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90-Day Claims Submission Q&A

GENERAL

 

When will the 90-day claims submission deadline take effect?

The regulations at 10 NYCRR Section 69-4.22(a)(4)) will be implemented effective February 10, 2019. Any claim with a date of service on or after February 10, 2019 will be subject to the 90-day claims submission deadline.

 

SUBMITTING CLAIMS

 

When does the 90-day claims submission clock begin?

The clock begins on the date of service. Claims must be submitted into the New York Early Intervention System (NYEIS) within 90 days of the date of service. A claim is considered submitted into NYEIS when it has a status of “Submitted.”

 

Does claim submission mean submission into NYEIS or EI Billing?

Claims must be submitted into NYEIS within 90 days of the date of service.

 

Some providers submit multiple claims for a child all at once. If some claims are rejected and some are not, are the ones not rejected considered filed?

After successful submission of invoices/claims, the claims are evaluated individually. The claims that are not denied or rejected will be considered filed. Providers may review the status of claims they have submitted by logging into NYEIS. Further information regarding electronic claiming can be found in the NYEIS User Manual, Unit 8: Provider Invoicing.

 

How does this new regulation impact respite and transportation services?

At this time, respite and transportation claims are excluded from the 90-day claiming regulation.

 

What changes have been made to NYEIS?

Because the date the claim is submitted has always been tracked in NYEIS, changes to the system were not necessary to meet this requirement. The extraordinary circumstance and claiming limit deadline will be implemented in EI Billing for all dates of service on or after February 10, 2019.

 

What will happen if I submit a claim after the 90-day deadline?

EI Billing Providers will still be able to submit claims more than 90 days after the date of service. If an extraordinary circumstance is entered into EI Billing and the claim is entered within 30 days of the date you are relieved from this extraordinary circumstance, the claim may be reimbursed from the escrow account after it is adjudicated through commercial insurance and Medicaid. If an extraordinary circumstance is not entered for a claim that is past the 90-day deadline, the claim may still be paid by commercial insurance and/or Medicaid as applicable, but will not be reimbursed from the municipal funded escrow account. There will be a “late claim adjustment” column added to EI Billing reports to reflect any amount that was not paid by escrow due to late filing.

 

Is there any change for claims that are submitted prior to the 90-day deadline?

There will be NO CHANGE in the process for any claims submitted to NYEIS within 90 calendar days of the date of service.

 

Will claims submitted past the 90-day submission deadline still be paid by Medicaid or commercial insurance?

Claims submitted past the 90-day submission deadline will be submitted to Medicaid or commercial insurance for adjudication as applicable. If a claim is submitted past the 90-day submission deadline and is partially paid by Medicaid or commercial insurance, a ‘Late Claim Adjustment’ showing the amount not paid will appear in the following EI Billing reports: Claim Status, Claim Research, Detail Claims, and Detail Transaction.

 

How can I view claims that are subject to the 90-day submission deadline?

If you have claims that have been submitted past the deadline with or without an extraordinary circumstance, you may view them by navigating to the Timely Filing Claim Status section on your EI Billing Provider Dashboard. Click the link to view your claims that are greater than 90 days.

 

How do I calculate 90 days from the date of service?

Follow these steps to calculate 90 days from a date of service:

  1. Open a new Excel document
  2. Type the date of service in cell A1 (e.g., 10/26/2018)
  3. In cell B1, type =A1+90 and press ‘enter’
  4. The date will appear in cell B1

 

CORRECTIONS, VOIDS, OVERLAPPING CLAIMS

 

What if a claim is rejected by NYEIS for corrections?

The New York State Department of Health (the Department) expects that claims entered are accurate, complete, and reflect actual services rendered upon submission into NYEIS. Claims that have been denied, rejected, or voided in NYEIS that need to be corrected and resubmitted must be included on a new claim in a new invoice and submitted into NYEIS within 90 days of the date of service. The earlier the claim is submitted into NYEIS, the earlier errors can be discovered and resolved.

 

What if a provider’s claim is denied because it overlaps with another provider’s claim?

