Section 540.6 - Billing for medical assistance.

540.6 Billing for medical assistance.

(a) (1) Claims for payment for medical care, services or supplies furnished by any provider under the medical assistance program must be initially submitted within 90 days of the date the medical care, services or supplies were furnished to an eligible person to be valid and enforceable against the department or a social services district, unless the provider's submission of the claims is delayed beyond 90 days due to circumstances outside of the control of the provider. Such circumstances include but are not limited to attempts to recover from a third-party insurer, legal proceedings against a responsible third-party or the recipient of the medical care, services or supplies or delays in the determination of client eligibility by the social services district. All claims submitted after 90 days must be accompanied by a statement of the reason for such delay and must be submitted within 30 days from the time submission came within the control of the provider, subject to the limitations of paragraph (3) of this subdivision.

(2) Any claim returned to a provider due to data insufficiency or claiming errors may be resubmitted by the provider upon proper completion of the claim in accordance with the claims processing requirements of the department within 60 days of the date of the notification to the provider advising the provider of such insufficiency or invalidity. Any returned claim not correctly resubmitted within 60 days or on the second resubmission is neither valid nor enforceable against the department or a social services district.

(3) Notwithstanding paragraphs (1) and (2) of this subdivision to the contrary:

(i) all claims for payment for medical care, services or supplies furnished by non-public providers under the medical assistance program must be finally submitted to the department or its fiscal agent and be payable within two years from the date the care, services or supplies were furnished in order to be valid and enforceable as against the department or a social services district; and

(ii) all claims for payment for medical care, services or supplies furnished by public providers must be finally submitted to the department or its fiscal agent and be payable within two years from the date the care, services or supplies were furnished (or within such other period as agreed by the department and the public provider for payments initially made by the public provider under a program other than the medical assistance program) in order to be valid and enforceable as against the department or a social services district.

(4) For purposes of this subdivision, a claim is considered submitted upon its receipt by the department or its fiscal agent.

(b) (1) The department, on the dates specified, will assume, for the social services district comprising the city of New York, payment responsibilities for all claims of the following specified providers of medical care, services and supplies authorized to be provided under title II of article 5 of the Social Services Law (medical assistance for needy persons) for the care, services and supplies rendered on and after the date specified for the assumption of payment responsibilities by the department:

(i) Practitioner--which include the following, on November 1, 1977:

(a) Physician.

(ii) Clinics--which include the following, on November 1, 1977:

(a) Hospital emergency room;

(b) Hospital outpatient (other than dental service);

(c) Diagnostic and treatment center (clinic, free standing);

(d) Psychiatric clinic;

(e) Hospital psychiatric care (outpatient).

(iii) Pharmacies--which include the following, on April 1, 1978:

(a) Prescription drugs;

(b) Nonprescription drugs;

(c) Medical supplies, including sickroom supplies, provided by the pharmacy.

(iv) Hospitals--which include the following, on June 1, 1978:

(a) Inpatient hospitals;

(b) Private psychiatric hospitals.

(v) Dentists, dental schools and dental clinics, on September 1, 1978.

(vi) Laboratories, on September 1, 1978.

(vii) Skilled nursing facilities, which include nonoccupant care provided therein pursuant to Subchapter C of Title 10 of the Official Compilation of Codes, Rules and Regulations (Parts 780 through 782), on December 1, 1978.

(viii) Health related facilities, on December 1, 1978:

(a) excluding those facilities operated by the Office of Alcoholism and Substance Abuse in the New York State Department of Mental Hygiene; and

(b) excluding any facilities for the mentally retarded (HRF or ICF) whether operated privately or by the New York State Department of Mental Hygiene.

(ix) Health maintenance organizations, on January 1, 1979.

(x) Health insurance premiums, including prepaid group health insurance plans, on January 1, 1979.

(xi) Medical equipment dealers, including medical and surgical supply dealers, on January 15, 1979. Institutions supplying home dialysis equipment to kidney dialysis patients on April 1, 1981.

(xii) Prosthetic and orthotic appliance dealers, on January 15, 1979.

(xiii) Hearing aid dealers, on January 15, 1979.

(xiv) Transportation services, on January 15, 1979.

(xv) Home health agencies, on January 15, 1979.

(xvi) Child care agencies, on February 1, 1979.

(xvii) Optometrists, on February 1, 1979.

(xviii) Opticians and optical dispensers, on February 1, 1979.

(xix) Referred ambulatory care, on December 1, 1978.

(xx) (Repealed)

(xxi) Clinical psychologists, on March 1, 1979.

