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 developed 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 for children's services?

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

What are eligible settings for Children and Family Treatment and Support Services?

Children and Family Treatement and Support services can be provided in the community, and in Community Residences (OMH). Services can also be provided in any licensed foster care setting, including institutions (e.g. RTC). Services cannot be provided in any hospital, inpatient or Residential Treatment Facility level of care.

Source: CFTSS June 2018

Can children's providers continue to provide services on a fee for service basis after the children's system transition?

Yes, services will continue to be provided on a fee for service basis for children who are not enrolled in a Medicaid Managed Care Plan (MMCP). However, services must be billed to the MMCP for children enrolled in managed care. 

Source: Children's Aligned HCBS June 2018

What types of children will need to remain Fee for Service during the transition?

Many children will remain Fee for Service because they are exempt or excluded from Medicaid managed care for reasons that are not impacted by this transition, such as children with comprehensive Third Party Health Insurance and children who are Native American. Children who will be mandatorily enrolled in Medicaid managed care as part of this transition are children who are only exempt due to 1915c waiver enrollment or who are excluded because they are in the care of a voluntary foster care agency (VFCA).

Source: Children's Aligned HCBS June 2018

Can you bill for the same family for group and individual in the same day for CFTS service FPSS? If so, can you charge the out of office add-on for both if they are both off-site?

Yes, you can bill for group and individual FPSS on the same day but you cannot charge the off-site twice if both appointments are in the same place back to back. However, if the provider had to travel twice in the same day to deliver services, providers may charge for off-site for both services. 

Source: July 2018 CFTSS Billing In-Person Training

For the CFTSS, OLP Crisis Triage, which has a 15 minute unit, what should be done if the call is less than 15 minutes? Can this be 5 minutes instead?

It is anticipated that Crisis calls usually take more than 15 minutes. Providers will not be able to bill for crisis triage call that are less than 15 minutes.

Source: July 2018 CFTSS Billing In-Person Training

In CFTSS, how do you bill for more than one OLP evaluation?

There is not a set limit in the billing manual. Providers should follow billing procedures as outlined in the billing manual.

Source: July 2018 CFTSS Billing In-Person Training

Why in CFTSS is only OLP Crisis Complex Care in 5 min units/max 20 minutes? Was it not agreed that all crisis OLP services would be kept consistent in terms of units and increments?

Crisis Complex Care (Follow Up to Crisis) is meant to be a brief follow up call post crisis services.

Source: July 2018 CFTSS Billing In-Person Training

Are providers allowed to provide multiple Children and Family Treatment and Support Services in a day?

Yes, multiple CFTSS can be provided on the same day as long as each service is provided at a different time either consecutively or at another point during the day. You cannot bill for OLP, CPST and PSR all during the same interval of time.

Source: July 2018 CFTSS Billing In-Person Training

In CFTSS, do you need a diagnosis to bill for OLP (Other Licensed Practitioner)?

You do not need a diagnosis to bill for OLP Evaluation. You should use R69 (or for United F99) in field 67 of the paper claim form. If you have seen the individual many times, it is likely a diagnosis would be determined and you would no longer be using R69.

Source: July 2018 CFTSS Billing In-Person Training

If a field on the claims form is not required and you complete it anyway, what will happen? For example if a field is required for one plan but not others and you set your default to fill it the way it is required for that one plan will the others deny you because you have completed a field that is not required?

Many plans will just ignore it and it will not disrupt the claim, but for some plans, it could lead to a denial. 

Claim testing is a great opportunity to determine the appropriate system set up to reduce denials. 

Source: July 2018 CFTSS Billing In-Person Training

How will clinicians know which codes to use?

It can be beneficial to create a Chargemaster that everyone at your organization has access to so that they understand which codes are used for which services as well as who (in terms of licensure) can provide and bill for each service.

For more information, view the Creating a Chargemaster webinar.

Source: July 2018 CFTSS Billing In-Person Training

Is there a set timeframe for submitting a CFTSS claim? Are there timeframes for resolving denials or other claims issues (not billed, pending, etc.)?

The state requires providers be given a minimum of 90 days to submit a claim. 

It is recommended that providers have a process in place to make sure that every service has been billed in a timely fashion. In addition, the process should include review of remittances (response from MMCP). The goal is to account for every service and its billing status.

