Preschool/School Supportive Health Services Program (SSHSP)

1. Preschool/School Supportive Health Services Program (SSHSP) Transition to Direct Medicaid Claiming Training SPRING 2016

2. Agenda • Welcome • 2016 Medicaid Alerts • Advantages of direct claims submission • Options for SSHSP providers • Computer Sciences Corporation Provider Training • Overview of ePACES • Direct Claiming – resources for troubleshooting • Medicaid Policy Update • More 2016 Medicaid Alerts • Reference and Contact Information

3. New York State Preschool and School Supportive Health Services Program (SSHSP) SSHSP Policy Updates

4. Medicaid Policy Updates • SSHSP Billing Providers to select new process for claim submission during 2016-17 School Year • School district and county options require careful review • How to submit claims • When to transition to a new claiming procedure • Content in presentation is overview, for full information consult Medicaid Alerts and updated information issued from SSHSP • Most appropriate billing/claiming solution, and implementation schedule will vary by LEA • Evaluate in-house resources, existing or proposed contract relationships • Current status of claim submission • Communicate with fiscal, service delivery, vendor partners involved in claiming to eliminate/minimize interruption in billing/claiming • Initiate planning early on for successful transition • RICs will also track school district and county plans for transition

5. Medicaid Policy Updates Medicaid Alert #16-02: SSHSP Claim Processing to Change during 2016-17 School Year • Medicaid Alert #16-02 notifies SSHSP providers of the change to direct claiming during the 2016-17 school year. • Direct claiming will enable LEAs to submit claims in “real time,” and not be restricted by the current monthly claiming calendar. • LEAs will have access to the most current student eligibility information through the Electronic Provider Assisted Claim Entry System (ePACES).

6. Medicaid Policy Updates Medicaid Alert #16-03: Transition Schedule and Resources for Direct Billing of SSHSP Claims • The transition to direct claiming is provided in this Medicaid Alert to assist school districts and counties in this process. • Prior to transition to direct claiming, providers will have access to: • Training sessions; • Opportunities to utilize eMedNY’s test environment for trial claim submission; and • Informational documents to be used as resources - posted on the Medicaid in Education Website http://www.oms.nysed.gov/medicaid

7. Advantages of Direct Claiming and Future Claiming Options New York State Preschool and School Supportive Health Services Program (SSHSP) Training Transition to Direct Medicaid Claiming

8. Current Billing/Claiming Processing LEA CNYRICeMedNY School District / County SED-contractedDOH-contracted Medicaid Service BureauMedicaid Management Information System CNYRICMed“Client Claiming” Collect Service Documentation Data Entry Processing Data to CNYRIC Medicaid Processing Cycle OR Payment Issued to LEA Uploaded File “Integration” Software / Programming Extract File • After March 2017, CNYRIC will no longer serve as a Medicaid Service Bureau • CNYRIC processes billing/claiming and submits to MMIS on a monthly calendar • All LEAs (except NYC) are presently required to use CNYRIC to process their SSHSP claims • LEAs must choose to submit data to CNYRIC either through Integration or Client Claiming

9. Future Billing/Claiming Processing Options During the 2016-17 school year, SSHSP billing providers must select a new method of transmitting their claims data to eMedNY: • Submit claims data directly from ePACES; AND / OR • Submit claims data directly from the eMedNY eXchange – (must first have access to ePACES); AND / OR • Use Medicaid Service Bureau to submit claims to MMIS. Starting this summer, the RIC will inquire what option(s) have been chosen – decisions are expected by January 2017.

10. Advantages of Direct Claims Submission • Direct claiming will enable LEAs to submit for reimbursement in “real time,” not restricted by the current monthly claiming calendar. Processing of the claim will begin immediately upon submission to eMedNY. Direct claiming will enable LEAs to received “real time” claim responses. • Direct submission of claims will allow any necessary action on the part of the LEA to take place timely when or if the claim requires an adjustment. Timely claims processing will result in fewer claims being time barred. Edits and data checks used by CNYRIC to pre-adjudicate claims will no longer prevent a claim from being processed through the MMIS. • LEAs will have access to the most current student eligibility information through the Electronic Provider Assisted Claim Entry System (ePACES), without lag time for matching student demographic information on a monthly basis.

