Frequently Asked Questions (FAQs) for eMedNY HIPAA Support

The ASC X12 835 Remit Advice and ASC X12 820 Premium Payment Advice are HIPAA mandated transactions. Neither of these transactions has the capability to report pended claims.

The 820 and 835 Pended Claims Reports are proprietary transactions developed by NYSDOH to report pended claims and/or denied claims.

The 835 Pended Claims Report format provides more detail for pended claims only.

Refer to the Pended Claims Report: Specification.

The 820 Managed Care Pended and Denied Claims Report reports both pended and denied claims with the eMedNY edit.

Refer to the Managed Care Capitation Premium Pended and Denied Claims Report: Specification.

A retro is reported similarly to an adjustment (Reversal, then Correction) on the 820 Premium Payment Advice. The reason for the differences is that retroactive rate adjustments are initiated by NYSDOH and therefore not submitted as an adjustment by the Plan.

WHAT DATA ELEMENTS UNIQUELY IDENTIFY A RETRO?

• Two sets of (Loop 2300B) RMR/ADX segments – similar to a regular Reversal/Correction.
• Both RMR02s report equal (TCNs).
• ADX01 at the individual level will have value H1.
• On the 820 Managed Care Pended and Denied Claims Report, a Retro Reversal is identified with a message "Retro Rate Reversal". A Retro Correction is identified with a message "Retro Rate Correction".
• On the 820 Managed Care Pended and Denied Claims Report, the CLAIM STATUS field will contain value PAID.

If you have questions about the reporting of Retros to a Health Plan on the 820, HIPAA Support can be reached at: eMedNYHIPAASupport@gdit.com.

When previously paid claims are adjusted by a Retroactive Rate Adjustment ("Retro"), the following values are returned in the 835:

A RETROACTIVE RATE REVERSAL is communicated by a Remittance Advice Reason Code (RARC) value of N689 (ALERT: REVERSAL DUE TO RETROACTIVE RATE CHANGE). The CLP segment contains 22 (Reversal) in CLP02.

A RETROACTIVE RATE CORRECTION is communicated by a Remittance Advice Reason Code (RARC) value of N419 (RETROACTIVE RATE ADJUSTMENT). The CLP segment contains 1 (Processed as Primary) in CLP02.

If you have questions about the reporting of Retros on the 835, HIPAA Transaction Support can be reached at: eMedNYHIPAASupport@gdit.com.

Previously paid claims that are valid, but have errors or inaccuracies can be adjusted by populating Loop-ID 2300, Segment CLM, and element CLM05-3 with a Claim Frequency Code of 7. The original, paid claim's Transaction Control Number (TCN) must also be included, in Loop-ID 2300, REF segment (REF01 = F8) of the 837. This is the same value returned by eMedNY in the electronic remittance advice (at CLP07 in the 835). When adjusting a fee-for-service claim using the 837 Professional or 837 Dental it is essential that all the original service lines are still present in the adjustment.

Previously paid claims that are not valid and were billed in error must be voided. This is done by sending a Claim Frequency code value of 8 (Loop-ID 2300, Segment CLM, element CLM05-3), along with the TCN as noted above.

Only previously paid claims should be adjusted or voided. Claims that were denied or rejected due to billing error should be corrected and rebilled as original claims.

A claim can be voided/adjusted as long as it is less than 6 years old, based on the Date of Service. However, claims over 2 years old are not paid by NYSDOH. So if a 2-year old claim is voided, it cannot be re-billed. Therefore in order to correct the information in a 2-year old or older claim, it should be adjusted instead of voided and re-billed.

All ASC X12 837 Health Care Claims are required to balance. This requirement includes Coordination of Benefits (COB) claims. Claims that fail to meet this requirement will not be accepted into the NY Medicaid claims processing system and will be reported back to the submitter as rejected claims in an ASC X12 277 Claim Acknowledgement transaction.

Charge Balancing

All claims must have the charges in balance according to a completely straightforward principle:

• The Total Claim Charge Amount in CLM02 must equal the sum of all Line Item Charge Amount elements reported in the SV segment(s) of the claim.

Coordination of Benefits Balancing

There are additional balancing requirements for Coordination of Benefits (COB) claims – those claims in which one or more prior payers are involved. COB claims balancing can be described as follows:

• Each payer must report in their remittance (ASC X12 835) payments plus adjustments equal to charges. The 835 remittance is required by the specification to balance. In the event of an out-of-balance Remittance Advice, please contact the issuing payer to have it corrected. The remittance information is crosswalked from the 835 into the Coordination of Benefits 837.

When there was an electronic remittance, all payment and adjustment amounts, along with associated Claim Adjustment Reason Codes and Claim Adjustment Group Codes, are crosswalked from the remittance into the claim. When this information was sent in Loop-ID 2100 it is crosswalked to Loop-ID 2320. When it was sent in Loop-ID 2110 it is crosswalked to Loop-ID 2430. When all COB data from the remittance is accurately entered into the claim the COB balancing remains intact.

In cases where the Primary payer was not billed because they do not cover the services (Cost Avoidance claims), the Coordination of Benefits (COB) Total Non-covered Amount segment (AMT*A8) must be sent in Loop-ID 2320.

