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

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

Will Youth Peer Support and Crisis Intervention (CI) be billable to the Medicaid Managed Care Plans (MMCPs) on 10/1/19 under the consolidated waiver even though they won’t be CFTSS until January 2020?

Youth Peer Support and Crisis Intervention are part of the Children’s HCBS package until January 2020 when the services become CFTSS.

When the HCBS package moves into Medicaid Managed Care (MMC) on 10/1/2019, all HCBS for children who are enrolled in MMC will be billed to MMC.

Source: State April Roundtable 2019

When a youth is hospitalized and an FPSS worker was at the home earlier the same day can Family Peer Support Services (FPSS) bill?

A FPSS provider cannot bill Medicaid for services while the child is in the hospital, as the hospital is already billing Medicaid for the child at that time.

However, if the service is provided before the child was admitted to the hospital, the service would be billable and not duplicative of another Medicaid service.  

As always, we encourage you to speak with your agency internal compliance officer and/or billing staff to delineate when a staff-person can serve the family.

Source: FPSS Preparing for MC Webinar May 2019

What category of service are children's HCBS billed under?

Children's HCBS will be billed under 0268. All HCBS designated providers should have that category added to their Medicaid ID number.

Source: Children's HCBS Webinar Series March 2019

Have the children's HCBS rates been released?

Yes, the children's HCBS rates can be found here.

Source: Children's HCBS Webinar Series March 2019

Can children's HCBS be delivered at two different times of day as long as the amount does not go over the daily rate?

Yes, different HCBS services can be provided on the same day and must be provided at different times in order to bill for both. Additional information on billing can be found here.

Source: Children's HCBS Webinar Series March 2019

When do providers bill Medicaid Managed Care Plans (MMCPs) for Children's HCBS?

Aligned HCBS services transition to Medicaid Managed Care on October 1, 2019. As of October 1, 2019, providers will bill Managed Care for children in plan receiving these services.

Source: Children's HCBS Webinar Series March 2019

Will service planning (not face to face with a client) for children's HCBS be able to be billed?

No, you cannot bill if not face-to-face.

Source: Children's HCBS Webinar Series March 2019

For the time period of 10/1/19-1/1/19, should Medicaid Managed Care Plans (MMCPs) be hard-denying claims for Crisis Intervention (CI) and Youth Peer Support and Training (YPST) (the interim children's HCBS) service for non-waiver children? Are there any scenarios where this would be appropriate?

MMCPs should pend the claim and confirm the waiver status of the child as there may have been a delay in placing the K1 RRE code on the child’s case.

Source: State Released MMCP FAQ Sept 27, 2019

If a Medicaid Managed Care Plan (MMCP) gets a claim from a provider who has been de-designated from children's HCBS, should the plan hard deny, or should they pay and notify the State?

Providers are required to be designated to provide Children’s HCBS. The MMCP can deny the claim if the provider was not designated at the time the service was provided.

Source: State Released MMCP FAQ Sept 27, 2019

Is the Medicaid Managed Care Plan (MMCP) supposed to pay children's HCBS claims that are not submitted properly by the provider, or can they deny these claims?

The remedial Plan of Care (POC) policy includes the significant issues that may be used by the MMCP to determine a children's HCBS claim is invalid and should not be paid. In general, if the claim is valid but cannot be processed for administrative reasons, the plan should pend the claim and work with the provider to correct the claim.

Source: State Released MMCP FAQ Sept 27, 2019

Based upon the four instances listed in state released remedial guidance in which a children's HCBS claim could be denied, can the plan deny claims during the transitional timeframe for non-allowable service combinations?

Medicaid Managed Care Plans may deny for non-allowable service combinations if their claims systems configuration for this process was approved on readiness review. Otherwise, plans should pend the claim and review with the care manager and provider to assure coverage of the most appropriate service for the child.

Source: State Released MMCP FAQ Sept 27, 2019

For Children's HCBS, as part of this transition period from 10/1/19 to 12/31/19, should Medicaid Managed Care Plans reimburse providers whatever is billed on the claim or reimburse the claim in compliance with the State’s posted rates?

Plans should reimburse Children's HCBS providers at the appropriate State rate.

Source: State Released MMCP FAQ Sept 27, 2019

The July 2019 State HCBS billing guidance explains that State designation as a children's HCBS provider is not required for vehicle modification, environmental modification and adaptive and assistive equipment providers. Therefore are these providers and services not applicable to the remedial process?

