Medicaid Billing Compliance

S2AY Network Administrative Manual

Reviewed February 29, 2016

Reviewed February 28, 2017

MEDICAID BILLING COMPLIANCE

Policy:

Agency staff will ensure that billing is conducted in accordance with Federal and State requirements.

Purpose:

To properly bill for services rendered.

Reference(s):

PECOS

Provider Excluded List

NYS Office of the Professions

GENERAL INFORMATION:

Federal and State regulations mandate that all Physicians ordering services for Agency patients are licensed in the State of New York. This also applies to Speech Language Pathologists providing services in the Early Intervention and Preschool Special Education Programs.

Workforce involved in billing Medicaid services may include, but not be limited to, Nurses, Therapists, Office Billing Clerks, Vendors, and Referral Sources.

Agency must verify that physicians/other Medicaid service providers are qualified to provide Medicaid reimbursed services. Verification must occur at time of patient referral and at least once per month thereafter.

Contracts will contain a provision requiring contractors to check all three exclusion lists before hiring staff and every 30 days thereafter to comply with Medicaid provisions.

A prescription or order written prior to exclusion remains valid for 180 days. Anything written ON OR AFTER the individual is excluded will be rejected for payment under the Medicaid system.

PROCEDURE:

Physicians

Agency staff will establish name and address of physician who will be ordering services for a specific patient.
Physician will be confirmed at first patient contact.
Agency will verify that physician has:

Current NYS licensure
Federal NPI number
PECOS enrollment (for Medicare patients only)

Agency will ensure that physician is not on any Medicare and Medicaid excluded lists at:
Excluded Parties List System (EPLS)
US Department of Health & Human Services, Office of Inspector General: List of Excluded Individuals and Entities
NYS Office of Medicaid Inspector General, Restricted, Terminated Individuals & Entities

Agency will ensure that physician has no licensure limitations to practice through NYS Board of Professional Misconduct.
All of the above must be verified prior to billing for patient services.

Other Workforce Involved in Billing Medicaid Services

Agency will verify that other workforce members have current NYS licensure and/or certification, if applicable.

Agency will ensure that all Medicaid service providers are not on any excluded parties lists at:
Excluded Parties List System (EPLS)
US Department of Health & Human Services, Office of Inspector General: List of Excluded Individuals and Entities
NYS Office of Medicaid Inspector General, Restricted, Terminated Individuals & Entities
All of the above must be verified prior to billing for patient services.

Any errors in Medicaid billing will be reported to the Agency Director. The Agency Director will consider whether the error is reportable to NYS Office of Medicaid Inspector General.