GENERAL
When will the 90-day claims submission
deadline take effect?
The regulations at
10 NYCRR Section 69-4.22(a)(4)) will be implemented effective February 10, 2019.
Any claim with a date of service on or after February 10, 2019 will be subject
to the 90-day claims submission deadline.
SUBMITTING CLAIMS
When does the 90-day claims submission
clock begin?
The clock begins
on the date of service. Claims must be submitted into the New York Early Intervention
System (NYEIS) within 90 days of the date of service. A claim is considered
submitted into NYEIS when it has a status of “Submitted.”
Does claim submission mean submission into
NYEIS or EI Billing?
Claims must be
submitted into NYEIS within 90 days of the date of service.
Some providers submit multiple claims for a
child all at once. If some claims are rejected and some are not, are the ones
not rejected considered filed?
After successful
submission of invoices/claims, the claims are evaluated individually. The
claims that are not denied or rejected will be considered filed. Providers may
review the status of claims they have submitted by logging into NYEIS. Further
information regarding electronic claiming can be found in the NYEIS User Manual, Unit 8: Provider
Invoicing.
How does this new regulation impact respite
and transportation services?
At this time,
respite and transportation claims are excluded from the 90-day claiming
regulation.
What changes have been made to NYEIS?
Because the date
the claim is submitted has always been tracked in NYEIS, changes to the system
were not necessary to meet this requirement. The extraordinary circumstance and
claiming limit deadline will be implemented in EI Billing for all dates of
service on or after February 10, 2019.
What will happen if I submit a claim after
the 90-day deadline?
EI Billing
Providers will still be able to submit claims more than 90 days after the date
of service. If an extraordinary circumstance is entered into EI Billing and the
claim is entered within 30 days of the date you are relieved from this
extraordinary circumstance, the claim may be reimbursed from the escrow account
after it is adjudicated through commercial insurance and Medicaid. If an
extraordinary circumstance is not entered for a claim that is past the 90-day
deadline, the claim may still be paid by commercial insurance and/or Medicaid
as applicable, but will not be reimbursed from the municipal funded escrow
account. There will be a “late claim adjustment” column added to EI Billing
reports to reflect any amount that was not paid by escrow due to late filing.
Is there any change for claims that are
submitted prior to the 90-day deadline?
There will be NO
CHANGE in the process for any claims submitted to NYEIS within 90 calendar days
of the date of service.
Will claims submitted past the 90-day
submission deadline still be paid by Medicaid or commercial insurance?
Claims submitted
past the 90-day submission deadline will be submitted to Medicaid or commercial
insurance for adjudication as applicable. If a claim is submitted past the
90-day submission deadline and is partially paid by Medicaid or commercial
insurance, a ‘Late Claim Adjustment’ showing the amount not paid will appear in
the following EI Billing reports: Claim Status, Claim Research, Detail Claims,
and Detail Transaction.
How can I view claims that are subject to
the 90-day submission deadline?
If you have
claims that have been submitted past the deadline with or without an
extraordinary circumstance, you may view them by navigating to the Timely
Filing Claim Status section on your EI Billing Provider Dashboard. Click the
link to view your claims that are greater than 90 days.
How do I calculate 90 days from the date of
service?
Follow these
steps to calculate 90 days from a date of service:
- Open a new Excel
document
- Type the date of
service in cell A1 (e.g., 10/26/2018)
- In cell B1, type
=A1+90 and press ‘enter’
- The date will
appear in cell B1
CORRECTIONS, VOIDS, OVERLAPPING CLAIMS
What if a claim is rejected by NYEIS for
corrections?
The New York
State Department of Health (the Department) expects that claims entered are accurate,
complete, and reflect actual services rendered upon submission into NYEIS.
Claims that have been denied, rejected, or voided in NYEIS that need to be
corrected and resubmitted must be included on a new claim in a new invoice and
submitted into NYEIS within 90 days of the date of service. The earlier the
claim is submitted into NYEIS, the earlier errors can be discovered and
resolved.
What if a provider’s claim is denied
because it overlaps with another provider’s claim?
