Early
Intervention Program Covered Lives legislation (A.5339/S.5560A)
On December 29, 2021, Governor Hochul signed
legislation (A.5339/S.5560A) that significantly changes the way claims for
Early Intervention services will be processed and paid. The legislation
establishes an Early Intervention Program (EIP) covered lives pool funded by an
assessment on insurance plans. The EIP pool funding will offset the municipal
and State share of EIP services not covered by Medicaid. EIP claims will no
longer be billed to commercial insurance. Claims will continue to be billed to
Medicaid for covered services and to municipal escrow for non-covered services.
The grid below outlines how claims with
a date of service on or after 1/1/2022 will be processed and paid based
on implementation of the covered lives legislation.
|
Scenario
|
Claim Process
|
|
Commercial
Insurance Only
|
Claims will be
sent to escrow for payment.
|
|
Commercial
Insurance and Medicaid
|
If the service is
Special Instruction or Service Coordination, claims will bypass CI and be
sent to Medicaid.
For all other
services, the claim will bypass both CI and Medicaid and be sent to escrow for
payment.
|
|
Medicaid or
Medicaid Managed Care Only
|
Claims will be
sent to Medicaid for payment.
Any Medicaid claim
which denies for coordination of benefits (CO22) will be moved to
escrow.
|
|
No coverage
|
Claims will be
sent to escrow for payment.
|
This change in legislation will also
impact how EIP Providers process their claims in EI Billing. When working in their
queue, Providers should address any new or outstanding commercial insurance claims
as follows:
- Any claims (including commercial and
non-commercial claims) with a date of service prior to 1/1/2022 should
be processed by the Provider as normal.
- Commercial claims with a date of service on
or after 1/1/2022 do not need to be processed by the provider and can
remain in your queue. These claims will be managed by Public Consulting Group
(PCG). By March 31, 2022, PCG will perform a review of all claims in a
provider’s queue. Any commercial claims identified during this review will be processed
based on the covered lives legislation. Once processed, these claims will then
be moved to escrow for payment.
- Any commercial insurance claims that were
paid for services provided on or after 1/1/2022, will be voided in EI Billing.
Once voided, the claims will be moved to escrow. Payers may request
reimbursement of voided claims directly from the EIP Provider. This is
determination is made by the Payer.
If I have additional questions or need further
information who should I contact?
Please click the link below to view an infographic and set of Frequently Asked Questions (FAQs) on the Covered Lives implementation:
Covered Lives Infographic and FAQ
Please click the link below to view a Q&A from April 21, 2022.
Please follow the link to view Insurance Circular Letter No. 6.
If you have additional questions after carefully
reviewing this article, contact the PCG Customer Service
Call Center at (866) 315-3747.
Article ID: 465, Created On: 2/24/2022, Modified: 5/26/2022