eMedNY Training Matrix
OMH Home and Community Based Waiver Services (HCBS)
The information contained in this document will assist providers enrolled in the New York State (NYS) Medicaid Program with understanding and complying with Medicaid requirements for billing and submitting claims (electronic or paper).�
Providers should use the information in this document along with the Medicaid Provider Manual posted at www.emedny.org
- Select Provider Manuals from the menu
- Click on the OMH Certified Rehabilitation Services Provider Manual
- Click on Billing Guidelines (UB-04)
Providers that bill electronically should refer to the 837I Companion Guide (CG) posted at www.emedny.org
.
- Select NYHIPAADESK from the menu
- Click on eMedNY Companion Guides and Sample Files
- Look for the box labeled "837 Institutional Health Care Claim" and click on 837 Institutional Companion Guide and the 837 Supplemental Companion Guide.
The NYS Medicaid Technical Supplementary Companion Guide provides technical information needed to successfully transmit and receive electronic data. The Technical Supplementary CG is available at www.emedny.org
.
- Select NYHIPAADESK from the menu
- Click on eMedNY Companion Guides and Sample Files
- Look for the box labeled "Technical Guides" and click on the link Technical Supplementary Companion Guide
Questions about the information in this Training Matrix should be directed to the eMedNY Call Center at the following number:� 1-800-343-9000
The following is an explanation of the information contained in the matrix and instructions for use.
| Column 1 UB04 Form Locator Number |
This refers to the Field Number on the UB04 Form. |
| Column 2 UB04 Form Locator Name |
This refers to the Field Name on the UB04 Form. |
| Column 3 HIPAA 837I Loop |
This refers to the 837 Institutional Loop in which this data is found for electronic submissions. |
| Column 4 HIPAA 837I Segment Information |
This refers to the 837 Institutional Segment in which this data is found for electronic submissions. |
| Column 5 NYS Medicaid Instructions |
This column puts forth instructions for use and content. |
Notes:�
Only fields with Medicaid Application are explained in this document.
The source of the codes referred to in this matrix is the UB04 manual.
| UB04 Form Locator Number | UB04 Form Locator Name | HIPAA 837I Loop | HIPAA 837I Segment Information | NYS Medicaid Instructions |
|---|---|---|---|---|
| 1 | Unlabeled | 2010AA | Billing Provider Name Billing Provider Address Billing Provider City, State, Zip Code |
Enter the billing provider�s name and address. |
| 3a | Patient Control Number | 2300 | Claim Information CLM01 |
UB04 Instructions: For record-keeping purposes, the provider may choose to identify a patient by using an office account number.� This field can accommodate up to 20 alphanumeric characters and is reported on the remittance statement.
HIPAA Instructions: Required data and is reported on HIPAA 835 electronic remittance. |
| 4 | Type of Bill | 2300 | Claim Information CLM05-1 CLM05-3 |
Entry in this field must always be three digits. First and second positions are the Type of Bill and Bill Classification. Enter the code "34" in the first two positions for OMH HCBS.
The third position (Frequency) is used to indicate Adjustment (Code 7) or Void (Code 8). For original claims the entry should be 0 (zero). |
| 6 | Statement Covers Period | 2300 | Statement Dates DTP03 |
Enter the date(s) on which the service was rendered.
UB04 Instructions:� Refer to OMH Certified Rehabilitation Services Provider Manual for instructions on entering the date(s) of service. Format will vary depending on rate code (monthly, 1st half month, 2nd half month, daily). The date format must be MMDDYYYY. HIPAA Instructions: The format of the date must be CCYYMMDD. |
| 8b | Patient Name | 2010BA | Subscriber Name NM103-NM105 |
Enter the client�s name. |
| 10 | Birth Date | 2010BA | Subscriber Demographic Information DMG02 |
Enter the client birth date according to the formats put forth in the Provider Manual or HIPAA Companion Guide. |
| 11 | Sex | 2010BA | Subscriber Demographic Information DMG03 |
Enter M for Male or F for Female. |
| 17 | STAT | 2300 | Institutional Claim Code CL103 | This field is used to indicate the specific condition or status of the patient as of the last Date of Service indicated in Field 6. Select the appropriate code from the UB04 Manual. |
| 31-34 | Occurrence Code/Date | 2300 | Occurrence Information HI(01-12)-2 |
NYS Medicaid uses the Occurrence Code field to report Accident Codes.� If applicable, enter the appropriate Accident Code to indicate whether the service rendered to the recipient was for a condition resulting from an accident or crime, and the date when the accident occurred.� Select the code from the UB04 Manual, Form Locators 31�34, Accident Related Codes.�� |
| 39-41 | Value Code | 2010AA | Billing Provider Secondary Identification REF02 |
Enter the 3-digit locator code issued by NYSDOH.� Providers need to enter an additional zero to the left of the two-digit codes to comply with eMedNY billing requirements.