The Department
expects claims to be entered accurately and completely, reflecting actual services
rendered when submitted into NYEIS. Claims that have been denied, including
those with overlapping times for a rendering provider and/or child, should be
reviewed by the provider. Providers routinely contact the NYEIS helpdesk for
assistance regarding overlapping claims. Providers should review the claims to
determine if there was an error (e.g., incorrect date or time) and collaborate
to resolve the issue. If a corrected claim must be submitted for either or both
providers, this must occur within 90 days of the date of service.
What if claims that are entered into NYEIS
subsequently encounter EI Billing issues or are rejected by EI Billing?
As long as
claims were submitted into NYEIS within 90 days of the date of service, the timeframe
has been met. A claim that subsequently encounters issues in EI Billing can be found
in the provider’s work queue with information on the action that must be taken
for the claim to move forward.
What if errors need to be corrected by the
county?
If errors are
discovered that require the municipality to make modifications, it is incumbent
upon the municipality to correct errors as soon as they are discovered to allow
the provider to submit claims within timely filing limits. Claims that require
correction must be submitted on a new claim and new invoice within 90 days of
the date of service. Providers and municipalities must ensure that service
authorizations (SA) accurately reflect the services agreed upon in a child and family’s
Individualized Family Service Plan (IFSP). Providers must also ensure the SA
and claims are accurate. Accurate data entry and review of the SA and claims
will assist in preventing errors. The earlier the claim is submitted into
NYEIS, the earlier errors can be discovered and resolved.
If a Billing Provider receives a response
file (F-File) from NYEIS indicating a claim was billed, is this considered a
billed claim?
No, the
invoice/claim is not in “Submitted” status until it has successfully passed the
initial file format check (HIPAA 5010 file format standard) and “pre-invoice”
error checks (F-File). Invoices/claims that have successfully passed these
first two steps are considered submitted. Claims are then processed through the
NYEIS invoice and claiming rules which may result in a claim status of
“Denied,” “Pending,” or “System Approved.” The status of claims may also be viewed
online in NYEIS. Providers should routinely monitor electronic claim file
transactions, including response files, and review claims online. Further
information regarding electronic claiming
can be found in the NYEIS User Manual,
Unit 8: Provider Invoicing.
INSURANCE DELAYS
What if Coordination of Benefits (CO-22)
and Assignment of Case Manager/Early Intervention Service Coordinator (Code 35)
denials require months to be corrected?
If claims were
submitted into NYEIS within 90 days of the date of service, the timeframe has been
met.
What if insurance carriers are slow to pay
or if the carrier determines there is a problem with the claim?
Insurance
adjudication has no bearing on the 90-day timeframe. The date of submission is determined
in NYEIS.
What if the incorrect insurance is billed
due to parents not updating the provider?
Updates to
insurance information in NYEIS do not impact the claim submission date. A claim
that is discovered to contain incorrect insurance information will be found in
the provider’s EI Billing work queue with information on the action that must
be taken for the claim to move forward.
OTHER DELAYS AND WAIVERS
What if there is a delay caused by the
county?
The Department
expects that data entered into the Early Intervention Program (EIP) data system,
NYEIS, is accurate and utilized in a manner that will comply with all federal
and state laws and regulations. The Department and the State Fiscal Agent (SFA)
will closely monitor delays to claiming that providers report may be caused by
the municipality. The Department will provide technical assistance to
municipalities and providers as necessary to mitigate reported delays.
What if counties are slow to approve
billing waivers?
When a claim is
submitted in NYEIS that violates an EIP billing rule, the provider is required
to submit a justification via workflow that is initiated in NYEIS. The status
of the claim appears as “Pending” until the Early Intervention
Official/Designee (EIO/D) provides a decision on the claim. If the request for
waiver is approved, the claim is marked “System Approved” and will be transmitted
to the SFA. The review and subsequent approval of a waiver request has no
impact on the 90-day claiming rule if the claim was marked “Submitted” within
90 days of the date of service. If the request for waiver is rejected, the
claim is marked “Denied.” In this case, if the claim requires correction, a new
claim and invoice must be submitted within 90 days of the date of service.
The Early Intervention Official/Designee
(EIO/D) may request corrections to evaluations which cause providers to send
the evaluation back to the therapist and then back to the EIO/D for review. How
can this process be managed to ensure the 90-day claiming timeframe is met?