Please refer to the ASC X12 Technical Report Type 3 ("Implementation Guide") for the 837 you use (Professional, Institutional, or Dental) for guidance about balancing (v.5010, Section 1.4.4 "Balancing" and Section 1.4.1.3 "Coordination of Benefits Claims from Paper or Proprietary Remittance Advices"). The Technical Report Type 3 for each of the X12 Health Care transactions are published by the Accredited Standards Committee X12, and are available at the following location:

• http://store.x12.org

Example files are available from the X12 website at:

• http://examples.x12.org/

Here are some additional guidelines that must be followed (please refer to Section 1.10.2.1 of the v.5010 835 Technical Report Type 3);

• Loop 2320, with its sub-loops 2330A and 2330B, is required for all payers potentially involved in adjudicating the claim.
• A prior payer's claim-level payment and adjustment(s) should be reported at the claim level.
• A prior payer's line-level payment and adjustment(s) should be reported at the line level;
• line-level payments are reported in SVD segments
• the sum of the payer's SVD02 Service Line Payment Amount elements is the amount carried in AMT*D
• the payer is identified in element SVD01 by the same value that was sent in element NM109 of the iteration of loop 2330B that identified them.
• For each primary payer that adjudicated the claim, their payment must be reported in the AMT segment in Loop 2320 (AMT*D).

In a Coordination of Benefits (COB) claim, the 837 Implementation Guide requires the CAS segment to be sent if the prior payer reported one or more adjustments and their adjudication was reported in an 835 transaction. However, because the prior payer's adjustments are used by NYSDOH in determining appropriate payment, any prior payer's adjustments, whether reported on an 835 or on paper, must be sent to assure proper payment. The information sent in the Coordination of Benefits claim should accurately and fully report what was sent by the prior payer, and should be reported on the same level (line or claim).

The maximum amount that a secondary payer considers for payment is the Total Claim Charge Amount in CLM02 minus the sum of all prior payer payments. In almost all cases, the secondary payer will not consider any amount that was billed that exceeds the primary payer's allowable / approved amount for a covered service.

If the prior payer did not make a payment, their remittance advice will still show total adjustments equal to the amounts charged.

However, if the otherwise prior payer was not billed because it is known that the services are not covered, the Coordination of Benefits (COB) Total Non-covered Amount segment must be sent (AMT*A8 in loop 2320).

Non-medical code set values such as Patient Status Code (Patient Discharge Status) must be valid on the Billing Date in the BHT segment. Exceptions exist for validation of Claim Adjustment Reason Codes (CARCs) in Coordination of Benefits claims. CARCs must be valid as of the Coordination of Benefits payer's adjudication date (DTP*573 in loop 2330B or loop 2430 in the COB 837 claim).

Medical codes are considered to be valid if they were published before the Date of Service (in the 837 Dental and 837 Professional) or before the "From" Statement Date (in the 837 Institutional).

Please refer to the specification for the Coordination of Benefits (COB) Non-covered Amount segment in the Type 3 Technical Report for the 837 Health Care Claim as published by the X12 Committee. Guides can be purchased here: http://store.x12.org/store/

In previous implementations of the 837, NYSDOH allowed claims submitters to bypass billing an otherwise prior payer when the services are not covered by that payer and they were not billed (this was indicated by sending a value of "0FILL" in the SBR segment in Loop-ID 2000B, at SBR09).

This process is now supported by a standard method.

For these claims, the "Coordination of Benefits (COB) Total Non-covered Amount" segment (AMT*A8 in loop 2320) should be sent. Although the other payer is not billed, the submitter will need to populate loop 2320 and its sub-loops 2330A and 2330B.

Note: The AMT*A8 segment indicates that the insurance plan identified in that occurrence of Loop-ID 2320 was not billed and therefore did not adjudicate the claim.

Because the other payer did not process the claim, no AMT segment other than AMT*A8, and no CAS segment, are to be sent in loop 2320; and no DTP segment is to be sent in loop 2330B.

Submitters need to be aware that NYSDOH requires them to maintain documentation on a yearly basis to prove that the services are not covered, and that the process is subject to audit and enforcement.

NYS DOH will not certify, endorse, or recommend software vendors. Although a list of software vendors has previously been provided at this website, NYS DOH has determined that publishing a list of vendors has the potential to be misconstrued as an endorsement of those listed. For this reason, the Vendor List is no longer published.

In the version 5010 837 Professional (005010X222) Loop 2400, element SV103, the Unit or Basis for Measurement Code "MJ" (Minutes) is required when billing for anesthesia services. The minutes of anesthesia are reported in SV104.

The ASCX12 Type 3 Technical Report (TR3) for the 5010 version of the 837 Professional Claim provides clear and specific instructions for counting anesthesia minutes. Anesthesia minutes are reported in SV104 of Loop 2400.

• Ordering Provider's NPI
• Driver's License Number (9-digits)
  NOTE: A NYS Driver's License Number must be reported as 9 digits (numeric characters). Out-of-state Driver's License Numbers must also be sent as 9 digits. If the out-of-state license is more than 9 digits send only the first nine digits. If it is less than 9 digits it may be zero filled on either the right or left to make a total of 9 digits. Eliminate any alpha characters in the license.
• Vehicles License Plate Number

For ePACES Professional claims:

The Driver's License Number and License Plate Number can be reported in the Professional Claim Information Tab if all the service dates have the same Driver License number and License plate number. If the service dates have a different Driver License number and/or License plate number, this information can be entered in the "More" option on each service line.

The Ordering Provider's information should be entered in the Ordering Provider section unless the passenger is a Restricted Recipient (for a Restricted Recipient, enter the National Provider Identifier (NPI) of the provider to whom the recipient is restricted in the Primary Care Provider field.

The ordering provider can also be entered on the Service Line Tab in the "More" option.

For Paper Claims:

The License Plate Number should be entered in the Service Provider field (field 21) with NO profession code.

The Driver's License Number (9-digits) should be entered in the Other Referring Provider ID field (field 22).

The 837 Professional and Dental Implementation Guides state that the Billing Provider is the entity to whom payment is being requested.

