nys medicaid handbook

Telehealth Reimbursement and Credentialing for Article 31 and 32 Providers. If you dont have a provider directory, call [Insert Member Services TollFree Number] to get a copy. Maybe you want to try them because they are easy to get to. If the plan decides to deny coverage for a medical service, you and your doctor asked for because: You have 45 days after you receive the plans final adverse determination to ask for an external appeal. The Medicaid Reference Guide (MRG) is available only as a portable document format (PDF) file. Here is information you can get by calling Member Services at [Insert Member Services number]. If your complaint involves clinical matters your case will be reviewed by one or more qualified health care professionals. When you have a question, check this Handbook or call our Member Services unit. NEW YORK STATE MEDICAID PROGRAM DURABLE MEDICAL EQUIPMENT, PROSTHETIC, ORTHOTIC, AND SUPPLY MANUAL POLICY GUIDELINES Section I - Definitions For the purposes of the Medicaid program and as used in this Manual, the following terms are defined to mean: Acquisition Cost Acquisition cost is the line item cost to the DMEPOS provider. Also, check the back of your drivers license to let others know if and how you want to donate your organs. For information, call, [Plans must describe the process for choosing a specialist as PCP. These include emergency care; family planning/HIV testing and counseling; and specific selfreferral services, including those you can get from within the plan and some that you can choose to go to any Medicaid provider of the service. Tell you why the delay is in your best interest; Make a decision no later than 14 days from the day we asked for more information, the service was not medically necessary; or, the service was experimental or investigational; or, the outofnetwork service was not different from a service that is available in our network; and, Within ten days from being told that your request is denied, or care is changing; or. Provider Contract Guidelines for MMCOs and IPAs. You feel the decision limits your Medicaid benefits. If you believe you have an emergency, call 911 or go to the emergency room You do not need your plans or your PCPs approval before getting emergency care, and you are not required to use our hospitals or doctors. Our Case Managers can provide support and assistance in identifying alternatives and resources when benefits have been exhausted. You must use a [Insert Plan Name] provider, but you do not need an OK from your PCP. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Medicare Resources Exhausted Benefits Fidelis Care offers case management services to members by phone. All dental providers enrolled in the Medicaid program are eligible for reimbursement for all types of services except for orthodontic care, dental anesthesia and those procedures where a specialty is indicated. Requests for the MRG in an alternate format should be made by sending an e-mail note to: If we are unable to make a decision about your Complaint because we dont have enough information, we will send a letter and let you know. NEW YORK STATE MEDICAID MANAGED CARE MEMBER HANDBOOK November 2022 22-23065 CDPHP Select Plan (518) 641-3800 or 1-800-388-2994, TTY/TDD 711, Behavioral Health Crisis 1-888-320-9584. . We can help you understand or get these documents. Your Provider Manual to the New York Medicaid Program offers you a wealth of information about Medicaid, as well as specific instructions on how to submit a claim for rendered services. The letter will tell you: Your complaint will be reviewed by one or more qualified people. Be sure to let them know you are disenrolling from [Insert Plan Name] and you want to reenroll in a new plan. You should keep your Medicaid benefit card. Manual Contents Information for All Providers Policy Guidelines Fee Schedule Fee Schedule Column Descriptions Preferred Diabetic Supply List (PDSL) - Magellan Procedure Codes Billing Guidelines DME Billing Guidelines General Professional Billing Guidelines General Remittance Guidelines Prior Approval Guidelines We will call you back the next work day. You can change your mind and these documents at any time. New York Medicaid CHOICE 18005055678. We will write you and will tell you the reasons for our decision. Detox services are available using your, Preschool and school services programs (early intervention), Comprehensive Medicaid Case Management program ("CMCM" program), Routine foot care (for those 21 years and older), Services from a provider that is not part of. This could be a child with an ear ache who wakes up in the middle of the night and wont stop crying. Be sure to call him or her whenever you have a medical question or concern. If anything is wrong, call us right away. Standard abbreviations are used throughout and are defined within the text and the Glossary. If you have any problems accessing the content on this web site, please contact