Code 35 Claims Payment to Providers - June 2016

The Department of Health (DOH) Bureau of Early Intervention (BEI) has approved the State Fiscal Agent (SFA) to reimburse providers for open service coordination services claims denied by Medicaid due to the “Code 35” restriction. Claims selected for reimbursement will meet the following two criteria:

• Early Intervention service coordination claims received by EI Billing through December 31, 2015
• Service coordination services claims remain unpaid and in a Code 35 Medicaid denial status

Payment of these service coordination service claims will be made from Early Intervention (EI) escrow accounts and will be processed by the SFA. These payments are subject to recoupment of previous overpayments.

The SFA will issue payment to providers for these claims on Thursday, June 30, 2016. This payment will be issued as a special check run and will be executed prior to the regular check run during that week. Any provider negative escrow balances will be deducted from this special check file. Providers will be able to view the associated claims as they would normally view claims associated with their escrow payments, in EIBilling>Reports>View Escrow Checks.

The Department is committed to ensuring service coordination services claims for Medicaid children are reimbursed through the Medicaid program. EI providers will continue to be responsible for working with their Service Coordinators and municipalities to fix any Code 35 issues with Medicaid.

The SFA will continue to pursue Medicaid reimbursement for service coordination services claims and adjustments will be made to provider payments as Medicaid payments are received for these claims.

If you have any questions, please call the PCG Customer Service Center at (866) 315-3747.