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New York Medicaid Program 29-I Health Facility BILLING GUIDANCE Archive
29-I Health Facility Billing Guidance Version 2023-1
April 2023 P a g e | 1 Table of Contents SECTION 1: GENERAL ............................................................................................................. 3 SECTION 2: FUNDAMENTAL REQUIREMENTS.......................................................................... 3 2.1 ARTICLE 29-I LICENSED SERVICES .................................................................................................. 3 2.2 MEDICAID-ENROLLED PROVIDER ................................................................................................... 4 2.3 MEDICAID MANAGED CARE CONTRACTING ..................................................................................... 4 2.4 PROVIDERS DESIGNATED TO DELIVER CFTSS AND CHILDREN’S HCBS SERVICES ..................................... 4 SECTION 3: SERVICES AND RATES ........................................................................................... 5 3.1 CORE LIMITED HEALTH-RELATED SERVICES (MANDATORY FOR ALL 29-I HEALTH FACILITIES TO PROVIDE) .... 5 3.2 CORE LIMITED HEALTH-RELATED SERVICES RATES (MEDICAID RESIDUAL PER DIEM) ................................. 6 3.3 CORE LIMITED HEALTH-RELATED SERVICES RATES FOR STEP DOWN AGENCIES ........................................ 7 3.4 OTHER LIMITED HEALTH-RELATED SERVICES (OPTIONAL SERVICES A 29-I HEALTH FACILITY MAY PROVIDE) .. 7 3.5 CONCURRENT BILLING ............................................................................................................... 11 3.6 OTHER LIMITED HEALTH-RELATED SERVICES FEE SCHEDULE.............................................................. 11 3.7 AGENCIES WITHOUT A 29-I LICENSURE ......................................................................................... 12 3.8 CORE LIMITED HEALTH-RELATED SERVICES REGIONS ....................................................................... 12 3.9 OTHER LIMITED HEALTH-RELATED SERVICES REGIONS ..................................................................... 12 3.10 MEDICAID MANAGED CARE PLAN PAYMENTS .............................................................................. 12 3.11 OTHER LIMITED HEALTH RELATED SERVICES DELIVERED WITH AN INTERPRETER .................................. 13 3.12 PROVISION OF 29-I SERVICES BY INTERNS AND LIMITED PERMITTEES ................................................ 14 SECTION 4: CLAIMS .............................................................................................................. 14 4.1 REQUIREMENTS TO QUALIFY FOR MEDICAID REIMBURSEMENT .......................................................... 14 4.2 MEMBER ENROLLMENT STATUS .................................................................................................. 15 4.3 29-I HEALTH FACILITY MEDICAID FEE-FOR-SERVICE CLAIMING (EMEDNY) ......................................... 15 4.4 GENERAL MEDICAID MANAGED CARE CLAIMING FOR 29-I HEALTH FACILITIES (ALL SERVICES) ................ 15 4.5 MEDICAID MANAGED CARE CLAIMING FOR CORE LIMITED HEALTH-RELATED SERVICES ......................... 16 4.6 SUBMITTING CORE LIMITED HEALTH-RELATED SERVICES CLAIMS FOR DAILY BILLED SERVICES ................. 17 4.7 CORE LIMITED HEALTH-RELATED SERVICES CODING TABLE ............................................................... 17 4.8 OTHER LIMITED HEALTH-RELATED SERVICES MEDICAID MANAGED CARE PLAN CLAIMING ..................... 17 4.9 SUBMITTING OTHER LIMITED HEALTH-RELATED SERVICES CLAIMS FOR DAILY BILLED SERVICES ............... 18 4.10 OTHER LIMITED HEALTH-RELATED SERVICES CODING TABLE ........................................................... 19 4.11 CLAIMS TESTING .................................................................................................................... 19 4.12 ABSENCES AND IMPACT ON CLAIMING ........................................................................................ 19 4.13 OTHER LIMITED HEALTH-RELATED SERVICES BILLABLE UNITS .......................................................... 22 Archive
29-I Health Facility Billing Guidance Version 2023-1
April 2023 P a g e | 2 4.14 PHYSICIAN ADMINISTERED DRUGS ............................................................................................. 23 4.15 COST ALLOCATION OF SERVICES ................................................................................................ 24 4.16 BILLING EXAMPLE: OFFICE VISIT ................................................................................................ 24 4.17 SUBMITTING AN OTHER LIMITED HEALTH RELATED SERVICE FFS CLAIM ............................................ 25 4.18 SUBMITTING AN OTHER LIMITED HEALTH-RELATED SERVICE MMCP CLAIM ...................................... 26 4.19 DESCRIPTION OF BILLABLE PROCEDURE CODES FOR OTHER LIMITED HEALTH-RELATED SERVICES ........... 26 4.17 PHARMACY/DURABLE MEDICAL EQUIPMENT (DME)/SUPPLIES ...................................................... 37 4.18 ROUTINE TRANSPORTATION ..................................................................................................... 38 4.19 MEDICAL TRANSPORTATION ..................................................................................................... 38 4.20 HCBS NON-MEDICAL TRANSPORTATION .................................................................................... 38 SECTION 5: POPULATIONS SERVED BY 29-I HEALTH FACILITIES ............................................. 39 5.1 CHILDREN/YOUTH IN FOSTER CARE PLACEMENT ............................................................................. 39 5.2 ADULTS OLDER THAN 21, FORMALLY IN FOSTER CARE WHO ARE STILL IN THE CARE OF THE 29-I HEALTH FACILITY ....................................................................................................................................... 43 SECTION 6: PROVIDER ASSISTANCE ...................................................................................... 43 6.1 WHERE TO SUBMIT QUESTIONS AND COMPLAINTS ......................................................................... 44 6.2 PRIOR APPROVAL / PRIOR AUTHORIZATION ................................................................................... 44 6.3 MEDICAID PRIOR APPROVAL OF ORTHODONTIA CARE FOR MEDICAID FOSTER CARE YOUTH ................... 45 6.4 OUT-OF-STATE PROVIDERS ........................................................................................................ 46 SECTION 7: APPENDICES ...................................................................................................... 47 APPENDIX A: UTILIZATION MANAGEMENT/MEDICAL NECESSITY GUIDELINES FOR 29-I CORE LIMITED HEALTH- RELATED SERVICES ......................................................................................................................... 47 APPENDIX B: CORE LIMITED HEALTH-RELATED SERVICES RATE CODING TABLE .......................................... 49 APPENDIX C: OTHER LIMITED HEALTH-RELATED SERVICES RATE CODING TABLE ........................................ 50 APPENDIX D: MODIFIER DESCRIPTIONS .............................................................................................. 62 APPENDIX E: REVENUE CODES FOR 29-I HEALTH FACILITY BILLING/CLAIMING ........................................... 63 APPENDIX F: HCBS SETTINGS OVERVIEW ........................................................................................... 67 APPENDIX G: COVERAGE FOR POPULATIONS OUTSIDE OF FOSTER CARE .................................................... 68 APPENDIX H: CORE AND OTHER LIMITED HEALTH-RELATED SERVICES COVERED UNDER OPTIONAL PHASE 1 LICENSURE OF 29-I HEALTH FACILITY SERVICES .................................................................................... 72 APPENDIX I: CONTACT INFORMATION ................................................................................................ 76 APPENDIX J: DEFINITIONS ............................................................................................................... 81
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SECTION 1: GENERAL
The purpose of this manual is to provide billing information regarding services provided by 29-I
Licensed Health Facilities and administered by the New York State Department of Health (NYS
DOH) and Office of Children and Family Services (OCFS). This manual applies to services covered
by both Medicaid Managed Care (MMC) and Medicaid fee-for-service (FFS) and outlines the
claiming requirements necessary to ensure proper claim submission for services delivered by a
29-I Health Facility. This manual is intended for use by both Medicaid Managed Care Plans
(MMCP) and 29-I Health Facilities.
This manual provides billing guidance only. It does not supersede applicable regulatory
requirements or procedures for admission to a program, record keeping, service
documentation, initial and on-going treatment planning, and reviews, etc. The contents of this
manual may be subject to change as required.
Voluntary Foster Care Agencies (VFCAs) that have not obtained 29-I licensure are NOT
authorized to provide and/or bill for health care services outlined in this guidance. All VFCAs
that are licensed as 29-I Health Facilities will have a NYS DOH issued license indicating
authorization to bill for Core Limited Health-Related Services and Other Limited Health-Related
Services. This manual does NOT provide guidance regarding Maximum State Aid Rates (MSAR)
payments. MSAR information and guidance can be found at
https://ocfs.ny.gov/main/Rates/FosterCare/Manual/SOP-ProgramManual.pdf.
SECTION 2: FUNDAMENTAL REQUIREMENTS
2.1 ARTICLE 29-I LICENSED SERVICES
VFCAs serving principally as facilities for the care of and/or boarding out of children shall be
subject to the provisions of Article 29-I of the Public Health Law (PHL) and applicable state and
federal laws, rules, and regulations. While 29-I licensure is optional, VFCAs are required to
obtain and maintain 29-I licensure to bill eMedNY and MMCPs for the services listed in this
document.
There are two categories of services that can be provided within 29-I Health Facilities: Core
Limited Health-Related Services (Mandatory) and Other Limited Health-Related Services
(Optional). 29-I Health Facilities must provide all Core Limited Health-Related Services. The Core
Limited Health-Related Services as described in this schedule, and the associated billing, are
available only to children/youth in the care of a 29-I Health Facility.
Pursuant to Article 29-I of Section 1 of the Public Health Law (PHL), VFCAs must be licensed for
the provision of Core Limited Health-Related Services and Other Limited Health-Related
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Services as described above to contract with and bill MMCPs and comply with Corporate
Practice of Medicine standards.
To become licensed as a 29-I Health Facility, the providers must submit an application to OCFS
and DOH, which indicates the location and describes the physical environment where each of
the Core Limited Health-Related Services and any Other Limited Health-Related Services will be
provided. In addition, the application must demonstrate compliance with all required rules and
regulations. Additional information regarding Core Limited Health-Related Services, Other
Limited Health-Related Services, and 29-I licensing requirements can be found at
https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/vol_fo
ster_trans.htm.
2.2 MEDICAID-ENROLLED PROVIDER
All eligible health care providers are required to enroll in Medicaid in order to receive
reimbursement for delivering a Medicaid service.
29-I Health Facilities must be enrolled with category of service code 0121 to bill for Core
Limited Health-Related Services, and category of service code 0268 to bill for Other Limited
Health-Related Services.
Information on how to become a Medicaid provider is available on the eMedNY website:
https://www.emedny.org.
2.3 MEDICAID MANAGED CARE CONTRACTING
To be paid for services delivered to a child/youth enrolled in a Medicaid Managed Care Plan, a
provider must be contracted and credentialed with that MMCP for the service rendered (i.e. in
the MMCP’s network). Plans must enter into Single Case Agreements (SCAs), if needed, to
facilitate payment to a 29-I Health Facility who has not contracted with the MMCP and will
deliver services to a child/youth. More information on Medicaid Managed Care contracting can
be found in the Transition of Children Placed in Foster Care and NYS Public Health Law Article
29-I Health Facility Services into Medicaid Managed Care
2.4 PROVIDERS DESIGNATED TO DELIVER CFTSS AND CHILDREN’S HCBS SERVICES
29-I Health Facilities may provide Children and Family Treatment and Support Services (CFTSS)
and Children’s Home and Community Based Services (HCBS) as part of their Other Limited
Health-Related Services. 29-I Health Facilities who wish to provide CFTSS and HCBS are required
to receive the appropriate designation(s) from the State.
Additional information can be found on the NYS Children’s Behavioral Health System
Transformation webpages:
Children and Family Treatment Supports and Services (CFTSS)
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https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children
/proposedspa.htm
Home and Community Based Services (HCBS)
https://www.health.ny.gov/healthcare/medicaid/redesign/behavioralhealth/children
/1115waiveramend.htm
Billing guidance regarding HCBS and CFTSS
https://www.health.ny.gov/healthcare/medicaid/redesign/behavioralhealth/children
/billing.htm
Provider Designation for HCBS and CFTSS
https://www.health.ny.gov/healthcare/medicaid/redesign/behavioralhealth/children
/providerdesign.htm
SECTION 3: SERVICES AND RATES
3.1 CORE LIMITED HEALTH-RELATED SERVICES (MANDATORY FOR ALL 29-I HEALTH
FACILITIES TO PROVIDE)
All Licensed Article 29-I Health Facilities are required to provide, or make available through a
contract arrangement, all Core Limited Health-Related Services. The five Core Limited Health-
Related Services play a vital role in assuring all necessary services are provided in the specified
time frames; children, parents and caregivers are involved in the planning and support of
treatment, as applicable; information is shared appropriately among professionals involved in
the child’s care; and all health-related information and documentation results in a
comprehensive, person-centered treatment plan. Medical necessity must be documented, as
referenced in Appendix A, and in accordance with the 29-I Health Facilities Licensing Guidelines
available at
https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/fi
naldraftvfcahealthfacilitieslicenseguidelines50118.pdf.
The five Core Limited Health-Related Services are listed below (detailed in the Article 29-I VFCA
Health Facilities License Guidelines Final Draft,
https://www.health.ny.gov/healthcare/medicaid/redesign/behavioralhealth/children/volfo
ster_trans.htm):
- Skill Building (provided by Licensed Behavioral Health Practitioners (LBHPs) as described in Article 29-I VFCA Health Facilities License Guidelines and any subsequent updates)
- Nursing Services
- Medicaid Treatment Planning and Discharge Planning
- Clinical Consultation/Supervision Services
- VFCA Medicaid Managed Care Liaison/Administrator Archive
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3.2 CORE LIMITED HEALTH-RELATED SERVICES RATES (MEDICAID RESIDUAL PER
DIEM)
The Medicaid residual per diem rate reimburses 29-I Health Facilities for Core Limited Health-
Related Services and is associated with the 29-I facility type (see Table 1: 29-I Health Facility
Types) and indicated on the Article 29-I License. All 29-I Health Facilities are required to provide
the Core Limited Health-Related Services to all children residing in the facility. Services are
standardized across each facility type and are reimbursed based on a standardized Medicaid
residual per diem rate schedule. Core Limited Health-Related Services (Medicaid per diem)
rates can be found at
https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/vol_fo
ster_trans.htm
Core Limited Health-Related Services are reimbursed with a Medicaid residual per diem rate
paid to 29-I Health Facilities on a per child/per day basis to cover the costs of these services. For
children/youth not enrolled in a plan, providers must bill Medicaid Fee-for service (FFS) via
eMedNY. For members who are enrolled in a managed care plan, providers must bill the
MMCP. The MMCP will bill the State for the per diem as pass through for the four-year
transition period. At the end of the transition period, the State will reassess progress of the
implementation and determine if transitional requirements should be extended.
Article 29-I of the PHL indicates which level(s) of care are provided by each 29-I Health Facility.
29-I Health Facilities are categorized by the level of care provided, as outlined in Table 1: 29-I
Health Facility Types. Core Limited Health-Related Services (Medicaid residual per diem) rates
differ based on both the level of care and the facility type the 29-I Health Facility is operating,
with one rate assigned to each of the 13 facility types. Since a 29-I Health Facility may operate
more than one facility type in one or more levels of care, it may be necessary for a 29-I Health
Facility to bill several different Core Limited Health-Related Services (Medicaid per diem) rates,
depending on how many facility types that 29-I Health Facility operates. The Core Limited
Health-Related Services (Medicaid per diem) rate billed must correspond to the rate for the
facility type the individual child/youth is residing in. However, only one Core Limited Health-
Related Services (Medicaid per diem) rate per day for each individual child/youth can be billed.
The Medicaid residual per diem rate is paid for the duration of the child’s stay in the 29-I Health
Facility; there are no annual or monthly limits applied to the per diem rate. There are four (4)
levels of care, which are identified in the table below:
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Table 1: 29-I Health Facility Types
Level
Description
Facility Type
Level 1
General Treatment
Foster Boarding Home
Level 2
Specialized Treatment
Therapeutic Boarding Home (TBH)/AIDS
Medically Fragile (former Border Babies)
Special Needs
Level 3
Congregate Care
Maternity
Group Home (GH)
Agency Operated Boarding Home (ABH)
Supervised Independent Living Program (SILP)
Level 4
Specialized Congregate
Care
Group Residence (GR)
Diagnostic
Institutional
Hard to Place / Other Congregate
Raise the Age
29-I Health Facilities are reimbursed to provide the Core Limited Health-Related Services under
the Article 29-I licensure through the Medicaid residual per diem, which are paid by MMCPs to
the 29-I Health Facility (or Fee-For-Service Medicaid for those children not enrolled in Managed
Care).
Refer to Appendix B for a list of the 13 Core Limited Health-Related Services rate codes that
correspond to the level and facility type.
