EI-NYEIS Ordering/Referring Communication

New York State Department of Health
New York Early Intervention System (NYEIS) Electronic Mailing List
EI-NYEIS Ordering/Referring Communication

Dear Colleague:

The New York State Department of Health (Department) issued preliminary guidance in December, 2013, on a new claim edit that was implemented by the Medicaid Program on January 1, 2014.  This requirement provides for the identification of the ordering /referring health care professional for services provided under the State Medicaid Plan, which includes Early Intervention (EI) services.  Implementation of this provision requires additional screening of Medicaid providers in an effort to improve the integrity of the Medicaid Program and reduce fraud, waste and abuse.

BEI has worked with our NYEIS system integrator to develop business requirements and modifications to NYEIS in order to comply with ordering/referring requirements.  All billing providers will be required to add the referring provider’s NPI on claims that are submitted in NYEIS in order to claim for EI services, whether a child is Medicaid eligible, has other third party commercial insurance or no insurance coverage.  Although the referring provider NPI is required for Medicaid claims, the Department believes that adding the referring provider NPI on claims, including Commercial Insurance claims, may enhance reimbursement from these payors.

Therefore, the purpose of this correspondence is to provide information to EI billing providers that the NPI of the referring provider will be required on EI claims that are submitted via on-line NYEIS and electronic 837 submission into NYEIS once the new version is deployed. The deployment of this version is scheduled to occur in mid-August 2015. BEI previously engaged stakeholders that use electronic 837 claim submission systems for input on implementation of this requirement for NYEIS.  Feedback from these providers determined that this change could be easily accommodated, once the specific requirements were provided by the Department. 

The referring provider NPI will be required for all claims for Service Coordination services, Multidisciplinary evaluation services and screenings, supplemental evaluations and all general services claims.  The matrix included in this correspondence provides Department guidance on which referring provider NPI is required for each type of claim submitted into NYEIS that will require an NPI.  BEI worked with the Office of Health Insurance Programs (Medicaid Program) to establish this guidance.

Additionally, while the referring provider NPI will be required on each EI service claim submitted as of the NYEIS version implementation in mid-August, EI program records requirements have always maintained that orders for EI services which require such an order, or prescriptions for EIP services written by a Physician, Nurse Practitioner or Physician Assistant be maintained in the child record.  For speech services, a recommendation from a Speech Language Pathologist (SLP) must be maintained in the child record.  EI providers should review existing and future orders and recommendations for EI services which require an order to ensure that the professional issuing the order is enrolled as a Medicaid provider.

Early Intervention Agency and Individual providers have enrolled in the Medicaid Program as Institutional billing providers.  For Early Intervention, Speech Language Pathologists are strongly encouraged to enroll as an ordering/prescribing/referring/attending (OPRA) provider as well.  Physicians, Nurse Practitioners and Physicians Assistants may also enroll as OPRA.  Occupational Therapists, Physical Therapists, Social Workers, and Audiologists are not permitted to order EI services, and do not need to enroll as OPRA providers for EI purposes. The web addresses provided below are resources that providers may access for more information regarding OPRA enrollment.

Medicaid Update of December 2013 (https://www.health.ny.gov/health_care/medicaid/program/update/2013/2013-12_pharmsped_edition.htm)

https://www.emedny.org

https://www.emedny.org/info/opra.aspx

https://www.emedny.org/info/ProviderEnrollment/index.aspx

While this correspondence provides the Department’s plan to implement OPRA requirements for NYEIS, additional guidance will be forthcoming regarding how the referring provider information captured on EI claims will be implemented with the State Fiscal Agent’s billing system to route claims to Medicaid and Commercial Insurance.  Additionally, further specific Department guidance will be provided to EI providers who use electronic 837 claiming, as soon as it becomes available.

Please contact the Bureau or Early Intervention at (518) 473-7016 or nyeista01@health.ny.gov should you have questions on this correspondence.