HHUNY Guidance Document: Member Medicaid Eligibility & Status

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1 HHUNY Guidance Document: Member Medicaid Eligibility & Status Version 1: March 16, P a g e

2 A member must be Medicaid active in order to qualify for Health Home services on a monthly basis. There are certain types of Medicaid that are not eligible for Health Home services and those are identified by Medicaid Coverage Codes and/or Restriction Exception (R/E) Codes that can be found here: Coverage Codes: rage_codes_final_ pdf R/E Codes: iction_exception_codes.pdf For Adult Health Homes, the Department of Health makes assignments based on past service utilization to identify potentially eligible members but they do not exclude members from this list that may potentially have an incompatible coverage or R/E code. This is why you may be assigned a DOH Assignment in which the member does not actually qualify for Health Home services. For this reason, and others, it is important to verify eligibility prior to serving the member. Medicaid eligibility can be ended while the member is enrolled in services, R/E codes can be affiliated to your member during enrollment, coverage may change for all these reasons, it is important to verify current state eligibility status for active members to reduce the risk of providing non-billable services. Verifying Medicaid Eligibility: The NYS Department of Health encourages all Health Homes and Care Management Agencies to confirm eligibility through EPACES, which is the most accurate source of information for any Medicaid Member. Medicaid Coverage Codes and R/E Codes can be found in EPACES as well to confirm health home compatibility. EPACES information is transmitted to MAPP on a weekly basis per DOH, meaning the Medicaid information in MAPP may not be the most current which can cause issues/delays with enrollment and billing but it is still a good place to review Medicaid status as most of you are in MAPP more than EPACES. HHUNY also verifies Medicaid eligibility with processes performed through the MAPP file uploads and claims submission as described below. HHUNY Workflows: Notification of Medicaid Eligibility Issues First Check: Entering a Referral Children s Health Home only: If you are entering a referral directly into MAPP for a Child, you will be notified immediately via MAPP that you are not able to process the referral due to Medicaid coverage issues 2 P a g e

3 Adult Health Home: HHUNY would notify you that the referral was rejected due to Medicaid coverage issues Second Check: Tracking File Submission to MAPP When HHUNY submits a Tracking File Record for a new segment (Start Date for Outreach or Enrollment) to MAPP, MAPP will reject the record if the member s Medicaid is inactive or is affiliated with an incompatible R/E or Coverage Code. Example: 1.) Member A is assigned on 1/4/17. Agency accepts assignment on 1/5/17 and the member chart is created in Netsmart on 1/6/17. The Client Search Note will trigger a Tracking File Segment record to be submitted to MAPP for an Outreach and/or Enrollment Segment (if you selected Client Enrolled). When the Tracking File Record is submitted, there are error codes that can be produced based on MAPP Medicaid status for that member: a. R/E Code incompatible with HH or b. Coverage Code incompatible with HH or c. Medicaid Coverage Ended prior to 1/1/17 If HHUNY receives notification of Medicaid issues through the Tracking File upload process, we will notify your agency via indicating a Tracking File Error. Third Step: Billing Support Upload File Submission to MAPP When HHUNY submits a Billing Support Upload File Record for an active member (Outreach or Enrolled) from Netsmart to MAPP, MAPP will reject the record if the member s Medicaid is inactive or is affiliated with an incompatible R/E or Coverage Code. Example: 1.) Member A is assigned on 1/4/17. Agency accepts assignment on 1/5/17 and the member chart is created in Netsmart on 1/6/17. The Client Search Note will trigger a Tracking File Segment record to be submitted to MAPP for an Outreach and/or Enrollment Segment (if you selected Client Enrolled) with a 1/1/17 start date. When the Tracking File Record is submitted, it is accepted in MAPP. Two months later, while the member is still in an active segment, HHUNY submits a billing upload file for 2/1/17 date of service and the following errors could exist: a. R/E Code incompatible with HH or b. Coverage Code incompatible with HH or c. Medicaid Coverage Ended prior to 1/31/17 (or any subsequent month post start date for an active segment) If HHUNY receives notification of Medicaid issues through the Billing File upload process, we will notify your agency via indicating a Billing File Upload Error. 3 P a g e

