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 matrix.ctacny.org

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

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

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

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

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