MedinEd@nysed.gov . Besides the regular checkups and the shots, you and your family need, here are some other ways to keep you in good health: Call Member Services at [Insert Member Services Number] to find out more and get a list of upcoming classes. .x(Ek] @p/ #8'D)"n> D@z17g -q0p/b` j) Ask your PCP or call Member Services at [Insert Member Services Number] for a list of places to go to get these services. If you need to see an eye specialist for care of an eye disease or defect, your PCP will refer you. Both programs, though, allow for some people to keep getting care through regular Medicaid. A copy of the most recent individual direct pay subscriber contract. View rights & responsibilities, provider info and more. If you need to see a specialist for ongoing care, your PCP may be able to refer you for a specified number of visits or length of time (a. If your complaint appeal involves clinical matters your case will be reviewed by one or more qualified health professionals, with at least one clinical peer reviewer, that were not involved in making the first decision about your complaint. When a delay would risk your health, we will let you know our decision in 48 hours of when we have all the information we need to answer your complaint but you will hear from us in no more than 7 days from the day we get your complaint. You or someone you trust can file a complaint with the plan if you dont agree with our decision to take more time to review your request. For help in finding a Medicaid family planning provider, call Member Services at [Insert Member Services Number]. The final authority remains Book 52A of McKinneys Consolidated Laws of New York and Title 18 of the Codes, Rules and Regulations of the State of New York. If you need care before the card comes, your welcome letter is proof that you are a member. ], [Insert Plan policies and procedures, and frequency, for allowing PCP changes, up to once every six months Plans may allow changes more often than every six months. You or someone you trust can also file a complaint about the review time with the New York State Department of Health by calling 1 8002068125. you need to have a breast or pelvic exam. We will tell you if we take these other actions. is mailed to active providers, and informs providers of up-to-date changes in the Medicaid Program. Managed Long Term Care (MLTC) Plan Member Handbook - Aetna Better Health You must file a complaint with. We also want you to know that most of our providers are paid in one or more of the following ways. Medicaid managed care provides a number of services you get in addition to those you get with regular Medicaid [Insert Plan Name] will provide or arrange for most services that you will need. New York's Medicaid program provides comprehensive health insurance to lower-income New Yorkers. The rest of this handbook is for your information when you need it. Your Provider Manual to the New York Medicaid Program offers you a wealth of information about Medicaid, as well as specific instructions on how to submit a claim for rendered services. PDF NEW YORK STATE DENTAL POLICY AND PROCEDURE MANUAL - eMedNY They do not change your right to quality health care benefits. RememberYou do not need prior approval for emergency services. See if You Qualify View Covered Services - In Spanish Blue Choice Option Member Handbook Pharmacy Benefit Change - Effective 4/1/23 Your Choice of Doctors & Hospitals Our Mission. Skip to main content. Write and tell you what information is needed. If you can, prepare for your first appointment. These counties operate a voluntary Medicaid managed care program. Later, a letter will be sent that tells you the decision. You can also call the New York State Growing Up Healthy Hotline (18005225006) for nearby places to get these services. The Medicaid Reference Guide is arranged in five sections: Categorical Factors; Income; Resources; Other Eligibility Factors; and Reference. If you call after hours or weekends, leave a message and where or how you can be reached. In that case, you can keep your doctor until after your delivery and follow up care. It must be at least 60 business days but no more than 90 calendar days. Timeframes for prior authorization requests: Timeframes for concurrent review requests: If we need more information to make either a standard or fast track decision about your service request, we will: You, your provider, or someone you trust may also ask us to take more time to make a decision. If your request is in a fast track review, we will call you right away and send a written notice later. Give your OK to any treatment or plan for your care after that plan has been fully explained to you. Keep this handbook handy for when you need it. You do not have to use a lawyer, but you may wish to speak with one about this. Targeted Case Management - New York State Education Department You do not need a referral from your PCP to get these services. The fee stays the same whether