PMPM CDPAP Services for New York
This topic applies to Agencies who must bill monthly administrative fees for PMPM CDPAP services. This is mandated through MLTC Policy 21.02; effective as of April 1, 2021.
Reimbursement for FI Administrative Costs is made on a three-tier (“Tier”) FI PMPM rate structure for Medicaid FFS Members (authorized to receive CDPAP services). Each Tier represents a range of authorized direct care hours of CDPAP services for the Member for the month the FI PMPM is billed; allowing an Agency to bill a monthly administrative fee.
The hourly visits must be billed (invoiced) and paid for the Caregivers to receive payment. Expect for the state to negotiate LOWER reimbursement rates; what is billed for these hours does not include any administrative reimbursements. There are no changes to your normal HHAeXchange workflow for billing and paying these direct care visits.
The administrative reimbursement (the PMPM) is billed once a month; which can be scheduled automatically via the Additional Bill Info feature at the Patient Contract Level. More information below.
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It is recommended that the FI PMPM claims be submitted no earlier than the first day of the month immediately following the month for which reimbursement for services is being claimed.
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In order to submit an FI PMPM claim, the FI must have also billed for at least one hour of direct care services for the consumer during the month for which the FI PMPM is being billed.
***To properly track the Accounts Receivable for the PMPM reimbursement, it is recommended that a separate contract be created for this cause. This separate contract would be created and appended to the contract list of each FI Patient. The 3 tiered service codes would then be added to this contract.
Complete the following steps to apply the FI PMPM rate to the Additional Bill Info feature.
The following factors must be considered for a successful process:
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Create a new contract specifically for the PMPM portion of billed services. This allows to more easily track the PMPM accounts receivable, separate from direct care hours.
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A Caregiver is required for billing purposes. Create a Caregiver if/as needed.
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Ensure to create the Service Code as Skilled (required to bill the visit successfully) to mitigate the overlapping shift issue in Prebilling between the Monthly Billing Visits and CDPAP Live-In Shifts (Non-Skilled). The HHAeXchange system allows overlapping to occur between Skilled and Non-Skilled visits.
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Update Patient’s Accepted Services to include Other (Skilled).
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Billing Dx Codes may be required for billing purposes. Billing Dx Codes can be entered at the Patient or Contract level.
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Go to Patient > Contracts for the applicable contract, click the Additional Options link, and select Additional Bill Info from the menu.
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On the Additional Bill Info window, scroll to the Monthly Billing section. Select the Monthly Billing checkbox to enable the options. Complete the required fields (denoted with red asterisk), to include the Billing Day.
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It is recommended to bill the PMPM early in the month for services rendered in the prior month.
Billing Codes (Service Codes) are created in at the contract level via Contract Setup and represent the tiered PMPM rates. Because this is not a payable service, use Non-Billable Pay Code (strongly recommended).
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Once selected, the system schedules a nightly process which runs on the selected Billing Day. In addition, it creates a Schedule with a Visit Confirmation Time appearing in the Patient and Caregiver calendars.
While the nightly process runs, the system checks for all Scheduling validations. If any validation (such as Patient Shift Overlap, Caregiver Shift Overlap, Caregiver Compliance) impacts Schedule creation, then the visit is not created on the calendars.
As a result of the nightly process, a visit may appear on the calendar the day after the selected Schedule date.
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Invoice and export as per the normal processes.