3.3 CORE LIMITED HEALTH-RELATED SERVICES RATES FOR STEP DOWN AGENCIES
Transitional rates will be updated yearly beginning July 1, 2021 through July 1, 2024. On July 1,
2024, all 29-I Health Facilities will be reimbursed the standard rate schedule based on facility
type. For 29-I Health Facilities that are receiving a transitional rate for Core Limited Health-
Related Services, rates will be specific to the facility type that is transitioning with a unique
agency-based rate.
3.4 OTHER LIMITED HEALTH-RELATED SERVICES (OPTIONAL SERVICES A 29-I HEALTH
FACILITY MAY PROVIDE)
The Other Limited Health-Related Services that can be provided by a 29-I Health Facility to
meet a child/youth’s individualized treatment goals and health needs are listed below. All Other
Limited Health-Related Services that a 29-I Health Facility provides must be included in the 29-I
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License and may require separate State designation prior to delivery of services. This manual
does not address service components, prior authorization, or other guidance on Children’s
HCBS and CFTSS and does not change those processes.
Children’s Home and Community Based Services Manual can be found here:
https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/1115_
waiveramend.htm
Children and Family Treatment and Support Services Provider Manual for EPSDT Services can be
found here:
https://www.health.ny.gov/healthcare/medicaid/redesign/behavioralhealth/children/propos
edspa.htm
- Children and Family Treatment Supports and Services (CFTSS)
a. Other Licensed Practitioners (OLP) b. Community Psychiatric Supports and Treatment (CPST) c. Psychosocial Rehabilitation (PSR) d. Family Peer Supports and Services (FPSS) e. Youth Peer Support and Training (YPST) f. Crisis Intervention (CI) - Children’s Waiver Home and Community-Based Services (HCBS)
a. Caregiver Family Supports and Services
b. Community Advocacy and Support
c. Respite (Planned and Crisis)
d. Prevocational Services e. Supported Employment
f. Day Habilitation
g. Community Habilitation
h. Palliative Care: Bereavement Therapy
i. Palliative Care: Expressive Therapy
j. Palliative Care: Massage Therapy
k. Palliative Care: Pain and Symptom Management
l. Environmental Modifications m. Vehicle Modifications
n. Adaptive and Assistive Equipment
o. Non-Medical Transportation
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Medicaid State Plan services a. Screening, preventive, diagnostic and treatment services relate to physical health, including but not limited to: i. Ongoing treatment of chronic conditions as specified in treatment plans
ii. Diagnosis and treatment related to episodic care for minor ailments, illness, or injuries, including sick visits
iii. Primary pediatric/adolescent care
iv. Immunizations in accordance with NYS or NYC recommended childhood immunization schedule v. Reproductive health care
vi. Laboratory tests b. Screening, preventive, diagnostic, and treatment services related to developmental and behavioral health. This includes the following:
i. Psychiatric consultation, assessment, and treatment
ii. Psychotropic medication treatment
iii. Developmental screening, testing, and treatment
iv. Psychological screening, testing, and treatment
v. Smoking/tobacco cessation treatment
vi. Alcohol and/or drug screening and intervention
vii. Laboratory testsOther Limited Health-Related Services do not include the following services, which should be provided by Medicaid participating providers (i.e. essential community providers) and billed directly by these providers to MMCPs/Medicaid FFS: surgical services
dental services orthodontic care general hospital services including emergency care birth center services emergency intervention for major trauma treatment of life-threatening or potentially disabling conditions Archive
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Other Limited Health-Related Services do not include nursing services, skill building activities (provided by LBHPs as described Article 29-I VFCA Health Facilities License Guidelines and any subsequent updates), and Medicaid treatment planning and discharge planning, including medical escorts and any clinical consultation/supervision services and tasks associated with the Managed Care Liaison/administrator in 29-I Health Facilities. These services are included in the Preventive or Rehabilitative Residential supports of the mandatory Core Limited Health-Related Services.
Other Limited Health-Related Services may be provided to children/youth in the care of any 29-I
Health Facility, including children/youth in foster care, children/youth placed in a 29-I Health
Facility by Committee on Special Education (CSE), babies residing with their parent who are
placed in a 29-I Health Facility and in foster care, pre-dispositional placed youth, and
children/youth in foster care placed in a setting certified by the Local Department of Social
Services (LDSS).
Children/youth who are discharged from a 29-I Health Facility may continue to receive Other
Limited Health-Related Services from any 29-I Health Facility up to one-year post discharge.
These services may continue beyond the one-year post discharge date, if any of the following
apply:
child/youth is under 21 years old and in receipt of services through the 29-I Health
Facility for an Episode of Care and has not yet safely transitioned to an appropriate
provider for continued necessary services; or
the child/youth is under 21 years old and has been in receipt of CFTSS or Children’s
HCBS through the 29-I Health Facility and has not yet safely transitioned to another
designated provider for continued necessary CFTSS or HCBS in accordance with their
plan of care; or
if the Enrollee is 21 years or older, providers may bill for Other Limited Health-Related
Services when the following applies:
o the Enrollee has been placed in the care of the 29-I Health Facility and has been
in receipt of Other Limited Health-Related Services prior to their 21st birthday,
and the Enrollee has not yet safely transferred to another placement or living
arrangement: and
o the Enrollee and/or their authorized representative is compliant with a safe
discharge plan; and
o the 29-I Health Facility continues to work collaboratively with the MMCP to
explore options for the Enrollee’s safe discharge, including compliance with
court ordered services, if applicable.
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The Medicaid residual per diem is not reimbursable after the individual’s 21st birthday. Adults
over the age of 21 are not eligible for CFTSS or Children’s HCBS.
For the purposes of this document, Episode of Care is defined as a course of treatment that
began prior to discharge by the same facility to the child/youth for the treatment of the same
or related health and/or behavioral health condition and may continue within one year after
the date of the child/youth’s discharge from the 29-I Health Facility. Additional details (i.e.
service descriptions, staffing requirements, practitioner qualifications, required assessments)
for Core Limited Health-Related Services and Other Limited Health-Related Services can be
found in the Article 29-I Health Facilities License Guidelines Final Draft, available at
https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/fi
naldraftvfcahealthfacilitieslicenseguidelines50118.pdf.
3.5 CONCURRENT BILLING
In circumstances in which the child is receiving services from an Article 29-I Health Care Facility
and a community provider such as an Article 31 or Article 28, there should be no duplication of
services. When a clinical need is identified that is distinctly different and not duplicative to
those needs being addressed through the 29-I Health Facility, it may be determined medically
necessary for both services to be provided concurrently.
For example, there may be cases in which the Article 29-I therapist is providing individual
therapy to the child and identifies the need for family therapy. If, based on the needs of the
family/caregivers, the therapist determines it necessary and beneficial for the family therapy to
be provided in an Article 31 clinic, this would be appropriate and allowable. In this case, both
the Article 29-I therapist and Article 31 therapist would have separate treatment plans
addressing different goals and objectives in therapy, thus substantiating distinct clinical needs
and interventions for each service. In accordance with best practice, the Article 29-I therapist
and Article 31 therapist are expected to collaborate, with consent from the child and family, to
assure alignment in their treatment interventions.
3.6 OTHER LIMITED HEALTH-RELATED SERVICES FEE SCHEDULE
Other Limited Health-Related Services are reimbursed on a standardized fee schedule for
services that the 29-I Health Facility provides (see Appendix C for a list of these services and
codes).
The Other Limited Health-Related Services Fee Schedule can be found at
https://www.health.ny.gov/healthcare/medicaid/redesign/behavioralhealth/children/volfo
ster_trans.htm.
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29-I Health Facilities will be reimbursed for Core and Other Limited Health-Related Services by
MMCPs for children enrolled in Medicaid Managed Care or by Fee-For-Service Medicaid for
children who are not enrolled in Medicaid Managed Care.
3.7 AGENCIES WITHOUT A 29-I LICENSURE
Agencies that do not obtain Article 29-I Licensure are not authorized to receive a Medicaid per
diem to provide Core Limited Health-Related Services.
3.8 CORE LIMITED HEALTH-RELATED SERVICES REGIONS
Core Limited Health-Related Services are not subject to regional reimbursement differences, as
the Medicaid per diem was calculated as a statewide Medicaid rate. The Medicaid per diem is
assigned to 29-I Health Facilities based on the facility types they are authorized to operate
under an Article 29-I License.
3.9 OTHER LIMITED HEALTH-RELATED SERVICES REGIONS
The regions as defined by the Department of Health and assigned to providers based upon the
geographic location of the provider’s headquarters are defined as follows:
• Downstate: 5 boroughs of New York City, counties of Nassau, Suffolk, Westchester,
Rockland, Putnam, Orange, Dutchess, Sullivan and Ulster
• Upstate: Rest of state
3.10 MEDICAID MANAGED CARE PLAN PAYMENTS
MMCPs must reimburse the NYS Medicaid FFS rates for Core Limited Health-Related Services
for the four-year transition period from July 1, 2021 through June 30, 2025. MMCPs must
reimburse Other Limited Health-Related Services for the four-year transition period at the
Medicaid FFS fee schedule (where available), unless alternative arrangements have been made
between plans and providers and have been approved by DOH and OCFS (e.g., Value-Based
Payment arrangements). MMCPs should submit passthrough payments for Core Limited Health
Related Services to the State within 30 days of claim payment, and no later than 180 days from
date of service. For pass through claims that are submitted more than 90 days after the date of
service, plans should use Delay Reason Code “03” to avoid claims rejecting due to untimely
filing. Please note, while use of Delay Reason Code 03 typically requires claim submission on
paper, the State has implemented a system edit to allow for managed care plans to 29-I Core
Limited Health Related Services claims electronically when using Delay Reason Code 03.
At the end of the transition period, the State will reassess progress of the implementation and
determine if transitional requirements should be extended.
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3.11 OTHER LIMITED HEALTH RELATED SERVICES DELIVERED WITH AN INTERPRETER
Reimbursement for Interpreter Services for children/youth receiving care by a 29-I Health
Facility is available for services provided during a medically necessary encounter for the
following Other Limited Health Related Service rate codes: 4588, 4589, 4590, 4591, 4592, 4593,
4594, 4595, 4596, 4597, 4598.
The need for medical language interpreter services must be documented in the medical record
and must be provided during an encounter. The 29-I Health Facility is responsible for
developing a business relationship with one or more agencies that can provide trained,
competent interpreters in the needed language(s). Interpreter services provided by the 29-I
Health Facility staff are not eligible for reimbursement. These interpreter services may be
provided in person by an interpreter or by telephone with a translation service. The interpreter
must demonstrate competency and skills in medical interpretation techniques, ethics, and
terminology. It is recommended, but not required, that such individuals be recognized by the
National Board of Certification for Medical Interpreters (NBCMI). The provider must document
the encounter in the child/youth’s medical record and include the location, type of
interpretation provided, name of interpreter, and agency. Interpretation services also includes
sign language for individuals who are deaf or hearing impaired.
Rate Code
Procedure code
Modifier
Max Units
Description
4673
T1013
2
units/encounter
In person
interpreter
services
4673
T1013
GQ
2
units/encounter
Telephone
interpreter
services
One Unit: Includes a minimum of eight and up to 22 minutes of medical language interpreter services. Two Units: Includes 23 or more minutes of medical language interpreter services. The time billed for interpretation services cannot exceed the length of time of the encounter. Claims must be submitted by the 29-I Health Facility providing the service. The rate of payment will be set at $11.00 for one unit of service up to a maximum of two billable units of service per patient per encounter. If the child/youth is seen for more than one encounter in a day, interpretation services may be billed for up to two units per encounter. Each claim must include rate code 4673 and Healthcare Common Procedure Coding System (HCPCS) procedure code Archive
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3.12 PROVISION OF 29-I SERVICES BY INTERNS AND LIMITED PERMITTEES
State regulations regarding the designation of providers of children’s behavioral health and
health services 18 NYCRR 505.38 require licensure of professionals under Title VIII of the
Education Law. Student interns and limited permittees practicing within the scope of the New
York State Education Law can deliver 29-I Core and Other Limited Health-Related Services under
the supervision of a licensed practitioner in the same field. Student interns without a license
from the New York State Education Department Office of the Professions and limited
permittees cannot enroll in Medicaid. Therefore, when submitting a claim for a service
delivered appropriately by an intern or limited permittee, 29-I Health Facilities must either
report the National Provider Identification (NPI) number of the supervising practitioner or the
OCFS unlicensed provider code (05448682) in the Attending Practitioner field on the claim for
these services until otherwise directed by the State. This does not allow for billing of services
rendered by other unlicensed providers that are not explicitly authorized to deliver OLHRS in
the 29-I Health Facility.
For more information: NYSED Office of the Professions
http://www.op.nysed.gov/opsearches.htm and contact http://www.op.nysed.gov/contact.htm
SECTION 4: CLAIMS
4.1 REQUIREMENTS TO QUALIFY FOR MEDICAID REIMBURSEMENT
For services to qualify for Medicaid reimbursement, the child’s/youth’s health/behavioral
health record, treatment plan, service plan and/or plan of care must reflect that the services
provided:
were medically necessary and appropriate (see Appendix A), and
were rendered by qualified practitioners within their scope of practice (including
supervision requirements), as defined in applicable State Law
Health/behavioral health care services must meet reasonable and acceptable standards of
health practice as determined by the State in consultation with recognized health
organizations. These standards include:
State-mandated licensure requirements any other State-mandated certification and
programmatic requirements that impact:
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o the types of providers that can deliver the services;
o the specific nature of the services; and
o the programmatic framework within which the services can be delivered,
including supervision requirements.
Additionally, the services must be those that are covered by New York State Medicaid.
4.2 MEMBER ENROLLMENT STATUS
Before delivering services to an individual, providers should always check ePaces to verify the
individual’s Medicaid enrollment status and MMCP enrollment status. Providers should verify
individual Medicaid and MMCP enrollment through the NYS system. Claims will not be paid if a
claim is submitted for an individual who is not enrolled with Medicaid, an individual is not
eligible for the service provided, or if the claim was submitted to an incorrect MMCP. Providers
should always verify that claims are submitted to the correct MMCP.
Providers may appeal claims that have been denied; providers may contact the MMCP for
information on how to appeal claim denials. In certain circumstances, providers may file a
complaint or external appeal with State agencies. See also
https://www.health.ny.gov/health_care/managed_care/complaints/.
4.3 29-I HEALTH FACILITY MEDICAID FEE-FOR-SERVICE CLAIMING (EMEDNY)
Claims for services delivered to an individual in receipt of fee-for-service Medicaid are
submitted by providers to eMedNY. See https://www.emedny.org for training on use of the
eMedNY system.
Claim submissions must adhere to the 90-day timely filing rules for Medicaid FFS. See State
Medicaid billing guidance available at
https://www.emedny.org/info/TimelyBillingInformation_index.aspx.
4.4 GENERAL MEDICAID MANAGED CARE CLAIMING FOR 29-I HEALTH FACILITIES
(ALL SERVICES)
MMCPs and providers must adhere to the billing and coding manual requirements of this
manual as well as clean claiming rules as outlined in billing tool found here:
https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/vol_fo
ster_trans.htm
The MMCP shall support both paper and electronic submission of claims for all claim types. The
MMCP shall offer providers an electronic payment option including a web-based claim
submission system. MMCPs rely on Current Procedural Terminology (CPT) codes and modifiers
when processing claims. Therefore, all MMCPs will require claims to be submitted with the CPT
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code and modifier (if applicable) in addition to the State-assigned rate code. Please refer to
Appendix B and Appendix C for a complete listing of CPT codes and associated modifiers. Claims
must include a National Provider Numbers (NPI) associated with the 29-I Health Facility.
MMCPs will be provided with a complete listing of all existing 29-I Health Facilities and the rate
codes they are authorized to bill under, as well as the rate amounts by MMIS provider ID,
locator code, and/or NPI and zip+4. Billing requirements depend on the type of service
provided.
Providers must adhere to timely filing guidelines as outlined in their contract with the MMCP and
per eMedNY guidelines (https://www.emedny.org/info/TimelyBillingInformation_index.aspx).
When a clean claim is received by the MMCP, they must adjudicate per prompt pay regulations. If
a provider does not have a contract or a Single Case Agreement in place with the MMCP, the
claim can be denied. Providers may contact the MMCP for information on how to appeal claim
denials. In certain circumstances, providers may file a complaint or external appeal with State
agencies. See also https://www.health.ny.gov/health_care/managed_care/complaints/
It is the provider’s responsibility to determine the type of coverage (Medicare, Medicaid, or
private insurance) that the member is eligible to receive. Medicaid is the payor of last resort
and all Medicare and third-party coverage must be exhausted before payment for 29-I health
services by Medicaid. However, 29-I health facilities are not required to bill and receive a denial
from third party health insurance (TPHI) prior to billing for Core and OLHRS for children/youth
in foster care, including HCBS and CFTSS provided to foster care children/youth by a 29-I Health
Facility.
