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 5 - Procedures and Forms
Part 540 - Authorization Of Medical Care
Section 540.6 - Billing for medical assistance
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 540.6
Current through Register Vol. 46, No. 39, September 25, 2024
(a)
(1)
Claims for payment for medical care, services or supplies furnished by any
provider under the medical assistance program must be initially submitted
within 90 days of the date the medical care, services or supplies were
furnished to an eligible person to be valid and enforceable against the
department or a social services district, unless the provider's submission of
the claims is delayed beyond 90 days due to circumstances outside of the
control of the provider. Such circumstances include but are not limited to
attempts to recover from a third party insuror, legal proceedings against a
responsible third-party or the recipient of the medical care, services or
supplies or delays in the determination of client eligibility by the social
services district. All claims submitted after 90 days must be accompanied by a
statement of the reason for such delay and must be submitted within 30 days
from the time submission came within the control of the provider, subject to
the limitations of paragraph (3) of this subdivision.
(2) Any claim returned to a provider due to
data insufficiency or claiming errors may be resubmitted by the provider upon
proper completion of the claim in accordance with the claims processing
requirements of the department within 60 days of the date of the notification
to the provider advising the provider of such insufficiency or invalidity. Any
returned claim not correctly resubmitted within 60 days or on the second
resubmission is neither valid nor enforceable against the department or a
social services district.
(3)
Notwithstanding paragraphs (1) and (2) of this subdivision to the contrary:
(i) all claims for payment for medical care,
services or supplies furnished by non-public providers under the medical
assistance program must be finally submitted to the department or its fiscal
agent and be payable within two years from the date the care, services or
supplies were furnished in order to be valid and enforceable as against the
department or a social services district; and
(ii) all claims for payment for medical care,
services or supplies furnished by public providers must be finally submitted to
the department or its fiscal agent and be payable within two years from the
date the care, services or supplies were furnished (or within such other period
as agreed by the department and the public provider for payments initially made
by the public provider under a program other than the medical assistance
program) in order to be valid and enforceable as against the department or a
social service district.
(4) For purposes of this subdivision, a claim
is considered submitted upon its receipt by the department or its fiscal
agent.
(b)
(1) The department, on the dates specified,
will assume, for the social services district comprising the city of New York,
payment responsibilities for all claims of the following specified providers of
medical care, services and supplies authorized to be provided under title II of
article 5 of the Social Services Law (medical assistance for needy persons) for
the care, services and supplies rendered on and after the date specified for
the assumption of payment responsibilities by the department:
(i) Practitioner--which include the
following, on November 1, 1977:
(a)
Physician.
(ii)
Clinics--which include the following, on November 1, 1977:
(a) Hospital emergency room;
(b) Hospital outpatient (other than dental
service);
(c) Diagnostic and
treatment center (clinic, free standing);
(d) Psychiatric clinic;
(e) Hospital psychiatric care
(outpatient).
(iii)
Pharmacies--which include the following, on April 1, 1978:
(a) Prescription drugs;
(b) Nonprescription drugs;
(c) Medical supplies, including sickroom
supplies, provided by the pharmacy.
(iv) Hospitals--which include the following,
on June 1, 1978:
(a) Inpatient
hospitals;
(b) Private psychiatric
hospitals.
(v) Dentists,
dental schools and dental clinics, on September 1, 1978.
(vi) Laboratories, on September 1,
1978.
(vii) Skilled nursing
facilities, which include nonoccupant care provided therein pursuant to
Subchapter C of Title 10 of the Official Compilation of Codes, Rules and
Regulations (Parts 780 through 782), on December 1, 1978.
(viii) Health related facilities, on December
1, 1978:
(a) excluding those facilities
operated by the Office of Alcoholism and Substance Abuse in the New York State
Department of Mental Hygiene; and
(b) excluding any facilities for the mentally
retarded (HRF or ICF) whether operated privately or by the New York State
Department of Mental Hygiene.
(ix) Health maintenance organizations, on
January 1, 1979.
(x) Health
insurance premiums, including prepaid group health insurance plans, on January
1, 1979.
(xi) Medical equipment
dealers, including medical and surgical supply dealers, on January 15, 1979.
Institutions supplying home dialysis equipment to kidney dialysis patients on
April 1, 1981.
(xii) Prosthetic and
orthotic appliance dealers, on January 15, 1979.
(xiii) Hearing aid dealers, on January 15,
1979.
(xiv) Transportation
services, on January 15, 1979.
(xv)
Home health agencies, on January 15, 1979.
(xvi) Child care agencies, on February 1,
1979.
(xvii) Optometrists, on
February 1, 1979.
(xviii) Opticians
and optical dispensers, on February 1, 1979.
(xix) Referred ambulatory care, on December
1, 1978.