Source: July 2018 CFTSS Billing In-Person Training

What is included in offsite rate for CFTSS? Is it per site or per unit/per client?

The off-site rate supplements the base service rate to account for additional costs associated with off-site billing. The base service rate codes and the off-site rate codes that correspond should be billed for the number of units the service was provided. The rates are billed per client. These rate codes will be billed on separate claims. 

Source: July 2018 CFTSS Billing In-Person Training

How long will CFTSS providers get the transition rate?

Providers will get a transition rate for 24 months from the transition date of 1/1/19. The rate will phase out over these 24 months, with reductions every six months. 

Source: July 2018 CFTSS Billing In-Person Training

If a child has multiple insurances, does a provider have to bill their commercial insurance first or can they just bill Medicaid?

Commercial insurance should be billed first because Medicaid is a payer of last resort. 

Even if it is a service that you know the other insurance will most likely not cover you should bill that insurance first and get denied and then bill Medicaid. Talk with your legal and compliance experts.

Source: July 2018 CFTSS Billing In-Person Training

Is there a deadline for claims testing for children's transformation?

MMCPs were required to open claims testing no later than December 1st 2018 and leave systems open for testing throughout the children’s transition. There is no deadline, but it should be completed before a provider bills for services. 

Source: CFTSS: OLP, PSR, CPST Billing and UM Office Hour 11.15.18

If IT infrastructure is not fully in place for billing on Jan 1 when the 3 CFTSS go live, can claims be backdated for a period of time?

Claims should be submitted with the accurate date of service, and providers have a minimum of 90 days to adhere to timely filing guidelines.  Providers can submit paper claims if needed to ensure meets their contracted timely filing guidelines. 

Source: CFTSS: OLP, PSR, CPST Billing and UM Office Hour 11.15.18

What are the specifics about billing for mileage for an off-site CFTSS visit? If PSR and CPST are provided in the same day can they both bill mileage for that client or is it only one of the services that can bill mileage per day?

There are set off-site rates, not a mileage reimbursement. Providers can only bill for one off-site if two different services were provided during the same trip.

Source: CFTSS: OLP, PSR, CPST Billing and UM Office Hour 11.15.18

Is there a rate code for CFTSS OLP Complex Care off-site?

Complex Care is provided by telephone, so there is no differentiation needed for offsite vs. on site.

Source: CFTSS: OLP, PSR, CPST Billing and UM Office Hour 11.15.18

Please provide billing guidelines for billing the transitioning children's Waiver/B2H - Health Home transition rates.

A Health Home Transitional webinar was conducted on January 16, 2019 for existing providers.

Source: CFTSS: OLP, PSR, CPST Billing and UM Office Hour 11.15.18

Is there a daily unit cap or is it a suggested cap for CFTSS?

The billing manual outlines the daily unit limits. In acknowledgement of the need for checks against fraud and abuse, but to ensure a client's access to services, service utilization in excess of the annual claim limits and "soft" unit limits will be based on medical necessity and subject to post-payment review. Documentation of the medical necessity for extended durations must be kept on file in the client's record. Please refer to UM Guidance for details on annual and daily limits.

Source: CFTSS: OLP, PSR, CPST Billing Update 11.6.18

Is there a key for what the CFTSS modifiers mean?

Modifier definitions can be found here:

https://hcpcs.codes/modifiers/ 

Source: CFTSS: OLP, PSR, CPST Billing Update 11.6.18

What makes a CFTSS service offsite? Is anything beyond administrative site offsite?

Offsite services are intended to be provided in the child’s home or community. All locations, including satellites, are considered on-site.

Source: CFTSS: OLP, PSR, CPST Billing Update 11.6.18

For CFTSS, is offsite billed separately or as a modifier that increases the rate when an offsite service occurs?

Offsite is billed as a separate claim, using a separate rate code. 

Source: CFTSS: OLP, PSR, CPST Billing Update 11.6.18

For CFTSS, do the base (service) rate and the offsite rate have to be separate claims or can they be multiple lines in one claim?

Because the off-site service requires the use of separate rate codes, they must be submitted on separate claims.

Source: CFTSS: OLP, PSR, CPST Billing Update 11.6.18

For CFTSS, if offsite is billed with 2 claims: the first using the service rate code and the second using the offsite rate code, and both include the same procedure code will this look like the same services were provided on the same day?

