- Background and
Scope
Public Consulting Group (PCG), hereinafter
referred to as the SFA, has billing and claiming criteria that requires the
following:
- Processing of
voided claims initiated in NYEIS
- Processing of
voided claims initiated in KIDS
- Processing of
voided claims initiated by providers no longer receiving early
intervention Escrow payments
- Recoupment of
all resulting overpayment made by Escrow
- Sending
outbound voided claims via an outbound 837 file or paper (whichever
appropriate) to all applicable third parties (commercial insurance/payer
and Medicaid).
- Purpose
The
purpose of this policy is to outline the appropriate claiming and billing
activities when a voided claim is received.
- Policy
Statement
As
required by the Department the SFA accepts and processes voids created through
the State’s source system.
·
The policy and procedure for managing Voids
from KIDS will be established separately.
Should claims be overpaid as a result of a
voided claim, the overpayment amount is recouped by the overpaying party, which
could be Escrow, Commercial Payer, Medicaid and/or BEI. Unless part of a void
project, claims overpaid by Escrow shall be deducted from the provider’s next
available Escrow payment. Claims overpaid as a result of a void project shall
be recouped in a lump sum or over a period of 10 weeks.
·
The policy and procedure for managing
negative balances for providers who no longer provide early intervention
services and therefore will not have claims to offset overpayments will be
established separately.
- Definitions
Q1 2015 VOIDS Project: A recoupment process
of overpayments for provider-generated voids put in to the EI system from
4/1/2013 to 12/31/2014
BEI: Bureau of Early Intervention
SFA: State Fiscal Agent
Claim: An itemized statement of services and
costs from an early intervention provider submitted to the SFA for payment
Original Claim: Initial submission of a claim
and resubmission of a previously voided claim
Voided Claim: A claim meant to nullify an
original claim
Recoup/Recoupment: Deduction of overpayments
from the provider’s future payment by the overpaying party
TPL: Third Party Liability(ies), this
includes commercial insurance/payers and Medicaid
Inactive Providers: Providers
who no longer provide early intervention services and therefore will not have
claim payments to offset overpayments
- NYEIS Procedure
All data files are
typically received from the DOH every Monday. In the event Monday is a holiday,
the files are received on Tuesday. The claims are submitted in two separate
files, one consisting of only Original Claims and the other consisting of only
Voided Claims. Both files are uploaded to the SFA’s claim system the same day
of receipt.
Original claims are
loaded to the claiming system prior to loading the voided claims.
Voids are processed
immediately for claims that fall into one of the following categories:
1.
Claim has not been sent to primary TPL
2.
Claim has not been sent to secondary TPL
3.
Claim has not received a response from third party
payer, including Medicaid within 25 days of submitting claim to the TPL
4.
Claim has been considered by all TPL and is pending
Escrow payment
5.
Claim has been considered by all TPL and Escrow
payment has been issued
6.
Claim is in a workable queue
Voids are not
processed for claims that are pending a response from a TPL within the first 25
days after claim submission.
Voided Claim Process when only Medicaid and
Escrow are involved
1. Voided claims are loaded to the SFA claim system
2. Using the NYEIS claim id field, the system locates the original claim
received.
·
In the absence of an original claim to void, the
void transaction is manually reviewed by the SFA to confirm there is no claim
to void. After confirmation, the void is closed in EIBilling.com by the SFA.
3. The transaction billed amount, other paid amount(s) and escrow paid
amounts are nullified.
4. The status of the claim is updated to “Voided” and can be viewed via
existing on-line claim reports within the EIBilling.
5. When the void is processed, the system recognizes the void and
simultaneously creates a void transaction for any Medicaid activity that may
have occurred on the claim.
6. 837I outbound claim files are created and submitted to Medicaid if
applicable.
7. The system deducts any escrow payment made on the voided claim from
future payments made to the associated billing agency.
8. The 835I response files acknowledging the processing of the void
Example:
Original Claim
DOS Procedure Billed Medicaid Escrow
5/1/14 90802 $75 $75 $0
Voided Claim
DOS Procedure Billed Medicaid
Escrow
5/1/14 90802 ($75) ($75) ($0)
In this example,
the claim has been voided. A void transaction is issued to Medicaid. Medicaid
will recoup from the provider the $75 they paid.