Therefore, a provider who is billing for their services rendered who is part of a professional group, and then the group must be sent as the Billing Provider.

The individual practitioner must be identified as the Rendering Provider.

Orthodontics are billed on the ASC X12N Health Care Claim: Professional (837). There are no rate codes for Orthodontics. Payment is fee-for-service (procedure-based).

For the correct adjudication and payment of claims, care must be taken to ensure that the correct National Provider Identifier is submitted.

Physician's Assistants must be identified by their NPI in the Rendering Provider Name segment ( 5010 837 Professional, Loop 2310D).

The Supervising Physician must also be identified (Loop 2310E). The Supervising Provider Name loop must also be sent (5010 837 Professional, Loop 2310D). The NPI is the only permitted identifier for the Supervising Provider.

NYS Medicaid policy does not allow Physician's Assistants to bill Medicaid directly.

NYS Medicaid will deny all claims when the Physician's Assistant is reported as the Billing Provider; or when the Physician's Assistant is identified as the Rendering provider but no Supervising Physician is entered.

Private Duty Nursing (PDN) is billed on the ASC X12N Health Care Claim: Professional (837). Home health is billed on the 837 Institutional because it is Rate Code based.

One of the following codes should be sent in Loop-ID 2300, REF segment with a Qualifier in REF01 of 4N, "Special Payment Reference Number".

Please refer to the specification for this segment in the 837 Institutional Type 3 Technical Report, published by the X12 Committee and available at:
http://store.x12.org/store/

Also refer to the Billing Guidelines section of your NYS Medicaid Provider Manual.

License Number for eMedNY - How to send a License Number as a Provider Identifier?

The NPI of the ordering, referring or service provider should be entered if they have an NPI, not their Medicaid Provider ID or license number.

Facilities Practitioner's NPI Reporting FAQ

NYS Medicaid has changed the requirements for individual practitioners that are also incorporated. In the past, one MMIS Provider ID was assigned for use as both the corporate and individual ID.

You will now be required to enroll the corporate entity as if it was a group practice using the organization's NPI. The individual NPI should be registered with your current MMIS Provider ID.

You can obtain the appropriate enrollment packet at: https://www.emedny.org/info/ProviderEnrollment/index.aspx or contact eMedNY Call Center at (800) 343-9000.

Certain provider types (as defined by either Category of Service (COS) or Rate Code) who bill NYSDOH for services to NYS Medicaid beneficiaries do not have to obtain a National Provider Identifier (NPI) because they are not health care providers as defined in Federal statutes. These providers are known as "Atypical" providers. These providers need to continue to use their NYS Medicaid Provider ID and Locator Code in performing their billing and related functions with NYSDOH.

As of October 1, 2009, Atypical providers who submit transactions with an NPI will experience denials of both claim and non-claim (MEVS) transactions.

General provider types that do not have to obtain an NPI for billing NYS Medicaid include:

• ALP - Assisted Living Program (COS 0267)
  PCPS Capitation Provider (COS 0220)
  Waiver Service (COS 0263)
  HHAS: Vendor Personal Care Services (COS 0264)
  PCS: Personal Emergency Response Services (PERS) (COS 0266)
  HHAS: OPWDD (previously OMRDD) Waiver Services (COS 0269)
  OS: Eyeglass Materials (Upstate) (COS 0408)
  Non Emergency Transportation (COS 0602, 0603, 0604, 0605, 0606, and 0609)
  Bridges to Health Waiver (COS 0124)

Provider types where NPI may be optional include:

• HHAS: Case Management Services (COS 0265) NPI is not required if the rate code is 5210 thru 5214.

Questions about Medicaid Billing should be directed to the eMedNY Call Center at 1-800-343-9000.

All providers whose claims for ambulatory services are processed by the APG (Ambulatory Patient Group) methodology have been assigned APG rate codes in the 1400 and 1500 range for their applicable services.

APG pricing involves payment calculations that include the procedures reported at the service lines. To receive the full payment they are entitled to for their services, APG providers need to accurately and completely code at the service line level. For more information refer to the NYSDOH APG webpage at:

http://www.health.ny.gov/health_care/medicaid/rates/apg/

Yes, token reimbursement is rate-based, as are regular Clinic services.
Only NYSDOH has authority to assign a Rate Code for use by a NYS Medicaid provider.

In order to understand how to build the 837 Institutional to correctly report Covered Days, please review the following;

• No day is ever covered (is a Covered Day) by more than one payer.
• The maximum number of days that can be covered by all payers on the claim is the number of days in the Statement Dates segment minus one for the discharge day.
• Covered Days reported under Value Code 80 are the days being billed to the destination payer.
• Covered Days as adjudicated by another (prior payer), are reported in the MIA segment in element MIA-01 of the iteration of loop 2320 for that payer.
• If there is Medicare Part A Coinsurance on an Inpatient stay, Medicare Part A will report Coinsurance Days in the 835 (or, if paper, on the Explanation of Medical Benefits form). Even though the Medicare Part A Coinsurance Days are a Coordination of Benefits item, they are reported in loop 2300 under Value Code 82.

Dental Clinics bill on the 837 Institutional, with these values;

• Facility Code (Type of Bill) of 79, Clinic-other, in CLM05-1 (Loop-ID 2300)
• Revenue Code of 0512, Dental Clinic, in SV201 (Loop-ID 2400)

For Inpatients that are discharged with status code 02, Discharged/Transferred to another short-term general hospital for inpatient care, the practitioner who authorized the discharge, if they are not the Attending Provider, is to be identified in the Referring Provider Name loop (loop 2310F).

