PMPM CDPAP Services Billing for New York

This topic applies to agencies who must bill monthly administrative fees for PMPM CDPAP services.

Reimbursement for FI Administrative Costs is made on a three-tier (Tier) FI PMPM rate structure. Each Tier represents a range of actual 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.

Tier

Rate Code

Number of Direct Care Hours per Month per Consumer

FI Monthly Reimbursement

1

2443

1-159 Hours

$146.45

2

2444

160-479 Hours

$387.84

3

2445

480 Hours and above

$1,046.36

There are no changes to your normal HHAeXchange workflow for billing and paying these direct care visits. Keep in mind that health plans may change reimbursement rates and what is billed for these hours may no longer include any administrative reimbursements.

The administrative reimbursement (the PMPM) is billed once a month. The following are recommended practices:

  • Submit the FI PMPM claims no earlier than the first day of the month immediately following the month for reimbursement for claimed services and no later than 90 days following the last day of the month the claim is being submitted for.

  • 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.

The Actual/Confirmed Hours for Internal and Linked Contracts section applies to Linked and Internal Contracts where PMPM billing was not in place prior to August 1, 2024.

For Internal Contracts where PMPM billing has been in place prior to August 1, 2021, continue the usual process. Refer to the Internal Contracts Prior to August 1, 2024 section below for instructions.

This process involves five phases: Service Code Setup, Billing Rate Setup, Generate and Review Report, Import and Process, and Export Invoice.

For Internal Contracts, verify billing format for Admin PMPM billing with the Payer to determine whether existing contract meets the requirements. If necessary, update the existing contract or create new contract to ensure billing compliance. Check with the Payer to verify that the e-billing format (837 I or P) meets the Payer's billing requirements.

Some Payers require that PMPM claims be submitted on a format different from your direct care labor claims. For example, direct care labor claims are submitted on the Professional Claims (837P) format while PMPM should be submitted on an Institutional Claims (837I) format. In these cases, the following two options are available:

  1. Update the direct labor claims e-billing format to match the required PMPM format. Contact HHAeXchange Support Team to implement the change.

  2. Create an additional contract for JUST the PMPM claims in the required format. Request the e-billing setup from HHAeXchange Support Team. Apply this contract to each Member as an additional contract. PMPM visits are then created under this contract and not the direct labor contract.

Service codes must be created for each contract and for each of the three PMPM tiers.

  • Linked Contracts: HHAeXchange creates these service codes as bundled codes, with a PA service code for each tier and a Skilled service code for each tier. Skilled service codes are used to help create PMPM visits for Patients who receive 24-hour care and do not have openings for a new shift. The Non-Skilled visit type can be used in most cases where overlapping services is not an issue. These codes are created as follows:

    • 2443 for Tier 1, PA discipline

    • 2443 Skilled for Tier 1, Other (Skilled) discipline

    • 2444 for Tier 2, PA discipline

    • 2444 Skilled for Tier 2, Other (Skilled) discipline

    • 2445 for Tier 3, PA discipline

    • 2445 Skilled for Tier 3, Other (Skilled) discipline

  • Internal Contracts: Follow the instructions below to create the service codes per Tier.

    HHAeXchange recommends that Providers create PA service codes for each tier. If they have Patients who receive 24-hour PA or Non-Skilled services, then Skilled service codes for each tier must also be created. Skilled service codes can be used to create PMPM visits for Patients who receive 24-hour PA or Non-Skilled services to avoid errors related to overlapping services.

    If required, ensure all applicable disciplines or service types are selected in the Accepted Services field in the Patient Profile

    • Create service code 2443 for Tier 1 (example in instructions below)

    • Create service code 2444 for Tier 2

    • Create service code 2445 for Tier 3

Complete the following steps to create a service code. In this example, service code 2443 is created.

  1. Go to Admin > Reference Table Management. Select Contract Service Code from the Reference Table dropdown field.

  2. The Contract Service Code window opens. Complete the necessary fields as per the following recommendations under the image. Required fields are denoted with a red asterisk.

    • Contract: Select the applicable contract.

