Restriction Exception (R/E) Code Compatibility with the Health Home Program

ARCHIVED September 24, 2024

  • Codes also available in Portable Document Format (PDF)
RE CODE RE CODE DESCRIPTION COMPATIBLE WITH HEALTH HOME SERVICES POLICY NOTES
02 RRP Podiatry YES
(See notes)		 Individuals can be in a Restricted Recipient Program (RRP) and enrolled in Health Home, but the Care Manager should work with the recipient and contact their Managed Care Plan, if applicable, to ensure compliance with any restrictions.
These are codes to restrict recipient to specific podiatric providers.
03 RRP Dental YES
(See notes)
These are codes to restrict recipient to specific dental providers.
04 RRP Durable Medical Equipment YES
(See notes)
These are codes to restrict recipient to specific durable medical equipment providers.
05 RRP Pharmacy YES
(See notes)
These are codes to restrict recipient to specific pharmacy providers.
06 RRP Physician YES
(See notes)
These are codes to restrict recipient to specific physicians.
08 RRP Clinic YES
(See notes)
These are codes to restrict recipient to specific clinics.
09 RRP In-Patient Hospital YES
(See notes)
These are codes to restrict recipient to specific hospitals for inpatient services.
10 RRP Dental Clinic YES
(See notes)
These are codes to restrict recipient to specific dental clinics.
11 RRP Physician Group YES
(See notes)
These are codes to restrict recipient to specific physician groups.
12 RRP Physician Assistant/Nurse Practitioner YES
(See notes)
These are codes to restrict recipient to specific PA/NP providers.
13 RRP Alternative Pharmacy YES
(See notes)
These are codes to restrict recipient to specific alternative pharmacy providers.
20 Enrollee in Special Needs MC Plan (HIV SNP) YES
(See notes)		 Like mainstream plans, recipients can be members of HIV SNP and enrolled in a Health Home program.
This code is used to identify enrollees in Special Needs Plans.
21 Enrollee in Special Needs MC Plan (HIV SNP) YES
(See notes)
This code is used to identify enrollees in Special Needs Plans.
23 OMH Children´s Waiver NO
(See notes)		 Children that received services through this previous waiver have been transitioned to the new Children´s Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code has ended effective 3/31/2019.
This code is used to identify recipients in the OMH Home & Community Based Services (HCBS) waiver for seriously emotionally disturbed (SED) children.
25 OPWDD - Sub-Chapter A Exception NO  
This code is for individuals receiving OPWDD for a limited period of time with no local shares.
30 LTHHCP - Long Term Home Health Care Program (Lombardi Waiver) NO
(See notes)		 Individuals receiving services through this waiver can either be enrolled in a Health Home or in the waiver, but cannot be in both as each provides care management services. Care managers should work with individuals to determine which service best meets their needs.
Code used for individuals authorized for long term care services who are eligible for nursing home level of care and are residing in the community. Services provided through a certified LTHHCP provider.
35 Case Management Program; Medicaid Service Coordination/Case Management Program (Medicaid OMH, COBRA, AI TCM, OPWDD) YES
(See notes)		 Children receiving OMH TCM services are being transitioned and adults receiving HIV COBRA, OMH TCM and OPWDD care management have transitioned into Health Homes. Individuals receiving EI TCM services will transition to Health Home enrollment at a later date. First Time Mothers/Newborns (NFP Targeted Case Management) will not transition and can not be enrolled in the Health Home program while enrolled in NFP. NFP Care Managers should refer individuals to the Health Home program upon disenrollment, if appropriate .
Comprehensive case management program.
38 ICF/DD Res NO
(See notes)		 Individuals receiving services through this waiver can either be enrolled in a Health Home or in the waiver, but cannot be in both as each provides care management services. Care managers should work with individuals to determine which service best meets their needs.
Recipient is a resident of an ICF-DD Facility.
39 Aid Continuing YES
(See notes)		 The care managers must work within the individuals established UT. Limitations on services may apply.
Recipient is subject to Utilization Threshold (UT) and exempt from copay.
44 HCBS at Home Non-Intensive Residential Habilitation NO
(See notes)		 At this time OPWDD waiver participants cannot be in a Health Home and the waiver. If waiver participants wish to receive care management through a Health Home they must dis-enroll from the waiver. Health Home care managers and OPWDD Medicaid Service Coordinator (MSC) managers should work with individuals to determine whether the waiver or Health Homes can best meet their needs.
Recipient is in a HCBS Non-Intensive AHRH to better serve consumers in their own homes and reduce demand for more costly residential placement.
45 HCBS at Home Intensive Residential Habilitation NO
(See notes)		 At this time OPWDD waiver participants cannot be in a Health Home and the waiver. If waiver participants wish to receive care management through a Health Home they must dis-enroll from the waiver. Health Home care managers and OPWDD Medicaid Service Coordinator (MSC) managers should work with individuals to determine whether the waiver or Health Homes can best meet their needs.
Recipient is in a HCBS IBS to better serve consumers in their own homes and reduce demand for more costly residential placement.
46 OPWDD Home & Community Based Services Waiver - HCB (Pure Waiver) NO
(See notes)
Identifies a recipient in home & community based services waiver program (HCBS).
47 OPWDD HCBS Community Habilitation Phase 2 NO
(See notes)		 At this time OPWDD waiver participants cannot be in a Health Home and the waiver. If waiver participants wish to receive care management through a Health Home they must dis-enroll from the waiver. Health Home care managers and OPWDD Medicaid Service Coordinator (MSC) managers should work with individuals to determine whether the waiver or Health Homes can best meet their needs.
Identifies a recipient in home & community based services waiver supervised CR or supervised IRA.
48 OPWDD HCBS Supportive IRAs and CRs NO
(See notes)
Identifies a recipient in home & community based services waiver supportive IRA & CR.
49 OPWDD HCBS Supervised IRA NO
(See notes)
Identifies a recipient in home & community based services waiver supervised IRA & CR.
