DSRIP Project 3.a.i Rate Codes Webinar FAQ

January 29, 2018

  • FAQs also available in Portable Document Format (PDF)
1. What is the purpose of DSRIP Project 3.a.i rate codes?
  1. The DSRIP Project 3.a.i rate codes are integrated service (IS) rate codes. They are institutional rates designed to provide an integrated service billing mechanism for Article 28, 31, & 32 licensed sites participating in DSRIP Project 3.a.i as identified by the Performing Provider System (PPS).
2. What information should the PPS send in on the "Project 3.a.i Provider Site Identification" template for the provider site in need of rate codes?
  1. Provider Name
  2. Provider Site Address
  3. Operating Certificate
  4. Provider Site NPI/MMIS
  5. Site Host Agency Certification (Article 28, 31, or 32)
  6. Services being integrated into the host model (physical health, mental health, and/or SUD services)
  7. Site Locator Code
  8. Site Zip+4
3. Q: What is a locator code?
  1. A: A locator code is assigned to a provider site when the provider enrolls in Medicaid. This is done through the provider enrollment unit at the Department of Health (DOH). It is based off of the provider site´s zip+4. If a zip+4 is provided within the template, the locator code may not be necessary.
4. Q: Where can we find the locator codes?
  1. A: If a provider site is unaware of their locator code and cannot locate it, the provider enrollment unit at the Department of Health can be contacted by email for the locator code (providerenrollment@health.ny.gov). Additionally, if a zip+4 is provided within the template, the locator code may not be necessary.
5. Q: Which categories of services under DSRIP are approved for the rate codes?
  1. A: Categories of Services eligible for the DSRIP rate codes are: COS 0160 (Freestanding Clinics) and COS 0287 (Hospital–based Clinics) under Articles 28, 31 and 32s. No other COS are eligible to receive these rate codes. For inquiries on a provider´s COS, please go here.
6. Q: What are the effective dates for the newly approved rate codes?
  1. A: DSRIP 3.a.i rate codes were effective 7/1/16. IOS Rate Codes are effective the date of approval. Please be advised approved Integrated Outpatient Service (IOS) providers will also receive the DSRIP 3.a.i rate codes on their file. This allows them to also re–submit previous claims back to 7/1/16, but does not allow for new submissions of claims for that time.
7. Q: The "DSRIP 3a.i Provider Education" letter authorizes providers to resubmit claims retroactively through July 2016. If a provider did not submit claims previously, but provided the integrated service at that time, can the provider now bill for those services with the new rate codes?
  1. A: No, the DSRIP letter referenced in the question applies to claims previously submitted where the appropriate rate code might not have been used. Additionally, there is a Medicaid requirement that claims are submitted within 90 days of service. However, if there is a valid reason for the delay in submission, there are delayed reason codes. The following Medicaid eMedNY website has delayed claim submission FAQs.
8. What happens to our facility´s previous APG Rate Codes?
  1. All previous APG rate codes on a provider file have remained on file and can continue to be used, but not in conjunction with the Integrated Service rate codes. A combination edit is in place to prevent the billing of Integrated Service rate codes with any other APGs for the same date of service.
9. How will our providers know they have new rate codes and how to use them?
  1. Upon Processing of DSRIP Rate Codes, eMedNY has sent an auto–processed letter to the provider site to notify them they have the new rate codes available to them. This is sent to the same provider site address that is on file with eMedNY and was vetted through the PPS submission of the ´Project 3.a.i Provider Site Identification´ template. Additionally, The DSRIP Team has sent a follow–up letter providing additional guidance to providers on these rate codes (DSRIP 3a.i Provider Education letter).
10. What is the PPS role once a provider receives new rate codes?
  1. The PPS remain the point of contact for all project 3ai provider coordination. The PPS should confirm understanding and discuss the usage of rate codes and reimbursement for services under Medicaid Fee–for–Service and Medicaid Managed Care. Please be advised provider site identification for DSRIP 3.a.i rate codes is separate from Project 3.a.i commitments and engagement.
11. Q: What are the benefits for providers to use these rate codes?
  1. A: Integrated Services Rate Codes were created to enable full reimbursement for two Evaluation & Management Services (E&Ms) provided at the same site on the same day. These rate codes remove the discounting of 10% that would otherwise apply for two Behavioral Health services (i.e. a mental health and substance use disorder service) or a Behavioral Health and Physical Health service delivered on the same day and submitted on a single claim. It is important to note that the rates for the services have not changed, i.e. the rates themselves are not "enhanced."