(xx) [Repealed]
(xxi) Clinical psychologists, on March 1,
1979.
(xxii) Private
psychiatric--inpatient, on March 1, 1979.
(xxiii) Nursing home facilities administered
by Bureau of Medical Assistance/New York City, on March 1, 1979.
(xxiv) Independent speech and physical
therapists.
(xxv) Occupational
therapists.
(xxvi) Medical
equipment dealers, including medical and surgical supply dealers, on January
15, 1979.
(xxvii) Prosthetic and
orthotic appliance dealers, on January 15, 1979.
(xxviii) Hearing aid dealers, on January 15,
1979.
(xxix) Transportation
services, on January 15, 1979.
(xxx) Home health agencies, on February 1,
1979.
(xxxi) Intermediate care
facilities--mentally retarded (private and day care), on February 1,
1979.
(xxxii) Institutions
supplying prescription drugs, nonprescription drugs and medical supplies to
kidney dialysis patients on April 1, 1981.
(2) The above specified providers of medical
care, services and supplies will submit claims to the district comprising the
city of New York for all items of care, services and supplies furnished prior
to date specified for the assumption of payment responsibilities by the
department; and thereafter, such providers will submit claims for medical care,
services and supplies furnished after such date to the department for all items
of medical care, services and supplies.
(3) Providers rendering medical care,
services and supplies to recipients of Medicaid who have received their
authorization from the following specified counties shall bill the department
for the specified care, services and supplies rendered on and after the date or
dates respectively specified for such county:
(i) Chemung County: All care, services and
supplies--August 1, 1979;
(ii)
Washington County: All care, services and supplies--August 1, 1979;
(iii) Nassau County: All care, services and
supplies--August 1, 1979, or such later date, to be specified by the
commissioner, which shall in no event be later than November 1, 1979. The
commissioner shall give at least 30 days' notice of the date specified in this
subparagraph;
(iv) Livingston
County: All care, services and supplies--September 1, 1980;
(v) Ontario County: All care, services and
supplies--September 1, 1980;
(vi)
Schuyler County: All care, services and supplies--September 1, 1980;
(vii) Seneca County: All care, services and
supplies--September 1, 1980;
(viii)
Steuben County: All care, services and supplies--September 1, 1980;
(ix) Wayne County: All care, services and
supplies--September 1, 1980;
(x)
Yates County: All care, services and supplies--September 1, 1980;
(xi) Monroe County: All care, services and
supplies--November 1, 1980;
(xii)
Dutchess County: All care, services and supplies--March 1, 1981;
(xiii) Orange County: All care, services and
supplies--March 1, 1981;
(xiv)
Putnam County: All care, services and supplies--March 1, 1981;
(xv) Rockland County: All care, services and
supplies--March 1, 1981;
(xvi)
Sullivan County: All care, services and supplies--March 1, 1981;
(xvii) Ulster County: All care, services and
supplies--March 1, 1981;
(xviii)
Westchester County: All care, services and supplies--May 1, 1981;
(xix) Warren County: All care, services and
supplies--May 1, 1981;
(xx)
Saratoga County: All care, services and supplies--May 1, 1981;
(xxi) Fulton County: All care, services and
supplies--May 1, 1981;
(xxii)
Montgomery County: All care, services and supplies--May 1, 1981;
(xxiii) Schenectady County: All care,
services and supplies--May 1, 1981;
(xxiv) Schoharie County: All care, services
and supplies--May 1, 1981;
(xxv)
Albany County: All care, services and supplies--May 1, 1981;
(xxvi) Rensselaer County: All care, services
and supplies--May 1, 1981;
(xxvii)
Greene County: All care, services and supplies--May 1, 1981;
(xxviii) Columbia County: All care, services
and supplies--May 1, 1981;
(xxix)
Cortland County: All care, services and supplies--July 1, 1981;
(xxx) Madison County: All care, services and
supplies--July 1, 1981;
(xxxi)
Oneida County: All care, services and supplies--July 1, 1981;
(xxxii) Onondaga County: All care, services
and supplies--September 1, 1981;
(xxxiii) Oswego County: All care, services
and supplies--July 1, 1981;
(xxxiv)
Cayuga County: All care, services and supplies--July 1, 1981;
(xxxv) Broome County: All care, services and
supplies--September 1, 1981;
(xxxvi) Chenango County: All care, services
and supplies--September 1, 1981;
(xxxvii) Delaware County: All care, services
and supplies--September 1, 1981;
(xxxviii) Otsego County: All care, services
and supplies-- September 1, 1981;
(xxxix) Tioga County: All care, services and
supplies--September 1, 1981;
(xl)
Tompkins County: All care, services and supplies--September 1, 1981;
(xli) Allegany County: All care, services and
supplies--October 1, 1981;
(xlii)
Cattaraugus County: All care, services and supplies--October 1, 1981;
(xliii) Chautauqua County: All care, services
and supplies--October 1, 1981;
(xliv) Genesee County: All care, services and
supplies--October 1, 1981;
(xlv)
Niagara County: All care, services and supplies--October 1, 1981;
(xlvi) Orleans County: All care, services and
supplies--October 1, 1981;
(xlvii)
Wyoming County: All care, services and supplies--October 1, 1981;
(xlviii) Clinton County: All care, services
and supplies--December 1, 1981;
(xlix) Essex County: All care, services and
supplies--December 1, 1981;
(l)
Franklin County: All care, services and supplies--December 1, 1981;
(li) Hamilton County: All care, services and
supplies--December 1, 1981;
(lii)
Herkimer County: All care, services and supplies--December 1, 1981;
(liii) Jefferson County: All care, services
and supplies--December 1, 1981;
(liv) Lewis County: All care, services and
supplies--December 1, 1981;
(lv)
St. Lawrence County: All care, services and supplies--December 1,
1981;
(lvi) Suffolk County: All
care, services and supplies--January 1, 1981; and
(lvii) Erie County: All care, services and
supplies--February 1, 1982.