For Medicaid members who are not in foster care, including children/youth who have been
discharged from foster care and children/youth placed with the facility by the Committee on
Special Education, acceptable documentation of attempts to secure third party reimbursement
before billing Medicaid, as required under 18 NYCRR §540.6, must be maintained. Acceptable
documentation includes documentation of a rejection by third party insurance for a date of
service within the previous 12 months of the date of service being billed, or since a change in
third party coverage, whichever is later. See the following regulation for more information:
https://regs.health.ny.gov/content/section-5406-billing-medical-assistance.
4.5 MEDICAID MANAGED CARE CLAIMING FOR CORE LIMITED HEALTH-RELATED
SERVICES
For 837i and UB-04 claims, the 29-I Health Facility will enter the rate code in the header of the
claim as a value code. This is done in the value code field by first typing in “24” followed
immediately with the appropriate four-digit rate code. This is the standard mechanism used in
Medicaid FFS billing.
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The 837i (electronic) or UB-04 (paper form) is used to bill for Core Limited Health-Related Every
claim must include the following:
Primary Diagnosis code using (https://www.cms.gov/Medicare/Coding/ICD10)
Core Limited Health-Related Services rate codes (Appendix B)
Valid CPT code(s)
CPT code modifiers (as needed)
Units of service
Patient reason for visit code
Revenue Codes (Appendix E)
Bill Type (079x) – please note that the last digit for the Bill Type represents the sequence
of this claim in the episode of care to account for corrected and resubmitted claims
General Billing Guidance for Institutional service claims (837i/UB-04) form can be found at https://www.emedny.org/ProviderManuals/AllProviders/General_Billing_Guidelines_Institutional.pdf.
Guidance regarding billing for the use of interpretation services can be found at https://www.health.ny.gov/health_care/medicaid/program/update/2012/oct12mu.pdf.
4.6 SUBMITTING CORE LIMITED HEALTH-RELATED SERVICES CLAIMS FOR DAILY
BILLED SERVICES
Core Limited Health-Related Services are billed daily and can be submitted with a range of
multiple dates of service on one claim. Claims for Core Limited Health-Related Services must be
submitted to the MMCP that the member is enrolled in and must be submitted in accordance
with the billing guidance provided by the plan.
4.7 CORE LIMITED HEALTH-RELATED SERVICES CODING TABLE
Appendix B lists the rate codes, procedure codes, and modifier code combinations that will be
required under Medicaid Managed Care to bill for the Medicaid residual per diem. Providers
will use these coding combinations to indicate to the MMCP that the claim is for services
provided to children/youth in the care of a 29-I Health Facility. The procedure and modifier
code combinations must be adhered to by both provider and MMCP to ensure appropriate rate
payment.
4.8 OTHER LIMITED HEALTH-RELATED SERVICES MEDICAID MANAGED CARE PLAN
CLAIMING
For 837i and UB-04 claims, the 29-I Health Facility will enter the rate code in the header of the
claim as a value code. This is done in the value code field by first typing in “24” followed
immediately with the appropriate four-digit rate code. This is the standard mechanism used in
Medicaid FFS billing.
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The 837i (electronic) or UB-04 (paper form) is used to bill for Core Limited Health-Related
Services and Other Limited Health-Related Services. Every claim must include the following:
Primary Diagnosis code using (https://www.cms.gov/Medicare/Coding/ICD10)
Other Limited Health-Related Services rate codes (Appendix C)
Valid CPT code(s)
CPT code modifiers (as needed)
Units of service
Patient reason for visit code
Revenue Codes (Appendix E)
Bill Type (079x) – please note that the last digit for the Bill Type represents the sequence
of this claim in the episode of care to account for corrected and resubmitted claims
General Billing Guidance for Institutional service claims (837i/UB-04) form can be found at https://www.emedny.org/ProviderManuals/AllProviders/General_Billing_Guidelines_Institutional.pdf.
Guidance regarding billing for the use of interpretation services can be found at https://www.health.ny.gov/health_care/medicaid/program/update/2012/oct12mu.pdf.
Providers must include the applicable rate code, CPT codes, and modifiers (see Appendix C for
billable and non-billable procedure codes). If there are two modifiers needed for one procedure
code, both modifiers must be present and do not require a provider to indicate them in the
exact same order for every claim for payment to be made.
4.9 SUBMITTING OTHER LIMITED HEALTH-RELATED SERVICES CLAIMS FOR DAILY
BILLED SERVICES
Other Limited Health-Related Services are billed daily. When submitting an MMCP claim for
Other Limited Health-Related Services delivered to the same child/youth on the same date and
under the same rate code, submit one claim for each rate code. On each claim, report the
procedure codes that reflect the services delivered during the encounter that are applicable to
the rate code. If the procedure codes are billable, the units should reflect the length of the
encounter related to each billable procedure code. Non-billable procedure codes will have zero
units and will not be reimbursed; however, they should be reported on the claim to accurately
represent services delivered during the encounter. Each rate code should be billed on separate
claim.
When an MMCP has a contract with a Behavioral Health Organization (BHO) to assist with
review and processing of behavioral health claims, it may result in the need for providers to
send behavioral health claims directly to the BHO and physical health claims to the MMCP.
Providers must be aware of these agreements and be able to route claims to the appropriate
place for timely reimbursement. The provider should speak directly to the MMCP they have
contracted with for additional information.
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4.10 OTHER LIMITED HEALTH-RELATED SERVICES CODING TABLE
Appendix C lists the common rate codes, CPT codes, and modifier code combinations that will
be required to bill Medicaid Managed Care for the Other Limited Health-Related Services.
Providers can add additional CPT codes, if appropriate, with the rate code descriptions outlined
in this manual and consistent with CPT coding standards.
Laboratory services must be billed using the Laboratory Fee schedule found at
https://www.emedny.org/ProviderManuals/Laboratory/index.aspx.
CFTSS and HCBS codes are located in the New York State Children’s Health and Behavioral
Health Services Billing and Coding Manual, located at
https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/b
illing_manual.pdf, and any subsequent updates.
4.11 CLAIMS TESTING
To facilitate a smooth transition to Medicaid Managed Care billing, the MMCPs will offer
billing/claim submission training to newly contracted providers and providers in active contract
negotiations. This will include testing claims submission and processing, and issuance of MMCP
contact and support information to assist programs in claim submission.
Providers are expected to test the claims submission process with MMCPs for all delivered
services prior to the service implementation date and upon executing a new contract. Claims
testing should begin 90 days prior to the implementation date.
4.12 ABSENCES AND IMPACT ON CLAIMING
The Medicaid residual per diem rate may not be claimed by the 29-I Health Facility when a
foster care youth is temporarily absent from the 29-I Health Facility under any circumstances
other than those specified in this Manual and future Department updates.
Absence Categories when it is Permissible to Claim the Medicaid Residual Per Diem: It is permissible to claim the Medicaid residual per diem rate for consecutive days one through seven, per episode of absence for the following absence categories: Trial discharge o The 29-I Health Facility may claim their Medicaid rate for the first consecutive seven days of the trial discharge period per episode of trial discharge. An episode of trial discharge ends when the child/youth is either returned to the physical custody of the 29-I Health Facility or finally discharged from the 29-I Health Facility, preparatory to final foster care discharge. Non-secure legal detention Absent without consent (AWOC) Archive
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April 2023 P a g e | 20 o The 29-I Health Facility may claim the Medicaid residual per diem rate for the first consecutive seven days of AWOC, per AWOC episode, under the condition that the responsible authorized agency uses diligent efforts to locate and return the youth to the 29-I Health Facility and follows all other requirements of NYS OCFS regulation 18 NYCRR 431.8 and any NYS OCFS regulation and policy updates related to AWOC.
It is permissible to claim the 29-I Health Facility Medicaid residual per diem rate for all days of the following absence categories: Weekend visits School and religious holidays Vacation days (including stay at camp) o All vacation days up to 21 days per calendar year, the maximum number that NYS OCFS specifies Visits to potential foster or adoptive parents, up to seven consecutive days per visit the maximum that NYS OCFS specifies Organized school trips Respite care and services (non-institutional and institutional)
Specifically, respite care may be reimbursed up to a maximum of seven weeks in any calendar year, not to exceed 21 consecutive days per episode, with a period of at least seven consecutive days before a subsequent respite care episode may be reimbursed.
Absence Categories when it is Not Permissible to Claim the Medicaid Residual Per Diem:
In the following circumstances of absence, it is not permissible to claim the 29-I Core Limited
Health-Related Services (Medicaid residual per diem) rate:
Inpatient hospital days
Other residential facility/setting days when that entity is reimbursed via a Medicaid
payment methodology that covers health care costs (i.e., skilled nursing facility,
residential school, or psychiatric center)
Day of transfer or discharge from the 29-I Health Facility
o The Medicaid rate may be claimed for the day of admission to a 29-I Health
Facility.
o If a child/youth is transferred from one 29-I Health Facility to another 29-I Health
Facility, the 29-I Health Facility making the transfer will receive payment for the
day of transfer. The 29-I Health Facility receiving the child/youth will receive
payment for the first full day that the child/youth is in their care.
o 29-I Health Facility will receive payment for the day of discharge.
Secure legal detention
Out-of-state congregate care placement setting
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April 2023 P a g e | 21 Home on trial discharge days after the seventh consecutive day of trial discharge, irrespective of how long the period of trial discharge lasts Non-secure legal detention days after the seventh consecutive day of non-secure legal detention, irrespective of how long the period of non-secure legal detention lasts, unless the setting for non-secure legal detention is either: o A different 29-I Health Facility than the one from which the youth is temporarily absent; or o Another residential facility that gets reimbursed via a Medicaid payment methodology or a non-Medicaid payment methodology that covers health care costs.
If the 29-I Health Facility has advised the fiscally responsible local department of social services (LDSS) that they will not accept the return of the absent youth in foster care to their agency, then: None of the absent days are reimbursable for the purposes of the Core Limited Health- Related Services (Medicaid residual per diem) rate; and The 29-I Health Facility must discharge the youth from their agency for purposes of payment of the childcare agency Medicaid rate; and Following the most current NYS OCFS regulatory requirements, the LDSS must initiate an appropriate placement following the absence (i.e., placement at a different 29-I Health Facility, a direct care foster care placement, etc.); and When the youth is discharged from foster care, the LDSS must follow the most current Medicaid eligibility redetermination requirements to facilitate seamless health care and health care coverage in the new placement setting.
29-I Health Facilities must comply with all NYS OCFS regulations and policies related to allowable absences. 29-I Health Facilities must keep abreast of all applicable NYS OCFS regulations and policies, and any updates related to temporary absences.
Special Categories of Absence and Impact on Claiming The Core Limited Health-Related Services (Medicaid residual per diem) rate may be claimed by a 29-I Health Facility when a youth in foster care under their auspices attends an in-state or out-of-state college or university, or in a vocational/technical training setting.
For the purposes of the Core Limited Health-Related Services (Medicaid residual per diem) rate, these youth are “residents” of the 29-I Health Facility. The Core Limited Health-Related Services (Medicaid residual per diem) rate for these youth may be claimed until they reach 21 years of age. Archive
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4.13 OTHER LIMITED HEALTH-RELATED SERVICES BILLABLE UNITS
In addition to the Core Limited Health-Related Services (Medicaid residual per diem), 29-I
Health Facilities may bill for encounter-based Other Limited Health-Related Services that are
provided to meet a child/youth’s individualized needs and are included in the facility’s 29-I
License. Appendix C includes rate codes, descriptions, units of service (i.e. 15 minutes, per dose,
per occurrence), and unit limits per rate code for Other Limited Health-Related Services. All unit
limits are “soft limits” and can be exceeded with medical necessity. If a service or procedure
code requires time beyond the 15-minute unit in the fee schedule, the 29-I Health Facility may
add additional 15-minute units to the claim in accordance with Table 2: Timed units per
Encounter of Service in this manual, up to the maximum.
When determining the number of units to bill, use the appropriate procedure code as described
in the American Medical Association CPT billing and coding manual.
Table 2: Timed Units per Encounter of Service
Range of minutes per face-
to-face encounter
Billable minutes
Billable units (15 minutes
per unit)
Under 8 minutes
1-7 minutes
Not billable
8-22 minutes
15 minutes
1 unit
23-37 minutes
30 minutes
2 units
38-52 minutes
45 minutes
3 units
53-67 minutes
60 minutes
4 units
68-82 minutes
75 minutes
5 units
83-97 minutes
90 minutes
6 units
98-112 minutes
105 minutes
7 units
113-127 minutes
120 minutes
8 units
In addition to rate codes, procedure codes are required when submitting Medicaid Managed Care claims. If an encounter requires multiple procedure codes to detail the services that were delivered, include all procedure codes that apply. Total time on the date of the encounter (office or other outpatient services [99202,99203,99204, 99205, 99212, 99213, 99214, 99215]): For coding purposes, time for these services is the total time on the date of encounter. It includes both the face-to face and non- face-to-face time personally spent by the physician and/or other qualified health care Archive
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professional(s) on the day of the encounter (includes time in activities that require the
physician or other qualified health care professional and does not include time in activities
normally performed by other clinical staff).
Time spent performing the following activities are billable when performed by a Physician or
other qualified health care professional:
Preparing to see the patient (e.g., review of tests)
Obtaining and/or reviewing separately obtained history
Performing a medically appropriate examination and/ or evaluation
Counseling and educating the patient /family/caregiver
Ordering medications, test, or procedures
Referring and communicating with other health care professional (when not separately
reported)
Documenting clinical information in the electronic or other health record
Independently interpreting results (not separately reported) and communicating results
to the patient/family/caregiver
Care coordination (not separately reported)
4.14 PHYSICIAN ADMINISTERED DRUGS
The Medicaid Program reimburses drugs by dose at acquisition cost when administered by
practitioners to their patients. Practitioners are required to maintain records that include drug
invoice with dose(s) administered, for auditing purposes.
To facilitate electronic claim submission and timely payment to practitioners, the Medicaid
Program consults national pricing references to establish a maximum reimbursable amount
(MRA) on its procedure code reference file. Claims submitted for most practitioner-
administered drugs will be paid at acquisition cost or up to the MRA. 29-I Health Facilities that
provide practitioner administered drugs during an office visit must be enrolled in Category of
Service 0163, to be reimbursed. Electronic claims must be submitted on an 837i claim form.
Note, drugs listed on the Physician Fee Schedule with a notation of BR (By Report) under
column E “BR,” must be submitted on a paper HCFA 1500 Claim Form, with a copy of the
itemized invoice as documentation. Regardless of claim type or whether a particular drug is
designated as BR in the Medicaid Physician Fee Schedule, practitioners must limit their charge
amount to their acquisition cost as established by invoice for the dose administered. The NYS
Medicaid Physician Drug and Drug Administration Services Fee Schedule can be found here:
https://www.emedny.org/ProviderManuals/Physician/index.aspx
Additional information on FFS billing can be found here:
https://www.health.ny.gov/health_care/medicaid/program/practitioner_administered/ffs_pra
ctitioner_administer.htm
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29-I Health Facilities are encouraged to reach out to the MMCPs that serve children/youth in
their care to better understand the MMCP’s process and requirements for reimbursement of
physician administered drugs.
4.15 COST ALLOCATION OF SERVICES
Other Limited Health-Related Services must be provided and billed for separately from those
services included in the Core Limited Health-Related Services. 29-I Health Facilities may not
separately bill for activities performed by a professional when the Full Time Equivalent (FTE) for
that position is funded within the Medicaid residual per diem rate for the provision of Core
Limited Health-Related Services.
29-I Health Facilities must appropriately allocate the costs associated with each type of service
in the annual cost report filings submitted to the State. Costs associated with the time spent by
practitioners providing Core Limited Health-Related Services must be allocated to and billed
under the Medicaid residual per diem. 29-I Health Facilities can allocate percentages of
individual practitioners’ FTEs to Core and Other Limited Health-Related Services, based on
actual time spent providing those services. 29-I Health Facilities may not bill for services
provided by an individual practitioner under both the Medicaid residual per diem and the Other
Limited Health-Related Services fee schedule, without an appropriate cost allocation
methodology in place.
Providers must also comply with the HCBS Settings Rules as outlined in Appendix F.
4.16 BILLING EXAMPLE: OFFICE VISIT
When billing for an office visit, the claim would include rate code 4594, one of the billable E&M
or prevention procedure codes (99202-99205, 99212-99215, 99381-99385, 99391-99395,
99401-99404), and any additional non-billable procedure codes relevant to the services that
was provided; see Appendix C for additional non-billable codes.
For example, if a child/youth was a new patient with moderate presenting problems (based on
medical decisions of the practitioner seeing the child/youth for the visit) and the child/youth
was seen for 45 minutes, the claim must reflect the following information:
Rate
code
Procedure Code description
Modifier
Procedure
Code
Billable
Units
Units
Billed
Unit Limit 12 units/day
4594
New Patient Office or outpatient visit
(typically 30 minutes) usually presenting
problem(s) are moderate severity
U9, SC
99204 (billable
code)
15 minutes
3 units
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Rate
code
Procedure Code description
Modifier
Procedure
Code
Billable
Units
Units
Billed
Service(s) provided in the office at times
other than regularly scheduled office hours,
or days when the office is normally closed
(e.g. holidays, Saturday, or Sunday) in
addition to basic service
N/A
99051 (non-
billable code)
N/A
N/A
Pharmacologic management, including
prescription and review of medication, when
performed with psychotherapy services
N/A
90863 (non-
billable code)
N/A
N/A
If there are multiple billable services delivered under the same rate code during one encounter,
each billable service must be indicated on the same claim with distinct procedure, modifier, and
units delivered. Each rate code must be reported on a separate claim.
