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Office of Mental Health

Information for Counties and Providers
EDI Rule
What Do You Need to Know?

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Q: What is the national deadline for HIPAA EDI standards?

October 16, 2003 - Covered entities must be ready to transmit and receive electronic health care transactions covered by the HIPAA rule in the new standardized format.

Tip: If you have not been preparing for HIPAA transaction standards, it is time to get started: 1. Find out if HIPAA transaction standards apply to you. 2. Call your health plans, payers and billing vendors and ask them about their HIPAA testing and implementation plans. 3. Talk with your provider association to find out what other providers are doing to be HIPAA compliant.

Note: The Centers for Medicare and Medicaid Services (CMS) posted a series of informational papers on their HIPAA web site, at Leaving OMH site. These papers are designed to help educate health care providers about HIPAA electronic transaction standards by providing important information, suggestions, guidance, tips and checklists that will assist providers becoming HIPAA compliant.

Q: What is the NYS Medicaid HIPAA compliance deadline?

October 6, 2004 - After that date, electronic claims transactions submitted in a non-HIPAA compliant format will not be paid and other electronic transactions submitted in a non-HIPAA compliant format will not be processed.
Note: Medicaid providers unable to meet the October 6 deadline were invited to apply for HIPAA exception processing. The deadline for submitting an application to CSC was October 15, 2004. Providers granted exception processing have until December 29, 2004 to complete testing and bring their electronic transactions into HIPAA compliance. For more information about exception processing go to Leaving OMH site, click on the News & Resources tab, and, under Resources -Documents, on * HIPAA Exception Processing Documentation.

Tip: Computer Sciences Corporation (CSC), the NYS Medicaid program fiscal contractor, and the Department of Health (DOH) developed extensive resources that are readily available for use by providers to help them towards HIPAA compliance, including NYSDOH companion and supplementary guides, edit/error knowledge base reports, FAQ’s and exception processing documentation. These resources may be found at the Leaving OMH site and the Leaving OMH site websites . For additional information regarding the October 15, 2004 HIPAA exception processing deadline, or if you have questions related to HIPAA billing, please contact the CSC HIPAA Support Help line at 1-800-522-5518.

Q: Does the HIPAA EDI rule apply to my business?

A: Health care providers are not required to bill or otherwise exchange PHI electronically (although they may be required to submit Medicare claims electronically – see next question below). However, if you are a provider who transmits protected health information (PHI) electronically for the purpose of billing, payment, inquiries about patient eligibility or the status of a claim, or any other standard health care transaction, you are most likely covered by HIPAA. In other words, unless your business activities and standard health care transactions are all conducted on paper, by telephone or Fax (from a dedicated Fax machine, not fax via computer), HIPAA applies to you and you must use the HIPAA standardized format and code sets.

Tip: To determine if you are a covered entity, go to the Health and Human Services (HHS) 'Covered Entity Decision Tool’, at support/tools/decisionsupport/default.asp Leaving OMH site. To learn more about the Covered Entity Status, go to Leaving OMH site (PDF)

Q: What if I submit claims on paper?

A: Providers that do not conduct any of their health care transactions electronically, may continue to submit paper claims. However, as of October 16, 2003, Medicare is prohibited by law from paying paper claims, except for small providers that are permitted to continue submit their claims on paper. Medicare defines a small provider as:

  • a provider of services with fewer than 25 full-time equivalent employees, or
  • a physician, practitioner, facility or supplier (other than provider of services) with fewer than 10 full-time equivalent employees.

Note: this provision does not preclude providers from submitting paper claims to other health plans, including Medicaid.

Q: When will NYS Medicaid start accepting my HIPAA compliant claims?

A: Effective September 27, 2003, Medicaid has accepted and processed the following HIPAA compliant transactions in full production mode:

  • 837 claims or equivalent encounter information
  • 835 payment and remittance advice
  • 820 premium payments
  • 278 referral certification and authorization
  • 277 claim status response
  • 276 claim status inquiry

Tip: MMIS providers and billing vendors can visit the eMedNY HIPAA site at Leaving OMH site for guidance and tips on what to do to get ready for HIPAA compliant transactions with NYS Medicaid. HIPAA companion and implementation supporting documents have been posted at Leaving OMH site (select News & Resources tab). These guides provide technical details for HIPAA implementation and instructions on how to program HIPAA compliant billing software.

The Computer Sciences Corporation (CSC) HIPAA Support Unit will answer provider questions related to the New York Medicaid HIPAA compliance requirements. Providers may contact the CSC HIPAA Support Help line at 1-800-522-5518,Monday – Friday, 9:00 AM – 5:00 PM.

