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Medicaid Managed Care and EI Billing

New York State Department of Health
New York Early Intervention System (NYEIS) Electronic Mailing List

Medicaid Managed Care and EI Billing


Dear Colleague:

This e-mail provides important information regarding children enrolled in a New York State Medicaid Managed Care Plan. It has been brought to the Department’s attention that numerous claims for children enrolled in Medicaid Managed Care Plans for their health care coverage were billed to the Managed Care plan in error, because the child’s health insurance information was incorrectly recorded in KIDS or NYEIS as a commercial insurance product. 

For purposes of the Medicaid Program, early intervention services are not included as part of the Medicaid Managed Care Plan benefits package.  Medicaid Managed Care Plans must not be billed for EIP services.  Rather, early intervention services are paid for using the fee for service system and are billed to the Medicaid Program using the child’s Medicaid client identification number (CIN) and reimbursed to the provider at Department established rates.

It is very important that children in the Medicaid Program are identified as Medicaid enrollees in Medicaid Managed Care Plans, and CINs are included in NYEIS.  This information must be recorded correctly in KIDS or NYEIS in order for claims to be routed appropriately to Medicaid.

The Department has worked with the interim State Fiscal Agent (SFA) to identify currently affected claims that were incorrectly billed to Medicaid Managed Care Plans based on the wrong data in KIDS or NYEIS (21,000 claims totaling $1,679,893.00) that have now been withdrawn and resubmitted to the Medicaid fee-for-service system. The SFA utilized data obtained from the Medicaid Program to temporarily flag a child’s Medicaid Managed Care Plan as non-billable in EI Billing. Any claim outstanding to commercial insurance where the child also has an active Medicaid CIN recorded was transmitted to Medicaid on Wednesday, August 28 (Medicaid cycle 1880). Providers may soon begin to receive payments or responses requesting additional information from the Medicaid Program regarding these claims. No explanation of benefits (EOB) details need to be recorded for the commercial insurance claims in EI Billing as the SFA will manually mark these claims as denied. The SFA will also notify the insurers to inform them that these claims can be disregarded as they were submitted in error.

Claims that are impacted by this issue have been identified from providers in the following counties:  Albany, Broome, Cattaraugus, Chautauqua, Chenango, Clinton, Cortland, Dutchess, Erie, Essex, Greene, Herkimer, Lewis, Monroe, Nassau, New York, Niagara, Oneida, Onondaga, Orange, Otsego, Putnam, Rensselaer, Rockland, Saratoga, Schenectady, Schoharie, Seneca, Steuben, Suffolk, Sullivan, Tompkins, Ulster, Warren, Washington, Westchester, Wyoming.  Providers in other counties are not impacted.

Service coordinators are responsible for collecting and updating a child’s insurance information on an ongoing basis. Service coordinators and municipalities must work together to correctly identify each child’s policy information in KIDS or NYEIS as soon as possible to prevent future claims from being inappropriately billed to the Medicaid Managed Care plan. It is critical that service coordinators and municipalities work together with families to determine the appropriate status of a child’s insurance and/or Medicaid coverage. In nearly all municipalities, once a child is determined to be eligible for Medicaid, they are required to enroll in a Medicaid Managed Care Plan.  For more information about enrollment, exclusions, or general information on Managed Care, please visit the NYS Department of Health Managed Care website at http://www.health.ny.gov/health_care/managed_care/index.htm or call the Medicaid Managed Care helpline at 1-800-505-5678.

A spreadsheet outlining the affected children has been created and is being sent via the Health Commerce System (HCS) Secure File Transfer (SFT) to Early Intervention Officials so that they can correct these records in the source data system. Please note that not all municipalities will receive a spreadsheet. The spreadsheet notes child information, child CIN, insurance recorded in systems, Medicaid Managed Care (MMC) insurer information from Medicaid, and data source (NYEIS/KIDS). The child must have a MA CIN recorded in order for claims to be billed to MA. Municipalities and service coordinators must review and determine if the insurer listed in the source data system is in fact a MMC insurer.

To resolve these errors for children enrolled in KIDS, the municipality must edit the commercial plan recorded in the child’s record and mark as “Do Not Bill”. This can be completed under the Other Tab, selecting private insurance, browsing to the MMC insurer, selecting the Set Billing Control and checking the “Do NOT use for EI Billing” box. If asked if you want to update bill’s insurance status, select Yes.

To resolve these errors for children enrolled in NYEIS the municipality or child’s service coordinator have the access rights to make this change. The user can view the child’s insurance information by selecting the Insurance Coverage link on the Child’s Homepage, selecting edit for the MMC insurer, and selecting the Yes dropdown in the “Is Plan Medicaid Managed Care?” field.

This data must be updated as soon as possible to prevent future claims from being sent to the MMC insurer. It is critical that service coordinators and municipalities work together with families to determine the appropriate status of a child’s insurance and/or Medicaid coverage.

Thank you for your attention to this important priority and data correction project.

Please note these additional resources for questions:
Questions regarding EI Billing:  1-866-315-3747 Monday-Friday 7am-7pm
Questions regarding NYEIS: nyeis@cma.com
Questions regarding KIDS: kids@health.state.ny.us
Questions for the Bureau of Early Intervention: bei@health.state.ny.us

Please do not respond to this e-mail announcement.

Thank You.

Article ID: 120, Created On: 9/18/2013, Modified: 10/28/2015

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