memoranda 2005

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8/1/2005 12:00:00 AM

MEDICARE/MEDICAID BILLING (Memo sent enclosing an e-mail from DOH clarifying the issue of billing Medicare for long term therapy services.)

M e m o r a n d u m

TO:                  Clinic Directors

                        Finance Directors


FROM:            Deb Williams, Director of Affiliate Services


DATE:             August 1, 2005

RE:                 Medicare/Medicaid Billing

Attached for your review is an email I received from Robert Pozniak from the NYS Department Health (DOH) clarifying the issue of billing Medicare for long term therapy services.  We finally have in writing what we have been trying to obtain for quite some time. 

As noted in the email, Medicaid does not require providers to continuously bill Medicare for the long term therapy services, in order to obtain a denialRather, each provider only needs to obtain a denial once per year per service, in order to use the 0FILL option to bill Medicaid.   All other billings can go directly to Medicaid using a 0FILL for Medicare. 

It is imperative that you keep the attached email as well as the annual denials, to present to auditors during an audit.  These documents clearly show that you are following the recommendations of DOH. 

If you have any questions or concerns, please do not hesitate to contact me at (518) 436-0178.


cc:  Executive Directors

       Susan Constantino

       Mike Alvaro

-----Original Message-----

From: Robert C. Pozniak [mailto:[email protected]]

Sent: Tuesday, June 28, 2005 2:13 PM

To: [email protected]

Subject: Medicare denials

Deb, this e-mail is confirmation regarding our phone conversation about Medicare denials for long-term therapy services provided to UCP clients.  I am aware that Medicare has instructed it's Carriers to return a claim adjustment group code of CO - Contractual Obligation with a Claim Adjustment Reason Code (CARC) of 50 - These are non-covered services because this is not deemed a "medical necessity" by the payer.  Previously, Medicare returned a claim adjustment group code of PR - Patient Responsibility with CARC 50.

To the best of my knowledge the long-term therapy services are still included as part of the NYS Medicaid State Plan Amendment approved by CMS as payable.  Assuming this is still the case, these claims can still meet the requirements/situations whereby "0FILL" claims may be submitted to Medicaid without continuously submitting the claim to Medicare.  NYS Medicaid only requires providers to obtain one denial each year from the primary payer, Medicare Part B in this instance.  Although preferably one denial would be obtained per recipient, one per type of service (by unique rate code) suffices from Medicare Part B as a primary payer without the need to submit one claim per Medicaid recipient per year.

Obviously, future changes to the NYS Program or the State Plan Amendment potentially may impact the current policy.

Robert C. Pozniak, Director

HIPAA Practice Group

Office of Medicaid Management

(518) 257-4511 fax (518) 257-4510

[email protected]

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