It is required that the facility reports the NPI of all of their affiliated practitioners. This can be accomplished by using the Facility Affiliated Practitioner application available at eMedNY.org.

Graduate Medical Education (GME) – How do I bill this type of claim?

Claims for Graduate Medical Education are billed exactly the same as the corresponding Inpatient Diagnosis Related Group (DRG) claim, with only the Rate Code being different. Providers are to use their GME Rate Code as assigned by the New York State Dept. Of Health.

NYSDOH reimburses for Methadone maintenance on a weekly basis. The Sunday date of service represents payment for the preceding week's services.

For Long Term Care Skilled Nursing Facility claims on the 837 Institutional, NAMI is expected in Loop-ID 2300 in the Value Information segment (HI*BE in loop 2300). The Value code for NAMI is 23.

The eMedNY system also receives NAMI information from local welfare offices. When NAMI is reported in a claim the system compares this value with the NAMI amount in the system. If the amounts differ, the larger amount is used in claims processing.

Newborn hearing screenings must be billed on the 837 Institutional.

When processing a claim the NYS Medicaid system assigns an internal Category of Service.

In order to receive the correct value a Newborn Hearing Screening the claim must be billed with a Type of Bill of 13, Hospital Outpatient; or a Clinic Type of Bill of 71-73, 75, or 77-79.

A procedure code must be sent in SV202-2. It is permissible to use V5008, Hearing Screening.

The Rate Code for Newborn Hearing Screening, Initial is 3138; Newborn Hearing Screening, Follow-up is 3139. A Revenue Code in the 051X range is also required.

For some Long-Term Care (LTC) clients, Medicaid will pay the adjustment amount(s), as reported in a Remittance Advice by the Medicare MCO (Managed Care Organization) under the Patient Responsibility Group Code 'PR'. Proper adjudication of the Medicaid claim requires the Claim Filing Indicator Code (loop 2320, SBR09) of '16' (Medicare Assigned Risk).

If the remit reported Medicare Coinsurance Days, they must be crosswalked to the claim and reported in the loop 2300 HI – Value Information segment.

All payments and adjustments reported in the remit must be crosswalked to the claim. Adjustments are crosswalked using the same Claim Adjustment Group Code, Claim Adjustment Reason Code (CARC), and Adjustment Amount as in the remit. Payments and adjustments reported in loop 2100 are crosswalked into the corresponding locations in loop 2320. Payments and adjustments reported in loop 2110 are crosswalked into the corresponding locations in loop 2430. Patient Responsibility amounts determined to be payable per NYSDOH policy will be paid by Medicaid.

Any days that the Medicare MCO did not cover cannot be billed to Medicaid on the same claim. A separate claim must be filed for those days.

Orthodontics are billed on the 837 Professional. Payment is fee-for-service (procedure-based).

A Managed Care Plan is not a "Health Care Provider" as defined under HIPAA, and is not eligible to receive a National Provider Identifier (NPI).

In all other respects, the format of an 837 Institutional claim submitted by a Managed Care Plan is the same as for any other Rate Based claim.

The Rate Code, reported in loop 2300, Value Information HI segment, is used to determine the amount of the premium payment. Here is an example, with a dummy Rate Code of 9999:

HI*BE:24:::9999~

The Rate Code is assigned by NYSDOH and is provided in the documentation received upon enrollment. Only one Rate Code can be sent per claim. Administratively, each plan submits a claim (one per every client enrolled in the plan) at the beginning of each month with a Date of Service of the 1st of the month. This is paid at the monthly premium payment due rate.

Additionally, there are a few other types of claims that are submitted as needed:

• Stop Loss - This claim has a unique Rate Code, which causes the claim to be pended to NYSDOH for pricing.
• New Born Delivery Charge - This has a unique Rate Code, which pays according to the associated rate on file. No pricing is required.

Some Home Health Agencies provide both Private Duty Nursing and Home Health services. Private Duty Nursing (PDN) is billed on the 837 Professional and is paid on a fee-for-service basis. Home health is billed on the 837 Institutional using the Rate Code(s) assigned to the provider by the New York State Dept. of Health.

Rate Codes are 4 - digit (numeric) values assigned to Institutional providers upon enrollment by the New York State Department of Health. Rate Codes are sent in Loop 2300 in the HI Value Information segment.

The data elements in this segment are composite elements and therefore have sub-elements. The NYS Medicaid Rate Code goes in sub-element 5, entitled "Monetary Amount". Examples are presented below using a "dummy" Rate Code of 9999:

HI*BE:24:::9999~

- or -

HI*BE:24:::99.99~ (Because sub-element 5 is a "Monetary Amount" field it is permissible to have a decimal point. This will not affect processing.)

HI*BE:80:::30*BE:24:::9999~ (This example shows Value Code 80 with 30 Covered Days, followed by Value Code 24 with a Rate Code of 9999.)

If the segment carries other Value Codes and associated "amount" fields, any available element can be used as long as the populated elements begin with HI01 and proceed sequentially. The order in which the Value Codes are sent does not matter.

Because the Value Information segment is sent at the claim level (Loop 2300), If multiple rate codes apply, each Rate Code must be billed on a separate claim. In rate-based claims submitters are required to complete the line level information (Loop 2400) in a manner consistent with the services performed. The accurate and complete reporting of services at the service line is required in all cases, and is critical for pricing for providers whose claims are priced using the APG (Ambulatory Patient Group) methodology (Providers whose claims are processed with the APG methodology should be aware that APG pricing involves payment calculations that include the procedures reported at the service lines. To receive the full payment they are entitled to for their services, APG providers need to accurately and completely code for their ambulatory services.) For more information refer to the NYSDOH APG webpage at:

http://www.health.ny.gov/health_care/medicaid/rates/apg/

Institutional (rate-based) providers who do not bill based on Covered Days can bill for multiple units of service and/or for multiple dates of service on a single claim. They will enter a date range on the claim level (Statement Dates) and then the individual dates of service on each line (Service Dates). All dates of service on the line level must be for the same rate code. If the rate code changes then a new claim must be started. All the dates on the lines should fall within the date range entered on the claim level.

