An overview of billing, potential issues, and
best practices
Health Home Biweekly Implementation Webinar, Session 15
April 24, 2013
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For the first two years of each phase, converting
OMH TCM, COBRA, and MATS programs bill
Medicaid directly for ALL Health Home services they
provide.
Converting programs bill for both their existing
members AND all new Health Home members.
Converting programs can bill a limited number of
claims per month under their legacy rate codes
(1800 series) and bill the remaining claims under the
1386/1387 rate codes.
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Health Homes are responsible for billing Medicaid
for fee for service members that are NOT
receiving services from a converting provider
Managed Care Plans are responsible for billing
Medicaid for their plan members that are NOT
receiving services from a converting provider.
After the first two years of each phase, Health
Homes and Managed Care Plans will bill directly
for ALL members regardless of the entity
providing Health Home services.
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The entity responsible for billing must submit a
claim to eMedNY in addition to submitting
member information to the HHTS Portal.
1386/1387 claim payments are calculated by
multiplying a member’s acuity score by the
appropriate base rate.
If a member does not have an acuity score on file,
the claim will pend until the average statewide
acuity score can be loaded at which time the claim
will pay.
Legacy rates (1800 series) are loaded with an
average rate based on past billing. Acuity scores
do not factor into payment of legacy claims.
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Acuity is a weighted average based on total
Medicaid fee-for-service and managed care
encounter costs associated with the Clinical Risk
Groups™ (CRG).
Acuity calculations are not real time, so a patient’s
acuity score may not always reflect the member’s
current health status.
Updated acuity scores will eventually be released
quarterly.
The statewide acuity score is the average acuity
score of the high risk high need HH eligible
members.
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Duplicate billing is when two entities bill for
Health Home services for the same member in the
same month.
The system will only allow for the billing of one
service per member per month
If two entities attempt to bill for Health Home
services for the same member during the same
month, the first claim submitted will be accepted
by the system and the second claim will be
denied.
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Confusion over which entity is responsible for
billing Medicaid for HH services.
Correct member enrollment information is not
submitted to the HHTS Portal in a timely manner.
Health Home partners have not yet completed
DEAA subcontractor packets enabling them to
share patient information.
Yes
Is member receiving Health Home services
from a converting case management program
(does the member have a value of Y in the
Direct Biller field on the Add record)?
Is the member enrolled in
Managed Care?
Yes
Converting programs bill
Medicaid directly for ALL
Health Home services they
provide to Managed Care
enrollees, under either
their legacy or the new
Health Home rate codes.
No
Is the member enrolled in
Managed Care?
No
Converting programs bill
Medicaid directly for ALL
Health Home services they
provide to FFS members,
under either their legacy
rate or the new Health
Home rate codes.
Yes
The Managed Care Plan
bills directly for all Health
Home services provided to
MCP enrollees that are not
receiving services from a
converting program.
No
The Health Home bills
directly for all Health
Home services provided to
FFS members that are not
receiving services from a
converting program.
NOTE: Converting programs (OMH TCM, MATS, and COBRA) bill directly for members that were
enrolled in their programs prior to Health Home conversion AND new members assigned to their
programs by Health Homes.
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Complete agreements ASAP to allow member
information exchange.
Submit correct records to the tracking system in a
timely manner.
Look up a member’s HH enrollment status using
the Portal member search function before
providing services.
CMAs must contact the member’s MCP or a HH
for FFS members to determine if a referred
member is already enrolled.
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DOH is implementing enhancements to the HHTS
Portal Member Lookup Function:
◦ Making HH enrollment history available to all Portal users
◦ New flag indicating if a member has recently received a
converting service.
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HH/MCP should be available to look up members’
HH enrollment in the portal for downstream
providers and should share all info downloaded
from the portal with CMAs they are working with.
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All regional Health Home partners (Managed Care
Plans, Health Homes, and Care Management Agencies)
should establish communication to better facilitate
Health Home services.
Please see the following power points regarding
sharing patient information.
◦ http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/2013-0327_hh_medicaid_webinar_session13.ppt
◦ http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/2013-0410_hh_cmart_weekly_support_call_session14.ppt