HCRA Compliance Reviews

The table below provide examples of acceptable and unacceptable responses. Please note that the content in these tables is for general information only and does not address all types of exceptions.

Type of Exception	Acceptable Responses/Documentation	Unacceptable Responses/Documentation
Out-of-state Provider	System print-outs from provider database, W-9 from provider, and/or EIN Finder which would identify the provider as not being from New York State. TIN and Physical location where services were provided must be identified on provided documentation.	A written response without supporting documentation. A response which fails to tie the physical location where services were provided with the TIN.
Discretely Billed Private Practicing Physician	Completed DOH attestation letter, which documents the required details and supporting documentation.	A written response without supporting documentation. An example would be an incorrectly completed HCFA 1500.
Out-Patient Referred Labs	Proof of the use of the industry standard billing code "14X " in conjunction with an industry standard occurrence code of not "41X " on a claim.	Non-supported codes.
Other Exclusions, e.g. Place of Service (POS) Codes	If non-industry standard codes are used, the reviewee must provide system generated documentation to support the codes.	Non-supported codes
Medicare, Medicaid, FEHBA	Line of Business (LOB) or product Group codes supported by system generated documentation.	Medicare, Medicaid, FEHBA fields within the data containing "Y " or " N " flags or non-supported codes.
Nonsurchargeable Services	Noted within the contract that specific services are not surchargeable. Be able to identify the TIN of nonsurchargeable providers.	A written response without a copy of the contract identifying the services that are not surchargeable.
Individual/Family Determinations	For family: additional appendable information that would indicate dependents	A written response without supporting documentation. Indication of field in data only without support or tie out to source
HCRA Region Determinations	Nine digit zip codes or crosswalk to from zip codes to HCRA region. Explanation for how system or process incorrectly assigned the member	A written response without supporting documentation. Indication of field in data only without support or tie out to source
Total Members per Month	Tie out or reconciliation of members to an outside report (DOI, Statutory filing, DOL 5500, FSs) showing the correct starting point.	-
Medicare, Medicaid, FEHBA	Medicare - System documentation to support that members were Medicare eligible, e.g. DOB or LOB codes. Medicaid or FEHBA - System documentation to support that members were Medicaid or FEHBA covered, e.g. product, Group, or LOB codes.	Medicare, Medicaid, FEHBA fields within the data containing "Y " or " N " flags or non-supported codes.