Those providers who receive a paper remittance will receive only the beginning date of service from the date range entered on the claim level. The 835 electronic remittances will return the entire date range from the claim level entry. The claim will be paid as a lump sum payment for all the lines under a single TCN.

The pricing will be: every time the system reads a different date of service on the line level it will look at the units, if the units are one unit, then it is applied to the rate code. If the unit is greater than one, the system will edit for the maximum permitted units for the rate code for that line. If any line fails, then the whole claim will be denied.

For payable claims, the system will add all the units from all the lines and multiply the rate amounts against the total units and pay one lump sum for the entire claim.

If the provider must adjust a claim, they must include all of the lines from the original claim (the same as the professional line level/document adjustments). If they leave off a claim line then that claim line is essentially voided.

The following provider types can bill multiple units by having service line units applied to the Rate Code:

1. Case Management
2. Home Health
3. Limited Licensure
4. Long Term Home Health
5. OMH Rehabilitative Services
6. OPWDD (previously OMRDD) Waiver services
7. Personal Care Services
8. Traumatic Brain Injury
9. Bridges to Health
10. Nursing Home Transition and Diversion Medicaid Waiver (NHTD)

Residential Treatment Days (formerly referred to as Title XIX Days) are to be billed to Medicaid as Covered Days. They are sent in the Value Information segment in loop 2300 under Value Code 80.

One of the following codes should be sent in Loop-ID 2300, REF segment with a Qualifier in REF01 of 4N, "Special Payment Reference Number".

Please refer to the specification for this segment in the 837 Institutional Type 3 Technical Report, published by the X12 Committee and available at:

http://store.x12.org/store/

Also refer to the Billing Guidelines section of your NYS Medicaid Provider Manual.

The 837 Institutional allows for a maximum of two occurrences of the loop 2300 Value Information segment (HI*BE). Each Value Information segment can report up to 12 Value Codes and the associated amounts.

When two or more Value Codes are to be reported, they can be sent in the same segment, up to the maximum of 12. The order in which they are sent does not matter.

For example when the Rate Code and Net Available Monthly Income (NAMI) are sent, either of the following methods are correct (the examples use the common delimiters of *, ~, and |. The example Rate Code is "9999" and the example NAMI amount is $500.00):

HI*BE|24|||9999*BE|23|||500~

HI*BE|23|||500*BE|24|||9999~

This example adds 30 Covered Days and 20 Non-covered Days. Again, the order does not matter:

HI*BE|24|||9999*BE|23|||500*BE|80|||30*BE|81|||20~

Rate Codes:

• DRG claims for NYS Medicaid are Rate-based. The Rate Code is sent in the 837 Institutional claim in loop 2300, in the Value Information segment.
• DRG claims are identified by the following Rate Codes:
• In-state Inlier : 2946
• In-state Outlier : 2956
• Out-of-state Inlier : 2953
• Out-of-state Outlier : 2958

General Billing Principles:

• All DRG claims can be billed from Admission to Discharge and do not have to be split billed according to the high trim point, which is the date that separates Inlier and Outlier segments.
• Claims can be billed for the period from admission to discharge under rate code 2946 even if the "high trim point" was within the DRG period (in other words the DRG inpatient stay included both Inlier and Outlier segments). The eMedNY system will automatically assign the Outlier rate code for the days after the high trim point.
• DRG claim have to be billed, at a minimum, up to the high trim point for the DRG assigned.
• The high trim point day itself is part of the Inlier period.
• The payment amounts for the Inlier and Outlier segments will be added together and paid as one sum. This amount will be reported on the remittance advice under Rate Code 2946.
• All DRG claims must have the actual hospital discharge date regardless of the Patient Status Code in the claim.
• The discharge date will not match the end date of service if the patient status is 30, Still a patient.
• For DRG claims, the NYS Medicaid 90-day timely submission requirement is applied based on the discharge date reported on the claim.

These functions can often be best performed by using the standard health care electronic transactions developed for Eligibility Inquiry and Response (ASC X12 270/271) and Claim Status Inquiry and Response (ASC X12 276/277). The inquiries and responses are generated and processed by software that is programmed to the transactions' specifications. For the specifications for these transactions, please visit; http://store.x12.org/store/

or

http://www.wpc-edi.com

For questions relating to the processing of specific claims or general billing or other Medicaid program information, please contact the eMedNY Call Center at 1-800-343-9000.

When performing Eligibility Inquiry via ASC X12N 270, the Primary Search criteria utilized by eMedNY is the Medicaid Identification Number available in the Member's Medicaid Benefit Identification Card.

Primary Search Method:

The Subscriber ID is the Member ID.

In rare cases when a requestor doesn't have the Member's ID card available for use, an alternate search option is available from eMedNY, as described below.

