Medicaid Managed Care Plan Claim Denials for Health Home Services

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October 24, 2019

To: Medicaid Managed Care Plans (MMCP), Health and Recovery Plans (HARP), HIV Special Need Plans (SNP)

From: Office of Health Insurance Programs, Division of Program Development and Management and Division of Health Plan Contracting and Oversight

Re: Claims denials for Health Home services

Dear Colleague,

This Department of Health is providing the following guidance regarding correction of inappropriate Health Home claim denials. To correct these denials, MMCP/HARP/SNP:

  1. Will waive timely filing and allow Health Homes to resubmit claims previously adjudicated and denied for lack of EOB, for dates of service on or after July 1, 2018.
  2. May limit the time for reprocessing claims to no less than 90 days following reconfiguration of the claims system.
  3. Will ensure claims system reconfiguration does not exceed 90 days
The identified inappropriate denials subject to this guidance are:
  1. Health Home claims are being denied in cases where the enrollee has Third Party Health Insurance (TPHI) solely due to the lack of an EOB. Notwithstanding contractual requirements for coordination of benefits for enrollees with TPHI, as Health Home is a Medicaid only service universally not reimbursable under commercial /TPHI coverage, MMCP/HARP/HIVSNP must ensure that valid Health Home claims are appropriately adjudicated and not denied for lack of evidence of the TPHI denial.
  2. Health Home services do not require prior or concurrent authorization and must not be denied for this reason;
  3. A CANS-NY initial assessment and core service billed a) in the same month and/or b) on the same claim is payable and must not be denied for these reasons. A second CANS- NY initial assessment performed in one month is payable if the child changes HH’s and must not be denied for this reason.
  4. A NYS Eligibility Assessment and core service billed in the same month and/or on the same claim is payable and must not be denied for these reasons.

The Department will be monitoring the implementation of this guidance. Failure to implement this guidance will result in regulatory action by the Department. If you have any questions, please submit through the Health Home BML and select Health Home Billing.