55 MCC Pharmacy YES Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but the care manager should work with the recipient and contact their Managed Care Plan to ensure compliance with any restrictions.
An HR recipient enrolled in the MCCP and receiving pharmacy services from the primary pharmacy.
56 MCC Physician YES Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but the care manager should work with the recipient and contact their Managed Care Plan to ensure compliance with any restrictions.
An HR recipient enrolled in the MCCP and assigned to a primary physician or a preferred provider. Non-emergent transportation must be ordered by a primary provider only. Ancillary services (pharmacy, DME & lab) must be ordered by primary or referred provider.
58 MCC Clinic YES
(See notes)		 Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but the care manager should work with the recipient and contact their Managed Care Plan to ensure compliance with any restrictions.
An HR recipient enrolled in the MCCP and assigned to a primary clinic where s/he must receive care or be referred for care. Ancillary services (pharmacy, DME & lab) must be ordered by primary only.
59 MCC Hospital YES
(See notes)		 Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but the care manager should work with the recipient and contact their Managed Care Plan to ensure compliance with any restrictions.
A recipient enrolled in the MCCP and assigned to a primary inpatient provider where s/he must receive care.
60 Nursing Home Transition and Diversion Waiver NO
(See notes)		 Individuals receiving services through this waiver can either be enrolled in a Health Home or in the waiver, but cannot be in both as each provides care management services. Care managers should work with individuals to determine which service best meets their needs.
Recipient enrolled in Nursing Home Transition & Nursing Home Diversion waiver
62 Care at Home (CAH) I (Administered by DOH) NO
(See notes)		 Children that received services through this previous waiver have been transitioned to the new Children´s Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code has ended effective 3/31/2019.
The Medicaid-waiver CAH I program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
63 Care at Home (CAH) II (Administered by DOH) NO
(See notes)
The Medicaid-waiver CAH II program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
64 Care at Home (CAH) III (OPWDD) NO
(See notes)		 Children that received services through this previous waiver have been transitioned to the new Children´s Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code has ended effective 3/31/2019.
The Medicaid-waiver CAH III program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
65 Care at Home (CAH) IV (OPWDD) NO
(See notes)		 Children that received services through this previous waiver have been transitioned to the new Children´s Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code has ended effective 3/31/2019.
The Medicaid-waiver CAH IV program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
67 Care at Home (CAH) VI (OPWDD) NO
(See notes)		 Children that received services through this previous waiver have been transitioned to the new Children´s Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code has ended effective 3/31/2019.
The Medicaid-waiver CAH IV program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
72 Bridges to Health (B2H) Seriously Emotionally Disturbed (SED) NO
(See notes)		 Children that received services through this previous waiver have been transitioned to the new Children´s Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code has ended effective 3/31/2019.
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
73 Bridges to Health (B2H) Developmentally Disabled NO
(See notes)
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
74 Bridges to Health (B2H) Medically Fragile (MedF) NO
(See notes)
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
75 LTC D/D Asset Protection YES  
Recipients are those who receive resource exemptions in the amount of LTC insurance benefit dollars paid to date. The amount determines the amount of resources disregarded in the Medicaid Budget Logic (MBL) budget.
76 LTC Total Asset Protection YES  
Recipients are those who have complete disregard of resources in Medicaid Budget Logic (MBL).
77 LTC Insurance-Non-Partnership YES  
Recipients have LTC insurance but not through the Partnership for LTC.
81 Traumatic Brain Injury (TBI) NO
(See notes)		 Individuals receiving services through this waiver can either be enrolled in a Health Home or in the waiver, but cannot be in both as each provides care management services. Care managers should work with individuals to determine which service best meets their needs.
HCBS/TBI waiver services include: service coordination, independent living skills training and development (ILST), structured day program services, substance abuse program services, positive behavioral interventions and support services (PBIS), community integration counseling (CIC), home and community support services (HCSS), environmental modifications (emods), respite services, assistive technology (AT), waiver transportation, and community transitional services (CTS).
82 Non-MMIS ID RRP Provider YES
(See notes)		 Individuals can be in a Restricted Recipient Program (RRP) and enrolled in Health Home, but the Care Managers should work with the individual and contact their Managed Care Plan to ensure compliance with any restrictions.
This code returns an eligible message "Restricted recipient contact MC plan for provider information"
83 Alcohol & Substance Abuse (ASA) YES
(See notes)		 The care manager should coordinate services within existing Fee-For-Services and Managed Care Plan eligibility requirements.
Recipient has been mandated to receive ASA services FFS in some instances. The recipient may also be in PCP where the plan is responsible for payment of some services.
84 OMH Base/Community Rehab & Support (CRS) with Clinical Treatment YES  
Recipient is enrolled in an outpatient rehab program for mentally ill adults (OMH). Recipients are exempt from UT.
85 OMH Base/Community Rehab & Support (CRS) without Clinical Treatment YES  
Recipient is enrolled in an outpatient rehab program for mentally ill adults (OMH). Recipients are exempt from UT.
86 OMH Intensive Rehab & Ongoing Rehab Services (IR/OR) YES  
Recipient is enrolled in an outpatient rehab program for mentally ill adults (OMH). Recipients are exempt from UT.
89 Money Follows the Person YES  
 