The Department expects claims to be entered accurately and completely, reflecting actual services rendered when submitted into NYEIS. Claims that have been denied, including those with overlapping times for a rendering provider and/or child, should be reviewed by the provider. Providers routinely contact the NYEIS helpdesk for assistance regarding overlapping claims. Providers should review the claims to determine if there was an error (e.g., incorrect date or time) and collaborate to resolve the issue. If a corrected claim must be submitted for either or both providers, this must occur within 90 days of the date of service.

 

What if claims that are entered into NYEIS subsequently encounter EI Billing issues or are rejected by EI Billing?

As long as claims were submitted into NYEIS within 90 days of the date of service, the timeframe has been met. A claim that subsequently encounters issues in EI Billing can be found in the provider’s work queue with information on the action that must be taken for the claim to move forward.

 

What if errors need to be corrected by the county?

If errors are discovered that require the municipality to make modifications, it is incumbent upon the municipality to correct errors as soon as they are discovered to allow the provider to submit claims within timely filing limits. Claims that require correction must be submitted on a new claim and new invoice within 90 days of the date of service. Providers and municipalities must ensure that service authorizations (SA) accurately reflect the services agreed upon in a child and family’s Individualized Family Service Plan (IFSP). Providers must also ensure the SA and claims are accurate. Accurate data entry and review of the SA and claims will assist in preventing errors. The earlier the claim is submitted into NYEIS, the earlier errors can be discovered and resolved.

 

If a Billing Provider receives a response file (F-File) from NYEIS indicating a claim was billed, is this considered a billed claim?

No, the invoice/claim is not in “Submitted” status until it has successfully passed the initial file format check (HIPAA 5010 file format standard) and “pre-invoice” error checks (F-File). Invoices/claims that have successfully passed these first two steps are considered submitted. Claims are then processed through the NYEIS invoice and claiming rules which may result in a claim status of “Denied,” “Pending,” or “System Approved.” The status of claims may also be viewed online in NYEIS. Providers should routinely monitor electronic claim file transactions, including response files, and review claims online. Further information regarding electronic claiming can be found in the NYEIS User Manual, Unit 8: Provider Invoicing.

 

INSURANCE DELAYS

 

What if Coordination of Benefits (CO-22) and Assignment of Case Manager/Early Intervention Service Coordinator (Code 35) denials require months to be corrected?

If claims were submitted into NYEIS within 90 days of the date of service, the timeframe has been met.

 

What if insurance carriers are slow to pay or if the carrier determines there is a problem with the claim?

Insurance adjudication has no bearing on the 90-day timeframe. The date of submission is determined in NYEIS.

 

What if the incorrect insurance is billed due to parents not updating the provider?

Updates to insurance information in NYEIS do not impact the claim submission date. A claim that is discovered to contain incorrect insurance information will be found in the provider’s EI Billing work queue with information on the action that must be taken for the claim to move forward.

 

OTHER DELAYS AND WAIVERS

 

What if there is a delay caused by the county?

The Department expects that data entered into the Early Intervention Program (EIP) data system, NYEIS, is accurate and utilized in a manner that will comply with all federal and state laws and regulations. The Department and the State Fiscal Agent (SFA) will closely monitor delays to claiming that providers report may be caused by the municipality. The Department will provide technical assistance to municipalities and providers as necessary to mitigate reported delays.

 

What if counties are slow to approve billing waivers?

When a claim is submitted in NYEIS that violates an EIP billing rule, the provider is required to submit a justification via workflow that is initiated in NYEIS. The status of the claim appears as “Pending” until the Early Intervention Official/Designee (EIO/D) provides a decision on the claim. If the request for waiver is approved, the claim is marked “System Approved” and will be transmitted to the SFA. The review and subsequent approval of a waiver request has no impact on the 90-day claiming rule if the claim was marked “Submitted” within 90 days of the date of service. If the request for waiver is rejected, the claim is marked “Denied.” In this case, if the claim requires correction, a new claim and invoice must be submitted within 90 days of the date of service.

 

The Early Intervention Official/Designee (EIO/D) may request corrections to evaluations which cause providers to send the evaluation back to the therapist and then back to the EIO/D for review. How can this process be managed to ensure the 90-day claiming timeframe is met?