4.17 SUBMITTING AN OTHER LIMITED HEALTH RELATED SERVICE FFS CLAIM
When submitting FFS Other Limited Health-Related Service claims for services delivered to the
same child/youth, during the same day and under the same rate code, 29-I Health Facilities will
need to submit one claim indicating one rate code. On each claim, report the procedure codes
that reflect the services delivered during the encounter that are applicable to the rate code. If
the procedure codes are billable, the units should reflect the length of the encounter related to
each billable procedure code. Non-billable procedure codes will have zero units and will not be
reimbursed; however, they should be reported on the claim to accurately represent the
services delivered during the encounter. Each rate code should be billed on a separate claim.
FFS Example: If a 29-I Health Facility provides Developmental Test Administration using rate
code 4589 for one hour and thirty minutes, the claim would need to reflect rate code 4589,
procedure codes 96112 and 96113 with a total of 6 units on the claim. All units being claimed
for the rate code for FFS claim must be reported on the first line to pay. See Table 3, below:
Table 3: FFS Claims Example
Example: (Same date
of service) 9/2/2021
Same Child:
“Youth receiving
care”
Procedure code
Units
Rate Code 4589 (same rate code)
96112
6
96113
0
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Table 4: Managed Care Claims Example
Example: (Same date
of service) 9/2/2021
Same Child:
“Youth receiving
care”
Procedure code
Units
Rate Code 4589 (same rate code)
96112
4
96113
2
4.19 DESCRIPTION OF BILLABLE PROCEDURE CODES FOR OTHER LIMITED HEALTH-
RELATED SERVICES
A description of billable procedure codes for Other Limited Health-Related Services is as
follows:
Alcohol and /or drug screening, testing and treatment: rate code 4588
Procedure code H0049: Alcohol and/or drug screening
Procedure code H0050: Alcohol and/or drug service, brief intervention, per 15 min
Procedure code 99408: Alcohol and/or substance (other than tobacco) abuse structured
screening (e.g. AUDIT DAST) and brief intervention (SBI) services 15 to 30 minutes
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April 2023 P a g e | 27 Procedure code 99409: Alcohol and/or substance (other than tobacco) abuse structured screening (e.g. AUDIT DAST) and brief intervention (SBI) services greater than 30 minutes When using the CRAFFT tool for alcohol and/or drug screening use one of the above procedure codes.
Developmental test administration: rate code 4589
Procedure Code 96112: Developmental test administration (including assessment of
fine and/or gross motor, language, cognitive level, social, memory, and/or executive
functions by standardized developmental instruments when performed), by physician or
other qualified health care professional, with interpretation and report; first hour
Procedure code 96113: Developmental test administration (including assessment of fine
and/or gross motor, language, cognitive level, social, memory, and/or executive
functions by standardized developmental instruments when performed), by physician or
other qualified health care professional, with interpretation and report; additional 30
minutes
Psychotherapy (Individual and Family): rate code 4590
Procedure code 90832: Psychotherapy, 30 min with child/youth
Procedure code 90834: Psychotherapy, 45 min with child/youth
Procedure code 90837: Psychotherapy, 60 min with child/youth
Procedure code 90846: Family Psychotherapy (without the child/youth) 50 minutes.
Sessions that are less than 26 minutes without the child/youth present are not eligible
for reimbursement.
Procedure code 90847: Family Psychotherapy (conjoint psychotherapy with child/youth
present) 50 minutes. Sessions where the child/youth is present may be billed by a 29-I
Health Facility if they are at least 8 minutes.
Psychotherapy (Group): rate code 4591 Procedure code 90849: Family Psychotherapy Multi-Family Group Psychotherapy Procedure code 90853: Group Psychotherapy (other than of a Multi-family)
Neuropsychological testing evaluation services: rate code 4592
Procedure code 96132: Neuropsychological testing evaluation services by physician or
other qualified health care professional, standardized test results and clinical data,
clinical decision making, treatment planning and report, and interactive feedback to the
patient, family member(s) or caregiver(s), when performed, first hour
Procedure code 96133: Neuropsychological testing evaluation services by physician or
other qualified health care professional, standardized test results and clinical data,
clinical decision making, treatment planning and report, and interactive feedback to the
patient, family member(s) or caregiver(s), when performed, each additional hour (list
separately on same claim) in addition to code for primary procedure
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Psychiatric/Psychological diagnostic examination: rate code 4593
Procedure code 90791: Can be billed once per day and not with an evaluation
management claim (Office visit rate code 4594, Procedure codes 99213, 99214, and
99215) claim on the same day, can be billed twice per day when patient is evaluated and
then patient with other informant or other informants without patient
Procedure code 90792: Can be billed once per day and not with an evaluation
management claim (Office visit rate code 4594, Procedure codes 99213, 99214, and
99215) on the same day, can be billed twice per day when patient is evaluated and then
patient with other informant or other informants without patient, includes medical
services
Procedure code 96136: Psychological or neuropsychological test administration and
scoring by physician or other qualified health care professional, two or more tests, any
method, first 30 minutes
Procedure code 96137: Psychological or neuropsychological test administration and
scoring by physician or other qualified health care professional, two or more tests, any
method, each additional 30 minutes (List separately in addition to code for primary
procedure on same claim)
Procedure code 96130: Psychological testing evaluation services by physician or other
qualified health care professional, including integration of patient data, interpretation of
standardized test results and clinical data, clinical decision making, treatment planning
and report and interactive feedback to the patient, family member(s) or caregiver(s),
when performed; first hour
Procedure code 96131: Psychological testing evaluation services by physician or other
qualified health care professional, including integration of patient data, interpretation of
standardized test results and clinical data, clinical decision making, treatment planning
and report and interactive feedback to the patient, family member(s) or caregiver(s),
when performed; Each additional hour (List separately in addition to code for primary
procedure on same claim)
Office Visit: rate code 4594 Procedure code 99202: New Patient Office or outpatient visit (typically 20 minutes) usually presenting problem(s) are moderate severity Procedure code 99203: New Patient Office or outpatient visit (typically 30 minutes) usually presenting problem(s) are moderate to high severity Procedure code 99204: New Patient Office or outpatient visit (typically 45 minutes) usually presenting problem(s) are moderate to high severity Procedure Code 99205: New Patient Office or outpatient visit (typically 60 minutes) usually presenting problem(s) are moderate to high severity Procedure code 99212: Established Patient Office visit (typically 10 minutes) usually the presenting problem(s) are self-limiting or minor Procedure code 99213: Established Patient Office visit (typically 15 minutes) usually the presenting problem(s) are low to moderate severity Archive
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Procedure code 99214: Established Patient Office visit (typically 25 minutes) usually
presenting problem(s) are moderate to high severity
Procedure code 99215, Established Patient Office visit (typically 40 minutes) usually
presenting problem(s) are moderate to high severity
Procedure code 99381: Preventive Medicine – Initial comprehensive evaluation and
management of an individual including an age and gender appropriate history,
examination, counseling/anticipatory guidance/risk factor reduction interventions, and
the ordering of laboratory/diagnostic procedures, new patient; infant (younger than 1
year)
Procedure code 99382: Preventive Medicine – Initial comprehensive evaluation and
management of an individual including an age and gender appropriate history,
examination, counseling/anticipatory guidance/risk factor reduction interventions, and
the ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1
through 4 years)
Procedure code 99383: Preventive Medicine – Initial comprehensive evaluation and
management of an individual including an age and gender appropriate history,
examination, counseling/anticipatory guidance/risk factor reduction interventions, and
the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5
through 11 years)
Procedure code 99384: Preventive Medicine – Initial comprehensive evaluation and
management of an individual including an age and gender appropriate history,
examination, counseling/anticipatory guidance/risk factor reduction interventions, and
the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12
through 17 years) Procedure code 99385: Preventive Medicine – Initial comprehensive
evaluation and management of an individual including an age and gender appropriate
history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18 –
39 years
Procedure code 99391: Established patient periodic comprehensive preventive
medicine reevaluation and management of an individual including an age and gender
appropriate history, examination, counseling/anticipatory guidance/risk factor
reduction interventions, and the ordering of laboratory/diagnostic procedures; infant
(age younger than 1 year)
Procedure code 99392: Established patient periodic comprehensive preventive
medicine reevaluation and management of an individual including an age and gender
appropriate history, examination, counseling/anticipatory guidance/risk factor
reduction interventions, and the ordering of laboratory/diagnostic procedures; early
childhood (age 1 through 4 years)
Procedure code 99393: Established patient periodic comprehensive preventive
medicine reevaluation and management of an individual including an age and gender
appropriate history, examination, counseling/anticipatory guidance/risk factor
reduction interventions, and the ordering of laboratory/diagnostic procedures; late
childhood (age 5 through 11 years) Procedure code 99394: Established patient periodic
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comprehensive preventive medicine reevaluation and management of an individual
including an age and gender appropriate history, examination, counseling/anticipatory
guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic
procedures; adolescent (age 12 through 17 years)
Procedure code 99395: Established patient periodic comprehensive preventive
medicine reevaluation and management of an individual including an age and gender
appropriate history, examination, counseling/anticipatory guidance/risk factor
reduction interventions, and the ordering of laboratory/diagnostic procedures; 18-39
years
Procedure code 99401: Preventive Medicine counseling and/or risk factor reduction
interventions provided to an individual approximately 15 minutes
Procedure code 99402: Preventive Medicine counseling and/or risk factor reduction
interventions provided to an individual approximately 30 minutes
Procedure code 99403: Preventive Medicine counseling and/or risk factor reduction
interventions provided to an individual approximately 45 minutes
Procedure code 99404: Preventive Medicine counseling and/or risk factor reduction
interventions provided to an individual approximately 60 minutes
Procedure code 99417 Prolonged office or other outpatient evaluation and
management service(s) (beyond the total time of the primary procedure which has been
selected using total time), requiring total time with or without direct patient contact
beyond the usual service, on the date of the primary service; each 15 minutes (List
separately in addition to codes 99205, 99215 for office or other outpatient Evaluation
and Management services, It may not be used with any other office/outpatient code.)
Do not report 99417 in conjunction with 99354, 99355, 99358, 99359, 99415, 99416. Do
not report 99417 for any time unit less than 15 minutes. 99417 cannot be reported on
the same day as non-face-to-face prolonged care codes 99358, 99359 or face-to-face
prolonged care codes 99354, 99355. The entire 15 minutes must be done, in order to
add on this new, prolonged services code to 99215 and 99205.
Use one of the billable procedure codes listed above for reproductive health related office visits.
When billing for an office visit, indicate what billable service was performed and any additional non-billable procedure codes (if applicable) to the Office Visit claim. Additional procedure codes will provide detail on how complex the visit was and what services were delivered. When coding the claim, ensure the most accurate coding using appropriate procedure codes based on established definitions defined in American Medical Association CPT coding manual.
Additional Non-Billable Procedure codes to be claimed with Office Visit rate code and
procedure codes in Appendix C
Procedure code 11730: Avulsion of nail plate, partial or complete, simple; single
Procedure code 11982: Removal, non-biodegradable drug delivery system
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Procedure code 11983: Removal with reinsertion, non-biodegradable drug delivery
implant
Procedure code 27372: Removal of foreign body, deep, thigh region or knee area
Procedure code 58300: Insertion of Intrauterine device (IUD)
Procedure code 58301: Removal of Intrauterine device (IUD)
Procedure code 69200: Removal foreign body from external auditory canal; without
general anesthesia
Procedure code 94640: Pressurized or non-pressurized inhalation treatment for acute
airway obstruction for therapeutic purposes and/or for diagnostic purposes such as
sputum induction with an aerosol generator, nebulizer, metered dose inhaler or
intermittent positive pressure breathing (IPPB) device
Procedure code 96372: Therapeutic, prophylactic, or diagnostic injection subcutaneous
or intramuscular
Procedure code 99050: Service(s) provided in the office at times other than regularly
scheduled office hours, or days when the office is normally closed (e.g. holidays,
Saturday, or Sunday) in addition to basic service
Procedure code 97804: Medical Nutrition Therapy Group (2 or more individuals)
Procedure code S0630: Removal of sutures by physician who did not close the wound
Procedure code S8110: Peak Expiratory Flow Rate
Procedure code 90863: Pharmacologic management, including prescription and review
of medication, when performed with psychotherapy services
Procedure code G2023: COVID-19 Specimen Collection without onsite laboratory testing
Smoking cessation treatment: rate code 4595 Procedure code 99407: (greater than 10 minutes)
ECG: rate code 4596 Procedure code 93000: Rhythm ECG, 12 leads with interpretation report triggered by an event to diagnose – with specific order and documentation in medical record
Screening-development/emotional/behavioral: rate code 4597 Procedure code 96110: Developmental screening (e.g. developmental milestone survey, speech, and language delay screen), with scoring and documentation, per standardized instrument Procedure code 96160: Administration of patient focused health risk assessment instrument (e.g. health hazard appraisal) with scoring and documentation, per standardized instrument Procedure code 96161: Administration of caregiver-focused health risk assessment instrument (e.g. depression inventory) for the benefit of the patient, with scoring and documentation per standardized instrument Archive
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Hearing and evaluation of speech: rate code 4598 Procedure code 92551: Screening pure test tone air only Procedure code 92521: Sound production (e.g. stuttering, cluttering) Procedure code 92522: Sound production (e.g. Articulation, phonological process, apraxia, dysarthria) Procedure code 92523: With evaluation of language comprehension and expression (e.g. Receptive and expressive language) Procedure code 92524: Behavioral and Qualitative analysis of voice and resonance Procedure code 92526: Treatment of swallowing dysfunction and/or oral function for feeding
Immunization Administration: rate code 4599
Vaccines for Children (VFC) Program
In New York, health care providers cannot bill Medicaid for vaccines they give to
children/youth, as vaccines must be received through the Vaccines for Children (VFC)
Program. The provider can bill separately for administration of the vaccine and must be
enrolled in the VFC program to do so. A child is eligible for VFC vaccine if they are younger
than 19 years of age and meets at least one of the VFC criteria.
Please reference https://www.health.ny.gov/prevention/immunization/vaccines_for_children/
for further information on New York’s VFC program. Additional guidance regarding billing for
this program is located at New York State Medicaid Update - July 2020 Volume 36 - Number 12
(ny.gov).
To be reimbursed for the administration of vaccines supplied by or available through the VFC Program, providers will be required to bill using the procedure code of the vaccine/toxoid administered, along with the "SL" modifier for ages 0 – 18 and “FB” modifier for ages 19+ (indicating the administration of a vaccine supplied by or available through the VFC Program or a vaccine supplied at no cost), and the vaccine administration CPT code. Please note that the “SL” modifier should be attached to the procedure code for the vaccine/toxoid administered and not to the administration code.
Procedure code 90460: Administration of FREE vaccine
Procedure code 90471: Administration of vaccine for youth 19 years of age and older
Procedure codes for the vaccine/toxoid administered: Please reference pages 39 – 42
of The New York State Medicaid Program Physician – Procedure Codes Manual, located
at
https://www.emedny.org/ProviderManuals/Physician/PDFS/Physician_Procedure_Code
s_Sect2.pdf
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When administering multiple immunizations in one visit, indicate multiple administrations by increasing the number of billable units on the claim. For example, for three immunizations delivered to a child/youth in one visit, indicate 3 units to claim the three doses administered.
COVID-19 Vaccine Administration:
29-I Health Facilities may bill Medicaid FFS and MMC plans for administration of authorized
COVID-19 vaccine when administered by provider or facility staff to Medicaid members in a
residential or other institutional setting. The administration fee is in addition to the rate (i.e.
per diem, per visit, per hour) reimbursed to the provider and must be billed to Medicaid
separately. Rate-based providers may also bill for COVID-19 vaccine administration on a stand-
alone claim when other services are not provided.
For a list of rate codes, procedure codes, rates, and further COVID-19 guidance, including guidance related to COVID vaccine counseling, please refer to https://health.ny.gov/health_care/medicaid/covid19/guidance/billing_guidance.htm for further information on New York State Medicaid Coverage Policy and Billing Guidance for the Administration of COVID-19 Vaccines Authorized for Emergency Use.
