Frequently Asked Questions

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What are some strategies for providers to use to figure out their costs?

Work with your CFO or budget team to calculate your staffing, administrative and unit of service costs. For a sample model, utilize the CTAC benchmarking tool.

Source: Contracting

If someone is denied due to medical necessity or if managed care is refusing to pay, is there an appeals process?

Yes. The first step in the appeals process would be to initiate a discussion with the managed care company. If this is unsuccessful, a formal appeals process can then be instituted. Managed care has created external and internal appeals processes. It's important to recognize that the formal appeals process can be lengthy and time-consuming.

Contact information for a specific plan's appeals department can be found on the MCO matrix at matrix.ctacny.org

Source: RCM, UM and Outcomes Event, NYC, 4.17.15

What should providers do when clean claims differ across payers?

Most times, 80%-90% of claims will be the same. MCTAC has developing a Billing tool and a Chargemaster Webinar to help with this. 

Source: RCM, UM and Outcomes Event, NYC, 4.17.15

What consideration will there be for complexity and comorbidity in the capitation formula?

Complexity of co-occurring  and chronic conditions for children are being taken into account when determining rates and program design.

Source: Transforming the Children's Medicaid System Webinar Part 3, 2.25.16

Are Personalized Recovery Oriented Services (PROS) clients, dual eligible clients, etc. designated as Fee-for-Service (FFS) or managed care?

PROS clients are included in, or carved-in to, Medicaid managed care.

Dual eligible clients are now excluded, or carved out, from Medicaid managed care but have an option for managed Medicare. Dual eligible clients who are not in Fully Integrated Dual Advantage (FIDA) programs will remain in FFS. Agencies should not dismantle FFS as clients are still enrolled in it (e.g. non-FIDA dual eligible clients).

Source: RCM, UM and Outcomes Event, NYC, 4.17.15

Can providers bill retroactively (i.e., "back bill")?

Plan eligibility is not retroactive. Accordingly, bill Managed Care Organizations (MCOs) fee-for-service (FFS) for 2-3 months. Refer to the guidance found in this presentation.

Source: RCM, UM and Outcomes Event, NYC, 4.17.15

Are clinicians mandated to code their own sessions?

Yes, clinicians are mandated to code their own sessions.

Source: Contracting

Can billing departments or billing systems automate codes based on keywords?

No, billing departments or billing systems cannot automate codes based on keywords.

What are the billing codes and where are they located?

A draft manual is available here. All plans and providers will use the same coding construct which will crosswalk procedure code and modifier code combinations back to fee-for-service (FFS) rate codes.

Source: RCM, UM and Outcomes Event, Buffalo, 5.1.15

Are we moving towards a Per-Month-Per-Member (PMPM) environment or a Fee-for-Service (FFS) environment?

We are moving towards a PMPM environment. Managed Care Organizations (MCOs) receive a fixed monthly payment for each member which covers a defined set of services, or benefits. Please refer to slide 16, "How Managed Care is Paid," found here

Source: Managed Care 101, 7.21.15