11. Computer Sciences Corporation New York State Preschool and School Supportive Health Services Program (SSHSP) Training Transition to Direct Medicaid Claiming

12. CSC/CSRA - eMedNY • Responsibilities • Processing Medicaid claims • Provider Manuals • Remittance statements and checks • Electronic Fund Transfer • Billing inquiries & guidelines • Provider training • Electronic Transmitter Identification Numbers (ETIN) • ePACES (Electronic Provider Assisted Claim Entry System) • Medicaid Eligibility Verification System (MEVS) • Maintain eMedNY website

13. eMedNY Website – Home Page www.eMedNY.org

14. Elements on SSHSP Institutional Claims • Student demographics – Client ID number, DOB, Gender, etc. • Procedure Code (CPT) – 5 digit (Refer to SSHSP Handout #5) • Date of service • Number of units • NPI numbers for: ordering/referring, attending/servicing and billing providers- (Refer to SSHSP Medicaid Alert 14-01). • Diagnosis code (from ICD-10 for DOS on or after 10/1/15) (Refer to SSHSP Medicaid Alert 14-02) Previously added by CNYRIC or software: • Revenue code (from NUBC) – 4 digit • Bill Type • Delay reason code • Rate Code – 4 digit (Refer to SSHSP Handout #5) • Procedure code modifier (if applicable) – 2 digit/character (Refer to SSHSP Medicaid Alert 14-06)

15. SSHSP providers must use this select list of Current Procedural Terminology (CPT) codes to bill Medicaid for SSHSP services. This handout contains CPT codes/rate codes for the following SSHSP services that can be billed to Medicaid: New York State SSHSP

16. EFT / ERA-PDF Remit

17. Claim Submission Methods • Electronically • HIPAA Compliant Software (837 Institutional) • eMedNY eXchange • FTP (File Transfer Protocol) • SOAP (Simple Object Access Protocol) • ePACES (electronic Provider Assisted Claim Entry System) a free, web-based application • Clearinghouse, Service Bureau/Billing Agency • Paper (UB-04 Claim) Additional Information for software vendors and developers - Companion Guides which include NYS Medicaid specific information intended to supplement the instructions published in ASC X12's Implementation Guides are found at https://www.emedny.org/HIPAA/5010/transactions/index.aspx

18. Claim Submission Methods (Continued) • To send or receive electronic claim information providers need the following: • ETIN (Electronic Transmitter Identification Number) • Certification Statement – updated annually • Trading Partner Agreement • User ID and Password • Electronic Remittance/PDF Remittance Request Form (to receive 835 or PDF remittance) Forms are available at - https://www.emedny.org/info/ProviderEnrollment

19. ETIN • SSHSP may obtain a new ETIN by submitting: • PROVIDER ELECTRONIC/PAPER TRANSMITTER IDENTIFICATION NUMBER (ETIN) • APPLICATION and CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID • SSHSP may be added to an existing ETIN (such as a billing service bureau or clearing house) by submitting a Certification Statement • New Service Bureaus will submit the ETIN Certification Statement for New Enrollments Form (EMEDNY-490602) with their enrollment application

20. ETIN Certification Statement • ETIN Certification Statement must be Notarized. • ETIN must be recertified annually to send or receive electronic transactions. Electronic Remittance Advice (ERA) 835 or PDF remit and Electronic Fund Transfer (EFT) required for recertification.

21. Provider Electronic/Paper Transmitter Identification Number (ETIN) Application • Used by provider(not service bureau) to obtain an ETIN • Submit at least one notarized Certification Statement with this form before an ETIN can be issued.

