Billing Guidance and Rates

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New York Medicaid Program 29-I Health Facility Billing Guidance

The purpose of this manual is to provide billing information regarding services provided by 29-I Licensed Health Facilities and administered by the New York State Department of Health (NYS DOH) and Office of Children and Family Services (OCFS).

This manual applies to services covered by both Medicaid Managed Care (MMC) and Medicaid fee-for-service (FFS) and outlines the claiming requirements necessary to ensure proper claim submission for services delivered by a 29-I Health Facility. This manual is intended for use by both Medicaid Managed Care Plans (MMCP) and 29-I Health Facilities.

This manual provides billing guidance only. It does not supersede applicable regulatory requirements or procedures for admission to a program, record keeping, service documentation, initial and on-going treatment planning and reviews, etc. The contents of this manual may be subject to change as required.

Voluntary Foster Care Agencies (VFCAs) that have not obtained 29-I licensure are NOT authorized to provide and/or bill for health care services outlined in this guidance. All VFCAs that are licensed as 29-I Health Facilities will have a NYS DOH issued license indicating authorization to bill for Core Limited Health-Related Services and Other Limited Health-Related Services.

This manual does NOT provide guidance regarding Maximum State Aid Rates (MSAR) payments. See the SOP Program Manual for MSAR information and guidance.

Article 29-I Billing FAQ

Article 29-I Core Limited Health-Related Services Rates (Medicaid residual per diem)

The Medicaid residual per diem rate reimburses 29-I health facilities for Core Limited Health Related Services and is associated with the 29-I facility type and indicated on the Article 29-I license. All 29-I health facilities are required to provide the Core Limited Health Related Services to all children residing in the facility. Services are standardized across each facility type and are reimbursed based on a standardized Medicaid residual per diem rate schedule.

Core Limited Health-Related Services are reimbursed with a Medicaid residual per diem rate paid to 29-I health facilities on a per child/per day basis to cover the costs of these services. For children/youth not enrolled in a plan, providers must bill Medicaid Fee-for service (FFS) via eMedNY. For members who are enrolled in a managed care plan, providers must bill the MMCP. The MMCP will bill the State for the per diem as pass through for the four-year transition period at the end of the transition period, the State will reassess progress of the implementation and determine if transitional requirements should be extended.

The Core Limited Health-Related Services (Medicaid per diem) rate billed must correspond to the rate for the facility type the individual child/youth is residing in. However, only one Core Limited Health Related Services (Medicaid per diem) rate per day for each individual child/youth can be billed. The Medicaid residual per diem rate is paid for the duration of the child’s stay in the 29-I Health Facility; there are no annual or monthly limits applied to the per diem rate.

New York State Children’s Health and Behavioral Health Services Billing and Coding Manual

The purpose of this manual is to provide billing information regarding the Children’s Health and Behavioral Health System Transformation as implemented by the New York State Department of Health (DOH), Office of Mental Health (OMH), Office of Alcohol and Substance Abuse Services (OASAS), Office of Children and Family Services (OCFS), and Office for People with Developmental Disabilities (OPWDD).

The implementation of the new services, and the transition to benefits and populations to Managed Care, included in the Children’s Transformation is being phased in throughout NYS and will include the transition of selected children’s benefits to Medicaid Managed Care. The Children’s Transformation is subject to Centers for Medicare and Medicaid (CMS) approvals and State approvals, and the timing of those approvals. The effective dates referred to in this manual may be updated accordingly.

This manual applies to services covered by Medicaid Managed Care (MMC) and the Medicaid fee-for-service (FFS) delivery system. This system transformation is for services available to children, defined as an individual under the age of 21. This manual outlines the claiming requirements necessary to ensure proper claim submission for services affected by the Children’s Health and Behavioral Health System Transformation. This manual is intended for use by Medicaid Managed Care Plans (MMCP), including Special Needs Plans (SNP), behavioral health service providers, and HCBS service providers.

This manual provides billing guidance only. It does not supersede applicable regulatory requirements or procedures for admission to a program, record keeping, service documentation, initial and on-going treatment planning and reviews, etc. Contents of this manual are subject to change.

Medicaid-Enrolled Provider

All eligible health care providers are required to enroll in Medicaid in order to receive reimbursement for delivering a Medicaid service. 29-I health facilities must be enrolled with category of service code 0121 to bill for the Core Limited Health-Related Services, and category of service code 0268 to bill for Other Limited Health Related Services.

Information on how to become a Medicaid provider is available on the eMedNY website.