Q: How can I get ready to bill Medicaid under HIPAA? When can I test with NYS Medicaid?

Open Provider Testing is currently available allow Medicaid trading partners to check the format and content of HIPAA transactions. Open testing will allow providers to:

  • Test their HIPAA inbound transactions to validate HIPAA compliance with NYS Medicaid billing rules
  • Draw samples of HIPAA compliant outbound transactions from a web site and process them through providers’ applications.

The validation tool, Edifecs, is available free of charge from an Edifecs web site customized for NYS Medicaid providers. Instructions for registration, set up, and use of the Edifecs validation tool have been posted at Leaving OMH site.

Note: Successful completion of Open Provider Testing is required before submission of HIPAA compliant transactions to NYS Medicaid.

Q: Which 837 claim form should I use – Institutional or Professional?

A: If you operate a program licensed by the NYS Office of Mental Health, and you bill Medicaid, then you are considered an Institutional Provider and you must use the 837 Institutional Claim (837 I) when billing Medicaid.

Q: I am told that under HIPAA, local codes are being eliminated and providers must use CPT-4 or HCPCS procedure codes instead. What procedure codes must I use when billing Medicaid?

A: The NYS Medicaid program requires both a valid procedure code and the 4-digit MMIS rate code on their 837 I claim form. In other words, if you are a provider licensed by the NYS Office of Mental Health you must continue to use your MMIS rate codes for all your rate-based Medicaid claims, together with a valid procedure code. The rate code is entered into the Value Information HI Segment (Value Code 24) of the 837 I form. There is only one rate code per claim. A valid HCPCS or CPT procedure code must be reported in the institutional service line SV202 on the 837 I form. (On September 10, 2004, OMH issued guidelines on valid procedure codes for counties and licensed mental health providers - see next question below).

Note, that the last zero (0) character of the MMIS rate code (position 5), which, in version 4, is added to create the five-character procedure code on Claim Form A, is eliminated under HIPAA. Similarly, the letter R, which, in version 4, is added in position 5 of school supportive health/early intervention services claims, is also being eliminated under HIPAA.

Providers of rehabilitation services should note that the $ 1.00 services codes, MMIS rate codes 4500-4507 (child) and 4372-4382 (adult), are no longer valid after October 15, 2003. The MMIS edit that now denies the monthly rehabilitation services payment without the $1.00 service codes will be turned off. Providers will be able to bill for monthly rehabilitation services without the $1.00 service codes. T o compensate for the loss of the $1.00 rehabilitation service codes, community residence rates will be increased by $4 for the monthly service, effective 11/01/03 (half-month rates will be increased by $2.00).

Q: What are the OMH guidelines on valid procedure codes required for claims adjudication?

On September 10, 2004, OMH issued the following guidelines:
Under HIPAA, the NYS Medicaid program requires both a 4-digit MMIS rate code and a valid procedure code on the 837 I claim form. In other words, if you are a provider licensed by the New York State Office of Mental Health, you must continue to use your 4-digit MMIS rate codes for all your rate-based Medicaid claims, together with a valid procedure code. The rate code is entered into the Value Information HI Segment (Value Code 24) of the 837 I form. There is only one rate code per claim. A valid HCPCS or CPT procedure code must be reported in the institutional service line SV202 on the 837 I form. Providers may report multiple procedures on a claim.

To streamline and simplify the billing process, OMH designated a unique and distinct principal procedure code for each of 17 current and planned OMH-licensed mental health program types and components.

The table below displays the 17 OMH-licensed program types and program components, along with their valid MMIS rate codes. The OMH designated principal program procedure and associated code are shown to the right of each program.

You will also notice that most HCPCS and CPT procedures specify a time segment, such as ‘per 15 minutes’, ‘per hour’ or ‘per month’. This feature of the HCPCS and CPT code sets is relevant for procedure–based payment systems, but NOT for the New York State Medicaid program. The NYS Medicaid program, which uses a rate-based payment system for institutional providers, maintains a system of 4-digit rate codes to establish provider service payments, pursuant to OMH reimbursement and licensing standards set forth in regulation. OMH Medicaid reimbursement regulations specify the minimum required service duration, which may be a fraction or a multiple of the time segment described in the principal program procedures. However, because the New York State Medicaid program only edits for a valid HCPCS or CPT procedure code, the duration of service specified in the HCPCS or CPT procedures will not affect the adjudication of claims.

Please take note of the following: The attached procedure code table was developed from national CPT and HCPCS code sets that do not necessarily reflect New York State program designs. The procedure codes provided on the table were found to best define the core services offered in each of the 17 OMH programs.