Consistent with the April 1, 2019, transition, if the FFS authorization process for AT/EMods/ V-Mods has already begun prior to 10/1/19 (meaning the Description and Cost Projection Form has been provided to the LDSS), the process is to be completed through the FFS delivery system.

MCOs are responsible for new requests for these services for eligible enrollees 10/1/19 and forward. New requests for AT/E-Mods/VMods are subject to MCO prior authorization requirements starting 10/1/19, including review for medical necessity of the service.

Source: State Released MMCP FAQ Sept 27, 2019

Are providers allowed to negotiate rates with Medicaid Managed Care Plans (MMCPs) for Children’s HCBS Palliative Care services?

MMCPs are required to pay the government rates for children's HCBS for at least 24 months. By Statute, behavioral health services provided by OMH licensed or OASAS certified agencies are reimbursed at FFS rates through 2023.

Source: State September Roundtable 2019

Should the agency providing Family Peer Support Services (FPSS) submit one claim per child even if two parents attend the group?

The provider can only submit one claim per child, regardless of, if two parents are in attendance in the group session.

Source: FPSS Billing Nov 2019

Can a Family Peer Support Service (FPSS) provider bill for collateral visits (e.g. with a teacher, community provider)?

Collateral billing is not allowed for FPSS and not listed as an allowable modality in the CFTSS Provider manual.

Source: FPSS Billing Nov 2019

What happens with Voluntary Foster Care billing on July 1st 2021?

Voluntary Foster Care Agencies (VFCAs) are required to obtain and maintain Article 29-I licenses to bill for Core Limited Health-Related Services and Other Limited Health Related Services. VFCAs that have not obtained 29-I licensure are not authorized to provide these services. Article 29-I Facilities must bill Medicaid Managed Care Plan (MMCP) for those children enrolled in a MMCP.

Source: 2.10.21 Article 29-I Billing Office Hour

Will initial enrollments be retrospective to the first day of the month a child/youth enters foster care? For example, if entry to foster care is 8/10, would the effective month of enrollment be 8/1?  How would payment for services rendered by FFS providers between 8/1 and 8/10 be affected?

If a child/youth enters foster care on 8/10, and is not excluded from enrollment, the effective date of the Medicaid Managed Care (MMCP) enrollment is 8/1, as long as the LDSS opened the Medicaid case during the same month. Providers should wait till the enrollment process is completed prior to submitting claims to the MMCP.

Source: 2.10.21 Article 29-I Billing Office Hour

Do 29-I Facilities follow the same billing rules for CFTSS and children’s HCBS as any other agency or are there differences when these are billed as part of Other Limited Health Related Services?

29-I Facilities must adhere to Children and Family Treatment and Support Services (CFTSS) and children's Home and Community Based Service (HCBS) billing requirements. The appropriate billing manual can be viewed here. 

Source: 2.10.21 Article 29-I Billing Office Hour

If the plan(s) has a subcontract with Beacon, or another plan for behavioral health, do we, the provider, bill Beacon or the MMCP for Article 29-I Core Services? Other Limited Health Related Services?

Core Limited Health Related Services are always billed directly to the Medicaid Managed Care Plan that you, the provider, are contracted with and not the delegate. For Other Limited Health Related Services, providers need to review their contract and talk with MMCP as this is different across plans.  

Source: 2.10.21 Article 29-I Billing Office Hour

For Article 29-I Core Limited Health Relates Services, what Diagnosis should I use?

Providers should use an applicable ICD-10 diagnosis. If the youth has more than one diagnosis, the provider only needs to include one on the claim. Providers may only use the ICD-10 code of R69 when the child/youth does not have a diagnosis identified at the time of the claim submission.

Source: 2.10.21 Article 29-I Billing Office Hour

If a child, covered by a 29-I facility shows up for sick child visit but the doctor is also able to address something unrelated, are 2 bills submitted?

If the office visit covers both issues there would be one claim for the duration of the visit. This would include the additional procedure codes to describe what occurred in the encounter, define the complexity of the visit and support the time that it took. If the child goes into the office visit and there is another BILLABLE encounter that is distinctly different than the reason for the visit and outlined as permissible in the billing manual then there would be two claims.

See Article 29-I Billing Office Hour presentation for more details.

Source: 2.10.21 Article 29-I Billing Office Hour

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