(c) The uniform billing form (UBF-1) shall be used for all acute care hospital inpatient bills for a patient's stay whose admission to the hospital occurred on or after the appropriate implementation date as specified by the State Department of Social Services.
(d) Providers rendering personal care services under a contractual arrangement with local social services districts as described in section 505.14 of this Title shall bill the department for the specified service rendered on and after the date(s) respectively specified for such social services district as follows:
(1) Chenango County: All personal
care services--July 1, 1985;
(2)
Genesee County: All personal care services--July 1, 1985;
(3) Livingston County: All personal care
services--July 1, 1985;
(4) Niagara
County: All personal care services--July 1, 1985;
(5) Ontario County: All personal care
services--July 1, 1985;
(6) Orleans
County: All personal care services--July 1, 1985;
(7) Wyoming County: All personal care
services--July 1, 1985;
(8) Clinton
County: All personal care services--August 1, 1985;
(9) Essex County: All personal care
services--August 1, 1985;
(10)
Hamilton County: All personal care services--August 1, 1985;
(11) Jefferson County: All personal care
services--August 1, 1985;
(12)
Lewis County: All personal care services--August 1, 1985;
(13) St. Lawrence County: All personal care
services--August 1, 1985;
(14)
Yates County: All personal care services--September 1, 1985;
(15) Cayuga County: All personal care
services--September 1, 1985;
(16)
Cortland County: All personal care services--September 1, 1985;
(17) Schuyler County: All personal care
services--September 1, 1985;
(18)
Seneca County: All personal care services--September 1, 1985;
(19) Tompkins County: All personal care
services--September 1, 1985;
(20)
Wayne County: All personal care services--September 1, 1985;
(21) Cattaraugus County: All personal care
services--October 1, 1985;
(22)
Chautauqua County: All personal care services--October 1, 1985;
(23) Chemung County: All personal care
services--October 1, 1985;
(24)
Franklin County: All personal care services--October 1, 1985;
(25) Steuben County: All personal care
services--October 1, 1985;
(26)
Tioga County: All personal care services--October 1, 1985;
(27) Columbia County: All personal care
services--November 1, 1985;
(28)
Dutchess County: All personal care services--November 1, 1985;
(29) Erie County: All personal care
services--November 1, 1985;
(30)
Orange County: All personal care services--November 1, 1985;
(31) Putnam County: All personal care
services--November 1, 1985;
(32)
Rensselaer County: All personal care services--November 1, 1985;
(33) Rockland County: All personal care
services--November 1, 1985;
(34)
Sullivan County: All personal care services--November 1, 1985;
(35) Ulster County: All personal care
services--November 1, 1985;
(36)
Madison County: All personal care services--December 1, 1985;
(37) Otsego County: All personal care
services--December 1, 1985;
(38)
Oswego County: All personal care services--December 1, 1985;
(39) Saratoga County: All personal care
services--December 1, 1985;
(40)
Warren County: All personal care services--December 1, 1985;
(41) Washington County: All personal care
services--December 1, 1985;
(42)
Delaware County: All personal care services--January 1, 1986;
(43) Fulton County: All personal care
services--January 1, 1986;
(44)
Greene County: All personal care services--January 1, 1986;
(45) Herkimer County: All personal care
services--January 1, 1986;
(46)
Montgomery County: All personal care services--January 1, 1986;
(47) Oneida County: All personal care
services--January 1, 1986;
(48)
Schoharie County: All personal care services--January 1, 1986; and
(49) New York City: All personal care
services--July 1, 1986.