22. Self-Help

23. Enrollment • Provider must obtain or be added to an ETIN number • Primary Administrator requests TOKEN number by contacting eMedNY Call Center at 800-343-9000 with the following: • Provider NPI / MMIS ID • Email Address • ETIN • Contact Information • Series of emails and online steps to complete the ePACES enrollment process • ePACES Enrollment Reference sheet is available at https://www.emedny.org/HIPAA/QuickRefDocs/ePACES-Enrollment_Overview.pdf

24. Training • eMedNY Call Center available to assist with provider questions – 800-343-9000 • eMedNY Provider Services Regional Representatives available throughout state – to request training contact the eMedNY Call Center. • Seminars and Webinars available on eMedNY Training page at https://www.emedny.org/training/index.aspx

26. Home Screen • Web-based application • Role-based security • Submit claims • Check claim status • Verify eligibility • Obtain DVS and Prior Approvals

27. Support Files and User Admin User Administration – Add new users and update their access to ePACES functions Provider and Other Payer - Create lists of providers and payers to be included on claims and other ePACES transactions. Submitter Information – shows the ETIN under which the ePACES transactions are being submitted

28. User Administration • In order to access the ePACES program, every user must have an individual User ID and Password. • The User ID and program privileges are created and maintained by the System Administrator. • The System Administrator may add new users, review and edit privileges of existing users, change passwords, unlock existing user accounts and inactivate existing users.

29. Adding A New User After clicking on “Add New User”, enter the user’s information:

30. Adding A New User (Cont) ePACES will generate a user name and temporary password for the new user

31. Adding A New User (Cont) The ePACES program will then ask if the user will have administrator privileges: • If yes, then the user will be set up as an alternate administrator • If no, each user’s privileges can be edited

32. Provider Support File • Select “Add New Provider” to create a list of attending/servicing, referring providers. Enter Name or NPI • Edit and Delete icons can used to modify the list.

33. Other Payer Support File • Select “Add New Payer” • Enter Medicare in Other Payer Name and select Medicare Part B payer in “Claim filing Indicator” • Click submit. You will be returned to the main page

34. Adding Other Payers To add a new payer to the system: • Click the “Add New Payer” button • Enter the organization or Payer Name • Select the appropriate claim filing indicator • Click submit. You will be returned to the main page

35. Submitter Information The submitter function allows the TSN/ETIN enrolled in ePACES to be viewed for reference.

36. Medicaid Eligibility Verification System - MEVS • Methods for checking eligibility • ePACES: Free Internet based application • Audio Response Unit: (touch-tone telephone method)1-800-997-1111 • Alternate access: Batch and Real-time 270/271 Eligibility Inquiry & Response Eligibility verification is necessary to avoid risk of receiving no payment

37. MEVS / DVS Provider Manual

47. 24 Rate Code

49. Timely Claiming Submission for SSHSP Providers • Effective December 1, 2013, New York State adjusted the claiming window for SSHSP claims to 12 months following the date of service. • SSHSP claims submitted more than 90 days after the date of service must include a valid delay reason code (3) on the claim in order to be processed. • Important: Do not include a delay reason code (3) on the claim if it is not over 90 days. The claim will deny. • New York State Medicaid does not planning on changing the 12-month claiming policy at this time.

50. Timely Claim Submission • Initially submit claims within 90 days of the date of service to be valid and enforceable, unless the claim is delayed due to circumstances outside the control of the provider. • Claims submitted after 90 days must be submitted within 30 days from the time submission came within the control of the provider. • If a claim is returned to a provider due to data insufficiency or claiming errors (rejected or denied), it must be corrected and resubmitted within 60 days of the date of notification to the provider. • In addition, paid claims requiring correction or resubmission must be submitted as adjustments to the paid claim within 60 days of the date of notification. • In most cases adjustments, rather than voids, must be billed to correct a paid claim. • Claims not correctly resubmitted within 60 days, or those continuing to not be payable after the second resubmission, are neither valid nor enforceable. https://www.emedny.org/ProviderManuals/AllProviders/PDFS/Information_for_All_Providers-General_Billing.pdf