UB04 Instructions: The Value Code Field is divided into two sections: Code Identifier and Amount Field.� Enter Code 61 followed by the Locator Code assigned to the provider/service address at the time of enrollment. HIPAA Instructions: Qualifier "LU" indicates Locater Code. |
| 39-41 | Value Code | 2300 | Value Information HI(01-12)-2 HI(01-12)-5 |
The Value Code Field is divided into two sections: Code Identifier and Amount Field.
Enter Code 24 followed by the Rate Code that applies to the service rendered. UB04 Instructions: The four-digit Rate Code must be entered to the left of the dollars/cents delimiter. |
| 39-41 | Value Code | 2300 | Value Information HI(01-12)-2 HI(01-12)-5 |
The Value Code Field is divided into two sections: Code Identifier and Amount Field. Enter Code 31 to report a Patient Participation/Spend-down followed the overage amount.� |
| 39-41 | Value Code | 2320 | Payer Prior Payment AMT02 |
UB04 Instructions: The Value Code Field is divided into two sections: Code and Amount.
Enter A3 or B3 followed by the amount the other insurance carrier paid. The choice of A3 or B3 will be driven by the line assigned to the Insurance Carrier in Form Locator 50. |
| 42 | Rev. CD (Revenue Code) |
2400 | Institutional Service Line SV203 | UB04 Instructions: Enter Revenue Code 0001 to indicate that Total Charges are entered in Form Locator 47.
HIPAA Instructions: See Companion Guide and Rate Code Crosswalk. |
| 47 | Total Charges | 2400 | Institutional Service Line SV203 | Enter the total amount charged for the service(s) rendered.
UB04 Instructions: The charged amount for the entire claim must be entered on the line corresponding to Revenue Code 0001.� |
| 50 | Payer Name | 2320 | Segment Name � Other Subscriber SBR09 |
UB04 Instructions: This field is divided into three sections: A, B, C.
Medicaid Only Claim: No Third Party: Enter the word �Medicaid� in line A of this field. Leave lines B and C blank. Medicaid and one Primary Payer: Enter the name of the primary payer in line A of this field. Enter the word �Medicaid� on line B of this field. Leave Line C blank. Medicaid and two Primary Payers: Enter the name of the primary insurance carrier on line A. Enter the secondary payer in line B. Enter the word �Medicaid� on line C. HIPAA Instructions:� See Companion Guide. |
| 56 | NPI | 2010AA | Billing Provider Name NM109 | UB04 Instructions: For providers who are required by the Federal government to obtain a National Provider ID (NPI): until National Provider ID (NPI) implementation by NYS Medicaid, the Medicaid Provider ID number must also be completed according to
instructions for Form Locator 57 below. However, providers are strongly encouraged to begin reporting their billing provider's NPI information, as soon as possible. HIPAA Instructions:� See Companion Guide. |
| 57 | Other PRV ID | 2010AA | Billing Provider Secondary Identification
REF02 |
UB04 Instructions: Enter the Medicaid Provider ID number on line A, B, or C that matches the line assigned to Medicaid in form locator 50.
Note: When other payers are involved, and Medicaid is being indicated on lines B or C, enter the other payer�s ID number or the word "None" on the lines above the Medicaid ID number. HIPAA Instructions:� See Companion Guide. |
| 60 | Insured�s Unique ID | 2010BA | Subscriber Name
NM109 |
UB04 Instructions: Enter Recipient�s Medicaid ID Number. The Medicaid ID should be entered in the same line (A, B, or C) that matches the line assigned to Medicaid in Form Locators 50 and 57.