12. Q: Is there a requirement to use these rate codes?
  1. A: No, there is no requirement to use the newly added rate codes. However, if Project 3.a.i rate codes are not used, full reimbursement will not be made for two Evaluation & Management codes if provided at a single site on the same day, and the multiple services billed on a single claim will be subject to a 10% discount.
13. Q: Can I still participate under DSRIP Project 3.a.i if I am ineligible to receive the rate codes?
  1. A: Yes, although some categories of service may be ineligible for DSRIP rate codes, that does not preclude them from participating in DSRIP project 3.a.i. Please be advised provider site identification for DSRIP 3.a.i rate codes is separate from Project 3.a.i commitments and engagement.
14. Q: What happens to DSRIP rate codes after the demonstration ends in 2020?
  1. A: It is undetermined at this time. However, through the Regulatory Modernization Initiative and various workgroups, DOH/OMH/OASAS are currently looking for a pathway to continue the benefits of Integrated Services for patients and DSRIP providers.
15. Q: Are the MCOs aware of and have they received educational information about the new rate codes for approved providers?
  1. A: Yes, between August and November 2017, the MCOs have received notification of the newly created DSRIP rate codes. Also, the September 2017 Medicaid Update provides a list of available DSRIP rate codes and the payment expectations. Please see the following link: https://www.health.ny.gov/health_care/medicaid/program/update/2017/2017–09.htm#integrated
16. Can physical health services be provided in Behavioral Health sites other than through the Plan–assigned Primary Care Practitioner (PCP)?
  1. A: Yes, physical health services may be delivered in behavioral health settings and are reimbursable by the plans. Not all behavioral health sites offer longitudinal preventive and primary care that would be amenable to the plan assigned PCP model and these providers should still be reimbursed for the physical health services they deliver. For DSRIP sites that committed to Project 3.a.i, Model 2 of Behavioral Health integration, the expectation and project requirement is that over time providers achieve fully integrated care and have a credentialed, plan–assigned PCP. This will allow those members without a PCP to receive comprehensive Primary Care that includes consistent management of chronic conditions such as diabetes, hypertension and other medical conditions.
17. Q: What happens if a provider site has DSRIP 3.a.i Rate Codes loaded, but is in the process of receiving its approval for Integrated Outpatient Services (IOS) application?
  1. A: Once a provider is approved to be an IOS provider, the provider should use those rate codes associated with IOS. Essentially the payment would be the same, however, there is no limitation on integrated services that can be provided within an IOS provider site, as long as those services are approved. While the future of DSRIP rate codes is still to be determined, IOS approval remains.
18. Q: Can Skilled Nursing Facilities (SNF) do integrated services and be eligible for the rate codes?
  1. A: No, Integrated Services are intended for Article 28, 31 and 32 Outpatient Clinics.
19. Q: What should a PPS do if providers were submitted to receive rate codes but are no longer participating in project 3.a.i for the PPS?
  1. A: It is requested that the PPS notify the DSRIP Team (dsrip@health.ny.gov) of these changes so the rate codes can be removed.
20. Q: What should a PPS do if a provider site received a DSRIP 3.a.i rate code but has now become a Certified Community Behavioral Health Clinic (CCBHC) or any other provider type that is ineligible?
  1. A: CCBHCs are paid the Prospective Payment System rate. They should not be billing an integrated services rate code. The PPS should notify the DSRIP Team (dsrip@health.ny.gov) of any provider site that is no longer eligible for the rate code. The team will remove that site from the PPS spreadsheet and notify provider enrollment to terminate the rate code for that site.
21. Q: How should a PPS send back revisions of the "Project 3ai Provider Site Identification" template?
  1. A: Revisions can be indicated by highlighting the entire row within the spreadsheet after incorrect information is replaced. If it is not highlighted as corrected, the DSRIP team will not know a change in the spreadsheet has occurred. Please send revisions to the DSRIP Team at the following email address (dsrip@health.ny.gov).
22. Q: What role can the State DSRIP Team play to ensure that major EHR vendors incorporate these changes into their software systems?
  1. A: We recommend providers reach out to their EHR vendor directly for these concerns, as each EHR is unique and each provider organization´s needs are different.
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