90 Managed Care Excluded YES  
Recipient is excluded from mandated managed care auto assignment of a plan
91 Managed Care Exempt YES  
Recipient is exempt from managed care enrollment
92 DOH/ Managed Care Exempt YES  
Recipient is exempt from managed care enrollment
93 Managed LTC YES
(See notes)		 Individuals can be in both a Health Home and a MLTC plan. The Health Home and MLTC plan must have an administrative services agreement outlining their respective responsibilities.
Recipients are marked who are required to enroll in a managed LTC program
94 OMH Exempt YES  
Recipient exempt from managed care enrollment
95 OPWDD Waivered Services Look-Alikes YES  
Recipient exempt from managed care enrollment
96 Seriously & Persistently Mentally Ill Adults (SPMI) & Seriously Emotionally Disturbed Children (SED) YES
(See notes)		 Children receiving services through this waiver can either be enrolled in a Health Home or in the waiver, but cannot be in both as each provides care management services. Care managers should work with individuals to determine which service best meets their needs.
Recipient exempt from managed care enrollment
A1 Health Home Program - Care Management Agency YES Released 7/16/18.
Member is in outreach or enrolled with a Care Management Agency
A2 Health Home Program - Health Home YES Released 7/16/18.
Member is in outreach or enrolled with a Health Home
AL Assisted Living NO  
System generated based on claims for assisted living.
B7 Non EP BHP Aliessa YES  
 
C1 Copay Exempt (Hospice) YES  
 
C2 Medicare or Medicaid Hospice Elected YES
(See Note)		 HH/CMAs must work with Hospice provider/program to ensure delineation of care management services is not duplicative.
 