(xxii) Private psychiatric--inpatient, on March 1, 1979.

(xxiii) Nursing home facilities administered by Bureau of Medical Assistance-New York City, on March 1, 1979.

(xxiv) Independent speech and physical therapists.

(xxv) Occupational therapists.

(xxvi) Medical equipment dealers, including medical and surgical supply dealers, on January 15, 1979.

(xxvii) Prosthetic and orthotic appliance dealers, on January 15, 1979.

(xxviii) Hearing aid dealers, on January 15, 1979.

(xxix) Transportation services, on January 15, 1979.

(xxx) Home health agencies, on February 1, 1979.

(xxxi) Intermediate care facilities--mentally retarded (private and day care), on February 1, 1979.

(xxxii) Institutions supplying prescription drugs, nonprescription drugs and medical supplies to kidney dialysis patients on April 1, 1981.

(2) The above specified providers of medical care, services and supplies will submit claims to the district comprising the city of New York for all items of care, services and supplies furnished prior to date specified for the assumption of payment responsibilities by the department; and thereafter, such providers will submit claims for medical care, services and supplies furnished after such date to the department for all items of medical care, services and supplies.

(3) Providers rendering medical care, services and supplies to recipients of Medicaid who have received their authorization from the following specified counties shall bill the department for the specified care, services and supplies rendered on and after the date or dates respectively specified for such county:

(i) Chemung County: All care, services and supplies--August 1, 1979;

(ii) Washington County: All care, services and supplies--August 1, 1979;

(iii) Nassau County: All care, services and supplies--August 1, 1979, or such later date, to be specified by the commissioner, which shall in no event be later than November 1, 1979. The commissioner shall give at least 30 days' notice of the date specified in this subparagraph;

(iv) Livingston County: All care, services and supplies--September 1, 1980;
(v) Ontario County: All care, services and supplies--September 1, 1980;

(vi) Schuyler County: All care, services and supplies--September 1, 1980;

(vii) Seneca County: All care, services and supplies--September 1, 1980;

(viii) Steuben County: All care, services and supplies--September 1, 1980;

(ix) Wayne County: All care, services and supplies--September 1, 1980;

(x) Yates County: All care, services and supplies--September 1, 1980;

(xi) Monroe County: All care, services and supplies--November 1, 1980;

(xii) Dutchess County: All care, services and supplies--March 1, 1981;

(xiii) Orange County: All care, services and supplies--March 1, 1981;

(xiv) Putnam County: All care, services and supplies--March 1, 1981;

(xv) Rockland County: All care, services and supplies--March 1, 1981;

(xvi) Sullivan County: All care, services and supplies--March 1, 1981;

(xvii) Ulster County: All care, services and supplies--March 1, 1981;

(xviii) Westchester County: All care, services and supplies--May 1, 1981;

(xix) Warren County: All care, services and supplies--May 1, 1981;

(xx) Saratoga County: All care, services and supplies--May 1, 1981;

(xxi) Fulton County: All care, services and supplies--May 1, 1981;

(xxii) Montgomery County: All care, services and supplies--May 1, 1981;

(xxiii) Schenectady County: All care, services and supplies--May 1, 1981;

(xxiv) Schoharie County: All care, services and supplies--May 1, 1981;

(xxv) Albany County: All care, services and supplies--May 1, 1981;

(xxvi) Rensselaer County: All care, services and supplies--May 1, 1981;

(xxvii) Greene County: All care, services and supplies--May 1, 1981;

(xxviii) Columbia County: All care, services and supplies--May 1, 1981;

(xxix) Cortland County: All care, services and supplies--July 1, 1981;

(xxx) Madison County: All care, services and supplies--July 1, 1981;

(xxxi) Oneida County: All care, services and supplies--July 1, 1981;

(xxxii) Onondaga County: All care, services and supplies--September 1, 1981;

(xxxiii) Oswego County: All care, services and supplies--July 1, 1981;

(xxxiv) Cayuga County: All care, services and supplies--July 1, 1981;

(xxxv) Broome County: All care, services and supplies--September 1, 1981;

(xxxvi) Chenango County: All care, services and supplies--September 1, 1981;

(xxxvii) Delaware County: All care, services and supplies--September 1, 1981;

(xxxviii) Otsego County: All care, services and supplies--September 1, 1981;

(xxxix) Tioga County: All care, services and supplies--September 1, 1981;

(xl) Tompkins County: All care, services and supplies--September 1, 1981;

(xli) Allegany County: All care, services and supplies--October 1, 1981;

