SPECIAL NOTIFICATION TO ALL NYC OMH AND OASAS SERVICE PROVIDERS
September 21, 2015
This notification is to alert providers of mental health and substance use disorder services of a systems billing issue associated with the inclusion of behavioral health services in the Medicaid managed care benefit package.
Effective October 1, 2015, the Medicaid managed care (MMC) benefit package is expanding to include additional behavioral health (BH) services. However, until edits are in place a systems issue will allow a claim submission for an MMC-covered service to be paid by Medicaid fee-for-service (FFS).
This issue applies to adult (21 years of age and older) NYC consumers that are enrollees of Medicaid managed care plans, HIV Special Needs Plans (HIV SNP), and the new Health and Recovery Plans (HARPs). Providers of the affected programs are already aware that effective October 1, 2015 for adult NYC residents, all behavioral health services will be included in the MMC benefit package.
From dates of service October 1, 2015 forward, providers of those BH services that were previously carved out of the benefit package may not directly bill Medicaid fee-for-service for services delivered to NYC adult plan enrollees, and must instead submit those claims to the individual’s managed care plan. All of the BH programs associated with the BH inclusion into the MMC benefit package are listed below (services marked with an asterisk are already an MMC plan benefit for persons without SSI or SSI-related status):
OMH – Clinic*, Inpatient Psych*, CPEP, Continuing Day Treatment, Partial Hospitalization, IPRT, ACT, and PROS
OASAS – Part 822 Chemical Dependence Clinic, Part 822 Chemical Dependence Outpatient Rehab, Part 822 MMTP/OTP, Part 818 Inpatient Rehabilitation*
Beginning on October 1, providers will have to take special care that they do not bill Medicaid FFS for in-plan behavioral health benefits for adult residents of NYC. During the period of October 1 – October 22, the MEVS system will incorrectly respond “Mental Health carve-out” for SSI NYC adult consumers. This response should not deter providers from billing the MMC plans for BH covered services beginning 10/1/15 (for both SSIs and non-SSI individuals).
When the updated edits are implemented on October 22, 2015 they will be effective retroactive to October 1. However, this will not cause an automatic recovery of any improper billings that were submitted prior to that date. OMH and OASAS, in conjunction with DOH, will be reviewing FFS claims and will zero out (void) any improper claims. If a provider appears to have disregarded this notice and continued to bill FFS for the majority of their “managed care” claims, there is the potential that a referral could be made to the Office of the Medicaid Inspector General (OMIG) or the State Comptroller (OSC).
General questions should be directed to the Provider Hotline at 1-800-343-9000.
OMH specific questions should be directed to [email protected] (or call 518-474-6911).
OASAS specific questions should be directed to: [email protected]