    • Discipline: Select PA

    • Service Code: Enter 2443 (unless otherwise directed by payer)

    • Rate Type: Select Visit

    • Visit Type: Select Routine

    • Place of Service: Select Nursing Facility (32)

    • Select the following checkbox fields:

      • Mutual

      • Allow Patient Shift Overlap

      • Bypass Prebilling Validations

      • Allow Temporary Caregivers

      • No Authorization Required for Billing

    • Description: Enter a brief description for the service code (such as PMPM Tier Code).

    • Export Code: Enter the Service Code as the first value, followed by five colons (:::::), followed by the Service Code description.

    • Revenue Code: This code is defined by the Payer. There is no standard or default requirement.

    • HCPCS Code: Enter 2443 (same as Service Code field above).

  3. Click Save to save the service code.

Repeat instructions above to create service codes for the remaining tiers.

For Internal Contracts where Payers have requested Providers to bill with unique service codes for the three administrative tiers, follow the Payer's instructions and set up the codes accordingly. This can mean replacing the Export Code, HCPCS Code, and/or Revenue Code values.

Billing rates must be created to apply the service codes created in Phase 1 for the applicable Internal Contract. Rates must align with the FI Monthly Reimbursement amount (as seen in the Tier table above), OR any unique rate negotiated between the agency and the Payer. As with service codes, a rate must be applied to each created service code. The instructions below demonstrate how to apply a contract rate to service code 2443. Follow these steps to create all other applicable rates.

Complete the following steps to apply the service code to the billing rates.

  1. Go to Admin > Contract Setup > Search Contract to locate the Contract.

  2. Select the Billing Rates tab.

  3. On the Billing Rates page, select the New Rate button.

  4. The Contract Rate window opens. Complete the necessary fields, as per the recommendations under the image.

    • Discipline: Select Other (Skilled)

    • Service Code: Enter 2443.

    • From Date: Select the effective start date.

    • To Date: Select the end date

    • Rate: Enter the rate in dollar amount.

    • Billing Units: Enter 1.

    • Ensure the Active checkbox field is selected.

  5. Click Save to save the rate.

Repeat instructions above to create rates for the remaining rates per tier.

The CDPAP PMPM Tier Report/Extract is a workable report in CSV format which allows Providers to review and verify patients and tiers. It also serves as the visit import when the information is ready.

For the selected month, this report shows the following information:

  • Which Patients received CDPAP direct care hours

  • The number of hours of billed CDPAP direct care hours per patient

  • The number of unbilled, unconfirmed, and scheduled direct care hours per patient

  • Which tier each patient falls under, based on billed hours

Complete the following steps to generate, download, and review the CDPAP PMPM Tier Report/Extract, in preparation to bill the PMPM visits.

  1. Go to Report > Visits > Visit > CDPAP PMPM Tier Report/Extract.

  2. Use the filter fields to apply to the report. Click Print CSV to generate the report and save (download) to your workstation.

    CDPAP PMPM Tier Report

  3. Review the CDPAP PMPM Tier Report/Extract to determine the points below:

    • Review the Total Billed column in relation to the service code. Is the Tier code correct?

    • Is the tier for each patient accurate? HHAeXchange populates tiers according to billed hours at the time the report is run.

    • The Unbilled Hours amount reflects any additional hours that may be present on a Patient’s calendar, that are not yet billed. This can be scheduled, partially confirmed, or confirmed but not yet billed visits. For example, does this affect the recommended tier if the unbilled hours become billed? If so, then modify the tier, or delay the import of that visit for a specific Patient.

    • To make these adjustments, the following methods are recommended:

      • Remove the entire row from the report; OR

        • When using this option, save the removed row in a secure location to revisit at a later time.

        • Ensure that the entire row is deleted from the current report. Do not leave a blank row as this affects the visit import.

      • Remove the Visit Start Date and Visit End Date values. These visits remain in Prebilling as unconfirmed shifts and act as placeholders.

      • Modify rows as necessary, provided that the modified field follows the formatting and conventions outlined in the NY PMPM Confirmed Visit Import specifications.