Laboratory Services:
Rate code 4600
Procedure code 80178: Lithium
Rate code 4671
Procedure code 81002: Urinalysis, by dip stick or tablet reagent; non-automated,
without microscopy
Procedure code 81003: Urinalysis, by dip stick or tablet reagent; automated, without
microscopy
Procedure code 81007: Urinalysis; Bacterium screen, except B
Rate code 4672 Procedure code 87426: Infectious agent antigen detection by immunoassay technique (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative, multiple- step method; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV, SARS- CoV-2 [COVID-19])
Rate code 4673 Procedure code T1013: interpreter services (in person and telephone)
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Rate Code 4674
Procedure code 81025: Urine pregnancy test, by visual color comparison methods
Rate code 4675
Procedure code 83036: Hemoglobin; glycosylated (A1C)
Rate code 4676
Procedure code 85018: Blood count; Hemoglobin (HGB)
Rate code 4677
Procedure code 86701: Antibody; HIV-1
Rate code 4678
Procedure code 87210: Smear, primary source with Interpretation
Rate code 4679 Procedure code 87631: Infectious agent detection by nucleic ac
Rate code 4680 Procedure code 87880: Infectious agent detection by immunoassay
Rate code 4681 Procedure code 87804: Infectious agent antigen detection by IM (Influenza rapid test)
Rate code 4682 Procedure code 87635: Molecular PCR Test Procedure code U0002: Molecular PCR Test
Rate code 4683
Procedure code G2023: COVID-19 Specimen Collection (can be reimbursed if specimen
collection is a standalone service not associated with an office visit or a COVID-19
Molecular PCR test)
Rate code 4684
Procedure code 86580: All intradermal Tuberculosis (TB) tests, including TB skin tests,
TB delayed hypersensitivity tests (DHT or DHR), Mantoux and/or tine tests and the
purified protein derivative test (PPD)
29-I Health Facility Laboratory Fee Schedule
Procedure Code
Description
29-I Health
Facility Fee
Drug Testing
80178
Lithium
$8.00
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29-I Health Facility Laboratory Fee Schedule
Procedure Code
Description
29-I Health
Facility Fee
Urine Dip
81002
Urinalysis, by dip stick or tablet reagent; non-automated, without
microscopy
$2.00
81003
Urinalysis, by dip stick or tablet reagent; automated, without
microscopy
$2.00
81007
Urinalysis; Bacterium scree, except B
$2.00
Pregnancy Test
81025
Urine pregnancy test, by visual color co
$2.00
Hematocrit or Hemoglobin
83036
Hemoglobin; glycosylated (A1C)
$11.00
85018
Blood count; Hemoglobin (HGB)
$2.00
HIV
86701
Antibody; HIV-1
$11.00
Saline Prep
87210
Smear, primary source with Interpretation
$4.00
RSV
87631
Infectious agent detection by nucleic ac
$97.00
Strep Rapid
87880
Infectious agent detection by immunoassay
$4.00
Influenza Rapid Test
87804
Infectious agent antigen detection by IM (Influenza rapid test)
$15.00
COVID-19 Tests
87635
Molecular PCR test (effective 3/13/2020) – INFECTIOUS AGENT
DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE
RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2)
(CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE
TECHNIQUE
$51.31
U0002
Molecular PCR test (effective 3/13/2020) – 2019-NCOV
CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY
TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL
TARGETS), NON-CDC.
$51.31
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29-I Health Facility Laboratory Fee Schedule
Procedure Code
Description
29-I Health
Facility Fee
87426
Infectious agent antigen detection by immunoassay technique (e.g.,
enzyme immunoassay [EIA], enzyme-linked immunosorbent assay
[ELISA], immunochemiluminometric assay [IMCA]), qualitative or
semiquantitative, multiple-step method; severe acute respiratory
syndrome coronavirus (e.g., SARS-CoV, SARS-CoV-2 [COVID-19])
$45.23
87637
Multiplex test: Infectious agent detection by nucleic acid (DNA or
RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
(Coronavirus disease [COVID-19]), influenza virus types a and b, and
respiratory syncytial virus, multiplex amplified probe technique.
$142.63
COVID-19 Specimen Collection
G2023
Specimen collection for severe acute respiratory syndrome
coronavirus 2 (SARS- CoV-2) (Coronavirus disease [COVID-19]) when
provided as a stand-alone service
$23.46
All intradermal Tuberculosis (TB) tests
86580
All intradermal Tuberculosis (TB) tests, including TB skin tests, TB
delayed hypersensitivity tests (DHT or DHR), Mantoux and/or tine
tests and the purified protein derivative test (PPD)
$5.00
Procedure code G2023 is reimbursable only when the specimen collection is a stand-alone
service and is not reimbursable in conjunction with any other service, including an office visit or
when billing for a COVID-19 test.
29-I VFCA Health Facilities may only bill for one instance of each laboratory procedure per day.
The performance of multiple laboratory procedures of the same type for the same child/youth
on the same day is not reimbursable. However, the performance of multiple laboratory
procedures of different types for the same child/youth on the same day remains reimbursable.
For example, billing for both a Hemoglobin test and a COVID-19 polymerase chain reaction
(PCR) test given to the same child/youth on the same day is permissible. If two PCR tests are
given to the same child/youth on the same day; only one is reimbursable.
29-I Health Facilities providing laboratory services must have a valid Clinical Laboratory
Improvement Amendments (CLIA) certification and only provide laboratory services outlined in
their CLIA certification. The objective of the CLIA program is to ensure quality laboratory
testing. All clinical laboratories must be properly certified to receive Medicaid reimbursement;
CLIA has no direct Medicare or Medicaid program responsibilities. Reimbursements will only
apply to the specific waivered labs outlined in this manual. 29-I Health Facilities must provide
proof of CLIA certification to the State upon request. Additional information on CLIA
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certifications can be found here: https://www.cms.gov/Regulations-and-
Guidance/Legislation/CLIA. COVID testing must meeting the complexity of the laboratory
certification. Additional information regarding CLIA-waived COVID tests can be found at
https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-
authorizations-medical-devices/vitro-diagnostics-euas#individual-molecular.
4.17 PHARMACY/DURABLE MEDICAL EQUIPMENT (DME)/SUPPLIES
Beginning April 1, 2023, Medicaid members enrolled in a MMCP, including children/youth
placed in foster care, Health and Recovery Plans (HARPs), and HIV-Special Needs Plans (SNPs)
will have their pharmacy benefits transitioned to NYRx, the Medicaid Pharmacy program
formerly known as the Medicaid fee-for-service pharmacy program. The transition will not
apply to members enrolled in Child Health Plus (CHPlus).
Most drugs currently covered by the MC plans will continue to be covered by NYRx; however,
some drugs may require prior authorization.
The NYRx Pharmacy Benefit includes:
Covered outpatient prescription and over the counter (OTC) drugs that are listed on
the eMedNY “Medicaid Pharmacy List of Reimbursable Drugs” located at: https://
www.emedny.org/info/formfile.aspx
o More information on NYRx Pharmacy benefits, including the NYRx Formulary
and a link to the Preferred Drug Program can be found at:
https://www.health.ny.gov/health_care/medicaid/program/pharmacy.htm
Pharmacist administered vaccines and supplies, such as enteral and parenteral
nutrition, family planning, and medical/surgical supplies, listed in the New York State
Medicaid
Program
Pharmacy
Procedure
Codes
document
found
at:
https://www.emedny.org/ProviderManuals/Pharmacy/PDFS/Pharmacy_Procedure_
Codes.pdf
Services related to COVID-19, including testing, with pharmacy-specific guidance
found at: https://health.ny.gov/health_care/medicaid/covid19/guidance/index.htm
Additional Information and Questions:
Providers must be enrolled in NYS Medicaid to provide services to Medicaid members.
For information regarding provider enrollment, visit:
https://www.emedny.org/info/ProviderEnrollment/HowDoIDo.pdf.
Additional questions should be directed to providerenrollment@health.ny.gov or by
calling Provider Enrollment at (800) 343-9000.
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For more information regarding the pharmacy benefit transition from NYS Managed
Care to NYRx, visit:
https://www.health.ny.gov/health_care/medicaid/redesign/mrt2/pharmacy_transition.
Policy questions can be directed to the Medicaid Pharmacy Policy unit at (518) 486-3209
or by emailing nyrx@health.ny.gov
• Policy questions for DMEPOS providers can be directed to the Bureau of Medical Review
at (800) 342-3005 or by emailing OHIPMEDPA@health.ny.gov.
4.18 ROUTINE TRANSPORTATION
Transportation related to accessing routine health care services is covered within the Core
Limited Health-Related Services (Medicaid residual per diem) rate. It is the responsibility of the
29-I Health Facility to arrange for ordinary and routine health care-related transportation
services required to serve the child/youth in their care, such as a trip to a local medical
appointment.
4.19 MEDICAL TRANSPORTATION
29-I Health Facilities are not responsible for non-routine transportation. Examples include:
Frequency of medical appointments exceeds regular and routine medical care
Emergency ambulance transports
Transportation between medical facilities
Medical destinations which are long distance (i.e. 30 miles or more away from the
facility
Outside the common medical marketing area where ordinary and routine health care is
received
These types of trips are arranged through the regional Department of Health contracted
Medicaid Transportation Manager and are billed by the transportation provider as fee for
service Medicaid transportation.
Medicaid enrollees have freedom of choice when choosing a transportation provider within the
most cost effective, medically appropriate mode of transport (e.g. taxi/livery, ambulette, public
transit) as determined by the Transportation Manager; additional guidance can be found at
https://www.emedny.org/ProviderManuals/Transportation/index.aspx.
4.20 HCBS NON-MEDICAL TRANSPORTATION
29-I Health Facilities that meet requirements to provide HCBS as outlined in the Children’s
Home and Community Based Services Provider Manual
(https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/
hcbs_manual.pdf) and any subsequent updates will bill using the NYS Children’s Health and
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Behavioral Health Services Billing and Coding Manual
(https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/
billingmanual.pdf) and any subsequent updates.
SECTION 5: POPULATIONS SERVED BY 29-I HEALTH FACILITIES
5.1 CHILDREN/YOUTH IN FOSTER CARE PLACEMENT
Most New York State children and youth in foster care are Medicaid eligible simply by virtue of
their foster care status. This includes children/youth who are United States citizens or have
satisfactory immigration status.
For more information, please see the following General Information Systems document issued
by the Medicaid Program:
http://www.health.state.ny.us/healthcare/medicaid/publications/docs/gis/05ma041.pdf.
VFCAs may serve children/youth who are not in foster care. 29-I Health Facilities may provide
Core Limited Health-Related Services and Other Health-Related Services to the following
populations; however, it is not always the responsibility of MMCPs to reimburse for payment
for these services, as outlined below and in the chart in Appendix G.
KINSHIP – IN FOSTER CARE CERTIFIED KINSHIP SETTING
Children/youth Enrolled in MMCP
MMCPs are responsible for paying the Medicaid residual per diem for all days that the
enrolled child/youth is enrolled in plan and resides in the certified kinship setting with
active Foster Care status until the date of discharge from VFCA or date of disenrollment.
This information should be communicated to MMCPs via the transmittal form.
MMCPs will reimburse for Other Limited Health-Related Services.
Medicaid FFS (Children/youth NOT Enrolled in MMCP)
For the period when the child is enrolled in Medicaid FFS, VFCAs will bill Medicaid FFS
the residual per diem rate from the date of admission to the date of discharge and/or
change in FC status.
Medicaid FFS will reimburse for Other Limited Health-Related Services.
KINSHIP – IN FOSTER CARE NON-CERTIFIED KINSHIP SETTING
Children/youth Enrolled in MMCP
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For a child/youth who is enrolled in a MMCP and is placed in a kinship setting that is not
certified as a Foster Care setting, the residual per diem cannot be claimed.
If the kinship placement is certified at a later date, the VFCA can retroactively claim the
residual per diem for the Core Limited Health-Related Services up to 90 days. The MMCP
will be responsible for the period during which the child/youth was in active Foster Care
status, placed in the kinship setting, and enrolled in the MMCP.
MMCPs will be responsible for reimbursement for Other Limited Health-Related
Services.
Medicaid FFS (Children/youth NOT Enrolled in MMCP)
For children/youth who are enrolled in Medicaid FFS and are placed in kinship settings
that are not certified as a Foster Care setting, a residual per diem cannot be claimed.
If the kinship placement is certified at a later date, then the VFCA can claim the residual
per diem retroactively up to 90 days. Medicaid FFS will be responsible for the period
during which the child/youth was in active Foster Care status, placed in the kinship
setting, and enrolled in Medicaid FFS.
Medicaid FFS will be responsible for reimbursement for Other Limited Health-Related
Services to the VFCA provider based on the appropriate fee schedule.
COMMITTEE OF SPECIAL EDUCATION (CSE)1
Children/youth Enrolled in MMCP
For children/youth who are placed with a 29-I Health Facility by their school district’s
Committee of Special Education (CSE), the school district will reimburse for Other
Limited Health-Related Services that are included in the child/youth’s Individualized
Education Plan (IEP).
The MMCP will reimburse for Other Limited Health-Related Services that are not listed
in the IEP. The MMCP may request the IEP from the child/youth’s school district if this
information is necessary for care coordination.
MMCPs are not responsible for covering the residual per diem rates for Core Limited
Health-Related Services.
1 A school placed youth may continue with placement in a 29-I Health Facility past their 21st birthday as outlined in Education Law: Section 4402(5) of NYS Education Law indicates that students with disabilities reaching the age of 21 between July 1 and August 31 are eligible to remain in school until the 31st day of August or until the end of summer program, whichever occurs first. Students turning age 21 between September 1 and June 30 are entitled to remain in school until June 30 or until the end of the school year, whichever comes first. Archive
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Medicaid FFS (Children/youth NOT Enrolled in MMCP)
For children/youth who are placed with a VFCA by the CSE, the school district will
reimburse for Other Limited Health-Related Services that are included in the
child/youth’s IEP.
Medicaid FFS will reimburse for Other Limited Health-Related Services that are not
listed in the IEP.
Medicaid is not responsible for covering the residual per diem rates for Core Limited
Health-Related Services.
When billing for children residing in the 29-I Health Facility and placed by the Committee on
Special Education (CSE), the 29-I Health Facility will follow the existing guidance in the
Standards of Payment guidance found at https://ocfs.ny.gov/main/Rates/Default.asp.
8D BABIES
Children/youth Enrolled in MMCP
For babies/children of children/youth in foster care (8D babies), the MMCP will
reimburse for both Core Limited Health-Related Services and Other Limited Health-
Related Services.
Medicaid FFS (Children/youth NOT Enrolled in MMCP)
Medicaid FFS will be responsible for reimbursement for both Core Limited Health-
Related Services and Other Limited Health-Related Services.
PRE-DISPOSITIONAL PLACED YOUTH
Children/youth Enrolled in MMCP
MMCPs are not responsible for covering the residual per diem rates for Core Limited
Health-Related Services.
The MMCP will reimburse for Other Limited Health-Related Services provided by the 29-
I Health Facility.
Medicaid FFS (Children/youth NOT Enrolled in MMCP)
Medicaid FFS will reimburse for Other Limited Health-Related Services provided by the
29-I Health Facility.
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OUT-OF-STATE PLACEMENT (NON-TITLE IV-E)
Children/youth Enrolled in MMCP
Children who are not Title IV-E eligible and are placed out of state are excluded from
MMCP enrollment.
Medicaid FFS (Children/youth NOT Enrolled in MMCP)
Medicaid FFS will reimburse for Other Limited Health-Related Services provided by the
29-I Health Facility.
Medicaid FFS will reimburse for the residual per diem for Core services for days the
enrolled child/youth is placed with the 29-I Health Facility.
OUT-OF-STATE PLACEMENT (TITLE IV-E)
MMCP or Medicaid FFS
Children/youth who are Title IV-E eligible should be enrolled in Medicaid FFS by the
state in which the child/youth is residing.
Core and Other Limited Health-Related Services will be reimbursed in accordance with
that state’s Medicaid rules.
CHILD HEALTH PLUS (CHPLUS) ENROLLEES
Children/youth placed in foster care who do not qualify for Medicaid due to immigration
status will be enrolled in CHPlus.
CHPlus plans will reimburse for Core Limited Health-Related Services provided by 29-I
Health Facilities in their networks.
CHPlus plans will reimburse 29-I Health Facilities in their networks for Other Limited
Health-Related Services that are covered under the child/youth’s CHPlus plan.
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5.2 ADULTS OLDER THAN 21, FORMALLY IN FOSTER CARE WHO ARE STILL IN THE
CARE OF THE 29-I HEALTH FACILITY
MMCP or Medicaid FFS
Youth who are 21 years or older may continue to receive Other Limited Health-Related
Services if the following circumstances apply:
o the Enrollee has been placed in the care of the 29-I Health Facility and has been
in receipt of Other Limited Health-Related Services prior to their 21st birthday;
and
o the Enrollee has not yet safely transferred to another placement or living
arrangement; and
o the Enrollee and/or their authorized representative is compliant with a safe
discharge plan; and
o the 29-I Health Facility continues to work collaboratively with the MMCP to
explore options for the Enrollee’s safe discharge, including compliance with
court ordered services, if applicable.
Neither MMCPs nor Medicaid FFS will reimburse the residual per diem for Core Limited Health- Related Services after the individual’s 21st birthday. Adults over the age of 21 are not eligible for CFTSS or Children’s HCBS.
