Here is a follow up to questions that Trading Partners have previously posted:

There are 3 instances in which 0FILL needs to be used:

1) When the previous payer denied the claim.

2) When the previous payer paid zeroes.

3) When the provider did not bill prior payer.

Prior Approval numbers must be entered on claims in the following manner. Providers who do not follow the instructions below will receive denials for edit 00244 Prior Approval Not On Or Removed From File (Adjustment Reason Code 15):  

  Locator Code must be entered in the following manner. Providers who do not follow the instructions below will receive denials for edit 00098 Locator Code Invalid (Adjustment Reason Code 16) or edit 00129 Rate Code Not On Rate File (Adjustment Reason Code 16)

The eMedNY System has various edits in place to ensure that valid Ordering/Referring/Prescribing Provider information is entered on claims. If an MMIS Provider ID is used, the system will validate the ID, then cross match to the License number to ensure that the License number has an active ordering status. If a License Number is used and the Provider has an MMIS Provider ID on file, the same cross matching editing is performed. Therefore, MMIS Provider Ids, License Numbers and Profession Codes must be entered properly so that the appropriate editing can be performed. Claims that contain invalid or incorrectly entered MMIS Provider Ids/License Numbers/Profession Codes may fail one of the following edits:

eXchange error message "Inbound batch submission is currently unavailable" - this means the User ID has not been activated. You might have created the eXchange profile, but after you did that, you need to call 800 343 9000 to get the User ID activated. Unfortunately this takes 4-5 business days to implement.  

CLP08, Facility Code Value will only be returned on the 835 for Rate-Based claims (837 Institutional).  This field will be be populated when reporting on fee-for-service claims.

Hospice is no longer required to use revenue codes 0235, 0650 thru 0659 to derive the correct Category of Service.

Dental Clinics MUST submit with a diagnosis code and may use 7999.

For all rate based Institutional 837 Claims, payment will be based on the Rate Code and Statement Dates information from the claim level. See the tip-bit about Revenue Code 0240 for information about reporting multiple units for a Rate Code. 837P & D claims as well as Ordered Amb and Lab on the 837I will continue to be processed based on the fee-for-service information from each service line.

Revenue Code 0240 can be used whenever appropriate.  In addition, we have a new function for 0240.  Rate Based services that may be billed as a single Rate Code with multiple units must include the 0240 Revenue Code line.  The 0240 Revenue Code line ( loop 2400 SV204=UN and SV205=number of units) is where the number of units billed must be reported.  If the 0240 Rev Code is not provided, the rate will be paid as one unit.  Revenue Code 0240 is ONLY used on that line where the units are being reported or claimed. (2400 SV204=UN and SV205=number of units) and is used by providers to report units (hours etc.,) such as Home Health, Case Management, PCA etc.

The recently updated Rate Code Crosswalk now includes information about Category of Service/Type of Bill associations. Review the top section of this important document.

835 - The number of paid units is NOT returned for Institutional claims. Therefore, Home Health PCA, Case Management and others Rate Based claims will NOT get the units paid if they receive the 835.  To determine the units they would have to divide the paid amount by the rate. Keep in mind that the paid amount could be altered by an insurance payment, CAS or patient spend down.

Remit process - Claims will be sorted by the ETIN sent in NM109, loop 1000A of the 837s, and the Pay-to Provider (where Pay-to means either the Billing Provider, or a Group Provider on 837P/837D).  The check and the remit will be cut based on the combination of Pay-to Provider and ETIN.  The remittance will be sent back to the User ID requested on the Elect Remit Selection Notice (Form).  Said User ID is associated to an ETIN on the Form, and therefore, the ETIN should be the same ETIN as in NM109.  Initially we will send one file (ISA) per check.  Each file will contain a single transaction (ST-SE).

·        Date of service - Claim vs. Line:

The date of service for 837 claims that are non-Clinic and nonresidential, such as Nursing Home, ICF, etc., is the from-date of service as submitted in the 2300 loop. The date(s) of service entered on the line level (2400 loop) will not override the date of service in the 2300 loop. The State History File will reflect the from-and-thru dates of service from the 2300 loop as the paid dates(s) of service. The paper remittance will reflect only the from-date from the 2300 as the paid date, but the 835 will show both the from-and-thru date(s) as entered in the 2300 loop .