the patient needs one visit or many or even none at all. It lists the covered and the noncovered services. Treat health care staff with the respect you expect yourself. Your PCP will call you back as quickly as possible. You can also call the managed care staff at your local Department of Social Services. New eyeglasses (with Medicaid approved frames) are usually provided once every two years. You can visit an anonymous testing and counseling site. %%EOF We will let you know our decision in 45 days of when we have all the information we need to answer your complaint but you will hear from us in no more than 60 days from the day we get your complaint. Manuals, Forms and Policies - Fidelis Care Or, you can sign up with a primary care physician at one of the FQHCs that we work with, listed below. The health plan has a review team to be sure you get the services we promise. You can make any needed changes before sending the form back to us. Its purpose is to assist districts in determining Medicaid eligibility for applicants/recipients. You will be given the reasons for our decision and our clinical rationale, if it applies. This plan does not cover family planning and reproductive health services such as birth control services, sterilizations and abortions. You are not happy about a decision we made that denied medical care you wanted. After you have received emergency care, you may need other care to make sure you remain in stable condition Depending on the need, you may be treated in the Emergency Room, in an inpatient hospital room, or in another setting This is called, For more about emergency services, see page, all inpatient mental health and chemical dependence services (including alcohol and substance abuse), most outpatient mental health services (contact plan for specifics), Medicaid recipients who receive SSI or who are certified blind or disabled get mental health and chemical dependence (including alcohol and substance abuse) services from any Medicaid provider by using their Medicaid Benefit Card Detoxification services, however, are covered by, occupational, physical and speech therapists and audiologists, when ordered by your physician and authorized by, when the stay in the nursing home is not determined permanent by your LDSS. 2642 0 obj <>/Filter/FlateDecode/ID[]/Index[2623 29 2653 1]/Info 2622 0 R/Length 103/Prev 764015/Root 2624 0 R/Size 2654/Type/XRef/W[1 2 1]>>stream This includes a request for home health care while you are in the hospital or after you have just left the hospital. You have the right to ask us whether we have any special financial arrangement with our physicians that might affect your use of health care services. We will call you with our decision or try to reach you to tell you. Many consumers now get their health benefits through managed care. Infrastructure Program Extension Guidance. They do this by checking your treatment plan against medically acceptable standards. You and the plan will be told the final decision within two days after the decision is made. We hope our health plan serves you well. The following resources are provided to assist those who are in need of more information about NYS Medicaid pharmacy benefits and Managed Care plans: Enrollment in Medicaid Managed Care is available at any local Department of Social Services. You can get a faster decision if your doctor says that a delay will cause serious harm to your health. Infrastructure Application Form B - Lead Agency Information. We do not offer a Medicaid managed care service that you can get from another health plan in your area. There is no differential in levels of reimbursement between general practitioners and specialists. You feel the doctors decision stops or limits your Medicaid benefits. He or she will give you an earlier appointment. ](Plan Name), believes that providing you with good dental care is important to your overall health care. [Include if covered by plan] [If nonemergency transportation is covered by the plan, specify the type of service provided; the name of the provider (if there is a single contractor); the phone number to call to request the service; and if applicable, how far in advance a member needs to call to request the service Also include the following statement:], [Delete FQHC if plan does not contract with them], [Include here if family planning is covered by the plan.]