Frequently Asked Questions

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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

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