SECTION 6: PROVIDER ASSISTANCE
MMCPs are required to develop and implement provider training and support programs for
network providers. This training and support will allow network providers to gain the
appropriate knowledge, skills, and expertise, and receive technical assistance to comply with
the MMCP’s requirements. Training and technical assistance shall be provided to network
providers on billing/claims submission, coding, data interface, documentation requirements,
and UM requirements.
Network providers shall be informed in writing regarding the information requirements for UM
decision making, procedure coding, and submitting claims. MMCPs will provide technical
assistance in other areas such as claim submission as indicated by provider performance
identified through the quality management and provider profiling programs put in place by the
MMCP. MMCPs will ensure providers receive prompt resolution to their inquiries.
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6.1 WHERE TO SUBMIT QUESTIONS AND COMPLAINTS
Medicaid Managed Care Billing/claiming questions:
MMCPs will address billing and claiming questions for claims submitted to the MMCP, see your
Managed Care contract for additional information.
FFS Billing Questions:
eMedNY Call Center:
1-800-343-9000
https://www.emedny.org/contacts/emedny.aspx
For provider inquiries pertaining to non-pharmacy billing, claims or provider enrollment:
7:30 a.m. - 6:00 p.m. Eastern Time, Monday through Friday (excluding holidays)
For provider inquiries pertaining to eligibility, Point of Service (POS), Dental or Pharmacy claims: 7:00 a.m. - 10:00 p.m., Eastern Time, Monday through Friday (excluding holidays) 8:30 a.m. - 5:30 p.m., Eastern Time, Holidays and Weekends
General eMedNY Information:
P.O. Box 4611
Rensselaer, N.Y. 12144-8611
https://www.emedny.org/
Medicaid Managed Care Complaints can be sent to NYS DOH Complaint team at:
1-800-206-8125 or email: managedcarecomplaint@health.ny.gov
Program coverage questions and 29-I licensure questions can be emailed to OCFS and DOH at:
OCFS MAILBOX: ocfs-managed-care@ocfs.ny.gov
DOH MAILBOX: BH.Transition@health.ny.gov
6.2 PRIOR APPROVAL / PRIOR AUTHORIZATION
For Core Limited Health-Related Services (Medicaid residual per diem rate), Medicaid prior
approval/prior authorization requirements do not apply. MMCPs may not require prior
authorization for Core Limited Health-Related Services or for any mandated Other Limited
Health-Related Services assessment for a child/youth in foster care, except as necessary to
arrange for out of network services. The mandatory assessments and timeframes are outlined
in the 29-I Health Facility guidance, located at
https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/fi
naldraftvfcahealthfacilitieslicenseguidelines501_18.pdf.
29-I Health Facilities must have procedures to assure that caseworkers, children/youth, any of
their caregivers and others who bring children/youth residing in a 29-I Health Facility to receive
healthcare services in the community effectively communicate to community providers that the
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child/youth is under the care of the 29-I Health Facility. This will facilitate compliance with both
Medicaid billing and Medicaid prior approval/prior authorization requirements that impact
claims payment and promote willingness of providers to serve the 29-I Health Facility
population.
29-I Health Facility staff that bring children/youth for healthcare services should be directed to
supply the healthcare provider with contact information for a 29-I Health Facility Medicaid
Managed Care Liaison who can advise providers when it is appropriate to bill the FFS and when
it is appropriate to bill the MMCP. This will assist the provider in determining whether Medicaid
prior approval/prior authorization requirements must be followed.
Other Limited Health-Related Services that are not mandated as outlined in the 29-I Health
Facility Guidance are subject to prior approval/prior authorization and utilization standards set
forth by the contract agreement between the 29-I Health Facility and the MMCP.
Prior authorization is not required for Core Health-Related Services and/or mandated
assessments. If prior authorization is required and not obtained for services outside of Core
Health-Related Services and/or mandated assessments, claims for these services may be
denied.
6.3 MEDICAID PRIOR APPROVAL OF ORTHODONTIA CARE FOR MEDICAID FOSTER
CARE YOUTH
Orthodontia care is outside the 29-I Medicaid residual per diem and Other Health-Related
Services rates, and therefore is billable directly to the Medicaid Program through Medicaid
Managed Care Plans or through FFS.
The most current Medicaid FFS prior approval process for orthodontia care must be followed,
which is located at
https://www.emedny.org/ProviderManuals/Dental/PDFS/Dental_Policy_and_Procedure_Manu
al.pdf.
Orthodontia Care for non-Medicaid Eligible Youth in Foster Care Enrolled in the Physically
Handicapped Children’s Program
Prior approval/authorization processes must be followed when Physically Handicapped
Children’s Program (PCHP)-approved orthodontists render orthodontia care to PHCP-enrolled,
non-Medicaid foster care children/youth serviced by VFCA programs. It is expected that these
instances will be limited.
Counties vary with response to the scope of their PHCP program, and there are county-specific
variations with respect to the programmatic and financial eligibility requirements. Any
questions related to these issues should first be directed to the local county department of
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SECTION 7: APPENDICES
APPENDIX A: UTILIZATION MANAGEMENT/MEDICAL NECESSITY GUIDELINES FOR 29-
I CORE LIMITED HEALTH-RELATED SERVICES
Medical necessity must be established for Core Limited Health-Related Services and is required
for 29-I Health Facilities to bill the Medicaid residual per diem rate. Medical necessity must be
determined by one of the following Licensed Practitioners of the Healing Arts (LPHA) operating
within the scope of practice:
Physician
Psychiatrist
Psychologist
Nurse practitioner
Psychoanalyst
Registered nurse
Clinical nurse specialist
Clinical social worker
Master social worker
Marriage and family therapist
Mental health counselor
Licensed creative arts therapist
Documentation of medical necessity must include how the Core Limited Health-Related
Services are intended to address any of the following:
- Deliver preventive supports through an array of clinical and related activities including psychiatric supports, information exchange with Medicaid community and skill-building.
- Reduce the severity of the health issue that was identified as the reason for admission.
Provide targeted treatment related directly to the child’s ability to function successfully in the home and school environment (e.g., compliance with reasonable behavioral expectations; safe behavior and appropriate responses to social cues and conflicts; medically appropriate care).
Admission Criteria Continued Stay Criteria Discharge Criteria Criteria 1 AND 2 must be met: - Medical necessity must be determined by one of the following Licensed Practitioners of the Healing Arts (LPHA) operating within the scope of practice: Criteria 1 OR 2 AND 3, 4, & 5 must be met:
- The child/youth has not fully reached established service goals and there is an expectation that continuation of services will Any one of the following criteria must be met:
- The child/youth no longer meets continued stay criteria OR
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Physician
Psychiatrist
Psychologist
Nurse practitioner
Psychoanalyst
Registered nurse
Clinical nurse specialist
Clinical social worker
Master social worker
Marriage and family
therapist
Mental health counselor
Licensed creative arts
therapist
- Addresses the prevention,
diagnosis, and/or treatment
of overall health (physical
and/or behavioral); the
ability to achieve age-
appropriate growth and
development; and the
ability to attain, maintain, or
regain functional capacity.
allow the child/youth to make progress OR - Continuation of the service is needed to prevent the loss of functional skills already achieved AND
- The child/youth continues to meet admission criteria AND
- An alternative service(s) would not meet the child/youth needs AND
- The treatment plan has been
appropriately updated to
establish or modify ongoing
goals.
multiple attempts on the part of the provider to apply reasonable engagement strategies, has decided to no longer consent to the placement OR - The child/youth and/or
family/ discharge resource
has successfully reached
individual/family established
service goals and is able to
satisfactorily meet the
child/youth’s overall health
care needs.
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APPENDIX B: CORE LIMITED HEALTH-RELATED SERVICES RATE CODING TABLE
Level
Description
Facility
Rate
Code
Procedure
Code
Modifier
Unit
Measure
Unit
Limit
Level
1
General
Treatment
Foster Boarding
Home
4288
H0041
N/A
Per diem
1/day
Level
2
Specialized
Treatment
Therapeutic
Boarding Home
(TBH)/AIDS
4289
S5145
N/A
Per diem
1/day
Medically Fragile
4290
S5145
TF
Special Needs
4291
S5145
U1
Level
3
Congregate
Care
Maternity
4292
S5145
HD
Per diem
1/day
Group Home
(GH)
4293
S5145
HA
Agency Operated
Boarding Home
(ABH)
4294
S5145
U2
Supervised
Independent
Living Program
(SILP)
4295
S5145
U3
Level
4
Specialized
Congregate
Care
Group Residence
(GR)
4296
S5145
HA, U5
Per diem
1/day
Diagnostic
4297
S5145
TG
Institutional
4298
S5145
U5
Hard to
Place/Other
Congregate
4299
S5145
U6
Raise the Age
4300
S5145
U7
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APPENDIX C: OTHER LIMITED HEALTH-RELATED SERVICES RATE CODING TABLE
Rate Code
Unit Limit per
Rate Code
Rate Code Description
4588
24 units/year
Alcohol and Drug Testing
Billing Unit Measure: 15 minutes
Service Description
Modifier
Procedure Code
Alcohol and/or drug screening
U9
H0049
Alcohol and/or drug services, brief intervention, per 15 minutes
U9
H0050
Alcohol and/or substance (other than tobacco) abuse structured screening
(e.g. AUDIT DAST) and brief intervention (SBI) services 15 to 30 minutes
U9
99408
Alcohol and/or substance (other than tobacco) abuse structured screening
(e.g. AUDIT DAST) and brief intervention (SBI) services greater than 30
minutes
U9
99409
Rate Code
Unit Limit per
Rate Code
Rate Code Description
4589
48 units/year
Developmental Testing
Billing Unit Measure: 15 minutes
Service Description
Modifier
Procedure Code
Developmental test administration (including assessment of fine and/or
gross motor, language, cognitive level, social, memory, and/or executive
functions by standardized developmental instruments when performed), by
physician or other qualified health care professional, with interpretation and
report; first hour
U9, SC
96112
Developmental test administration (including assessment of fine and/or
gross motor, language, cognitive level, social, memory, and/or executive
functions by standardized developmental instruments when performed), by
physician or other qualified health care professional, with interpretation and
report; each additional 30 minutes
U9, SC
96113
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Rate Code
Unit Limit per
Rate Code
Rate Code Description
4590
12 units/day
Psychotherapy (Individual and Family)
Billing Unit Measure: 15 minutes
Service Description
Modifier
Procedure Code
Psychotherapy, 30 min with child/youth
U9
90832
Psychotherapy, 45 min with child/youth
U9
90834
Psychotherapy, 60 min with child/youth
U9
90837
Family Psychotherapy (without the child/youth) 50 minutes (do not
report less than 26 minutes)
U9
90846
Family Psychotherapy (conjoint psychotherapy with child/youth
present) 50 minutes
*Sessions where the child/youth is present may be billed by a 29-I
Health Facility if they are at least 8 minutes
U9
90847
Rate Code
Unit Limit per Rate
Code
Rate Code Description
4591
8 units/day
Psychotherapy Group
Billing Unit Measure: 15 minutes
Service Description
Modifier
Procedure Code
Multi-Family Group Psychotherapy
U9
90849
Group Psychotherapy (other than of a Multi-family)
U9
90853
Rate Code
Unit Limit per Rate
Code
Rate Code Description
4592
48 unit/year
Neuropsychological testing/evaluation services
Billing Unit Measure: 15 minutes
Service Description
Modifier
Procedure Code
Neuropsychological testing evaluation services by physician or other
qualified health care professional, standardized test results and
clinical data, clinical decision making, treatment planning and
report, and interactive feedback to the patient, family member(s) or
caregiver(s), when performed, first hour
U9, SC
96132
Neuropsychological testing evaluation services by physician or other
qualified health care professional, standardized test results and
clinical data, clinical decision making, treatment planning and
report, and interactive feedback to the patient, family member(s) or
caregiver(s), when performed, each additional hour (list separately)
in addition to code for primary procedure
U9, SC
96133
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Rate Code
Unit Limit per Rate
Code
Rate Code Description
4593
48 units/year
Psychiatric diagnostic examination
Billing Unit Measure: 15 minutes
Service Description
Modifier
Procedure
Code
Psychiatric diagnostic examination
U9
90791
Psychiatric diagnostic examination, includes medical services
U9
90792
Psychological or neuropsychological test administration and scoring
U9
96136
Psychological or neuropsychological test administration and scoring/additional
30 minutes
U9
96137
Psychological testing evaluation services by physician or other qualified health
care professional, including integration of patient data
U9
96130
Psychological testing evaluation services by physician or other qualified health
care professional, including integration of patient data/additional hour
U9
96131
Rate Code
Unit Limit per
Rate Code
Rate Code Description
4594
12 units/day
Office Visit
Billing Unit Measure: 15 minutes
Service Description
Modifier
Procedure
Code
New Patient Office or outpatient visit (typically 20 minutes) usually presenting
problem(s) are low to moderate severity
U9, SC
99202
New Patient Office or outpatient visit (typically 30 minutes) usually presenting
problem(s) are moderate severity
U9, SC
99203
New Patient Office or outpatient visit (typically 45 minutes) usually presenting
problem(s) are moderate to high severity
U9, SC
99204
New Patient Office or outpatient visit (typically 60 minutes) usually presenting
problem(s) are moderate to high severity
U9, SC
99205
Established Patient Office visit (typically 10 minutes) usually the presenting
problem(s) are self-limiting or minor
U9, SC
99212
Established Patient Office visit (typically 15 minutes) usually the presenting
problem(s) are low to moderate severity
U9, SC
99213
Established Patient Office visit (typically 25 minutes) usually presenting
problem(s) are moderate to high severity
U9, SC
99214
Established Patient Office visit (typically 40 minutes) usually presenting
problem(s) are moderate to high severity
U9, SC
99215
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Preventive Medicine – Initial comprehensive evaluation and management of an
individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, new patient; infant (younger
than 1 year)
U9, SC
99381
Preventive Medicine – Initial comprehensive evaluation and management of an
individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, new patient; early childhood (age
1 through 4 years)
U9, SC
99382
Preventive Medicine – Initial comprehensive evaluation and management of an
individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, new patient; late childhood (age
5 through 11 years)
U9, SC
99383
Preventive Medicine – Initial comprehensive evaluation and management of an
individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, new patient; late childhood (age
12 through 17 years)
U9, SC
99384
Preventive Medicine – Initial comprehensive evaluation and management of an
individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, new patient; 18-39 years
U9, SC
99385
Established patient periodic comprehensive preventive medicine reevaluation
and management of an individual including an age and gender appropriate
history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures; infant (age
younger than 1 year)
U9, SC
99391
Established patient periodic comprehensive preventive medicine reevaluation
and management of an individual including an age and gender appropriate
history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures; early
childhood (age 1 through 4 years)
U9, SC
99392
Established patient periodic comprehensive preventive medicine reevaluation
and management of an individual including an age and gender appropriate
history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures; late
childhood (age 5 through 11 years)
U9, SC
99393
Established patient periodic comprehensive preventive medicine reevaluation
and management of an individual including an age and gender appropriate
history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures; adolescent
(age 12 through 17 years)
U9, SC
99394
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Established patient periodic comprehensive preventive medicine reevaluation
and management of an individual including an age and gender appropriate
history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures; 18-39
years
U9, SC
99395
Preventive Medicine counseling and/or risk factor reduction interventions
provided to an individual approximately 15 minutes
U9, SC
99401
Preventive Medicine counseling and/or risk factor reduction interventions
provided to an individual approximately 30 minutes
U9, SC
99402
Preventive Medicine counseling and/or risk factor reduction interventions
provided to an individual approximately 45 minutes
U9, SC
99403
Preventive Medicine counseling and/or risk factor reduction interventions
provided to an individual approximately 60 minutes
U9, SC
99404
Prolonged office or other outpatient evaluation and management service(s)
(beyond the total time of the primary procedure which has been selected using
total time), requiring total time with or without direct patient contact beyond
the usual service, on the date of the primary service; each 15 minutes (List
separately in addition to codes 99205, 99215 for office or other
outpatient Evaluation and Management services
U9, SC
99417
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Non-Billable Procedure codes applicable to an Office Visit
When billing for an office visit, indicate what services were performed by adding additional non-billable procedure
codes to the Office visit claim. Additional non-billable procedure codes will not be reimbursed separately; however,
they will provide detail on how complex the visit was and specifically what services were delivered in the billable office
visit time period in the claim. When coding the claim, ensure the most accurate coding using appropriate procedure
codes based on established definitions in the latest version of American Medical Association CPT manual with the
guidance provided in this document.