(e)
(1) As
a condition of payment, all providers of medical assistance must take
reasonable measures to ascertain the legal liability of third parties to pay
for medical care and services.
(2)
No claim for reimbursement shall be submitted unless the provider has:
(i) investigated to find third-party
resources in the same manner and to the same extent as the provider would to
ascertain the existence of third-party resources for individuals for whom
reimbursement is not available under the medical assistance program;
and
(ii) sought reimbursement from
liable third parties.
(3) Each medical assistance provider shall:
(i) request the medical assistance recipient
or his representatives to inform the provider of any resources available to pay
for medical care and services;
(ii)
make claims against all resources indicated on a Medicaid identification card
or communicated to the provider via the electronic Medicaid eligibility
verification system, via the medical assistance information and payment system
(MMIS) toll-free inquiry telephone number of via the MMIS transaction telephone
system, and all resources which the provider has discovered, prior to
submission of any claim to the medical assistance program;
(iii) continue investigation and attempts to
recover from potential third-party resources after submission of a claim to the
medical assistance program to at least the same extent that such investigations
and attempts would occur in the absence of reimbursement by the medical
assistance program;
(iv) if the
provider is informed of the potential existence of any third-party resources by
an official of the medical assistance program, or by any other person who can
reasonably be presumed to have knowledge of a probable source of third-party
resources, investigate the possibility of making a claim to the liable third
party and make such claim as is reasonably appropriate; and
(v) take any other reasonable measures
necessary to assure that no claims are submitted to the medical assistance
program that could be submitted to another source of reimbursement.
(4) Any reimbursement the provider
recovers from liable third parties shall be applied to reduce any claims for
medical assistance submitted for payment to the medical assistance program by
such provider or shall be repaid to the medical assistance program within 30
days after third-party liability has been ascertained; when a claim has been
submitted to a third party whose liability was ascertained after submission of
a claim to the medical assistance program the provider must make reimbursement
to the medical assistance program within 30 days after the receipt of
reimbursement by the provider from a liable third party.
(5) A provider of medical assistance shall
not deny care or services to a medical assistance recipient because of the
existence of a third-party resource to which a claim for payment may be
submitted in accordance with this subdivision.
(6) A provider of medical assistance must
review and examine information relating to available health insurance and other
potential third-party resources for each medical assistance recipient to
determine if a health insurance identification card or any other information
indicates that prior or other approval is required for nonemergency,
post-emergency, nonmaternity, hospital, physician or other medical care,
services or supplies. If approval is required as a condition of payment or
reimbursement by an insurance carrier or other liable third party, the provider
must obtain for the recipient, or ensure that the recipient has obtained, any
necessary approval prior to submitting any claims for reimbursement from the
medical assistance program. The provider must comply with all Medicare or other
third-party billing requirements and must accept assignment of the recipient's
right to receive payment or must acquire any other rights of the recipient
necessary to ensure that no reimbursement is made by the medical assistance
program when the costs of medical care, services or supplies could be borne by
a liable third party. If a provider fails to comply with these conditions, any
reimbursement received from the medical assistance program in violation of the
provisions of this paragraph must be repaid to the medical assistance program
by such provider. No repayment will be required if the provider can produce
acceptable documentation to the department that the provider reasonably
attempted to ascertain and satisfy any conditions of approval or other claiming
requirements of liable third-party payors in the same manner and to the same
extent as the provider would for individuals for whom reimbursement is not
available under the medical assistance program, as described in paragraphs (1)
through (5) of this subdivision,.
(7) A provider of medical assistance who
becomes aware, or reasonably should have become aware, of available health
insurance or other potential third party resources that can be claimed from a
liable third party by the provider as an agent of a social services official in
accordance with the provisions of Part 542 of this Title, must submit a claim
for such payment to the liable third party in the manner described in Part 542,
except that a provider will not be required to submit such a claim to a liable
third party when the claim is for prenatal care for pregnant women or
preventive pediatric services (including early and periodic screening,
diagnosis and treatment services). If a provider fails to submit such a claim
as required by this paragraph, reimbursement for such claim will not be made by
the medical assistance program and any reimbursement received in violation of
the provisions of this paragraph must be repaid to the medical assistance
program by such provider. If a provider has satisfied the requirements
described in paragraphs (1) through (6) of this subdivision, no repayment will
be required if the provider can produce documentation acceptable to the
department that the provider reasonably attempted to ascertain whether such
claim could be submitted in the manner described in Part 542 of this Title. If
a provider submits a claim in accordance with the provisions of Part 542 of
this Title and all or a portion of such claim is rejected by the liable third
party through no fault of the provider, that portion of the claim that is so
rejected may be submitted to the medical assistance program for
payment.
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