Alternate Search Method:

In rare instances, when the Subscriber ID may not be available to the requestor, eMedNY does support an Alternate Search Option:

The eMedNY Name Search Option allows the requestor to locate a NY Medicaid member by using other values in the Subscriber Loop (2100C) of the 270 Eligibility Inquiry:

• Member's Last Name (NM103)
  First Name (NM104)
  Date of Birth (DMG02)
  Gender (DMG03)
  Social Security Number (REF02)

Please note that an unsuccessful eligibility inquiry could occur when search criteria other than the Member's Medicaid ID are used. When an Eligibility Response from eMedNY indicates that the member could not be identified, the issue could be that the Social Security Number or other data items provided were not matched against a member file in the eMedNY system. In the ASC X12N 271 Eligibility Response this will be reported in the AAA segment (Loop 2100C). Data Element AAA01 will contain "N" and element AAA03 will contain "72".

After verifying these data items, if you continue to receive the AAA segment as described above, please retain the transaction reference number, the date and time, and the UserId (the username entered when logging in to eMedNY), and the search criteria you used. This will enable support personnel to examine the inbound and outbound data to determine the cause.

For further assistance, contact: Call Center at 800-343-9000; or email eMedNYHIPAASupport@gdit.com

Implementation guides (Type 3 Technical Reports) for the X12 transactions can be ordered at:
http://store.x12.org/store

The NCPDP Telecommunication Standard Implementation Guide is available to NCPDP Members at:
https://standards.ncpdp.org/Access-to-Standards.aspx

Health Care Code Lists are at:
http://www.wpc-edi.com/reference/

The HIPAA statute, Final Rules, and NPRMS (Notices of Proposed Rulemaking) are available at:
https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/HIPAA-ACA/

CAQH CORE® is a multi-stakeholder initiative developing operating rules for health reform mandates and administrative simplification. These rules are available at:
http://www.caqh.org/ORMandate_index.php

The home page for the National Plan and Provider Enumeration System (NPPES), the registry for the NPI (National Provider Identifier) is at:
https://nppes.cms.hhs.gov/NPPES/Welcome.do

Other resources pertaining to the National Provider Identifier:
https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/

Link for information from CMS about ICD-10-CM and ICD-10-PCS codes:
http://www.cms.gov/Medicare/Coding/ICD10/

View eMedNY ICD-10 information:
https://www.emedny.org/icd/index.aspx

Information about the HCPCS code set, including quarterly updates are available from CMS at:
https://www.cms.gov/HCPCSReleaseCodeSets/02_HCPCS_Quarterly_Update.asp

Information from New York State Department of Health about Medicaid is at:
http://www.health.ny.gov/health_care/medicaid/index.htm

New York State Medicaid Update:
http://www.health.ny.gov/health_care/medicaid/program/update/main.htm

Information at the Federal level about Medicaid can be found at:
http://www.medicaid.gov

The CMS online Manuals system includes Transmittals and Program Memoranda at:
http://www.cms.hhs.gov/Manuals/

Updates to the HIPAA Regulations are at:
http://aspe.hhs.gov/datacncl/adminsim.shtml

CPT-4, or Level 1 HCPCS, is maintained and licensed by the American Medical Association and is available for purchase in various hardcopy and softcopy formats from of variety of vendors.

A Claims Cycle is a weekly financial processing event in which NYS Medicaid claims are paid and remittance notifications are prepared. Each cycle receives a unique sequential cycle number. In order to have the best chance that your electronic claim submissions are included in the current week's cycle, please send them to the eMedNY system before 6:00 PM on Monday. eMedNY will continue processing claims received after 6:00 PM on Mondays, and will get as many as possible into the current cycle. However, you should not have any reasonable expectation that claims received after the Monday cut-off will make it into the current cycle. Those that do not make the cut-off will be included in the next weekly cycle.

When claims (sent as X12 837) have been accepted into the eMedNY system for adjudication, a 277 Claim Acknowledgment (277CA) transaction is returned. The six digits following the "R" in the first node of the filename are the date stamp of the 277CA.

This date can be used to look up a corresponding cycle number using the Cycle Processing Calendar. Claims that were finalized at adjudication (not pended) will be reported in that cycle's remittance advice.

New York Medicaid and eMedNY takes every step and measure to secure your data.

NYS Medicaid beneficiary data is confidential and is protected by HIPAA and other Federal law, as well as by State law. Non-disclosure of this information – even the fact of enrollment in Medicaid – except as permitted or required by applicable law is an essential component for compliance with Medicaid policy.

One important step to protect this data is to safeguard user IDs and passwords. Under no circumstances should login information to NYS Medicaid systems be shared, distributed, or recorded in a form and location accessible to any other than the assigned user.

All computer systems, internal and external media, and other repositories of patient data, including hardcopy stored in filing cabinets; or patient information in any form, including verbal communication, must be handled as confidential information.

The security of electronic transactions sent to and received from the eMedNY systems is encrypted when using one of the established transmission methods, such as FTP or eMedNY eXchange.

If troubleshooting transactions involves sending email to eMedNY support staff and the text of the email contains any patient-identifiable data the data MUST be thoroughly de-identified. Alternatively the email can be encrypted by use of a secure email server; or the patient data can be sent within an email attachment in the form of a password-protected, encrypted "zip" file archive. The password MUST NOT be sent in the same email. It should either be sent in a separate email or conveyed to the support person verbally by telephone.

Any information that is reasonably likely to permit identification of the Medicaid beneficiary is confidential. Many data items are protected and should be de-identified as per 45 C.F.R. §164.514.

Warning: As per the Health Insurance Portability and Accountability Act (HIPAA), eMedNY is required to assign unique user ids and passwords for identifying and tracking each eMedNY user's identity [Ref: § 164.312(a)(2)(i)]. Users that share their user id and password are in violation of the HIPAA Security Regulation. If this practice is detected, the user's access will be revoked and other sanctions may apply.