  4. Save the report with an updated name. This is now the file to import in the next phase .

  1. Go to Admin > Import PMPM Confirmed Visits File to upload the validated CDPAP PMPM Tier Report/Extract. The validated report is used to auto-create Confirmed visits. Complete the necessary fields, as per the recommendations under the image.

    • Choose Import Interface Type: Select Confirmed Visits Import Process (NYPMPM)

    • Select File for Upload: Select the saved CDPAP PMPM Tier Report file.

      • Ensure to rename the file each time it is loaded to prevent errors.

      • The system checks the file to confirm that the appropriate column headers are used.

      • File size limit is 10 MB

      • Only CSV files are accepted

    • User Guide: A Confirmed Visits Import Process NYPMPM link is available providing specification guidance and format.

  2. Select Upload and Import to process the import. Click OK in the confirmation. Allow 24 to 48 hours for processing. Process time depends on the volume and frequency of files.

  3.  When processing is complete, the user who uploads the file receives an email from secure-ssis@hhaexchange.com with the following information:

    • A summary of the success rate of the imported visits. For example, 900 of 1000 rows imported successfully.

    • An attachment is included showing the failed rows with failed reason.

The agency is responsible for the review, correction of errors, and resubmission, as necessary.

The final step is to invoice and export the imported PMPM visits. It is recommended that invoices are generated for PMPM claims after completing direct care labor invoicing.

When exporting the claims, follow the normal claim export process under Billing > Electronic Billing > E-Submission Batches.

Refer to the PMPM CDPAP Contract Status page to determine the appropriate time to submit billing for each Payer.

Below are the frequently asked questions with answers to address concerns.

One of the three PMPM rate codes is identified in the HCPCS Code field on the Service Code. Ensure that the code is an exact match to prevent incorrect claims creation.

As of October 18, 2024, the claim From Date is the first day of the month and the claim Through Date is the last day of the month for all Payers.

Exception: For Eldperplan, this is the first day of the month for both the From Date and Through Date.

As of October 18, 2024, the Service Date is the actual date of the visit.

Yes, Value Code 24 is populated with the rate code entered in the HCPCS Code field on the Service Code.

This is current for Linked/UPR contracts. Applicable to Internal contracts as of October 18, 2024.

As of October 18, 2024, if the Export Code on the Service Code is 2443, 2444, or 2445, then Form Locator 43 and 44 remains blank.

If the Export Code on the Service Code is anything OTHER THAN 2443, 2444, or 2445, then the Export Code is populated in Form Locator 43 and 44 as follows:

The first section is the original Service Code value, followed by five colons (:::::), followed by the Service Code Description. In cases where there is a modifier, count the colon separator used as the first of the five.

As of October 18, 2024, the Diagnosis Code will be Z741. For Payers who require a different diagnosis code, the value is added to the Revenue Code field on the Service Code with a colon delimiter.

This image shows the entered value with added colon and number in the Revenue Code fiield.

Some Payers have specified that the last digit of the Bill Type must be a 3. As of October 18, 2024, this 3 value for the last digit/frequency can be added to the Location field in the Service Code to populate on the claim accordingly.

This image shows the highlighted Location Code with an entered 3 value in the fiedl.

The administrative reimbursement can be scheduled automatically via the Additional Bill Info feature at the Patient Contract Level. More information below.

***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:

  • 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.

  • A Caregiver is required for billing purposes. Create a Caregiver if/as needed.

  • 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.

  • Update Patient’s Accepted Services to include Other (Skilled).

  • Billing Dx Codes may be required for billing purposes. Billing Dx Codes can be entered at the Patient or Contract level. Refer to the Setting Billing Dx Codes for instructions.

  1. Go to Patient > Contracts for the applicable contract, click the Additional Options link, and select Additional Bill Info from the menu.

  2. 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, to include the Billing Day.

    It is recommended to bill the PMPM early in the month for services rendered in the prior month.

    Additional Bill Info Window: Monthly Billing

    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).

  3. 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.

    Visit Created on Patient Calendar

    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.

    In addition, as a result of the nightly process, a visit may appear on the calendar the day after the selected Schedule date.

  4. Invoice and export as per the normal processes.