Service Description
Procedure Code
Avulsion of nail plate, partial or complete, simple; single
11730
Removal, non-biodegradable drug delivery system
11982
Removal with reinsertion, non-biodegradable drug delivery implant
11983
Removal of foreign body, deep, thigh region or knee area
27372
Insertion of Intrauterine device (IUD)
58300
Removal of Intrauterine device (IUD)
58301
Removal foreign body from external auditory canal; without general anesthesia
69200
Pressurized or non-pressurized inhalation treatment for acute airway obstruction for
therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol
generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB)
device
94640
Therapeutic, prophylactic, or diagnostic injection subcutaneous or intramuscular
96372
Service(s) provided in the office at times other than regularly scheduled office hours, or days
when the office is normally closed (e.g. holidays, Saturday, or Sunday) in addition to basic
service
99050
Removal of sutures by physician who did not close the wound
S0630
Peak Expiratory Flow Rate
S8110
Pharmacologic management, including prescription and review of medication, when
performed with psychotherapy services
90863
Medical Nutrition Therapy group (2 or more individuals)
97804
Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2)
(Coronavirus disease [COVID-19])
G2023
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Rate
Code
Unit Limit per
Rate Code
Rate Code Description
4595
2 units/day
Smoking cessation treatment
Billing Unit Measure: 15 minutes
Service Description
Modifier
Procedure Code
Smoking cessation treatment (over 10minutes)
U9, SC
99407
Rate
Code
Unit Limit per
Rate Code
Rate Code Description
4596
12 units/year
ECG
Billing unit measure: one occurrence
Service Description
Modifier
Procedure Code
Rhythm ECG, 12 leads with interpretation report
triggered by an event to diagnose – with specific
order and documentation in medical record
U9, SC
93000
Rate
Code
Unit Limit per
Rate Code
Rate Code Description
4597
1 unit/day
Screening-developmental/emotional/behavioral
Billing Unit Measure: one occurrence
Service Description
Modifier
Procedure Code
Developmental screening (e.g. developmental
milestone survey, speech, and language delay
screen), with scoring and documentation, per
standardized instrument
U9, SC
96110
Brief emotional/behavioral assessment (e.g.
Depression inventory, attention
deficit/hyperactivity disorder [ADHD] scale), with
scoring and documentation, per standardized
instrument 15-30 minutes
U9
96127
Administration of patient focused health risk
assessment instrument (e.g. health hazard
appraisal) with scoring and documentation, per
standardized instrument
U9, SC
96160
Administration of caregiver-focused health risk
assessment instrument (e.g. depression
inventory) for the benefit of the patient, with
scoring and documentation per standardized
instrument
U9
96161
Rate
Code
Unit Limit per
Rate Code
Rate Code Description
4598
8 units/day
Hearing and evaluation of speech
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Billing Unit Measure: 15 minutes
Service Description
Modifier
Procedure Code
Hearing- screening pure test tone air only
U9, SC
92551
Evaluation of speech fluency (e.g. stuttering,
cluttering)
U9, SC
92521
Evaluation of speech sound production (e.g.
Articulation, phonological process, apraxia,
dysarthria)
U9, SC
92522
Evaluation of speech sound production, with
evaluation of language comprehension and
expression (e.g. Receptive and expressive
language)
U9, SC
92523
Behavioral and Qualitative analysis of voice and
resonance
U9, SC
92524
Treatment of swallowing dysfunction and/or oral
function for feeding
U9, SC
92526
Rate Code
Unit Limit per Rate Code
Rate Code Description
4599
4 units/day
Immunization Administration
Billing Unit Measure: one occurrence
Service Description
Modifier
Procedure Code
Administration of FREE vaccine
90460 Administration of vaccine for youth 19 years and older FB 90471 Actual vaccine/toxoid administered SL Procedure codes for the vaccine/toxoid administered: Please reference pages 39 – 42 of The New York State Medicaid Program Physician – Procedure Codes Manual, located here. VFC Guidance https://www.cdc.gov/vaccines/programs/vfc/index.html
Rate Code
Unit Limit per Rate
Code
Rate Code Description
4600
1/day
Laboratory
Billing Unit Measure: one Laboratory procedure
Service Description
Procedure Code
Lithium
U9, SC
80178
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Rate Code
Unit Limit per
Rate Code
Rate Code Description
4671
1/day
Laboratory
Billing Unit Measure: one Laboratory procedure
Service Description
Modifier
Procedure Code
Urinalysis, by dip stick or tablet
reagent, non-automated, without
microscopy
U9, SC
81002
Urinalysis, by dip stick or tablet
reagent, automated, without
microscopy
U9, SC
81003
Urinalysis; Bacterium scree,
except B
U9, SC
81007
Rate Code
Unit Limit per
Rate Code
Rate Code Description
4672
1/day
Laboratory
Billing Unit Measure: one Laboratory procedure
Service Description
Modifier
Procedure Code
Infectious agent antigen
detection by immunoassay
technique
87426 Multiplex testing: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types a and b, and respiratory syncytial virus, multiplex amplified probe technique
87637
Rate Code
Unit Limit per
Rate Code
Rate Code Description
4673
N/A
Interpreter Services
Billing Unit Measure: Includes a minimum of eight and up to 22 minutes of medical language interpreter
services. These services are billed at a maximum of two billable units of service per patient per encounter;
however, if the child/youth is seen for more than one encounter in a day, interpretation services may be
billed for up to two units per encounter.
Service Description
Modifier
Procedure Code
In person interpreter services
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Telephone interpreter services
GQ
T1013
Rate Code
Unit Limit per
Rate Code
Rate code Description
4674
1/day
Laboratory
Billing Unit Measure: one Laboratory procedure
Service Description
Modifier
Procedure Code
Urine pregnancy test, by visual
color
U9, SC
81025
Rate Code
Unit Limit per
Rate Code
Rate Code Description
4675
1/day
Laboratory
Billing Unit Measure: one Laboratory procedure
Service Description
Modifier
Procedure Code
Hemoglobin; glycosylated (A1C)
U9, SC
83036
Rate Code
Unit Limit per
Rate Code
Rate Code Description
4676
1/day
Laboratory
Billing Unit measure: one Laboratory procedure
Service Description
Modifier
Procedure Code
Blood count; Hemoglobin (HGB)
U9, SC
85018
Rate Code
Unit Limit per
Rate Code
Rate Code Description
4677
1/day
Laboratory
Billing Unit Measure: one Laboratory procedure
Service Description
Modifier
Procedure Code
Antibody; HIV-1
U9, SC
86701
Rate Code
Unit Limit per
Rate Code
Rate Code Description
4678
1/day
Laboratory
Billing Unit Measure: one Laboratory procedure
Service Description
Modifier
Procedure Code
Smear, primary source with
Interpretation
U9, SC
87210
Rate Code
Unit Limit per
Rate Code
Rate Code Description
4679
1/day
Laboratory
Billing Unit Measure: one Laboratory procedure
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Service Description
Modifier
Procedure Code
Infectious agent detection by
nucleic ac
U9, SC
87631
Rate Code
Unit Limit per
Rate Code
Rate Code Description
4680
1/day
Laboratory
Billing Unit Measure: one Laboratory procedure
Service Description
Modifier
Procedure Code
Infectious agent detection by
immunoassay
U9, SC
87880
Rate Code
Unit Limit per
Rate Code
Rate Code Description
4681
1/day
Laboratory
Billing Unit Measure: one Laboratory procedure
Service Description
Modifier
Procedure Code
Infectious agent antigen
detection by IM (Influenza rapid
test)
U9, SC
87804
Rate Code
Unit Limit per
Rate Code
Rate Code Description
4682
1/day
Laboratory
Billing Unit Measure: one Laboratory procedure
Service Description
Modifier
Procedure Code
Molecular PCR Test INFECTIOUS
AGENT DETECTION BY NUCLEIC
ACID (DNA OR RNA); SEVERE
ACUTE RESPIRATORY
SYNDROME CORONAVIRUS 2
(SARS-COV-2) (CORONAVIRUS
DISEASE [COVID-19]),
AMPLIFIED PROBE TECHNIQUE
87635 Molecular PCR Test 2019-NCOV CORONAVIRUS, SARS-COV- 2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC.
U0002
Rate Code
Unit Limit per
Rate Code
Rate Code Description
4683
1/day
Specimen collection SARS- CoV-2
Billing Unit Measure: one Laboratory procedure
Service Description
Modifier
Procedure Code
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G2023
Rate Code
Unit Limit per
Rate Code
Rate Code Description
4684
1/day
Intradermal Tuberculosis (TB) tests
Billing Unit Measure: one Laboratory procedure
Service Description
Modifier
Procedure Code
All intradermal Tuberculosis (TB)
tests, including TB skin tests, TB
delayed hypersensitivity tests
(DHT or DHR), Mantoux and/or
tine tests and the purified protein
derivative test (PPD)
86580
Rates and Rate codes for Children and Family Treatment and Support Services (CFTSS) can be found here:
https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/proposed_spa.ht
m
Rates and Rate codes for Home and Community Based Services (HCBS) can be found here:
https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/1115_waiver_ame
nd.htm
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APPENDIX D: MODIFIER DESCRIPTIONS
Use of Modifiers for 29-I Health Facilities Medicaid Residual Per Diem and Fee Schedule
CPT Modifier TF Specialized Treatment (Intermediate care) Medically Fragile
CPT Modifier U1 Medicaid Level 1 Specialized Treatment Special Needs
CPT Modifier HD (Pregnant/parenting) Congregate Care Maternity
CPT Modifier HA (Child/adolescent program) Congregate Care Group
CPT Modifier U2 Medicaid Level 2 Congregate Care
CPT Modifier U3 Medicaid Level 3 Supervised Independent Living
CPT Modifier TG (Complex/high level of care)
CPT Modifier U5 Medicaid Level 5 Specialized Congregate Care
CPT Modifier U6 Medicaid Level 6 Specialized Congregate Care Other
CPT Modifier U7 Medicaid Level 7 Specialized Congregate Care Raise the Age
CPT Modifier U9 Medically Necessary Service
CPT Modifier SC Medically Necessary Medical Service
CPT Modifier SL NYS Vaccines for Children
CPT Modifier FB NYS Vaccines for Youth 19+
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APPENDIX E: REVENUE CODES FOR 29-I HEALTH FACILITY BILLING/CLAIMING
Service
Revenue Code(s)
Alcohol and Drug Testing
0513 – Clinic, Psychiatric clinic
0520 - Freestanding Clinic, General
0900 - Behavioral Health Treatments/Services,
General
0914 - Behavioral Health Treatments/Services,
Individual therapy
Developmental testing
0513 – Clinic, Psychiatric clinic
0520 - Freestanding Clinic, General
0900 - Behavioral Health Treatments/Services,
General
0914 - Behavioral Health Treatments/Services,
Individual therapy
0918 - Behavioral Health Treatments/Services -,
Testing
Psychotherapy (Individual and Family)
0513 – Clinic, Psychiatric clinic
0520 - Freestanding Clinic, General
0900 - Behavioral Health Treatments/Services,
General
0914 - Behavioral Health Treatments/Services,
Individual therapy
0916 - Behavioral Health Treatments/Services,
Family therapy
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Service
Revenue Code(s)
Psychotherapy Group
0513 – Clinic, Psychiatric clinic
0520 - Freestanding Clinic, General
0900 - Behavioral Health Treatments/Services,
General
0914 - Behavioral Health Treatments/Services,
Individual therapy
0916 - Behavioral Health Treatments/Services,
Family therapy
Neuropsychological testing / valuation services
0513 – Clinic, Psychiatric clinic
0520 - Freestanding Clinic, General
0900 - Behavioral Health Treatments/Services,
General
0914 - Behavioral Health Treatments/Services,
Individual therapy
0918 - Behavioral Health Treatments/Services -,
Testing
Psychiatric diagnostic examination
0513 – Clinic, Psychiatric clinic
0520 - Freestanding Clinic, General
0900 - Behavioral Health Treatments/Services,
General
0914 - Behavioral Health Treatments/Services,
Individual therapy
Office Visit
0529 - Freestanding Clinic, Other
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Service
Revenue Code(s)
Office Visit Preventive Medicine
0770 - Preventive Services, General
Smoking cessation treatment
0513 – Clinic, Psychiatric clinic
0520 - Freestanding Clinic, General
0900 - Behavioral Health Treatments/Services,
General
0914 - Behavioral Health Treatments/Services,
Individual therapy
ECG
0730 - EKG/ECG Electrocardiogram, General
Screening-developmental/emotional/behavioral
0513 – Clinic, Psychiatric clinic
0520 - Freestanding Clinic, General
0900 - Behavioral Health Treatments/Services,
General
0914 - Behavioral Health Treatments/Services,
Individual therapy
0918 - Behavioral Health Treatments/Services -,
Testing
Hearing
0529 - Freestanding Clinic, Other
Evaluation of speech
0449 - Speech Therapy Language Pathology,
Other
Immunization administration
0771 - Preventive Services, Vaccine
administration
Laboratory Services
0300 – Laboratory, General
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Service
Revenue Code(s)
0301 - Laboratory, Chemistry
0302 - Laboratory, Immunology
0305 - Laboratory, Hematology
0306 - Laboratory, Bacteriology and
Microbiology
0307 - Laboratory, Urology
0309 - Laboratory, Other
0310 – Laboratory Pathology, General
0311 - Laboratory Pathology, Cytology
0312 - Laboratory Pathology, Histology
0319 - Laboratory Pathology, Other
29-I Clinic services (per diem) Other
0519 – Clinic, Other
0529 - Freestanding Clinic, Other
Behavioral Health Outpatient Revenue Codes https://www.ctacny.org/sites/default/files/trainings-pdf/revenu-codes-updated-12-21- 15_1.pdf
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APPENDIX F: HCBS SETTINGS OVERVIEW
The CMS Final Rule (§441.301(c)(4) and §441.710) defines the qualities that all home and
community-based settings must possess to be in compliance with the rule. In the final rule, CMS
also clarifies which settings do NOT qualify as home and community-based settings.
HCBS Settings Rule Resources The CMS Final Rule on the HCBS Settings Requirement can be found here: https://www.federalregister.gov/documents/2014/01/16/2014-00487/medicaid-program- state-plan-home-and-community-based-services-5-year-period-for-waivers-provider
CMS has created a Settings Requirements Compliance Toolkit that may be found here: https://www.medicaid.gov/medicaid/hcbs/index.html
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April 2023P a g e | 68 APPENDIX G: COVERAGE FOR POPULATIONS OUTSIDE OF FOSTER CARE Medicaid Enrollment/ Placement For days in which the child/youth is enrolled in a MMCP
For days in which the child/youth is enrolled in Medicaid FFS
Commercial/Other Payor
Service Type/Fee
Schedule
Other Limited Health-
Related Services:
Residual Per Diem
(Core Health):
Other Limited
Health-Related
Services
Residual Per Diem
(Core Health)
Other Limited
Health-Related
Services
Residual Per Diem
(Core Health)
Reimbursed based on
OLHRS fee schedule or
State approved
alternate arrangement
for the 4-year
transition period
Reimbursed at FFS
Level/Facility Type
rate for the 4-year
transition period
Reimbursed
based on OLHRS
fee schedule
Reimbursed at FFS
Level/Facility Type
Rate
Reimbursed per
subscriber policy;
coordination of
benefits if child also
covered by Medicaid
Reimbursed per
subscriber policy;
coordination of
benefits if child also
covered by Medicaid
Foster Care
Placement in the
care of 29-I in
NYS
MMCP pays for OLHRS
provided by 29-I
MMCP pays per diem
for days enrollee is
placed with 29-I
Medicaid FFS pays
for OLHRS
provided by 29-I
Medicaid FFS pays
per diem for days
enrollee is placed
with 29-I
Commercial/third
party insurance
carrier pays for
covered services, as
applicable
Commercial/third
party insurance
carrier pays for
covered services, as
applicable
Kinship –
certified
placement
MMCP pays for OLHRS provided by 29-I
MMCP pays per diem
for days enrollee is
placed with 29-I
Medicaid FFS pays
for OLHRS
provided by 29-I
Medicaid FFS pays
per diem for days
enrollee is placed
with 29-I
Commercial/third
party insurance
carrier pays for
covered services, as
applicable
Commercial/third
party insurance
carrier pays for
covered services; as
applicable. Medicaid
FFS/MMC will pay per
diem with proof that
the benefit is not
covered under TPI.