Note: When other payers are involved, and Medicaid is being indicated on lines B or C, enter the patient ID for the other payer or the word "None" on the lines above the Medicaid ID number. HIPAA Instructions:� See Companion Guide. |
| 64 | Document Control Number | 2300 | Original Reference Number REF 02 |
If submitting an Adjustment (Replacement) or a Void to a previously paid claim, this field must be used to enter the Transaction Control Number (TCN) assigned to the claim to be adjusted or voided. The TCN is the claim identifier and is listed in the Remittance Advice. If a TCN is entered in this field, the third position of Form Locator 4 (Type of Bill) must be 7 or 8.
UB04 Instructions: The TCN must be entered on the line (A, B, or C) that matches the line assigned to Medicaid in Form Locators 50 and 57. Note: When other payers are involved, and Medicaid is being indicated on lines B or C of Form Locators 50 and 57, the word "None" must be entered above the Medicaid TCN on lines A and/or B. Note: The adjusted claim may not contain more claim lines than the original claim. Also please note that if an adjustment is submitted without one or more of the lines paid from the previous claim, those omitted lines will be voided. |
| 67 | Diagnosis Codes | 2300 | Principal, Admitting, E Code and Patient Reasons for Visit Diagnosis Information HI01-2 |
UB04 Instructions: If applicable, using the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) coding system, enter the appropriate code which describes the main condition or symptom of the recipient.� The ICD-9-CM code must be entered exactly as it is listed in the manual.
Note:� Three digit and four digit diagnosis codes will be accepted only when the category has no subcategories. A designated mental illness diagnosis code is required for OMH HCBS. HIPAA Instructions:� See Companion Guide |
| 78 | Other NPI Qual Last/First |
2310C | Other Provider Secondary Identification REF02 |
If applicable, enter the Ordering/Referring Provider.
Enter the Medicaid ID number of the provider ordering the services. If the ordering provider is not enrolled in Medicaid, enter his/her license number according to the instructions below. Note: Providers are strongly encouraged to begin reporting National Provider ID (NPI) information for the Ordering/Referring provider. However, until NPI implementation by NYS Medicaid, the Medicaid Provider ID number or license number must be completed. Instructions for Entering a Medicaid Provider ID Number Enter the code "DN" in the unlabeled field between the words "Other" and "NPI" to indicate the 10-digit NPI of the provider is entered in the box labeled "NPI". After the word "QUAL," leave the first box blank to indicate the Medicaid Provider ID number of the provider is entered in the field to the right of the qualifier. On the line below the ID numbers, enter the last name and first name of the provider. Instructions for Entering License Numbers Enter the code "DN" in the unlabeled field between the words "Other" and "NPI" to indicate the 10-digit NPI of the provider is entered in the box labeled "NPI". New York State License Enter the first two digits of the Profession Code in the box to the right of the box labeled "QUAL". In the next box to the right, enter the 3rd digit of the Profession Code and an 8 digit license number. If necessary, place zeros between the profession code and the license number to enter a 9-digit number in the field. |
HCBS Waiver - UB-04 Sample Claim
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OMH HCBS Waiver Services
| Rate Code | Rate Code Description | Category of Service | Type of Bill | Revenue Code |
|---|---|---|---|---|
| 4650 | ICC Monthly | 0268 | 34, 74-75 | 024# |
| 4651 | ICC 1st Half Month | 0268 | 34, 74-75 | 024# |
| 4652 | ICC 2nd Half Month | 0268 | 34, 74-75 | 024# |
| 4653 | Respite Hourly | 0268 | 34, 74-75 | 024# |
| 4654 | Respite Daily | 0268 | 34, 74-75 | 024# |
| 4655 | Family Support | 0268 | 34, 74-75 | 024# |
| 4656 | Skill Building | 0268 | 34, 74-75 | 024# |
| 4657 | Intensive In-Home Hourly | 0268 | 34, 74-75 | 024# |
| 4658 | Intensive In-Home ICC Staff | 0268 | 34, 74-75 | 024# |
| 4659 | Crisis Response Hourly | 0268 | 34, 74-75 | 024# |
| 4660 | Crisis Response-ICC Staff | 0268 | 34, 74-75 | 024# |
| 4661 | ICC Case Mgt. Start-Up Full Month | 0268 | 34, 74-75 | 024# |
| 4662 | ICC Case Mgt. Start-Up Half Month | 0268 | 34, 74-75 | 024# |
| 4663 | ICC/Inpatient-Full Month | 0268 | 34 74-75 | 024# |
| 4664 | ICC/Inpatient-Half Month | 0268 | 34, 74-75 | 024# |