For all inbound X12 transactions (837, 276, 270, 278, and 834), that are not rejected at the Interchange level, a 999 Implementation Acknowledgement transaction will be returned to the sender either to report X12 structure and syntax errors; or as an acknowledgement in receipt of accepted transactions. This transaction set is returned by default.

Transmissions that are rejected for Interchange-level errors will be responded to with a TA1 transaction, only if requested in ISA14.

Charge Balancing

For the X12N 837 (Health Care Claim), 270 (Eligibility Inquiry), 276 (Claim Status Inquiry), 278 (Request for Review), and 834 (Benefit Enrollment and Maintenance) transactions, a 999 Implementation Acknowledgement transaction will be returned to the sender either to report structure and syntax errors; or as an acknowledgement in receipt of accepted transactions. This transaction set is returned by default.

The format of the 999 transaction is defined by the X12 Committee, and is published only in the Type 3 Technical Report (TR3) X12C/005010X231, available for purchase from store.x12.org.

The following discussion assumes that a 999 was sent in response to an 837 with a segment terminator of tilde ~ ; an element separator of asterisk * ; and a sub-element separator of vertical pipe |

To understand and locate an error in your 837, as reported in the 999 transaction:

1. The first step is to associate the response file with a claims file. The response file will have a filename of "R" followed by a date and time. It will be a response to a claims file that you can see in your "Sent" box with the exact same date and time in the filename (examples; in eXchange R060101133010.00.x12.; or in FTP R060101133010). Have both files open at the same time. A powerful programmer’s text editor such as UltraEdit is preferable but a word processor such as MS Word will work.
2. Next insert a line break after each segment. Do this for both files (there will be equivalent command dialogues in other text editors and word processors).
• If using a text editor it may be necessary to switch to "Hex" (hexadecimal) view. Starting at the top of the file replace all occurrences of tilde with tilde followed by Carriage Return and Line Feed (in hex, replace "7E" with "7E 0D 0A").
• If using Ms Word use the "Find/Replace" dialog. Click "Replace", and "More" and then enter a tilde in the "Find" section and also enter a tilde in the "Replace" section. Leave the cursor after this tilde. Next click "Special" and select "Manual Line Break", and then click "Replace All".
3. Line numbers are displayed at the bottom of the screen and down the left side in UltraEdit and at the bottom in Word. You can also add line numbers in the body of the document in Word by selecting File/Page Setup/Layout and clicking on Line Numbers.
4. Save the modified files with new names.
5. Within the "R-file" will be one AK1 and one AK9 segment for each Functional Group (GS - GE) that you sent in one transmission. There will be one AK2 and one IK5 segment for each Transaction Set (ST – SE) that was contained in your Functional Group. Search for "IK5*R" to identify rejected transactions. If IK5 segment(s) indicate rejection the AK9 segment will indicate a rejected (AK9*R) or partially rejected (AK9*P) Functional Group. The 999 can report non-fatal errors with a code or "E" in IK5 but only rejections need to be resolved.
6. Find an AK1 segment preceding each "rejection" IK5 segment. It will look like this:

AK1*HC*(number)~

The number in AK102 is the "Group Control Number" that you sent in GS06. You now have to find that Functional Group in your claims file. Search for "(number)*X*" to find the GS segment with that Group Control Number.

7. Back in the R-file, find an AK2 segment following AK1. It will look like this:

AK2*837*(number)~

The number in AK202 is the "Transaction Control Number" that you sent in ST02. Find the ST segment with that number in ST02. It will be after the GS segment that you already identified in the claims file.

8. In the R-file, find the IK3 segment following AK2. IK301 will show the type of segment that had the error. IK302 contains a segment number, IK303 contains a loop designator, and IK304 contains an error code. For example,

IK3*CLM*27*2300*8~

An error was found in a CLM segment; it was the 27th segment in the Transaction Set; it was in loop 2300; and it had Data Element Errors. To find the exact segment you count segments from ST, which is segment 1. Since each segment is on a separate line you just have to count the lines.

9. If the error was for a data element there will be an IK4 segment. It will show the data element number within the segment. IK401 contains the data element number that caused the error; IK402 is the X12 Data Element Reference Number from the X12 Data Dictionary; IK403 is an error code; and IK404 contains a copy of the bad data. For example,

IK4*5|1*1331*7*01~

Data element 5, sub-element 1 had an error; the X12 Reference Number for the data item is 1331; the error was "invalid code value"; and the bad data was "01". This is the location for the Place of Service (837P and 837D) or Facility Type Code (837I). A value of "01" is not valid here.

10. Take steps to correct the bad data and check for similar occurrences elsewhere in the Transaction Set. Because rejection occurs on the level of the entire Transaction Set all claims within the Transaction Set should be resubmitted. The Transaction Set begins with the ST segment and ends with the SE segment, and includes all segments in between.

NYSDOH will reject most instances of lowercase letters in the transaction (with a few exceptions like patient name, provider name (NM1-02, NM1-03)).

Refer to the Basic Character Set information found in the ASC X12 TR3s for more information regarding valid characters.

For an inventory of the response files sent by the eMedNY system in response to inbound ASC X12 transactions, please see the .

Claim Status is available immediately for all claims that have been adjudicated. Generally claims are adjudicated within 48 hours of submission, although processing times vary with system load.

This is especially true during the first week of each month. If a positive Implementation Acknowledgment (999) transaction was received and the claim was not rejected in a 277 Claim Acknowledgment transaction, then the claim was accepted to be adjudicated.

When a Claim Status Inquiry is submitted on claims that have not been adjudicated, the response is "Claim/Encounter Not Found".

Trading Partners should wait until their "R-file" response to the batch of claims has been returned to the submitter, before resubmitting their Claim Status Inquiry.