OMH Licensed/Operated Programs MMIS Rate Code Principal Program Procedure CPT/HCPCS Code
Assertive Community Treatment (ACT) 4508-4512 Assertive Community Treatment, face-to-face, per 15 minutes H0039
Continuing Day Treatment (CDT) 4307-4348 Skills Training and Development, per 15 minutes H2014
Clinic Treatment 4093-4098, 4301-4306, 4601-4606 Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 - 30 minutes face-to-face with the patient 90804
Comprehensive Emergency Program (CPEP) 4007-4010 Crisis Intervention Services, per 15 minutes H2011
Community Residence Rehabilitation Services (CR) 4369-4371, 4383-4394 Psychosocial Rehabilitation Services, per diem H2018
Day Treatment 4060-4067 Behavioral Health Day Treatment, per hour H2012
Family-Based Treatment (FBT) 4395-4397 Therapeutic Behavioral Services, per diem H2020
Home and Community Based Waiver Services (HCBWS) 4650-4670 Case Management, per month T2022
Intensive Case Management (ICM) Supportive Case Management (SCM)
Blended Case Management (BCM)
5200, 5203-5206, 5251-5259 Targeted Case Management, each 15 minutes T1017
Intensive Psychiatric Rehabilitation Services (IPRT) 4364-4368 Psychosocial Rehabilitation Services, per 15 minutes H2017
Partial Hospitalization (PH) 4349-4363 MH Partial Hospitalization Treatment, Less than 24 Hours H0035
Pre-Paid Mental Health Plan (PMHP) 2340 MH Service Plan Development by Non-Physician H0032
Personalized Recovery Oriented Services (PROS) - Clinic Treatment Component 4525 Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy 90862
Personalized Recovery Oriented Services (PROS) - Community Rehabilitation and Support/ Base Component 4520-4524 Comprehensive Community Support Services, per diem H2016
Personalized Recovery Oriented Services (PROS) - Intensive Rehabilitation Component 4526, 4528 Therapeutic Behavioral Services, per 15 minutes H2019
Personalized Recovery Oriented Services (PROS) - Ongoing Rehabilitation Support Component 4527, 4529 Supported Employment, per diem H2024
Residential Treatment Facility (RTF) 1212, 1222-1225 Health and Behavior Assessment/Intervention, each 15 minutes 96150

Q: What are Revenue Codes and who must use them?

The 837 I claim form requires both a valid MMIS Rate Code and a valid HIPAA Revenue Code. The Rate Code is billed at the claim header level while the Revenue Code is billed on the claim line, together with applicable Units of Service (days, units) and Charge Amounts. To find out what Bill Type, Invoice Type and Revenue Code you must use in conjunction with your valid Rate Code, go to Leaving OMH site , click on the News & Resources tab, then on NYSDOH Supplementary Guides (under Resources – Documents) and select Rate Code Crosswalk.

Providers that bill Medicare or other Third Party insurers prior to Medicaid, must indicate the Rate Code in the Value Information HI Segment (Value Code 24), the corresponding HIPAA Revenue Code in SV201 and indicate units and associated charges when billing multiple units for the Rate Code.

Q: What MMIS codes are eliminated under HIPAA?

A: The following MMIS Code Sets and Codes are no longer reported under HIPAA:

  1. Category of Service and OMH Provider Specialty Codes

    MMIS Category of Service (COS) and Provider Specialty codes are not valid HIPAA codes and, therefore, they are being eliminated. Instead, MMIS will use information from the provider and provider rate reference files to confirm the provider’s COS and program specialty codes and establish the approved service payment rate.

  2. Patient Status Code ‘A’ The MMIS Patient Status Code A (now used in pre-admission visits, which are exempt from the designated mental illness diagnosis requirement) has no comparable HIPAA code value and, therefore, is eliminated under HIPAA. The MMIS diagnosis edit is being changed to allow deferred diagnosis (ICD-9-CM code 799.9) as a valid OMH Designated Mental Illness. The Office of Mental Health will monitor the 3 pre-admission visit limitation on a post-payment audit basis.
  3. Place of Service Code

    MMIS now requires outpatient mental health providers to specify one of 4 valid Place of Service Codes (POS) on every Medicaid claim: 2 (Home or Homebound); 3 (Inpatient Hospital); 6 (ART31 Clinic); 7 (Hospital Outpatient); and, 9 (Off-site or Other). The MMIS POS code set is eliminated under HIPAA and replaced by the ‘Facility Type Code’. The 5 MMIS POS codes are mapped to HIPAA Facility Type Codes, as follows:

