New York Codes, Rules and Regulations
Title 18 - DEPARTMENT OF SOCIAL SERVICES
Chapter II - Regulations of the Department of Social Services
Subchapter E - Medical Care
Article 3 - Policies and Standards Governing Provision of Medical and Dental Care
Part 508 - Child/teen Health Plan (c/thp)
Section 508.11 - Payment

(a) Examinations performed in accordance with section 508.8 of this Part by providers who are certified under article 28 of the Public Health Law will be reimbursed at the clinic rate established pursuant to such article. Reimbursement will be based upon a complete examination performed according to the periodicity schedule. The appropriate rate code identifying the C/THP examination must be used on the claim form. Clinics billing for C/THP examinations should use specialty code 908 and rate code 3110R on claims submitted to the department.

(b) Except for examinations covered under subdivision (a) of this section, the reimbursable fees for services performed under the C/THP will be those established by the State Department of Health and approved by the Division of the Budget. The C/THP fee for a private physician will be based upon a complete physical examination performed according to the periodicity schedule. Services performed during a C/THP examination or as a follow-up to that examination which are not part of the examination fee, such as immunizations, urinalysis, and pure-tone conduction screening, are eligible for separate reimbursement on a fee-for-service basis. These services should be billed on the same claim form as the C/THP examination. In addition to the C/THP examination, children are eligible to receive all the care and services available under the State medical assistance program. However, only visits rendered in accordance with the recommended C/THP periodicity schedule can be billed as a C/THP exam.

(c) If the child is brought back to complete a component of the examination, a second visit fee or rate cannot be claimed for reimbursement under the medical assistance program. Providers certified pursuant to the provisions of article 28 of the Public Health Law cannot claim an additional fee to complete a component of the previous C/THP examination, regardless of the date of service. However, private physicians are eligible to seek reimbursement for ancillary services (e.g., Mantoux test, immunizations) on a fee-for-service basis, regardless of date of service.