EPS - CHHA Billing Guidance

  • Guidance is also available in Portable Document Format (PDF)

    • March 1, 2017

    Dear Provider

    A review of the Certified Home Health Agencies (CHHA) Episodic Payment System (EPS) has found Medicaid overpayments were made to a number of CHHA providers. These identified overpayments included but are not limited to the following:

    1. Payment for full episodic payment instead of pro–rated episodic payment when the recipient was transferred into a Managed Long Term Care Plan within 60 days of episode;
    2. Payment for multiple episodic payments within 60 days of episode;
    3. Payment to two separate CHHA providers for the same recipient within 60 days of episode.

    The review also revealed situations where erroneous discharge codes were used by a CHHA in providing multiple episodes to the same patient, or an erroneous discharge code used for a patient who was discharged to a managed long term care plan. These types of errors are clearly within the control of the billing CHHA to submit correctly and in accordance with the Billing Guidelines dated April 9, 2013, posted on the NYS DOH website at: Episodic Billing Guidelines 4–9–2013.

    Additionally, there were instances where providers created a new episode apparently based on a change in rate code (due to a new Outcome and Assessment Information Set [OASIS], or a change in age group). Such a situation should NOT trigger a new episode. The CHHA should still bill a full 60–day episode, where applicable. In accordance with previously published billing guidance, the rate code should be based on the most recent OASIS assessment available as of the start date of the episode (or within 5 days after the start date), and the age group must match the patient's age on the "through" date of the claim.

    To minimize future billing errors that could result in similar overpayments, all CHHA providers should check their billing systems to ensure that they are in full compliance with the above–noted billing requirements for partial episodes.

    NYS DOH will continue to monitor these billings and provide updated billing guidance as necessary. The NYS Office of the Medicaid Inspector General will seek to recover all inappropriate payments made to providers.

    Any questions regarding CHHA rates, CHHA billing and other CHHA related issues can be sent via email to BLTCR–CH@health.ny.gov.

    Information regarding CHHA rates, CHHA billing questions , and other CHHA related issues may be found here.

    Sincerely,

    Steven M. Simmons
    Director
    Bureau of Residential Health Care Reimbursement
    Division of Finance and Rate Setting
    Office of Health Insurance Programs