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For days in which the child/youth is enrolled in Medicaid FFS
Commercial/Other Payor
Kinship –
placement not
certified
MMCP pays
negotiated rates to
the provider chosen by
the kinship care
provider
N/A
Medicaid FFS will
reimburse the
based on the
appropriate fee
schedule
N/A
Commercial/third
party insurance
carrier pays for
covered services, as
applicable
Commercial/third
party insurance
carrier pays for
covered services, as
applicable
CSE
CSE/LDSS pays for
OLHRS documented in
child’s IEP
MMCP pays for OLHRS outside child’s IEP N/A Core Health services are included in CSE daily rate (MSAR room and board + per diem) paid by CSE/LDSS CSE/LDSS pays for OLHRS documented in child’s IEP
MMCP pays for OLHRS outside child’s IEP N/A Core Health services are included in CSE daily rate (MSAR room and board + per diem) paid by CSE/LDSS CSE/LDSS pays for OLHRS documented in child’s IEP
Insurance carrier pays for covered services outside child’s IEP N/A Core Health services are included in CSE daily rate (MSAR room and board + per diem) paid by CSE/LDSS 8D Babies
MMCP pays for OLHRS
provided by 29-I
MMCP pays per diem
for days the child is
placed with the 29-I
Health Facility for the
reimbursement rate
at the program level
where the child is
placed
Medicaid FFS
reimburses for
OLHRS provided
by 29-I
Medicaid FFS pays
per diem for days
the child is placed
with the 29-I
Health Facility for
the
reimbursement
rate at the
program level
where the child is
placed
Commercial/third
party insurance
carrier pays for
covered services, as
applicable
Commercial/third
party insurance
carrier pays for
covered services, as
applicable
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For days in which the child/youth is enrolled in Medicaid FFS
Commercial/Other Payor
Pre-dispositional
Placed Youth
MMCP pays for OLHRS
provided by 29-I
Core Health Services
are paid by LDSS
Medicaid FFS
reimburses for
services provided
by the 29-I
Core Health
Services are paid
by LDSS
Commercial/third
party insurance
carrier pays for
covered services, as
applicable
Commercial/third
party insurance
carrier pays for
covered services, as
applicable
Out of state
placement (non-
IV-E)
Excluded from MMCP
enrollment
Excluded from MMCP
enrollment
Medicaid FFS
reimburses for
services provided
by the 29-I
Medicaid FFS pays
per diem for days
enrollee is placed
with 29-I
Commercial/third
party insurance
carrier pays for
covered services, as
applicable
Commercial/third
party insurance
carrier pays for
covered services, as
applicable
Out of state
placement (IV-E)
To be enrolled
Medicaid in the state
in which the child is
living
To be enrolled
Medicaid in the state
in which the child is
living
To be enrolled
Medicaid in the
state in which the
child is living
To be enrolled
Medicaid in the
state in which the
child is living
Commercial/third
party insurance
carrier pays for
covered services, as
applicable
Commercial/third
party insurance
carrier pays for
covered services, as
applicable
Former FC
Adults older
than 21 that are
MMCP pays for
services provided by
29-I as long as there is
N/A
Medicaid FFS pays
for services
provided by 29-I
N/A
Commercial/third
party insurance
carrier pays for
Commercial/third
party insurance
carrier pays for
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For days in which the child/youth is enrolled in Medicaid FFS
Commercial/Other Payor
still in the care
of the 29-I
no break in service
and the 29-I has
documented efforts to
safely discharge the
adult. Adults over 21
are not eligible for
CFTSS or children’s
HCBS.
as long as there is
no break in
service and the
29-I has
documented
efforts to safely
discharge the
adult. Adults over
21 are not eligible
for CFTSS or
children’s HCBS.
covered services, as
applicable
covered services, as
applicable
Comprehensive
care setting,
such as an
inpatient
setting, nursing
facility, RTF, PC,
or OPWDD
facility
OLHRS are not billable
while child is in one of
these settings
Per diem is not
billable while child is
in one of these
settings
OLHRS are not
billable while
child is in one of
these settings
Per diem is not
billable while child
is in one of these
settings
OLHRS are not
billable while child is
in one of these
settings
Per diem is not
billable while child is
in one of these
settings
Children under
the custody of
the juvenile
justice system
N/A
N/A
N/A
N/A
N/A
N/A
Child Health Plus
(CHPlus)
enrollees
N/A
N/A
N/A
N/A
CHPlus pays for
covered services, as
applicable
CHPlus pays per diem
for days enrollee is
placed with 29-I
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APPENDIX H: CORE AND OTHER LIMITED HEALTH-RELATED SERVICES COVERED UNDER OPTIONAL PHASE 1
LICENSURE OF 29-I HEALTH FACILITY SERVICES
The table below outlines the services that are covered under the Medicaid residual per diem rate for Core Health-Related Services during the
Phase 1 Opt-in period.
Service listed in eMedNY
Provider Manual
Included in Medicaid Residual Per Diem for Core
Limited Health-Related Services?
Included in Other Limited Health-Related Services?
Administrative Personnel
Yes
Administrative staff must be involved in 29-I Health Facility
Service delivery for this service to fall under the Medicaid
residual per diem.
No
Nurse
Yes
Applies to all nursing services and assessments that can
be provided by a Registered Nurse (RN) or Licensed
Practical Nurse (LPN) as outlined in the 29-I Health
Facility Guidance.
No
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Service listed in eMedNY
Provider Manual
Included in Medicaid Residual Per Diem for Core
Limited Health-Related Services?
Included in Other Limited Health-Related Services?
Practitioner Employed by
29-I:
Physician Specialist
Physician
Nurse Practitioner
Registered Physician
Assistant
Psychiatrist
Psychologist
Clinical Social Worker
Marriage and Family
Therapist
Mental Health
Counselor
Yes
Clinical consultation/ program supervision services or Skill Building as described in 29-I Health Facility Guidance are included in the Medicaid residual per diem.
Yes
Encounter-based services outside of Core clinical consultation/program supervision services (e.g. testing/ assessments) may be billed as Other Limited Health- Related Services.
Practitioner/Service
Provider Not Employed
by 29-I:
Physician Specialist
Physician
Nurse Practitioner
Registered Physician
Assistant
Psychiatrist
Psychologist
Ophthalmologist/
Optometrist
Clinical Social Worker
Marriage and Family
Therapist
Mental Health
Counselor
Home Health Care
Yes
Non-29-I practitioners must continue to be paid directly by the 29-I Health Facility out of the Medicaid residual per diem, as outlined in the Medicaid Child (Foster) Care Manual available here: https://www.emedny.org/ProviderManuals/ChildCare/PDF S/ChildCarePolicyGuidelines.pdf
No
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Service listed in eMedNY
Provider Manual
Included in Medicaid Residual Per Diem for Core
Limited Health-Related Services?
Included in Other Limited Health-Related Services?
X-ray/Radiology
Physical Therapy
Occupational Therapy
Dental
Yes
Dental providers must continue to be paid through the
Medicaid residual per diem, as outlined in the Medicaid
Child (Foster) Care Manual available here:
https://www.emedny.org/ProviderManuals/ChildCare/PDF
S/ChildCarePolicyGuidelines.pdf.
No
Dentistry is not an allowable service under the 29-I
licensure.
Prescription Drugs and
Durable Medical
Equipment/Supplies
No
http://www.health.ny.gov/health_care/medicaid/program/p
harmacy.htm
No
Non-prescription drugs
No
No
Laboratory
No
Yes
Transportation
Yes
Transportation for routine health care services are
included in the Core Medicaid residual per diem, as
described in this Billing Manual. Non-routine transportation
should be billed directly by the transportation provider to
Medicaid FFS.
No
Speech & Audiology
No
Yes
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April 2023P a g e | 76 APPENDIX I: CONTACT INFORMATION LOCAL DEPARTMENT OF SOCIAL SERVICES For questions involving: Updated and/or corrected Medicaid eligibility and foster care placement status Billing roster issues Questions and issues Locating Medicaid-enrolled health providers, VFCA liaisons, and those delegated to bring foster care youth for health appointments
Local Department of Social Services contact information can be found at: http://www.ocfs.state.ny.us/main/localdss.asp.
MEDICAID POLICY UNIT
For questions regarding: Medicaid policy related to health services covered within the VFCA Medicaid rate or Medicaid fee-for-service (518) 486-6562
NYS DOH RATE SETTING UNIT
For questions regarding:
Childcare agency VFCA rate categories
Medicaid rate setting
Medicaid cost reporting processes
fostercare@health.ny.gov
NYS DOH ORTHODONTIA POLICY UNIT
(800) 342-3005 Option #2 Archive
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For questions regarding
VFCA authorization process
Out-of-state placement
VFCA program approval, including health care component
OCFS rate categories; rate setting
Cost reporting related to the maintenance rate assignment process
(518) 408-4064
OCFS INTERSTATE COMPACT UNIT
For questions regarding: Interstate Compact on the Placement of Children (518) 473-1591 OCFS REGIONAL CONTACTS For questions regarding: Updated eligibility and/or foster care placement status Outstanding questions and issues
Only contact the appropriate Regional Office, as indicated on the chart below, after contacting the appropriate local department of social services. Archive
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April 2023P a g e | 78 Regional Office Counties Served Contact Information Albany Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington 52 Washington St. Rensselaer, NY 12144
Telephone: (518) 486-7078 Fax: (518) 486-7625
Buffalo Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming Ellicott Square Building 295 Main Street Room 545, 5th Floor Buffalo, NY 14203
Telephone: (716) 847-3145 Fax: (716) 847-3742
New York City
Bronx, Kings, New York, Queens and
Richmond
Adam Clayton Powell State
Office Bldg.
163 West 125th Street, 18th
Floor
New York, NY 10027
Telephone: (212) 383-1983
Fax: (212) 383-2512
Rochester
Chemung, Livingston, Monroe, Ontario,
Schuyler, Seneca, Steuben, Wayne, Yates
259 Monroe Avenue Room 307 Rochester, NY 14607
Telephone: (585) 238-8201
Fax: (585) 238-8289
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Telephone: (315) 423-1200 Fax: (315) 423-1198 Yonkers Dutchess, Nassau, Orange, Putnam, Rockland, Suffolk, Sullivan, Ulster, Westchester
117 East Stevens Avenue Suite 300 Valhalla, NY 10595 Archive
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For questions regarding: Outstanding questions and issues
Only contact Central Office after contacting the appropriate regional office. (518) 408-4064
OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE
For questions regarding:
Processing bills from providers not enrolled in the New York State Medicaid Program
Health care outside the New York State childcare agency Medicaid rate
(518) 474-7527
ORTHODONTIA PRIOR APPROVAL
For all counties except the five boroughs of New York City:
(800) 342-3005 Choose: Option #2
For the five boroughs of New York City:
(212) 978-5560
ONLINE LINKS
To order additional information regarding the Interstate Compact on the Placement of Children,
please refer to the American Public Human Services Association publication website:
www.aphsa.org.
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APPENDIX J: DEFINITIONS
For the purposes of the Medicaid Program, and as used in this Manual, the following terms are
defined as follows:
8D BABIES
Babies/children (8D) residing with a parent who is in foster care and receiving services from a
29-I Health Facility
AGENCY OPERATED BOARDING HOME
A level 3 congregate care facility that is a family-type home for the care and maintenance of not
more than six children that is operated by a VFCA, in quarters or premises owned, leased, or
otherwise under the control of such agency. Such a home may provide care for more than six
brothers and sisters of the same family.
COURT-ORDERED SERVICES
Services the Plan is required to provide to enrollees pursuant to orders of courts of competent
jurisdiction, provided however, that such ordered services are within the Plan's benefit package
and reimbursable under Title XIX of the Federal Social Security Act, SSL 364-j(4)(r).
COMMITTEE ON SPECIAL EDUCATION (CSE) PLACEMENT
Children/youth who are placed in a 29-I Health Facility setting by their local school district’s Committee on Special
Education (CSE) for children/youth to receive specialized services (e.g. developmental; behavioral) that cannot be
met through the services provided by the local school district.
DIAGNOSTIC
A Level 4 specialized congregate care facility operated by a VFCA for the 24-hour care and
maintenance of children and the program has been classified as Diagnostic.
DIRECT CARE FOSTER CARE YOUTH
These youth are served directly by the fiscally responsible local department of social services
(LDSS). Most of these youth are placed directly by the LDSS in LDSS-run individual family foster
boarding homes. A few are served in other types of foster care group/congregate care type
arrangements.
ESSENTIAL COMMUNITY PROVIDERS
Essential Community Providers are, as identified by the State, providers with expertise in
serving children placed in foster care. MMCPs will reimburse for covered Benefit Package
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services in accordance with the Medicaid Managed Care/HIV Special Needs Plan/Health and
Recovery Plan Model Contract.
FOSTER CARE CHILD/YOUTH
A foster care child/youth is a child/youth who is:
in the legal custody of the Commissioner of the local department of social services (and
in some cases, in the legal custody of the NYS Office of Children and Family Services
Commissioner, and assigned foster care status) and
cared for away from his or her home 24 hours a day in a duly authorized or certified
facility or program, including, but not limited to, the following foster care settings:
o a foster family boarding home,
o an agency operated boarding home,
o a group home,
o a group residence or
o an institution;
and is:
- a youth under the age of 18 years; or
- is between the ages of 18 years and 21 years who entered foster care before his or her
18th birthday and has consented to remain in foster care past his or her 18th birthday,
and
o is a student attending a school, college, or university; or regularly attending a
course of vocational or technical training designed to fit him or her for gainful
employment; OR
o lacks the skills or ability to live independently.
Youth in Foster care are sometimes served transitionally on either a short-term or a long-term basis in other service system settings, such as NYS Office for People With Developmental Disabilities licensed settings. When a youth in foster care who is served under the auspices of a NYS Medicaid-enrolled VFCA is temporarily placed in another service system setting that gets reimbursed by a Medicaid payment methodology, or via a non-Medicaid payment methodology that covers health care costs, then the VFCA must not simultaneously bill their VFCA Medicaid rate.
FOSTER FAMILY BOARDING HOME
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six children, and such person or family receives payment from the agency for the care of such
children.
GROUP HOME
A level 3 congregate care facility that is a family-type home for the care and maintenance of not
less than 7 nor more than 12 children who are at least five years of age, operated by a VFCA, in
quarters or premises owned, leased or otherwise under the control of such agency, except that
such minimum age is not applicable to siblings placed in the same facility nor to children whose
mothers are placed in the same facility.
GROUP RESIDENCE
A Level 4 specialized congregate care facility operated by a VFCA for the care and maintenance
of not more than 25 children
HARD TO PLACE
A Level 4 specialized congregate care facility operated by a VFCA for the 24-hour care and
maintenance of children and the program has been classified as Hard to Place.
INSTITUTION
A Level 4 specialized congregate care facility operated by a VFCA for the 24-hour care and
maintenance of 13 or more children.
KINSHIP
Setting where a child/youth is considered to be in foster care and placed in a relative’s home.
Kinship providers can be certified 29-I Health facilities or actively pursuing certification.
MATERNITY
A level 3 congregate care facility operated by a VFCA for the 24-hour care and maintenance of
children and the program has been classified as Maternity.
MEDICALLY FRAGILE
A level 2 specialized treatment facility that is a residence owned, leased or otherwise under the
control of a single person or family who has been certified by a VFCA to care for not more than
six children, and such person or family receives payment from the agency for the care of such
children.
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RAISE THE AGE
A Level 4 specialized congregate care facility operated by a VFCA for the 24-hour care and
maintenance of children and the program has been classified as Raise the Age.
SINGLE CASE AGREEMENT (SCA)
An agreement between a non-contracted provider and the MMCO with in which the provider is
reimbursed for the care for one specific child’s case.
SPECIAL NEEDS
A level 2 specialized treatment facility that is a residence owned, leased, or otherwise under the
control of a single person or family who has been certified by a VFCA to care for not more than
six children, and such person or family receives payment from the agency for the care of such
children.
SUPERVISED INDEPENDENT LIVING PROGRAM (SILP)
A level 3 congregate care facility for youth under the supervision of an authorized VFCA and are
intended to provide a transitional experience for children for whom the plan of care is
discharge from care to their own responsibility. Youth live in a unit separate from the rest of
the agency dwellings. A SILP living unit may house not more than four children; children must
be at least 16 years of age and not more than 21 years of age.
THERAPEUTIC/AIDS
A level 2 specialized treatment facility that is a residence owned, leased, or otherwise under the
control of a single person or family who has been certified by a VFCA to care for not more than
six children, and such person or family receives payment from the agency for the care of such
children.
TITLE IV-E
Title IV-E of the Social Security Act (42 U.S.C. §§ 671-679b) provides for federal reimbursement
for a portion of the maintenance and administrative costs of foster care for children who meet
specified federal eligibility requirements. In New York, the federal share is 50%. The federal
funds help offset the State and local costs of providing foster care to children. However, not all
children in foster care in New York are eligible for federal Title IV-E reimbursement as per the
guidelines located at https://ocfs.ny.gov/main/fostercare/titleiv-e/.
VOLUNTARY FOSTER CARE AGENCY (VFCA)
Any agency, association, corporation, institution, society, or other organization which is
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incorporated or organized under the laws of New York State with corporate power or
empowered by law to care for, to place out, or to board out children.
The entity must actually have its place of business in New York State and must be approved,
visited, inspected, and supervised by the New York State Office of Children and Family Services
or submit and consent to the approval, visitation, inspection, and supervision of the New York
State Office of Children and Family Services as to any and all acts in relation to the welfare of
children performed or to be performed under the provisions of Title 1 of Article 6 of the Social
Services Law.
Local departments of social services (LDSS) contract with VFCAs to serve particular youth in
foster care, commonly those with more complex health and social service needs.
The New York State Office of Children and Family Services has statutory oversight responsibility,
including oversight of health care, for both direct care youth in foster care and those served by
VFCAs.
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