Prompt payment
relies on accurate information being entered into NYEIS. Providers should review
their data entry for accuracy prior to submitting the evaluation components. Additionally,
municipalities must review all sections of the evaluation to ensure regulatory requirements
are met prior to accepting the evaluation. If corrections to an approved
evaluation are needed, this process must occur to allow the provider to have
adequate time to enter new claims on a new invoice within 90 days of the date
of service. The Department and the State Fiscal Agent will closely monitor
timeliness of the entry of evaluation results and submission of the associated claims.
What happens if the child gets sick and the
evaluation was delayed or the evaluation was otherwise delayed by the family?
The 90-day time
frame does not begin until the evaluation is completed. The date of service for
the evaluation is the date the evaluation was fully completed.
EXTRAORDINARY CIRCUMSTANCES
What are extraordinary circumstances?
An extraordinary
circumstance is a valid reason that a claim could not be submitted within 90 days
of the date of service. Extraordinary circumstances include:
- Natural Disaster
- Audit Findings
- Litigation
- Death of
Essential Personnel
- Hospitalization
of Essential Personnel
Please note that
extraordinary circumstances entered into EI Billing are automatically acknowledged,
but they are subject to an audit. You must retain records of extraordinary
circumstances, and you may be asked to furnish those records to BEI.
Is there a deadline for entering an
extraordinary circumstance?
Extraordinary
circumstances must be entered in EI Billing as soon as practicable and no more
than 30 days after the date of relief of the extraordinary circumstance. For
example, if there is a declared emergency/natural disaster that prevents the
provider from submitting a claim within 90 days of the date of service, the
extraordinary circumstance must be entered in EI billing no more than 30 days
after the end of the circumstance (in this example, after the declared
emergency has ended).
How do I enter an extraordinary
circumstance for a claim?
When an
extraordinary circumstance occurs, the provider should work to ensure that
claiming resumes as quickly as possible. Once the circumstance is resolved
(date of relief), the provider must enter the extraordinary circumstance into
EI Billing within 30 days. Follow these steps:
- Login to
EIBilling.com
- Click on the
‘Claiming’ tab, scroll over ‘Timely Filing’, and click ‘Enter Extraordinary
Circumstance’
- Select the type
of extraordinary circumstance from the drop-down and confirm
- Enter a specific
description of the extraordinary circumstance
- Enter a date of
event (when the extraordinary circumstance occurred) and confirm
- Enter a date of
relief (when the extraordinary circumstance ended) and confirm
- Click ‘Generate
Form’ and print the form
- Check the box to
confirm that the form printed and the information is correct
- Click ‘Submit’
- On the
acknowledgement page, check the box to acknowledge that you have read the
statement and will maintain records regarding the extraordinary circumstance
- Click ‘Print
Acknowledgement’
Retain the
Extraordinary Circumstance Form, Acknowledgement, and any records related to
the extraordinary circumstance in accordance with EIP guidance on retention of Early
Intervention Program records
Should an extraordinary circumstance be
entered before or after a claim is submitted?
We recommend
that extraordinary circumstances are entered BEFORE a claim is submitted in
NYEIS. This will help ensure that the claim is properly adjudicated. Providers
can enter extraordinary circumstances up to 30 days after the date of relief.
What if there is a NYEIS outage when the
provider attempts to enter the claim on day 89 or 90?
If a widespread
unscheduled outage of NYEIS occurred and prevented the provider from submitting
claims within 90days of the date of service, it may be considered a State Administrative
Delay. Scheduled outages of NYEIS or any local connectivity errors impacting access
to the Health Commerce System (HCS) and/or NYEIS will not be considered a State
Administrative Delay. If a scheduled outage is announced, it would be in the
billing providers’ best interest to submit claims in advance of the outage.
Billing providers should subscribe to the Department’s electronic mailing list
and view announcements posted in NYEIS for information regarding upcoming
system outages.
What happens if audit results show I don’t
have or have lost my records related to an extraordinary circumstance?
If your claims
are audited and you are not able to furnish records supporting an extraordinary
circumstance entered, recoupment will be made for associated claims. Funds
would be recouped from future escrow payments.
What if my extraordinary circumstance does
not fall into one of the listed categories?
At this time,
only the six listed extraordinary circumstance categories will be considered.
If you have a question or concern, please contact the BEI at (518) 473-7016 or beipub@health.ny.gov.
Article ID: 404, Created On: 2/4/2019, Modified: 3/21/2024