CF Community First Choice Option YES  
 
CH Home and Community Based Services - CREPS YES  
 
CM Managed Lont Term Care - CREPS YES  
 
CO Community First Choice Option OPWDD YES  
 
D0 DSRIP Opt Out Undeliverable Mail YES  
 
D1 DSRIP Opt Out of Data Sharing YES  
 
D2 DSRIP Opt In To Data Sharing YES  
 
E1 Primary Payer Documentation on file for zero fill YES  
 
G1 Transgender Male to Female YES  
 
G2 Transgender Female to Male YES  
 
H1 HARP Enrolled without HCBS Eligibility YES  
 
H2 HARP Enrolled with Tier 1 HCBS Eligibility YES  
 
H3 HARP Enrolled with Tier 2 HCBS Eligibility YES  
 
H4 HIV SNP HARP Eligible without HCBS Eligibility YES  
 
H5 HIV SNP HARP Eligible with Tier 1 HCBS Eligibility YES  
 
H6 HIV SNP HARP Eligible with Tier 2 HCBS Eligibility YES  
 
H7 Opted out of HARP YES  
 
H8 State-Identified for HARP Assessment YES  
 
H9 HARP Eligible - Pending Enrollment YES  
 
I1 OPWDD MC Class 1 NO  
 
I2 OPWDD MC Class 2 NO  
 
I3 OPWDD MC Class 3 NO  
 
I4 OPWDD MC Willowbrook NO  
 
I5 CCO/HH Enrollment Level 1 NO  
 
I6 CCO/HH Enrollment Level 2 NO  
 
I7 CCO/HH Enrollment Level 3 NO  
 
I8 CCO/HH Enrollment Level 4 NO  
 
I9 CCO/Basic HCBS Plan Support NO  
 
K1 HCBS LOC YES  
HCBS At Level of Care Acuity
K2 HCBS LON YES  
HCBS at Level of Need Acuity
K3 HCBS SED YES  
HCBS Serious Emotional Disturbance
K4 HCBS MF YES  
HCBS Medical Fragility
K5 HCBS DDFC YES  
HCBS Developmental Disability & in Foster Care
K6 HCBS DDMF YES  
HCBS Developmentally Disabled & Medically Fragile
K7 HCBS CT YES  
HCBS Abuse Neglect Maltreatment Complex Trauma
K8 VFCA YES  
Child in Care of a Voluntary Foster Care Agency
K9 FC YES  
Child is in or Associated with Foster Care
KK FO1 YES  
Child is Eligible for Medicaid as Family of One
M1 MAGI Remains in WMS YES  
Child is Eligible for Medicaid as Family of One
N1 Regular SNF Rate - MC Enrollee NO These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral.
Permanently placed in SNF
N2 SNF AIDS - MC Enrollee NO These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral. Pag
Permanently placed in SNF
N3 SNF Neuro-Behavioral - MC Enrollee NO These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral.
Permanently placed in SNF
N4 SNF Traumatic Brain Injury - MC Enrollee NO These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral.
Permanently placed in SNF
N5 SNF Ventilator Dependent - MC Enrollee NO These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral.
Permanently placed in SNF
N6 vPartial Cap 21+ Nursing Home Certifiable NO These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral.
Permanently placed in SNF
N7 NH Budgeting Approved NO These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral.
Permanently placed in SNF
N8 Transfer Penalty Period DHPCO NO These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral.
Permanently placed in SNF
N9 NH Resident Pending NH Eligibility Determination NO These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral.
Permanently placed in SNF
NH Nursing Home NO Care Managers must work with the Nursing Home to identify if the member is permanently placed. If the member becomes permanently place the member should be disenrolled from the Health Home Program. If a member is transitioning from the NH to the community the Care Manager should work with the NH to ensure a smooth transition for the member.
System generated based on claims for nursing home.
PL Pre-Release Upstate MC Ineligible YES (See Note) Care manager can only work with member in the month this code is ended.
 
