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Frequently Asked Questions (FAQs)
HIPAA 5010 and NCPDP D.0 FAQs
- NEW
820 and 835 Supplementary Files
- How do these compare with the 820 and 835?
820 or 835 -
Why am I not receiving an 820 or 835 transaction in response to my 837?
837 COB Tutorial
– Medicaid secondary to Medicare, with full line item detail
837 COB Tutorial
– Tertiary Claim to Medicaid with full line item detail
APG
– How do I bill an APG claim versus another Institutional claim?
Adjustment and Void
- How should we report an adjustment or a void?
Anesthesia
- Claims with minutes are denied - How should we bill our services?
ASCII Table
Balancing in the 837
- Can you provide guidance on claim balancing?
Bus Token Reimbursement
- Is there a way to bill for NYS Medicaid clinic patients?
Clinics
- How to bill claims with multiple lines?
COB and Medicare
- Where do Approved, Co-insurance, and line item amounts go?
COB and the CAS Segments -
What is sent if the charges were not covered by the prior payer?
Code Checking
- Can we tell if a medical or non-medical code is valid on a specific date?
Coverage and Claims Questions -
Who do I contact if I have coverage or claim questions?
Cycle -
What is the Claims Cycle?
Data Security
- What steps should you take in securing your data?
Date Range
- How should I report a date range?
Delay Reason Code
- How do we indicate this if we file an 837 claim late?
Dental Clinic, Facility Code, Producer/Service ID field
- what goes in CLM05 and SV201?
Dental Emergency Indicator on 837D
- How to work around the lack of an Emergency Indicator?
Diagnosis Related Group (DRG) claims -
what are the billing procedures for DRG claims and DRG with Alternate Level of Care?
Discharged Patient to Hospital
- What is required when billing on the 837 Institutional?
Document Level Processing
Epogen
– How should Epogen be billed?
Functional Acknowledgment
- When will I receive a 997 transaction?
Functional Acknowledgment Rejection
– How do I identify exactly where an error occurred?
Graduate Medical Education (GME)–
How do I bill this type of claim?
Group ID as Billing Provider -
Can a medical group be used as the Billing Provider?
HIPAA Information
- Where are the Implementation Guides, Code Sets, and Rules?
ICD-9-PCS Procedure Codes
- Can they be used for Hospital Outpatient Claims at claim level?
Invalid Character errors
- How can we clear these up?
ISA and GS Segments
License Number
- How to send a License Number as a Provider Identifier?
Location Code and Location Number
- How are these elements assigned and used?
Long Term Care
- How should Medicaid be billed for clients with a Medicare Managed Care plan?
Long Term Care
- How should Medicaid be billed for clients with Medicare?
Methadone Maintenance
- Why must these be billed with a Sunday date of service?
NCPDP Companion Guides
and Sample Data - Are these available?
Net Available Monthly Income (NAMI)
- What are the reporting requirements for LTC?
Newborn Hearing Screening
- How should we bill for this service?
NPI, Facility Practitioner NPI Reporting
– Do Institutional Providers need to maintain the reporting of Affiliated Practitioners as their Attending Providers change?
NPI - Facility Practitioner NPI Reporting
- Does the affiliate reporting requirement apply to a hospital physician’s group?
NPI - Facility Practitioner NPI Reporting
- How do facilities with multiple NPIs report?
NPI - Facility Practitioner NPI Reporting
- Is there a way to enter large numbers of attending providers?
NPI - Facility Practitioner NPI Reporting
- What date should I use for the Effective Start Date?
NPI - Facility Practitioner NPI Reporting
- Who needs to report their attending provider’s NPIs and License Numbers?
NPI, National Provider Identifier
– Can I submit with both an NPI and my Medicaid ID?
NPI, National Provider Identifier
- I am exempt from NPI. Do I have to enter the NPI of the ordering, referring or service provider, or can I continue to use the license number or Medicaid Provider ID?
NPI, National Provider Identifier
- I submitted my claim with a group NPI, and the claim was denied on a remittance for the individual provider, why?
NPI, National Provider Identifier
- I submitted paper claims with an NPI and never see the claims on a remittance, what has happened to them?
NPI, National Provider Identifier
- My check/remittance has a provider number on it that is not mine, what should I do?
NPI, National Provider Identifier
- My claims are getting denied for edit 02067 – Attending Provider not linked to Billing Provider, what does that mean?
NPI, National Provider Identifier
- What is the Facility Affiliated Practitioner NPI and License file?
NPI, National Provider Identifier
- What methods are available to affiliate a practitioner with a facility?
NPI, National Provider Identifier
- When I enrolled as a sole practitioner, I was given a single MMIS Provider ID to use for my corporate entity and as an individual. Now I have an individual NPI and an organization NPI. How should I register the two NPIs?
NPI, National Provider Identifier
- Can I use an NPI to bill for services that don’t require an NPI?
NPI, National Provider Identifier
- How can I tell if I need to get an NPI for NYS Medicaid billing?
Orthodontics
–
What is the correct 837 for billing?
Physician's Assistants Billing
– Rendering Provider reporting for physicians and group practitioners
POA
- What are the requirements for reporting Present on Admission?
PPAC
- What HCPCS codes are used for the Preferred Physicians and Children Program?
PAC and PAS programs
- How should I submit claims for these programs?
Patient Status Code
- What is required for Skilled Nursing Facility claims?
Premium Billing -
How should a Managed Care Plan submit a HIPAA 837I for premium billing?
Private Duty Nursing and Home Health
- What is the correct 837 for billing?
Provider Taxonomy
- How does this code set affect our billing for New York Medicaid?
Provider Test Environment
- What are the processing and cycle cutoff times for test claim submissions?
Rate Codes
- How should rate-based claims, including multiple rates, be submitted?
Receiver Name Segment
- What identifiers go in the Receiver Name loop NM1 segment?
Receiving Invalid File Format Message
- What causes this?
Recycled Pends -
How are they reported, and how do I establish the manner in which I receive them?
Rendering Provider
- How can we report this without overwriting the Billing Provider?
Residential Treatment Days
- How should Title XIX Days be reported?
Response Timeframe
- What is the response time for Claim Status Inquiry and Response?
Retros 820
- How are Retroactive Rate Adjustments reported on the 820?
Retros 835
- How are Retroactive Rate Adjustments reported on the 835?
Revenue Codes in the 837I
- What should be in SV201 for NYS Medicaid Claims?
Sample data for Nursing Home patient with Medicare Managed Care
Social Security Numbers
- How can an invalid number be identified?
Trading Partner Agreement
- Who needs to have a TPA on file?
Transaction Limits
- How many ST_SE loops may be contained within an ISA_IEA?
Utilization Threshold Override
- How are the Service Authorization Exception Codes used?
Value Information -
How can several Value Code amounts be reported on one claim?
Vendor List
- Does NYSDOH maintain a list of software vendors?
Vendor List
- How do software vendors test for compliance with eMedNY?
What Are the Response Files Sent By eMedNY?
Zero Charge on claims
- What causes the zero charge edit on a service line or claim?
Zero Fill or 0FILL
- What is the 0FILL plan that is referenced in the 837 Companion Guides?
Archived Frequently Asked Questions (FAQs)
New York State Department of Health
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