Frequently Asked Questions
- General Managed Care
- Utilization Management
- Home and Community Based Services
- Outcomes and Analytics
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Is there a key for what the CFTSS modifiers mean?
Modifier definitions can be found here:
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.
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.
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)
Is offsite billed the same for OLP, PSR, and CPST? Please provide an example of how offsite would be billed.
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.
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.
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.
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.
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
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.
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
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.
Have the children's HCBS rates been released?
Yes, the children's HCBS rates can be found here.
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.
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.
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.
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.
Are clinicians mandated to code their own sessions?
Yes, clinicians are mandated to code their own sessions.
Can billing departments or billing systems automate codes based on keywords?
No, billing departments or billing systems cannot automate codes based on keywords.