Never Pay Lists
Formerly known as Carve Out List
As of October 2012, there will no longer be a carve out list. The full list of APG carve outs is contained within the Never Pay Procedures list and the Never Pay APGs list. In order to avoid duplicate maintenance of files, please refer to the two Never Pay lists for the carve outs.
The carve out list displayed the following procedures:
- Never Pay Procedures List: This is a list of procedures that are not paid under the APG reimbursement methodology. This list also provides information as to whether there is an alternative payment available (i.e., the provider is allowed to bill for the procedure against a Medicaid fee schedule). If an alternate payment mechanism is available the procedure is considered to be a "carve out".
- Never Pay APGs List: This is a list of APGs where all the procedures within that APG are never pay procedures. This list also provides information as to whether there is an alternative payment available; in which case all procedures grouping to that APG are carve out if they can be found on a Medicaid fee schedule. To find all the procedures grouping to a specific APG, please refer to the 3M Versions and Crosswalk.
Providers should review the ordered ambulatory fee schedule to determine if the procedure is reimbursable in Medicaid outside of the APG reimbursement methodology, however, providers would also refer to the dental fee schedule for orthodontia only. Any drugs that are carved out of APGs will be on the ordered ambulatory fee schedule and not the pharmacy fee schedule.
The best way to determine of a specific procedure (Px) is an APG carve out is to:
- Look at the Never Pay Procedures list.
- If the Px is on the list, and is noted as a carve out, skip to step 4.
- If the Px is NOT on the list, go to step 2.
- Look at the APG Crosswalk to determine the APG to which the Px groups.
- Look at the Never Pay APG list.
- If the APG is NOT listed, the Px is not a carve out. Do NOT go to step 4.
- If the APG is a Never Pay APG and is noted as a carve out, go to step 4.
- Look at the appropriate fee schedule at eMedNY.org (see link below).
- If the Px is NOT listed, there is no payment available under Medicaid.
Please refer to the fee schedule for coverage information (http://www.emedny.org/ProviderManuals/index.html).