(xlii) Cattaraugus County: All care, services and supplies--October 1, 1981;

(xliii) Chautauqua County: All care, services and supplies--October 1, 1981;

(xliv) Genesee County: All care, services and supplies--October 1, 1981;

(xlv) Niagara County: All care, services and supplies--October 1, 1981;

(xlvi) Orleans County: All care, services and supplies--October 1, 1981;

(xlvii) Wyoming County: All care, services and supplies--October 1, 1981;

(xlviii) Clinton County: All care, services and supplies--December 1, 1981;

(xlix) Essex County: All care, services and supplies--December 1, 1981;

(l) Franklin County: All care, services and supplies--December 1, 1981;

(li) Hamilton County: All care, services and supplies--December 1, 1981;

(lii) Herkimer County: All care, services and supplies--December 1, 1981;

(liii) Jefferson County: All care, services and supplies--December 1, 1981;

(liv) Lewis County: All care, services and supplies--December 1, 1981;

(lv) St. Lawrence County: All care, services and supplies--December 1, 1981;

(lvi) Suffolk County: All care, services and supplies--January 1, 1981; and

(lvii) Erie County: All care, services and supplies--February 1, 1982.

(c) The uniform billing form (UBF-1) shall be used for all acute care hospital inpatient bills for a patient's stay whose admission to the hospital occurred on or after the appropriate implementation date as specified by the State Department of Social Services.

(d) Providers rendering personal care services under a contractual arrangement with local social services districts as described in section 505.14 of this Title shall bill the department for the specified service rendered on and after the date(s) respectively specified for such social services district as follows:

(1) Chenango County: All personal care services--July 1, 1985;

(2) Genesee County: All personal care services--July 1, 1985;

(3) Livingston County: All personal care services--July 1, 1985;

(4) Niagara County: All personal care services--July 1, 1985;

(5) Ontario County: All personal care services--July 1, 1985;

(6) Orleans County: All personal care services--July 1, 1985;

(7) Wyoming County: All personal care services--July 1, 1985;

(8) Clinton County: All personal care services--August 1, 1985;

(9) Essex County: All personal care services--August 1, 1985;

(10) Hamilton County: All personal care services--August 1, 1985;

(11) Jefferson County: All personal care services--August 1, 1985;

(12) Lewis County: All personal care services--August 1, 1985;

(13) St. Lawrence County: All personal care services--August 1, 1985;

(14) Yates County: All personal care services--September 1, 1985;

(15) Cayuga County: All personal care services--September 1, 1985;

(16) Cortland County: All personal care services--September 1, 1985;

(17) Schuyler County: All personal care services--September 1, 1985;

(18) Seneca County: All personal care services--September 1, 1985;

(19) Tompkins County: All personal care services--September 1, 1985;

(20) Wayne County: All personal care services--September 1, 1985;

(21) Cattaraugus County: All personal care services--October 1, 1985;

(22) Chautauqua County: All personal care services--October 1, 1985;

(23) Chemung County: All personal care services--October 1, 1985;

(24) Franklin County: All personal care services--October 1, 1985;

(25) Steuben County: All personal care services--October 1, 1985;

(26) Tioga County: All personal care services--October 1, 1985;

(27) Columbia County: All personal care services--November 1, 1985;

(28) Dutchess County: All personal care services--November 1, 1985;

(29) Erie County: All personal care services--November 1, 1985;

(30) Orange County: All personal care services--November 1, 1985;

(31) Putnam County: All personal care services--November 1, 1985;

(32) Rensselaer County: All personal care services--November 1, 1985;

(33) Rockland County: All personal care services--November 1, 1985;

(34) Sullivan County: All personal care services--November 1, 1985;

(35) Ulster County: All personal care services--November 1, 1985;

(36) Madison County: All personal care services--December 1, 1985;

(37) Otsego County: All personal care services--December 1, 1985;

(38) Oswego County: All personal care services--December 1, 1985;

(39) Saratoga County: All personal care services--December 1, 1985;

(40) Warren County: All personal care services--December 1, 1985;

(41) Washington County: All personal care services--December 1, 1985;

(42) Delaware County: All personal care services--January 1, 1986;

(43) Fulton County: All personal care services--January 1, 1986;

(44) Greene County: All personal care services--January 1, 1986;

(45) Herkimer County: All personal care services--January 1, 1986;

(46) Montgomery County: All personal care services--January 1, 1986;

(47) Oneida County: All personal care services--January 1, 1986;

(48) Schoharie County: All personal care services--January 1, 1986; and

(49) New York City: All personal care services--July 1, 1986.

