 10,975.08          
12345678910110 AB12340C 1/20/2025 662.1 5,006.17 5,006.17          
12345678910110 AB12340C 11/27/2025 662.3 10,975.08 10,975.08          
12345678910110 AB12340C 11/15/2025 662.2 7,777.23 7,777.23          
12345678910110 AB12340C 11/29/2025 662.1 5,619.88 5,619.88          
12345678910110 AB12340C 12/18/2025 662.3 10,975.08 10,975.08          
12345678910110 AB12340C 12/21/2025 662.2 7,294.14 7,294.14 913,391.58 400,000.00 60,000.00 699,534.33 453,391.58
 
  Your claim total is 913,391.58

anything over 700,000.00 will get 100% reimbursement		 913,391.58

700,000.00		 claim total
100% reimbursement 213,391.58 everything over 700,000.00 that we are working with
 
 

400,000.00 threshold now applied		 700,000.00

400,000.00

not taken out of the calculation until now

20 percent copay		 300,000.00
60,000.00		  
  240,000.00  
 
100% reimbursement


Threshold - copay		 213,391.58

240,000.00		  
added together = total due plan 453,391.58  

Updated April 15, 2025