All receivers of a remittance advice will have all claims that were pended in the current cycle reported to them. There is no need to submit the Pended Claim Recycle Request Form unless the provider wishes to change the recycled pend reporting option.

Establishing how often pend information is returned on a remit.

Providers can establish how often pend information is returned on remits by submitting a form. This form is available for download at eMedNY.org under Provider Enrollment > Provider Maintenance Forms > Miscellaneous Maintenance forms: Pended Claim Recycle Request Form.

For assistance with the Pended Claim Recycle Request Form please contact the eMedNY Call Center at 1-800-343-9000 and request Provider Enrollment.

Transaction Control Number (TCN) is a unique claim identifier assigned to each claim or encounter received.

Format: YYDDD#########TA

YYDDD = Julian date of TCN creation

A Julian Date reports the day as a sequential number within the year. For example, June 1, 2001 as a Julian Date is: 01213; and January 1, 2020 is 20001.

######### = sequence number

• '0' = paper
• '2' = electronic
• '3' = Point Of Service
• '4' = HIPP

• '0' = original
• '1' = credit adjustment
• '2' = debit adjustment

The TCN appears on a paper remit with dashes added to improve readability. When the TCN is sent on an adjustment or void it must not include the dashes.

In the Receiver Name loop (Loop-ID 1000B), NM103 is required to be NYSDOH and in NM109 a value of 141797357 is required.

Receiving Invalid File Format Message - What causes this?

They could be any one or a combination of the following:

• Invalid Characters (i.e /*, //*, //). These characters are interpreted as JCL by our system.
• Submitting Blocked Files (all files must be streamed data).
• Missing or invalid ISA, IEA, GS or GE Segment.
• Non Printable ASCII Characters (less than 32), other than as required per specification in NCPDP transactions.
• Extended ASCII Characters 128 - 255 and character 127.
• Delimiters embedded within data.

Below, is a table of ASCII Characters between 32 and 126.

PRINTABLE CHARACTERS

For all production batch X12 transactions NYSDOH has set a limit of 5,000 Transaction Sets (ST-SE) within a Functional Group (GS-GE).

There is no limit being imposed at this time to the number of Functional Groups that can be sent within an Interchange (ISA-IEA) for batch submissions.

Real time transactions are limited to one ST/SE per ISA/IEA. The Provider Testing Environment has enforced transaction limits as documented in the eMedNY Trading Partner Information Standard Companion Guide.

Implant and Implant-related dental procedure codes are billed on the ASC X12N/005010X224A2 Health Care Claim: Dental (837). There are NO rate codes for Dental Implants procedure codes. Payment is fee-for-service (procedure-based).

The 837 Professional and Dental Implementation Guides state that the Billing Provider is the entity to whom payment is being requested.

Therefore, a provider who is billing for services rendered as part of a professional group, the group must be sent as the Billing Provider.

The individual practitioner must be identified as the Rendering Provider.

One of the following codes should be sent in Loop-ID 2300, REF segment with a Qualifier in REF01 of 4N, "Special Payment Reference Number".

Please refer to the specification for this segment in the 837 Institutional Type 3 Technical Report, published by the X12 Committee and available at:
http://store.x12.org/store/

Also refer to the Billing Guidelines section of your NYS Medicaid Provider Manual.

Testing of X12 HIPAA transaction sets is accomplished by submitting files through one of the established transmission methods:

• eMedNY eXchange
• FTP connection

A test submission is indicated to the system by a value of "T" in the Usage Indicator of the ISA (Interchange Header) segment, in data element ISA15. See eMedNY Trading Partner Information Standard Companion Guide for complete details on supported transactions and limitations of testing with eMedNY.

Upon successful completion of transaction validation and testing, trading partners are advised to periodically check the New York Medicaid HIPAA Support Web Page for Companion Guide updates, FAQs, and other notifications which may require software updates to accommodate published changes. Please visit: www.emedny.org.

Testing involves submitting test transactions, which may include patient information that is protected by HIPAA and other Federal and State law. Therefore certain precautions and policies must be followed.

If the trading partner intends to test directly with eMedNY systems they must meet the requirements described below.

Warning: As per the Health Insurance Portability and Accountability Act (HIPAA), eMedNY is required to assign unique user ids and passwords for identifying and tracking each eMedNY user's identity [Ref: 45 C.F.R. § 164.312(a)(2)(i)]. Users that share their user id and password are in violation of the HIPAA Security Regulation. If this practice is detected, the user's access will be revoked and other sanctions may apply.

Trading Partners who exchange electronic healthcare transactions directly with NYS Medicaid (eMedNY systems) must meet all applicable requirements of the HIPAA Privacy and Security Rules. NYS policy further requires vendors who fall into this category to obtain:

• a "Service Bureau" NYS Medicaid ID
• an Electronic Transmitter Identification Number (ETIN)
• a User-ID and password, which must be unique for each user who will interact with NYS Medicaid
• a Trading Partner Agreement with the NYS Medicaid Fiscal Agent, eMedNY.

Please contact the eMedNY Call Center to obtain this enrollment information. The contact telephone number is 800-343-9000. You will need to choose the option for enrollment.

Questions about testing can be directed to emednyHIPAASupport@gdit.com.

The Provider Test Environment (PTE) response and cutoff times are different from in the production system. The PTE may experience processing delays if the production environment is experiencing heavy volume. The PTE will respond to an uploaded transaction as follows:

NOTE: This is an inventory of all possible responses, some of these responses will only be returned under certain circumstances.

Please reference the Transaction Information Companion Guide and the Trading Partner Information Companion Guide at: www.emedny.org/HIPAA/5010/transactions/