DOH Medicaid Update August 1999 Vol.14, No.8

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These instructions apply only to those providers who are named plaintiffs in the above-cited action.

• This article is to once again remind providers that all edit correction and data submission opportunities ended with the May 11, 1999 deadline.
• In the April 1999 Medicaid Update, providers were told that the June 1999 purge cycle would be the final cycle in which Medicare lawsuit claims would be processed for payment. At that time, it was anticipated that the purge run would occur in cycle #138. The June purge cycle occurred instead, in cycle #139.
• Providers were also told in a note in the April Medicaid Update that all unresolved lawsuit claims remaining after the June purge cycle would be denied and reported out in remittances, in a regular cycle soon after that purge cycle.
• Please Note: Unresolved Medicare lawsuit claims described above, were denied in cycle #140, and were reported out to providers in remittances from that cycle.
• Providers may, however, still submit voids for processing, if necessary.

For assistance, please call your Computer Sciences Corporation (CSC) Healthcare Systems representative at:

Practitioner Services: 1-800-522-5518 or [518] 447-9860
Institutional Services: 1-800-522-1892 or [518] 447-9810
Professional Services: 1-800-522-5535 or [518] 447-9830

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The Utilization Threshold (UT) program places limits on the number of times Medicaid recipients can receive certain medical services in a benefit year. The limits on these services are:

Medical Service	Limit
Physician/clinic	10 visits
Pharmacy	40 or 43 pharmacy items, depending on the recipient's age/aid category
Laboratory	18 procedures
Mental Health Clinic	40 visits
Dental clinic	3 vists

Increases in a recipient's UT limits can only be granted upon submission by the individual's primary care provider of a Threshold Override Application (TOA). Recipients are informed of the need to have a TOA submitted via warning and at-limit letters.

TOAs are processed by Computer Sciences Corporation (CSC), the Medicaid Management Information System (MMIS) fiscal agent. CSC has informed the Department of Health (DOH) that the volume of TOAs submitted by primary care providers has increased significantly. CSC attributes this increase to the fact that providers, especially hospitals and clinics, are submitting multiple TOAs for the same person. In many other cases, providers are submitting TOAs when a recipient's medical condition does not warrant an increase in his/her service limits. Submission of these unnecessary TOAs requires CSC to do additional work which delays the processing of legitimate TOAs.

In order for the UT program to work effectively, providers that submit TOAs should follow these guidelines:

• Check EMEVS which will inform providers when a recipient is either nearing his/her service limit or is at limit, in which case a TOA should be submitted.
• Submit TOAs onlywhen the recipient's medical condition justifies doing so. TOAs should not be routinely submitted for all Medicaid recipients.
• Provide specific information on the recipient's medical condition in the Medical Assessment section of the TOA. TOAs should be individually tailored to address the needs of the recipient.
• Based on your assessment of the recipient's medical condition, submit only one TOA at a time for an individual. The requested increase should reflect the recipient's medical needs for the remainder of his/her benefit year. Some hospitals are sending TOAs in every time a recipient is seen. Also, multiple TOAs are often submitted by hospitals for one recipient on the same date.

It is important that providers use the most current version of the TOA when requesting increases in service limits. Please check the top left corner of the form to determine the date. The current TOA is dated July, 1993 (A copy of the form is reproduced in this edition. You may make copies of the form and use them to request UT increases). Providers should also send the completed form to the address indicated on the TOA: Computer Sciences Corporation, Medicaid Override Application System, P.O. Box 4420, Albany, NY 12204-0420.

Any questions about this article should be directed to Stephen B. Jackson, Bureau of Enforcement Activities, at (518) 473-5317. If you need TOAs, please call CSC at (800) 421-3893.

Federal and State statutes and regulations require that a Skilled Nursing Facility (SNF) must not require individuals applying to reside or residing in the facility to waive their rights to benefits under Medicaid or Medicare. Under 42 CFR 483.12(d), a SNF must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State plan, any gift, money, donation, or other consideration as a precondition of admission, expedited admission or continued stay in the facility. Thus, SNFs are required to refund any payment received from a resident or family member for the period of time that the Medicaid eligibility was pending and for which the resident was determined eligible for Medicaid.

SNFs must take immediate action to identify all individuals eligible for reimbursement of private payments made by residents or family members during the time that Medicaid eligibility was pending and for which the resident was determined eligible for Medicaid, and make the appropriate reimbursements. Failure to comply with these resident rights requirements could result in an enforcement action against the nursing home.

Any questions regarding this issue should be addressed to the Office of Continuing Care, Bureau of Surveillance and Quality at (518) 408-1267.

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Pharmacy claims for residents of nursing homes located in New York State will no longer be subject to edit 867 "NURSING HOME RESIDENT/PHARMACY SERVICES INCLUDED IN NH RATE". There will no longer be a delay in payment while the edit 867 pend is resolved. Claims for recipients in nursing homes located in New York State will be subject to new edit 1316, also entitled "NURSING HOME RESIDENT/PHARMACY SVS INCL IN NH RATE". This edit will allow pharmacy claims for residents of New York State nursing homes to adjudicate in the cycle in which they are originally processed. Claims for drugs which are found to be included within the cost components of the nursing home rate will continue to be denied.