PR Pre-Release Downstate MC Ineligible YES (See Note) Care manage can only work with member in the month this code is ended.
 
S1 Surplus Client Not Eligible for Medicaid MC or Medicaid Advantage (NYC ONLY) YES (See Note) Care manager should work with the individual to maintain their Medicaid eligibility.
 
T1 Upstate Temporary Assistance Non-MAGI YES  
 
T2 NYC Tax Claim YES  
 
T3 NYC Enhanced Shelter Allowance YES  
 
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
95 OPWDD Waivered Services Look-Alikes The Health Home Compatibility Changed from No to Yes with stipulations. Please see above.
Recipient exempt from managed care enrollment
A1 Health Home Program - Care Management Agency Added
Member is assigned, in outreach, or enrolled with a Care Management Agency
A2 Health Home Program - Health Home Added
Member is assigned, in outreach, or enrolled with a Health Home
AL Assisted Living Added
System generated based on claims for assisted living.
B7 Non EP BHP Aliessa Added
 
C1 Copay Exempt (Hospice) Added
 
G1 Transgender Male to Female Added
 
G2 Transgender Female to Male Added
 
NH Nursing Home Added
System generated based on claims for nursing home.
TR Transgender Individual Deleted as more specific codes were added. Please see G1 and G2.
 
Updated 1/25/2017
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
23 OMH Children´s Waiver Changed policy notes to delete " (once Health Homes have been designated to serve children)"
This code is used to identify recipients in the OMH Home & Community Based Services (HCBS) waiver for seriously emotionally disturbed (SED) children.
35 Case Management Program; Medicaid Service Coordination/Case Management Program (Medicaid OMH, COBRA, AI TCM, OPWDD) Changed policy notes to account for adults completion of transition and children transitioning into Health Homes.
Comprehensive case management program.
62 Care at Home (CAH) I (Administered by DOH) Changed policy notes to delete " (once Health Homes have been designated to serve children)"
The Medicaid-waiver CAH I program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
63 Care at Home (CAH) II (Administered by DOH) Changed policy notes to delete " (once Health Homes have been designated to serve children)"
The Medicaid-waiver CAH II program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
64 Care at Home (CAH) III (OPWDD) Changed policy notes to delete " (once Health Homes have been designated to serve children)"
The Medicaid-waiver CAH III program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
65 Care at Home (CAH) IV (OPWDD) Changed policy notes to delete " (once Health Homes have been designated to serve children)" Pag
The Medicaid-waiver CAH IV program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
67 Care at Home (CAH) VI (OPWDD) Changed policy notes to delete " (once Health Homes have been designated to serve children)"
The Medicaid-waiver CAH IV program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
72 Bridges to Health (B2H) Seriously Emotionally Disturbed (SED) Changed policy notes to delete " (once Health Homes have been designated to serve children)"
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
73 Bridges to Health (B2H) Developmentally Disabled Changed policy notes to delete " (once Health Homes have been designated to serve children)"
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
74 Bridges to Health (B2H) Medically Fragile (MedF) Changed policy notes to delete " (once Health Homes have been designated to serve children)"
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
92 DOH/ Managed Care Exempt Added
Recipient is exempt from managed care enrollment
CO Community First Choice Option Added
 
CF Community First Choice Option OPWDD Added
 
I1 OPWDD MC Class 1 Added
 
I2 OPWDD MC Class 2 Added
 
I3 OPWDD MC Class 3 Added
 
I4 OPWDD MC Willowbrook Added
 
M1 MAGI Remains in WMS Added
 
N8 Transfer Penalty Period DHPCO Added
 
N9 NH Resident Pending NH Eligibility Determination Added
 
Updated 2/21/2017
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
95 OPWDD Waivered Services Look-Alikes DELETED: To find a Developmental Disability Regional Office copy and paste the following link in your web browser.
ADDED: new instructions for inquiries.
Recipient exempt from managed care enrollment
Updated 5/9/17
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
CF Community First Choice Option Incorrectly labeled with OPWDD
 