 The services are differentiated by the required modifiers.  For example, 

OLP Licensed Evaluation: 7900 – 90791 – EP (up to 10 units)

OLP Individual Off-site – 7920 – 90791 EP, SC (one unit only)

Source: CFTSS: OLP, PSR, CPST Billing Update 11.6.18

Is offsite billed the same for OLP, PSR, and CPST? Please provide an example of how offsite would be billed.

Example: 

PSR: bill for the service using rate code 7913. If hourly, bill 4 units of 7913. If offsite, also bill 4 units of 7922.  

If Group PSR: bill 7914 for each person in the group.  If you provided 1 hour of group, each person gets 4 units of 7914.  If offsite also bill 7929 4 times for each person.  

Offsite services require that two claims are billed separately.  

Source: CFTSS: OLP, PSR, CPST Billing Update 11.6.18

For CFTSS, since two separate claims are required for offsite, does the provider have to wait for the service rate claim to process before submitting the offsite rate code?

The provider does not need to wait for the service rate claim to process before submitting the offsite rate code, they can be submitted at the same time.

Source: CFTSS: OLP, PSR, CPST Billing Update 11.6.18

For CFTS services provided to a group offsite, can you bill for offsite for each group member even though the group is obviously provided in one location?

Yes, once per client.

Source: CFTSS: OLP, PSR, CPST Billing Update 11.6.18

For determining upstate or downstate rates for CFTSS, is administration office the same as remit address?

The administration office is used to determine upstate vs. downstate rates. 

Source: CFTSS: OLP, PSR, CPST Billing Update 11.6.18

Is NYS going to mandate that all plans accept the two revenue codes of 0900 and 0911 for CFTSS: OLP, PSR, and CPST?

These are suggested and state approved revenue codes. These revenue codes are not mandated by the State.

Source: CFTSS: OLP, PSR, CPST Billing Update 11.6.18

If the staff qualifications meet OLP requirements, can both crisis and counseling be billed at the OLP level as a crosswalk from Intensive In Home (IIH) and crisis response?

OLP Crisis Activities and counseling can be billed in the same day by the same practitioner meeting OLP staff qualifications. Additional information can be found in the billing manual here.

OLP staff qualifications can be found here

Source: CFTSS: OLP, PSR, CPST Billing Update 11.6.18

When should children's providers begin using the CFTSS rate codes?

Providers of waiver services that crosswalk to OLP, CPST, or PSR must begin billing CFTSS codes for children currently enrolled in HCBS waiver programs on February 1, 2019. As of February 1, 2019, current (before Feb) HCBS Waiver services and their rate codes that are transitioning to CFTSS rate codes can no longer be billed. This includes the following services under the OMH HCBS or OCFS B2H Waivers: Skill Building; Crisis Avoidance, Management, and Training; Intensive In-Home Services; Immediate Crisis Response Service; and Crisis Response Services.

For children not enrolled in waivers, billing for CFTSS began on January 1, 2019.

Source: State January Roundtable 2019

Where can claims testing contact information be found for each Medicaid Managed Care Plan?

Providers should contact each MMCP to get instructions on claims testing. The MCTAC Matrix below includes a tab for contacts at each MMCP related to billing: https://matrix.ctacny.org/

Source: State January Roundtable 2019

Will the SED rate codes be billed to Medicaid Managed Care, or will standard codes be used after the children's transition is complete?

As of 7/1/19, providers should bill Medicaid Managed Care using standard APG rate codes. 

Source: State February Roundtable 2019

As an Article 31, outpatient mental health clinic, for children that we have been providing clinical services to and that can get to clinic, should we start billing that as OLP service or continue as we have been?

If the child is receiving clinic services, then it should continue to be billed as clinic. OLP is a distinct service, separate and apart from clinic. OMH has issued a guidance memo that addresses the relationship between OLP and clinic services and can be accessed here: https://omh.ny.gov/omhweb/bho/omh_clinic_and_olp.pdf

Source: State February Roundtable 2019

Who pays for the Other Licensed Practitioner (OLP) service for children in foster care?

OLP will be billed fee-for-service for children residing in a VFCA until the date those children are enrolled in managed care. If the child is already enrolled in managed care, OLP would be billed to the managed care plan (except for SSI children, who will receive CFTSS through managed care beginning 7/1/19.)  

Source: State February Roundtable 2019

Are Adult 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.

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