. You, the plan, and the LDSS all agree that disenrollment is best for you. aVdc@WC@CX, n((CuF Any changes that occur after the release of this version of Handbook #7 will be posted on this site with effective dates for implementation. medicaid@health.state.ny.us. Other counties allow Medicaid consumers to choose whether they want to join managed care. You may have an injury or an illness that is not an emergency but still needs prompt care. This may be because you have more information to give the plan to help decide your case. If you ask for a fair hearing and an external appeal, the decision of the fair hearing officer will be the one that counts. good start as a new member. Medicaid Managed Care Model Member Handbook. You and your doctors will have to give information about your medical problem. Get vision care, dental benefits, prescriptions, mental health services and more! Affinity by Molina Healthcare Medicaid Managed Care (MMC) The Medicaid Managed Care program offered through Affinity ranks among the largest in the New York metropolitan area. ). Provider Policy and Billing Handbook (Update 9) (974 KB) (REVISED-posted 03/29/18), Provider Policy and Billing Handbook (Update 9). As a member of [Insert Plan Name], you have a right to: As a member of [Insert Plan Name], you agree to: There may come a time when you cant decide about your own health care. If we have all the information we need you will know our decision in 30 work days. In order to get to know you better, we will get in touch with . The Emergency Room should NOT be used for problems like the flu, sore throats, or ear infections. If you or your doctor asks to have your action appeal reviewed under the fast track process. If you do not leave in the first 90 days, however, you must stay in [Insert Plan Name] for nine more months, unless you have a good reason (good cause). This monthly publication Be told where, when and how to get the services you need from. In some cases you may ask for a fair hearing from New York State. If you want a chemical dependence assessment for any alcohol and/or substance abuse outpatient treatment services, except outpatient detoxification services, you must use your Medicaid Benefit card to go to any provider that takes Medicaid. Dental Care [Include in this section when dental services are covered by the plan. [For Medicaid in NYC, use "New York City Department of Health and Mental Hygiene" instead of State Department of Health] to meet the health care needs of people with Medicaid. [List plans service areas that are served by New York Medicaid CHOICE] County(ies), you can also call the New York Medicaid CHOICE HelpLine at 1-800-505-5678. If you agree with our summary, you must sign and return the form to us. To search for a specific topic within a section, use the search function and enter the specific word or topic. Also, if before you get a service, you agree to be a "private pay" or "selfpay" patient you will have to pay for the service.This includes: If you have any questions, call Member Services at [Insert Member Services Number]. Medicaid Information | NY State of Health Just call Member Services at, In almost all cases, your doctors will be. Use the emergency room only for real emergencies. Items located in Sections 4.1, 4.2 and 4.3 are included in the NYRx transition. If you are still not satisfied, you or someone on your behalf can file a complaint at any time with the New York State Department of Health at 1800206 8125. Get a copy of your medical record, and talk about it with your PCP, and to ask, if needed, that your medical record be amended or corrected. If we decide that the requested service is not medically necessary, the decision will be made by a clinical peer reviewer, who may be a doctor or may be a health care professional who typically provides the care you requested. guide to the full range of health care services available to you. ]Plans shall inform member of their responsibility to arrange and pay for transportation to their PCP if member elects to select a participating PCP outside of the time and distance standards. You do not need a referral when you get this service as part of a family planning visit. We do not contract with FQHCs (Federally Qualified Health Centers) and you want to get your care from a FQHC. If you do not want special treatment, including cardiopulmonary resuscitation (CPR), you should make your wishes known in writing. If we deny payment for a service, we will send a notice to you and your provider the day the payment is denied. You will be given the reasons for our decision and our clinical rationale, if it applies. It's for New York State residents who meet the income or disability requirements. You can call Member Services at [Insert appropriate health plan tollfree number] if you need help filing an appeal. Lost eyeglasses, or broken eyeglasses that cant be fixed, will be replaced with the same prescription and style of frames. Click on the link to the Department of Health's Medicaid Update website. HIV counseling and testing [Only include here if Family Planning is covered by the plan]. With this Handbook, you should have a provider directory. If your original denial was because we said: In some cases, you may be able to continue the services while you wait for your action appeal to be decided. tell you to go to the nearest emergency room. NOTE: ALL updates will continue to be posted separately to the website. Family Planning [Include here if family planning is not covered by the plan.
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