TBI Billing Requirements
- Letter is also available in Portable Document Format (PDF)
May 14, 2025
Dear Administrator,
Effective July 1st, 2025,the New York State Department of Health (NYSDOH) will be implementing a billing change that will allow claims for Nursing Home Transition and Diversion (NHTD) and Traumatic Brain Injury (TBI) Waiver programs to be paid based on the county in which services were provided.
Currently, providers are billing based on the participant’s county of fiscal responsibility, or in some cases on the provider’s corporate headquarters or central office address. This change will align waiver billing with the Centers for Medicare and Medicaid Services (CMS) requirements, which specifies that services must be reimbursed based on the location of services provided. It will also standardize locator codes for all NHTD and TBI Waiver providers statewide.
A Federal Information Processing Standards (FIPS)1 code and corresponding locator code has been assigned to each county in New York State. The applicable 5-digit FIPS (if submitting electronically) or 3-digit county locator code (if submitting on paper) indicates the location (county) where the services were provided. This mustbe included on allNHTD and TBI claims submitted for dates of service on or after July 1st, 2025.
Submitting Electronic Claims
When submitting an electronic claim for NHTD or TBI services effective for claims with dates of service on or after July 1st, 2025, providers must enter Value Code 85 plus the applicable 5-digit FIPS codefrom the attached crosswalk in the Value Code box of the claim. Providers must continue to include any other Value Code that is necessary to accurately report the claim (e.g., Value Code 24) in this box.
Submitting Paper Claims
When submitting paper claims for NHTD or TBI services effective for claims with dates of service on or after July 1st, 2025, providers must enter Value Code 61 plus the applicable proxy locator codefrom the attached crosswalk in the Value Code box of the claim. Providers must continue to include any other Value Code that is necessary to accurately report the claim (e.g., Value Code 24) in this box.
System Updates
The eMedNY system has been reconfigured to associate FIPS codes to the correct proxy locator codes to ensure the correct reimbursement amount is paid for each Fee For Service claim2, and DFRS has been transitioning provider’s rate codes over to the new locator codes for the last few weeks. The NHTD and TBI Manuals will be updated to reflect this change in billing practice.
DFRS will be emailing a Webinar invitation to providers shortly. Questions regarding this change can be sent to: 1915CR@health.ny.gov.
Thank you,
New York State Department of Health
Office of Health Insurance Programs
Division of Finance and Rate Setting
Bureau Mental Hygiene Services and Rate Setting
CC: The Alliance of TBI and NHTD Waiver Providers
New York State Department of Health
Office of Aging and Long-Term Care
Center for Home and Community Based Services
Division of Community Integration and Alzheimer’s Disease
Bureau of Long-Term Medicaid Waiver Programs & Supports TBI & NHTD
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1. For the county FIPS to County Locator Codes Crosswalk please see the Excel attachment "2025.07.01 NHTD & TBI FIPS to County Locator Code Crosswalk". 1
2. As a result of system reconfigurations, agencies will receive an auto-generated letter from eMedNY including information related to FIPS codes/proxy locator codes and their effective date. System effective dates may not align with program/policy effective dates. Providers must follow the guidance found in this announcement and any subsequent announcements released by DOH for accurate information on effective dates and policy implications. 2
