Frequently Asked Questions

NYS Policy Top Question
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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

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 is developing a Billing tool and a Chargemaster to help with this. Additionally, consult the MCTAC resources page for additional information on RCM. 

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

For CPST, will children providers being able to bill for evidence based practices in the community under this new defined service?

Yes, the state is currently working through designing the provider designation process for EBPs.

Source: Children's System Transformation, Buffalo, 4.12.16

What is the turnaround time for returning not clean claims?

CSRA will provide the remittance statement with the denial of a claim in about 2 weeks from submission. Depending on reasoning for denial i.e. if it is due to data insufficiency or claiming errors (rejected or denied) the provider must resubmit the corrected claim within 60 days of the remittance notification.

Source: Children's System Transformation, Buffalo, 4.12.16

When dealing with court-ordered services, how do providers determine what Managed Care Organizations will pay for?

Appendix K of Model Contract requires plans to pay for court-ordered services. This applies to the children's system.

Source: Children's System Transformation, Long Island, 3.21.16

How does billing work for children with third party health insurance?

The policy regarding children enrolled in Medicaid who also have Third Party Health Insurance (TPHI) requires health care providers to first bill the Third Party.  If the TPHI denies the claim, then Medicaid should be billed. This policy is expected to remain unchanged even in a Medicaid Managed Care environment. 

Source: Children's System Transformation, NYC, 3.22.16

For Foster Care Children, will services for mental health be billed to the managed care program or will the provider continue to bill the Foster Care agency directly?

NYS is reviewing the health services available to all those in the foster care system (offered by Voluntary Foster Care Agencies as well as community based health providers). The mechanisms for how the services will be delivered and payments will be made is under development at this time; NYS hopes that as many services as possible will be billed to the managed care plans.

Source: Transforming the Children's Medicaid System Webinar Part 1, 1.27.16

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 for New York City 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