Note: For those cases where the patient is resident in an Article 28 nursing facility located outside of New York State, the pharmacy claim will continue to be subject to the current edit 867 process.

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Dental practitioner claims for residents of nursing homes located in New York State will no longer be subject to edit 868 "NURSING HOME RESIDENT/DENTAL SERVICES INCLUDED IN NH RATE". There will no longer be a delay in payment while the edit 868 pend is resolved. Claims for recipients in nursing homes located in New York State will be subject to new edit 1317, also entitled "NURSING HOME RESIDENT/DENTAL SVCS INCL IN NH RATE". Dental clinics will also be subject to this edit. This edit will allow dental and dental clinic claims for residents of New York State nursing homes to adjudicate in the cycle in which they are originally processed. Claims for dental services which are found to be included within the cost components of the nursing home rate will continue to be denied.

Note: For those cases where the patient is a resident in an Article 28 nursing facility located outside New York State, dental practitioner and dental clinic claims will be subject to the current edit 868 process.

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A number of providers have inquired about Computer Sciences Corporation's (CSC's) procedures for acknowledging the receipt of claims. The following summarizes those procedures as they apply toward the various types of claim submissions.

Paper

Due to the high volume of daily input into the CSC mailroom, it is not feasible to acknowledge receipt of paper claims. Paper claims are subjected to an immediate pre-screening process. Any claims which are rejected in this process are returned to the provider with an explanation of the deficiency.

Diskette and Cartridge

Again, due to the high volume of daily input into the CSC mailroom, it is not feasible to acknowledge receipt of mailed magnetic media. These media are passed through the fiscal agent's mag media front-end processing, which determines whether the media is readable and is in one of the acceptable billing formats. If the media does not pass front-end checks, it is returned to the submitter with a Magnetic Media Return Notice. The Notice includes a description of the problem encountered along with any supporting documentation, and is mailed within 24 hours of the receipt of the media. Media which passes the front-end checks is passed to the claims processing system. Providers may call to determine the status of a submitted piece of media. These calls should be made to the CSC Provider Relations unit at one of the numbers listed below. Claims status calls should NOT be made to CSC's Mag Media Unit. When calling, the submitter should be ready to supply the Tape Supplier Number (TSN) and the internal serial number they assigned to the piece of media.

Electronic Submission

Electronic submissions are made to CSC in one of two ways: dial-up via modem (this includes modem-submitted PACES claims); and via direct line input. Dial-up (modem submitted) claims are input through the CSC Electronic Gateway (EG). The EG will acknowledge the number of records received via screen message immediately after the conclusion of the submission transmission. This is followed shortly thereafter by a second message displaying the number of claims that have passed the validity check and moved on to the adjudication process. This message can also be downloaded at a later time. Procedures for doing so can be found in the NYS-MMIS EG user manual, which can be downloaded from the Gateway or obtained by calling the appropriate CSC Provider Relations unit. Providers may also call the CSC Provider Relations unit to learn how many of their modem-submitted claims have passed to the adjudication process.

Claims submitted electronically via direct line do not pass through the EG. Acknowledgement is provided through job control totals showing the number of records received. CSC's Provider Relations unit is not able to retrieve information on the number of these claims that have passed to the adjudication process.

Claims Status Check

All checks are dated the Monday on which their processing cycle is completed. After 10:00 a.m. on that Monday, providers may obtain the payment status of any individual claim (up to three claims please) by calling the appropriate CSC Provider Relations unit. Providers should be ready to supply the invoice number they used to submit the claim in question. This process is available regardless of the type of claim submission (paper, cartridge, diskette, dial-up, direct line, or claim capture via EMEVS).

CSC Provider Relations Unit Phone Numbers
Practitioner Services: 1-800-522-5518
Institutional Services: 1-800-522-1892
Professional Services: 1-800-522-5535

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Pursuant to amendment to 18 NYCRR 505.5(d)(2), the reimbursement methodology for Durable Medical Equipment (DME) has been changed. For dates of service on or after September 1, 1999, reimbursement for DME is limited to the lower of:

• the price indicated in the fee schedule for DME (Rev. 4/99); or
• the usual and customary price charged to the general public.

Reimbursement methodologies for DME with no price indicated in the fee schedule, Medical /Surgical Supplies, Prosthetics, Orthotics, Prescription Footwear and Enteral Therapy remain unchanged. (DME Manual replacement pages 4-1 and 4-2 reflecting this change will be mailed to enrolled DME providers.)

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The State Department of Health welcomes your comments or suggestions regarding the Medicaid Update.

Please send suggestions to the editor, Timothy Perry-Coon:

NYS Department of Health
Office of Medicaid Management
Bureau of Program Guidance
99 Washington Ave., Suite 720
Albany, NY 12210
(e-mail MedicaidUpdate@health.state.ny.us )

The Medicaid Update, along with past issues of the Medicaid Update, can be accessed online at the New York State Department of Health web site: http://www.health.state.ny.us/health_care/medicaid/program/main.htm