Prompt payment relies on accurate information being entered into NYEIS. Providers should review their data entry for accuracy prior to submitting the evaluation components. Additionally, municipalities must review all sections of the evaluation to ensure regulatory requirements are met prior to accepting the evaluation. If corrections to an approved evaluation are needed, this process must occur to allow the provider to have adequate time to enter new claims on a new invoice within 90 days of the date of service. The Department and the State Fiscal Agent will closely monitor timeliness of the entry of evaluation results and submission of the associated claims.

 

What happens if the child gets sick and the evaluation was delayed or the evaluation was otherwise delayed by the family?

The 90-day time frame does not begin until the evaluation is completed. The date of service for the evaluation is the date the evaluation was fully completed.

 

EXTRAORDINARY CIRCUMSTANCES

 

What are extraordinary circumstances?

An extraordinary circumstance is a valid reason that a claim could not be submitted within 90 days of the date of service. Extraordinary circumstances include:

  • Natural Disaster
  • State Administrative Delay
  • Audit Findings
  • Litigation
  • Death of Essential Personnel
  • Hospitalization of Essential Personnel

Please note that extraordinary circumstances entered into EI Billing are automatically acknowledged, but they are subject to an audit. You must retain records of extraordinary circumstances, and you may be asked to furnish those records to BEI.

 

Is there a deadline for entering an extraordinary circumstance?

Extraordinary circumstances must be entered in EI Billing as soon as practicable and no more than 30 days after the date of relief of the extraordinary circumstance. For example, if there is a declared emergency/natural disaster that prevents the provider from submitting a claim within 90 days of the date of service, the extraordinary circumstance must be entered in EI billing no more than 30 days after the end of the circumstance (in this example, after the declared emergency has ended).

 

How do I enter an extraordinary circumstance for a claim?

When an extraordinary circumstance occurs, the provider should work to ensure that claiming resumes as quickly as possible. Once the circumstance is resolved (date of relief), the provider must enter the extraordinary circumstance into EI Billing within 30 days. Follow these steps:

  1. Login to EIBilling.com
  2. Click on the ‘Claiming’ tab, scroll over ‘Timely Filing’, and click ‘Enter Extraordinary Circumstance’
  3. Select the type of extraordinary circumstance from the drop-down and confirm
  4. Enter a specific description of the extraordinary circumstance
  5. Enter a date of event (when the extraordinary circumstance occurred) and confirm
  6. Enter a date of relief (when the extraordinary circumstance ended) and confirm
  7. Click ‘Generate Form’ and print the form
  8. Check the box to confirm that the form printed and the information is correct
  9. Click ‘Submit’
  10. On the acknowledgement page, check the box to acknowledge that you have read the statement and will maintain records regarding the extraordinary circumstance
  11. Click ‘Print Acknowledgement’

Retain the Extraordinary Circumstance Form, Acknowledgement, and any records related to the extraordinary circumstance in accordance with EIP guidance on retention of Early Intervention Program records

 

Should an extraordinary circumstance be entered before or after a claim is submitted?

We recommend that extraordinary circumstances are entered BEFORE a claim is submitted in NYEIS. This will help ensure that the claim is properly adjudicated. Providers can enter extraordinary circumstances up to 30 days after the date of relief.

 

What if there is a NYEIS outage when the provider attempts to enter the claim on day 89 or 90?

If a widespread unscheduled outage of NYEIS occurred and prevented the provider from submitting claims within 90days of the date of service, it may be considered a State Administrative Delay. Scheduled outages of NYEIS or any local connectivity errors impacting access to the Health Commerce System (HCS) and/or NYEIS will not be considered a State Administrative Delay. If a scheduled outage is announced, it would be in the billing providers’ best interest to submit claims in advance of the outage. Billing providers should subscribe to the Department’s electronic mailing list and view announcements posted in NYEIS for information regarding upcoming system outages.

 

What happens if audit results show I don’t have or have lost my records related to an extraordinary circumstance?

If your claims are audited and you are not able to furnish records supporting an extraordinary circumstance entered, recoupment will be made for associated claims. Funds would be recouped from future escrow payments.

 

What if my extraordinary circumstance does not fall into one of the listed categories?

At this time, only the six listed extraordinary circumstance categories will be considered. If you have a question or concern, please contact the BEI at (518) 473-7016 or beipub@health.ny.gov.

Article ID: 404, Created On: 2/4/2019, Modified: 2/15/2019

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