CH Home and Community Based Services - CREPS Added
 
CM Managed Lont Term Care - CREPS Added
 
CO Community First Choice Option OPWDD Incorrectly labeled without OPWDD
 
D0 DSRIP Opt Out Undeliverable Mail Added
 
D1 DSRIP Opt Out of Data Sharing Added
 
D2 DSRIP Opt In To Data Sharing Added
 
PL Pre-Release Upstate MC Ineligible Added
 
PR Pre-Release Downstate MC Ineligible Added
 
T1 Upstate Temporary Assistance Non-MAGI Added
 
T2 NYC Tax Claim Added
 
T3 NYC Enhanced Shelter Allowance Added
 
Updated 3/2/2018
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
CF Community First Choice Option Compatibility Changed from No to Yes
 
CO Community First Choice Option OPWDD Compatibility Changed from No to Yes
 
Updated 4/23/2018
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
15 CCO/HH Enrollment Level 1 Added
 
16 CCO/HH Enrollment Level 2 Added
 
17 CCO/HH Enrollment Level 3 Added
 
18 CCO/HH Enrollment Level 4 Added
 
19 CCO/Basic HCBS Plan Suppor Added
 
35 Case Management Program; Medicaid Service Coordination/Case Management Program (Medicaid OMH, COBRA, AI TCM, OPWDD) Changed description to add "OPWDD care management have transitioned into Health Homes." and "First Time Mothers/Newborns (NFP Targeted Case Management) will not transition and can not be enrolled in the Health Home program while enrolled in NFP. NFP Care Managers should refer individuals to the Health Home program upon disenrollment, if appropriate . "
Comprehensive case management program.
A1 Health Home Program - Care Management Agency Changed date
Member is assigned, in outreach, or enrolled with a Care Management Agency
A2 Health Home Program - Health Home Changed date
Member is assigned, in outreach, or enrolled with a Health Home
Updated 7/11/2018
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
A1 Health Home Program - Care Management Agency Changed Description from "Tentative date of release is July 2018" to "Released 7/16/18".
Member is assigned, in outreach, or enrolled with a Care Management Agency
A2 Health Home Program - Health Home Changed Description from "Tentative date of release is July 2018" to "Released 7/16/18".
Member is assigned, in outreach, or enrolled with a Health Home
Updated 7/16/2018
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
23 OMH Children´s Waiver Changed Compatibility with the Health Home Program and Description
This code is used to identify recipients in the OMH Home & Community Based Services (HCBS) waiver for seriously emotionally disturbed (SED) children.
62 Care at Home (CAH) I (Administered by DOH) Changed Compatibility with the Health Home Program and Description
The Medicaid-waiver CAH I program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
63 Care at Home (CAH) II (Administered by DOH) Changed Compatibility with the Health Home Program and Description
The Medicaid-waiver CAH II program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
64 Care at Home (CAH) III (OPWDD) Changed Compatibility with the Health Home Program and Description
The Medicaid-waiver CAH III program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
65 Care at Home (CAH) IV (OPWDD) Changed Compatibility with the Health Home Program and Description
The Medicaid-waiver CAH IV program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
67 Care at Home (CAH) VI (OPWDD) Changed Compatibility with the Health Home Program and Description
The Medicaid-waiver CAH IV program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
72 Bridges to Health (B2H) Seriously Emotionally Disturbed (SED) Changed Compatibility with the Health Home Program and Description
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
73 Bridges to Health (B2H) Developmentally Disabled Changed Compatibility with the Health Home Program and Description
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
74 Bridges to Health (B2H) Medically Fragile (MedF) Changed Compatibility with the Health Home Program and Description
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
K1 HCBS LOC Added
HCBS At Level of Care Acuity
K2 HCBS LON Added
HCBS at Level of Need Acuity
K3 HCBS SED Added
HCBS Serious Emotional Disturbance
K4 HCBS MF Added
HCBS Medical Fragility
K5 HCBS DD Added
HCBS Developmentally Disabled
K6 HCBS DDMF Added
HCBS Developmentally Disabled & Medically Fragile
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
K7 HCBS CT Added
HCBS Abuse Neglect Maltreatment Complex Trauma
K8 VFCA Added
Child in Care of a Voluntary Foster Care Agency
K9 FC Added
Child is in or Associated with Foster Care
KK FO1 Added
Child is Eligible for Medicaid as Family of One
Updated 1/3/2019
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
23 OMH Children´s Waiver Changed "March 30, 2019" to "at a later date"
This code is used to identify recipients in the OMH Home & Community Based Services (HCBS) waiver for seriously emotionally disturbed (SED) children.
62 Care at Home (CAH) I (Administered by DOH) Changed "March 30, 2019" to "at a later date"
The Medicaid-waiver CAH I program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
63 Care at Home (CAH) II (Administered by DOH) Changed "March 30, 2019" to "at a later date"
The Medicaid-waiver CAH II program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
64 Care at Home (CAH) III (OPWDD) Changed "March 30, 2019" to "at a later date"
The Medicaid-waiver CAH III program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
65 Care at Home (CAH) IV (OPWDD) Changed "March 30, 2019" to "at a later date"
The Medicaid-waiver CAH IV program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
67 Care at Home (CAH) VI (OPWDD) Changed "March 30, 2019" to "at a later date"
The Medicaid-waiver CAH IV program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
72 Bridges to Health (B2H) Seriously Emotionally Disturbed (SED) Changed "March 30, 2019" to "at a later date"
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
73 Bridges to Health (B2H) Developmentally Disabled Changed "March 30, 2019" to "at a later date"
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
74 Bridges to Health (B2H) Medically Fragile (MedF) Changed "March 30, 2019" to "at a later date"
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
Updated 2/1/2019
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
23 OMH Children´s Waiver Changed compatibility from "Yes" to "No" and description from"Children receiving services through this waiver will be transitioning to Health Home Care Management or Care Management through an Independent Entity January 2019-March 2019. This RRE Code is expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new Children´s Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code has ended effective 3/31/2019."
This code is used to identify recipients in the OMH Home & Community Based Services (HCBS) waiver for seriously emotionally disturbed (SED) children.