4 Fourth Step: Claims Submission If an active Health Home member s tracking file and billing file information are accepted into MAPP, then the final steps to submit a claim that month would include running an electronic Medicaid Eligibility Verification (270) through our billing system and submitting a claim to Medicaid (or an MCO after 10/1/17). If the Medicaid Eligibility is returned as inactive through the 270 process, HHUNY will submit the claim and receive a denial so we can continue to run eligibility verifications on those denials until Medicaid is active again for the date of service. Your agency would be notified through an issue tracker in Millin if you utilize Millin CMA Portal or via if your agency does not utilize Millin CMA Portal. If the member s Medicaid will not be reinstated for a specific month of service, we would request permission to write-off the claim from your agency. Agency Workflows: Assignments Review Medicaid status, coverage codes, R/E codes prior to accepting the assignment If the member does not qualify based on Medicaid status, reject the assignment as an Outreach segment will not be accepted in MAPP for the member o If the member then makes it into assigned status in Netsmart and then you realize the Medicaid is not active/compatible, please opt the member out using the end code reason End Assignment- No Outreach, Non-Billable to remove the assignment on the first Client Search Note only If Medicaid status is appropriate for Health Homes, accept the assignment Outreach If the member did not have active Medicaid, or had an invalid coverage or R/E code and you attempt to put them into an Outreach segment (so active assignment but no active segment): The tracking file segment or Referral with an Outreach segment indicated will be rejected and the CMA will be notified as stated in HHUNY workflow above If a Member loses Medicaid eligibility while in an active Outreach segment: Option #1: If the member is interested in HH services and the Medicaid coverage that is compatible with HH can be reinstated, assist the member with obtaining Medicaid coverage through Outreach efforts Document these efforts in billable Client Search Notes and indicate a core service was provided on the Outreach Billing Questionnaire and HHUNY will continue to submit billing until Medicaid eligibility is reinstated (up to 90 days) There is risk with this process and you are not guaranteed payment for these services 4 P a g e

5 Option #2: If you choose to no longer work with the member once notified/aware of Medicaid ineligibility: Scenario #1: If you already provided an Outreach core service for the month, complete the billable Client Search Note and Outreach Billing Questionnaire for that month indicating a core service was provided. HHUNY will continue to submit the claim for 90 days if Medicaid eligibility is reinstated. If Medicaid eligibility is not reinstated, we will request permission to write-off the claim. Scenario #2: If you have not provided an Outreach core service for the month, complete a Client Search Note to opt the member out, indicate No Medicaid coverage in the note and then on the Outreach Billing Questionnaire indicate NOa core service was not provided that month so we do not attempt to bill Medicaid (be sure to back date the Client Search Note Date for the month of the last service provided). Enrolled If a Member loses Medicaid eligibility while in an Enrolled segment: Scenario #1: you are aware of this prior to providing a core service that month Option #1: (Best Practice) Coordinate efforts to get the Medicaid reinstated for the member if appropriate. Document your efforts as core services in CareManager Notes. Complete an Adult HML/Children s Billing Questionnaire with YES a core service was provided- HHUNY will continue to bill this claim until Medicaid is reinstated (up to 90 days) There is risk with this process and you are not guaranteed payment for these services Option #2: If you choose to no longer serve the member, discharge the member that month, enter details into a Contact Note of why you are discharging the member and Complete an Adult HML/Children s Billing Questionnaire with NO- a core service was not provided that month. Scenario #2: you are not aware of this and you provided a core service that month Document the service provided in a CareManager Note for that month Complete an Adult HML/Children s Billing Questionnaire with YES- a core service was provided- HHUNY will continue to bill this claim until Medicaid is reinstated (up to 90 days) or request permission to write-off if Medicaid will not be reinstated If you then choose to no longer serve the member, enter details into a Contact Note of Medicaid ineligibility and discharge the member (for a date within the last month of service) 5 P a g e