In the event that
there is no Medicaid and payment was issued from Escrow only, the claim is
voided and the overpaid amount is deducted from the billing agency’s future escrow
payments.
Example:
Original Claim
DOS Procedure Billed Escrow
Paid
5/1/14 90802 $75 $75
Voided Claim
DOS Procedure Billed Escrow
Paid
5/1/14 90802 ($75) ($75)
In this example,
the claim has been voided. Future escrow benefits to the billing agency shall
be reduced by $75.
F. Voided
Claim Process when Commercial Payers are involved
1. Voided claims are loaded to the SFA claim system.
2. Using the NYEIS claim id field, the system locates the original claim
received.
·
In the absence of an original claim to void, the
void transaction is manually reviewed by the SFA to confirm there is no claim
to void. After confirmation, the void is closed in EIBilling.com by the SFA.
3. The transaction billed amount, other paid amount(s) and escrow paid
amounts are nullified.
4. The status of the claim is updated to “Voided” and can be viewed via
existing on-line claim reports within the EIBilling.
5. When the void is processed, the system recognizes the void and
simultaneously creates a void transaction for any commercial payer and Medicaid
activity that may have occurred on the claim.
6. 837P outbound files are created and submitted to all
applicable payers for original claims with a commercial payer claim ID.
7. Voids associated with original claims that do not have a commercial payer
claim ID are managed by the SFA through a manual queue. Note: Currently, the SFA,
providers, and electronic remit files from payers do not currently update the
payer claim IDs on the original claims. Should this system enhancement occur,
the SFA will have the ability to increase the electronic void transactions with
payers which will in turn expedite the void process.
8.
837I outbound files
are created and submitted to Medicaid (if applicable).
9.
For voids initiated
via an 837, 835 response files are received from the commercial payers and
Medicaid acknowledging receipt of the void.
10. For voids initiated manually by the SFA, the voids
are manually processed directly with the commercial payers, using the SFA
system.
Example:
Original
Claim
DOS Procedure Billed BCBS
Paid Escrow Paid
5/1/14 90802 $75 $50 $25
Voided
Claim
DOS Procedure Billed BCBS
Paid Escrow Paid
5/1/14 90802 ($75) ($50) ($25)
In this example,
the claim has been voided. A void transaction is issued to BCBS and future
benefits to the billing provider/agency shall be reduced by $25. BCBS will also
recoup from the provider the $50 they paid.
- KIDS - PROCEDURE TBD
- INACTIVE PROVIDERS TBD
- RETRO VOIDED CLAIMS – PROJECT
Since
there is an inventory of voids not processed from 4/1/2013 to 12/31/14, the SFA
will with the exception of claims involving commercial payers which escrow will
be always be recouped at 100%, shall notify via email the impacted providers of
the amounts that will be voided and when they will be voided. The recoupment of
the resulting escrow overpayments will be completed one of two ways:
Option 1: Unless
contacted by the provider to select Option 2, Option 1 will be the default recoupment
method.
All voids will be
processed and recouped at 100% from the provider’s subsequent escrow payments until
the overpayment is recouped.
For
example:
$1000 total amount to be recouped
$1000 next escrow
payment scheduled
$1000 will be deducted from the next escrow payment
OR
$1000
total amount to be recouped
$500 next escrow payment
scheduled
$500 will be deducted
from the next escrow payment and the remaining $500 will be recouped from the
following escrow payments
Option 2: This option
will be available to providers whose impacted claims do not involve commercial
payers and who inform the SFA in writing within 10 business days of the SFA
notifying the provider of the overpayment.
The
amount of the provider’s overpayment will be divided among 10 weeks and,
processing by claim date of service, voids will be processed within the SFA
system as close to the weekly amount without splitting claims.
For example:
$1000 total amount to be recouped
$100 targeted to be
recouped each week
There are 16 claims to
void at $62.50 per claim
Two claims will be
voided per week totaling $125
- Down Stream Processes
All down-stream processes shall
take the voided claims into consideration. These include, but not limited to:
·
1099: voids are reflective in the year that they are processed
·
Reports
·
Data Warehouse
·
State Voucher
K.
Report
A monthly “Closed Void” report
will be created that will identify all voids that were received but could not
be processed because the SFA did not receive the original claim associated with
the void.
L.
Reference sources
N/A
- Attachments
N/A