(e) (1) As a condition of payment, all providers of medical assistance must take reasonable measures to ascertain the legal liability of third parties to pay for medical care and services.

(2) No claim for reimbursement shall be submitted unless the provider has:

(i) investigated to find third-party resources in the same manner and to the same extent as the provider would to ascertain the existence of third-party resources for individuals for whom reimbursement is not available under the medical assistance program; and

(ii) sought reimbursement from liable third parties.

(3) Each medical assistance provider shall:

(i) request the medical assistance recipient or his representatives to inform the provider of any resources available to pay for medical care and services;

(ii) make claims against all resources indicated on a Medicaid identification card or communicated to the provider via the electronic Medicaid eligibility verification system, via the medical assistance information and payment system (MMIS) toll-free inquiry telephone number of via the MMIS transaction telephone system, and all resources which the provider has discovered, prior to submission of any claim to the medical assistance program;

(iii) continue investigation and attempts to recover from potential third-party resources after submission of a claim to the medical assistance program to at least the same extent that such investigations and attempts would occur in the absence of reimbursement by the medical assistance program;

(iv) if the provider is informed of the potential existence of any third-party resources by an official of the medical assistance program, or by any other person who can reasonably be presumed to have knowledge of a probable source of third-party resources, investigate the possibility of making a claim to the liable third party and make such claim as is reasonably appropriate; and

(v) take any other reasonable measures necessary to assure that no claims are submitted to the medical assistance program that could be submitted to another source of reimbursement.

(4) Any reimbursement the provider recovers from liable third parties shall be applied to reduce any claims for medical assistance submitted for payment to the medical assistance program by such provider or shall be repaid to the medical assistance program within 30 days after thirdparty liability has been ascertained; when a claim has been submitted to a third party whose liability was ascertained after submission of a claim to the medical assistance program the provider must make reimbursement to the medical assistance program within 30 days after the receipt of reimbursement by the provider from a liable third party.

(5) A provider of medical assistance shall not deny care or services to a medical assistance recipient because of the existence of a thirdparty resource to which a claim for payment may be submitted in accordance with this subdivision.

(6) A provider of medical assistance must review and examine information relating to available health insurance and other potential thirdparty resources for each medical assistance recipient to determine if a health insurance identification card or any other information indicates that prior or other approval is required for non-emergency, post-emergency, non-maternity, hospital, physician or other medical care, services or supplies. If approval is required as a condition of payment or reimbursement by an insurance carrier or other liable third party, the provider must obtain for the recipient, or ensure that the recipient has obtained, any necessary approval prior to submitting any claims for reimbursement from the medical assistance program. The provider must comply with all Medicare or other third-party billing requirements and must accept assignment of the recipient's right to receive payment or must acquire any other rights of the recipient necessary to ensure that no reimbursement is made by the medical assistance program when the costs of medical care, services or supplies could be borne by a liable third party. If a provider fails to comply with these conditions, any reimbursement received from the medical assistance program in violation of the provisions of this paragraph must be repaid to the medical assistance program by such provider. No repayment will be required if the provider can produce acceptable documentation to the department that the provider reasonably attempted to ascertain and satisfy any conditions of approval or other claiming requirements of liable third-party payors in the same manner and to the same extent as the provider would for individuals for whom reimbursement is not available under the medical assistance program, as described in paragraphs (1) through (5) of this subdivision.

(7) A provider of medical assistance who becomes aware, or reasonably should have become aware, of available health insurance or other potential third party resources that can be claimed from a liable third party by the provider as an agent of a social services official in accordance with the provisions of Part 542 of this Title, must submit a claim for such payment to the liable third party in the manner described in Part 542, except that a provider will not be required to submit such a claim to a liable third party when the claim is for prenatal care for pregnant women or preventive pediatric services (including early and periodic screening, diagnosis and treatment services). If a provider fails to submit such a claim as required by this paragraph, reimbursement for such claim will not be made by the medical assistance program and any reimbursement received in violation of the provisions of this paragraph must be repaid to the medical assistance program by such provider. If a provider has satisfied the requirements described in paragraphs (1) through (6) of this subdivision, no repayment will be required if the provider can produce documentation acceptable to the department that the provider reasonably attempted to ascertain whether such claim could be submitted in the manner described in Part 542 of this Title. If a provider submits a claim in accordance with the provisions of Part 542 of this Title and all or a portion of such claim is rejected by the liable third party through no fault of the provider, that portion of the claim that is so rejected may be submitted to the medical assistance program for payment.

 

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