    HIPAA Code HIPAA Description MMIS Code MMIS Description
    73 Clinic – Free Standing 6 Clinic
    72 Hospital-Based 7 Outpatient Dept. Hospital
    32,33,34 Home Health 2 Home/Homebound
    41 – 58 Religious Non-medical Health Care Institutions 9 Other/Off-site
    11 Hospital Inpatient 3 Inpatient Hospital

    POS codes 2 (Home/Homebound) and 9 (Other) have no corresponding code values under HIPAA. Outpatient providers should use any of the Facility Type Codes ’32 – 34’ to indicate a ‘homebound’ visit. Similarly, providers should use any of the Facility Type Codes ’41 – 58’ to indicate an ‘off-site’ visit. The Office of Mental Health will monitor the 25% off-site limitation on a post-payment audit basis.

  4. $1.00 Service Codes

    The $1.00 rehabilitation service codes, MMIS Rate Codes 4500-4507 (child) and 4372-4382 (adult), are not valid after October 15, 2003. The MMIS edit that now denies the monthly rehabilitation services payment without a valid $1.00 service code will be turned off (see 4 th question above for additional information).

Q: Do we need a Trading Partner Agreement with Medicaid?

A Trading Partner Agreement (TPA) is used by health plans to describe specific health care information processing functions and requirements. The TPA is an agreement between NYS Medicaid, and health care providers (or their billing agent) which establishes a commitment on the part of the provider to comply with HIPAA transaction and security standards, as well as technical specifications and procedures code set standards required by the NYS Medicaid program (e.g. testing requirements, communications protocols, supplementary specifications as published in the NYS Medicaid Provider Companion Guides).

All providers must mail signed TPAs, filed by their Provider number, to NYS Medicaid in order to be able to send and receive HIPAA-compliant transactions. Providers that received hard copies of the TPA in the mail, should return signed copies ASAP to Computer Sciences Corporation, Attn: HIPAA TP Coordinator, 800 North Pearl Street, Albany, NY 12204.

As providers register for Open Provider Testing with NYS Medicaid, they will receive the TPA via email, along with their Trading Partner ID. Providers can register for Open Provider Testing at Leaving OMH site .

Tip: To download the TPA forms and instructions on how to complete them, you can also visit Leaving OMH site.

Q: What is e-Paces and how can I enroll?

A: The electronic Provider Assisted Claim Entry System (e-Paces) is a free of charge, HIPAA compliant, web-based application that allows Medicaid providers to request and receive HIPAA claims, eligibility, service authorization and claims status transactions. E-Paces was developed jointly between the NYS Medicaid program and Computer Sciences Corporation (CSC), Medicaid’s fiscal agent. The application will appeal to smaller providers since it is easy to understand and use. Providers need only a PC and a browser, with or without Java Script enabled, and access to the Internet (minimum: Netscape 4.7 or Internet Explorer 4.01). Also, providers are not constrained in their choice of operating system - they can run Microsoft, Macintosh or Linux – do not need to install any custom software and will always be accessing the most updated version since the application resides on a central server in Albany. E-Paces uses form-based authentication and anonymous and unknown users will not be allowed to go anywhere beyond the login screen.

Tip: To view CSC’s e-Paces presentation and find out how to enroll, visit Leaving OMH site . (PDF)

Q: What are the HIPAA Code Sets?

A: HIPAA code sets are used for encoding health information, such as medical diagnoses, medical and dental procedures, durable medical equipment and pharmaceutics. They are an integral part of electronic transactions and are used to describe health care services and administrative procedures, patient diagnosis, health care procedures, tests, supplies, drugs, and so forth. HIPAA refers to code sets as either medical (or clinical) codes or non-medical (or non-clinical) codes.

Medical code sets are clinical codes used in HIPAA transactions to identify what health care services, procedures and diagnoses pertain to a patient encounter. The codes characterize a medical condition or treatment and the specific code sets usually are maintained by professional medical societies and public health organizations. Medical code sets approved for use under HIPAA are:

  • ICD-9 CM, Volumes 1 & 2, for diagnoses
  • ICD-9 CM, Volume 3, for inpatient hospital procedures
  • HCPCS/CPT-4 for physician and other care health services
  • HCPCS for all other substances, equipment, supplies or other items used in health care services
  • NDC for drugs and biologics on retail pharmacy drug transactions (there is no standard code set for non-retail pharmacy drug claims)
  • CDT for dental procedures and nomenclature of dental services.

Non-medical codes sets describe a general administrative situation. State abbreviations, zip codes, race and ethnicity codes are examples of general administrative code sets. Other examples of non-medical code sets are Facility Type, Claim Adjustment Reason, Patient and Claim Status.