STATUTORY REFERENCE: Chapter 551 of the Laws of 2006
Notice to Physicians on Software Product used to accept/edit claims
In accordance with Insurance Law Sections 3224-b and 4803(a) and Public Health Law Section 4406-d(1), as amended by Chapter 551 of the Laws of 2006, the claims processing software product utilized by Total Care, A Today's Options® of New York Health Plan is AMISYS, Version 6.4.3. This software incorporates CPT -CM 9 2014 in editing procedure codes and for claim pricing determinations. If you have any questions or need additional information, please contact our Provider Relations Department at Toll Free at (877) 872-4716, or TTY: 711.
All healthcare providers must transition to ICD-10 on October 1, 2015, including those who do not deal with Medicaid or Medicare claims. Click here for answers to Frequently Asked Questions.
Accurate and complete UB04 claim forms submission, either by electronic or paper means, helps us efficiently adjudicate claims and provide you with timely and accurate payments for your services.
The list of required data elements below is provided for quick reference. Please ensure that your submissions include all of these critical elements.
- Name, Address and Phone Number of Facility
- Billing Address (if different)
- Federal Tax Identification Number
- National Provider Identifier (NPI)
- Type of Bill Code (no interim third-digit on DRG inpatient claims)
- Statement Covers From and Through
- Admission Date (Start of Care Date)
- Type of Admission
- Source of Admission
- Patient Discharge Status
- NDC Codes for all Administered Drugs
- Neonate Birth Weight Value Code - When Applicable
- Neonate Birth Weight in Grams – When Applicable
- HCPCS Codes for all Service Lines on outpatient claims
- Quantity of Units Submitted – Electronic Claims Zero Fill When Units Are Needed
- Dollar Charge Amount
- Principal/Primary Diagnosis Code
- Inpatient Admit Diagnosis
- Principal Procedure Code
- Surgeon Identification Number (NPI) – For Inpatient & Outpatient Surgical Claims
- Attending Provider Identification Number (NPI)
- Maternity/Birth Condition Codes
As of August 1, 2014, Molina Healthcare of New York began a system generated review of inpatient/outpatient UB04 electronic and paper claims based on the above list.
Submissions that are missing required data elements or contain inaccurate or invalid data for the specific claim type will be returned to the submitter for completion.
If you have any questions, please contact our Provider Services Department at 1-877-872-4716 or 315-234-5901.
- All Claims must be submitted within 90 days of the Date of Service, unless otherwise stated in your contract.
- If our Plan is secondary to another carrier, the claim with the Explanation of Benefits (EOB) or Explanation of Payment (EOP) must be submitted within 90 days of the receipt of the Carrier’s EOB or EOP. Also, all adjustments are subject to the 90 day submission time limit from the date on the Explanation of Payment (EOP).
- Any claims denied for untimely filing will be identified by EX-24 on the EOP. If a Provider appeals a claim that was denied with the EX-24 on the EOP, the appeal will be reviewed by the Provider Relations Department to determine whether the appeal should be upheld or reversed based on additional information submitted with the appeal such as Coordination of Benefit information. Providers will be notified by mail of the resolution.
- Providers may also submit an appeal for payment adjustments to a paid claim within 90 days of the EOP by using the Claim Adjustment Appeal Request Form available below.
- Please submit the form along with a timeline submission record and any supporting documentation related to the request for an adjustment to the Claims Department at the address listed below or fax to: 315-234-9812.
- The Claims Department will review the appeal to determine whether the 90 day limit for appeals has been met, and will respond to you by mail.
Claim Adjustment Appeal Request Form
Please mail or fax all correspondences and all supporting documentation to:
Molina Healthcare of New York, Inc.
5232 Witz Drive
North Syracuse, New York 13212-6501
Attention: Claims Department