62 Care at Home (CAH) I (Administered by DOH) Changed compatibility from "Yes" to "No" and description from"Children receiving services through this waiver will be transitioning to Health Home Care Management or Care Management through an Independent Entity January 2019-March 2019. This RRE Code is expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new Children´s Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code has ended effective 3/31/2019."
The Medicaid-waiver CAH I program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
63 Care at Home (CAH) II (Administered by DOH) Changed compatibility from "Yes" to "No" and description from"Children receiving services through this waiver will be transitioning to Health Home Care Management or Care Management through an Independent Entity January 2019-March 2019. This RRE Code is expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new Children´s Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code has ended effective 3/31/2019."
The Medicaid-waiver CAH II program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
64 Care at Home (CAH) III (OPWDD) Changed compatibility from "Yes" to "No" and description from"Children receiving services through this waiver will be transitioning to Health Home Care Management or Care Management through an Independent Entity January 2019-March 2019. This RRE Code is expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new Children´s Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code has ended effective 3/31/2019."
The Medicaid-waiver CAH III program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
65 Care at Home (CAH) IV (OPWDD) Changed compatibility from "Yes" to "No" and description from"Children receiving services through this waiver will be transitioning to Health Home Care Management or Care Management through an Independent Entity January 2019-March 2019. This RRE Code is expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new Children´s Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code has ended effective 3/31/2019."
The Medicaid-waiver CAH IV program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
67 Care at Home (CAH) VI (OPWDD) Changed compatibility from "Yes" to "No" and description from"Children receiving services through this waiver will be transitioning to Health Home Care Management or Care Management through an Independent Entity January 2019-March 2019. This RRE Code is expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new Children´s Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code has ended effective 3/31/2019."
The Medicaid-waiver CAH IV program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
72 Bridges to Health (B2H) Seriously Emotionally Disturbed (SED) Changed compatibility from "Yes" to "No" and description from"Children receiving services through this waiver will be transitioning to Health Home Care Management or Care Management through an Independent Entity January 2019-March 2019. This RRE Code is expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new Children´s Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code has ended effective 3/31/2019."
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
73 Bridges to Health (B2H) Developmentally Disabled Changed compatibility from "Yes" to "No" and description from"Children receiving services through this waiver will be transitioning to Health Home Care Management or Care Management through an Independent Entity January 2019-March 2019. This RRE Code is expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new Children´s Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code has ended effective 3/31/2019."
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
74 Bridges to Health (B2H) Medically Fragile (MedF) Changed compatibility from "Yes" to "No" and description from"Children receiving services through this waiver will be transitioning to Health Home Care Management or Care Management through an Independent Entity January 2019-March 2019. This RRE Code is expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new Children´s Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code has ended effective 3/31/2019."
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
N1 Regular SNF Rate - MC Enrollee Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral."
Permanently placed in SNF
N2 SNF AIDS - MC Enrollee Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral."
Permanently placed in SNF
N3 SNF Neuro-Behavioral - MC Enrollee Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Ho me Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral."
Permanently placed in SNF
N4 SNF Traumatic Brain Injury - MC Enrollee Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral."
Permanently placed in SNF
N5 SNF Ventilator Dependent - MC Enrollee Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral."
Permanently placed in SNF
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
N6 Partial Cap 21+ Nursing Home Certifiable Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral."
Permanently placed in SNF
N7 NH Budgeting Approved Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Ho me Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral."
Permanently placed in SNF
N8 Transfer Penalty Period DHPCO Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral."
Permanently placed in SNF
N9 NH Resident Pending NH Eligibility Determination Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral."
Permanently placed in SNF
NH Nursing Home Added "These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral."
System generated based on claims for nursing home.
K5 HCBS DD Changed "HCBS DD, HCBS Developmentally Disabled" to "HCBS DDFC, HCBS Developmentally Disability & in Foster Care" on February 17. 2021.
HCBS Developmentally Disabled
Updated 2/17/2021
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
95 OPWDD Waivered Services Look-Alikes Code 95 remains compatible with Health Home services. However, the Policy Notes which follow, regarding the steps Health Home Care Managers must take are outdated and no longer apply, and have been removed:
  • Care Managers must check with OPWDD to ensure an individual is not receiving Care Management from OPWDD before they can be outreached or enrolled in the Health Home Program. The following steps MUST be taken to ensure there is not duplication of services:
    • Step 1 - Enter Member's Name, Date of Birth, and CIN number in an excel file.
    • Step 2 - Encrypt with password the excel file.
    • Step 3 - Send excel file with subject line "RRE Code 95 Check" to OPWDD's BML at: fida-idd@opwdd.ny.gov
    • Step 4 - Send the password to the same BML with the same subject line.
Recipient exempt from managed care enrollment
Updated 4/1/2022

CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
C2 Medicare or Medicaid Hospice Elected Added
 
Updated 4/29/2022
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
KF FC Added
FC Child Must Remain in FFS
Updated 7/11/2023
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
E1 Primary Payer Documentation on file for Zero fill New Code Added
 
Updated 11/16/2023
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
H1 HARP Enrolled without HCBS Eligibility This code description has been changed to: HARP Enrolled
H2 HARP Enrolled with Tier 1 HCBS Eligibility This code description has been changed to: Tier 1 HARP BH HCBS Eligible
H3 HARP Enrolled with Tier 2 HCBS Eligibility This code description has been changed to: Tier 2 HARP BH HCBS Eligible
H4 HIV SNP HARP Eligible without HCBS Eligibility This code description has been changed to: HIV SNP BH High-Risk
H5 HIV SNP HARP Eligible with Tier 1 HCBS Eligibility This code description has been changed to: HIV SNP, Tier 1 BH HCBS Eligible
H6 HIV SNP HARP Eligible with Tier 2 HCBS Eligibility This code description has been changed to: HIV SNP, Tier 2 BH HCBS Eligible
H9 HARP Eligible - Pending Enrollment This code description has been changed to: BH High-Risk/ HARP Eligible
Updated 7/2/2024 effective: 5/23/24