Stop Loss FAQs

Table of Contents

Q. One of the least common mistake states: claims submitted using the first of the month as the date of service are denied as a duplicate claim. Does this apply to the CSC (eMedNY) file or the new electronic claim submission file in the column titled "ADMIT DATE"?

A. The comment refers to the CSC or eMedNY file. Capitation payments, which are automated, are paid and go out on the first of the month. When the first of the month is used as the date of service on a Stop Loss claim, the eMedNY system interprets the Stop Loss claim as a duplicate and will deny it with system edit 00705 or 00727.

The ADMIT DATE column on the new electronic submission form requires the actual admission date for the inpatient stay.

Q. What is a REMIT statement? Is this the 837 file received from CSC?

A. The REMIT statement is also referred to as the 837 file.

Q. When Rates Change do we have to resubmit?

A. Historically, Stop Loss has always waited until the appropriate rates for a specific time period were published before processing claims.

Between the lag time of submitting claims and the time required to access and adjudicate claims by Stop Loss, reimbursements were usually based on the latest rate available at the time of payment.

Because claims were reviewed and processed off-line, the only portion of the claims available for review electronically were the recalculated payments for the entire claim recorded in eMedNY. We had no process to do a mass adjustment other than a total resubmission of the claim as an adjustment.

With the implementation of claim documentation being submitted electronically, it will be possible at some point in the future to have a record of all claims paid for a specific rate code, time period and facility. With that information, it will be possible to do a mass adjustment for all claims affected by a rate change. Until that point in time, the only way to process a claim with a rate adjustment would be to resubmit the claim to eMedNY and Stop Loss as an adjustment to a previously paid claim.

Please keep in mind that post payment audits that change the charges and payments on hospital stays that have been previously submitted to Stop Loss should be resubmitted as adjustments to the previously paid claim.

Q. Do we void or rebill claims that require changes and have not been adjudicated?

Once a claim is pending there is nothing that allows the provider to cancel or void it.

If a claim has been submitted and requires changes, a Plan can wait until the claim is adjudicated and then file an adjusted claim or it can submit a new claim that includes the changes.

If you are submitting multiple claims for the same charges/dates of service, please notify Stop Loss with an e-mail to

Q. Are there any recommendations for health plans that continued to use AP-DRG´s beyond the State´s conversion to APR-DRG´s on 12/1/09?

A. We realize that many institutions continued to bill charges under AP-DRG for a significant period after the implementation of APR-DRG´s with an effective date of 12/1/09.

In an effort to inform Plans, hospitals and other service providers of upcoming changes, presentations outlining health care reform in the 2009-2010 budget year, including the change from AP-DRG to APR-DRG methodology on 12/1/09 were held in July of 2009.

Stop Loss is obligated to compare the Plan´s contract rate to the Medicaid rate and pay the lesser of the two. We were also required to recalculate claims with dates of service on or after 12/1/09 with the new rates and methodology as stated in Chapter 58 of the Laws of 2009, Public Health Law Section 35.

Q. SSI enrolled members shouldn´t be included into Stop Loss submissions. Is that correct?

A. Clients enrolled in mainstream managed care plans with SSI coverage are excluded from inpatient mental health claims only. SSI status does not affect claim submission for inpatient claims (rate code 2299) or residential health care claims (rate code 2297).

Clients enrolled in SNPS Plans (Special Needs Plans) are exempt from the exclusion of inpatient mental health claims when SSI coverage is present. This applies only to SNPS Plan enrollees.

Note:Mental health and substance abuse services provided to members who were not classified as SSI or SSI related at the time of service are still covered under the Stop Loss program even if the enrollee is retroactively classified SSI or SSI related and the retroactive period includes dates when such services were provided. However in this instance, plans are required to submit appropriate documentation (for example the enrollee roster showing the Aid Category at the time of service) along with the attestation and other supporting documentation for the Stop Loss claim.

Q. How Do We Handle Out of State Claims?

A. Calculating an out of state Inlier

Case payment rate upstate hospital (upstate teaching or non-teaching {rate code 2953}) × SIW + Capital per discharge (Rate code 2990) = Inlier reimbursement

Case payment rate downstate hospital (downstate teaching or non-teaching {rate code 2953}) × SIW + Capital per discharge (Rate code 2990) = Inlier reimbursement

  • Downstate facilities are providers located in areas that surround NYC- in New Jersey, the counties of Sussex, Passaic, Bergin, Hudson, Essex, Union, Middlesex and Monmouth. In Connecticut it applies to Fairfield and Litchfield and in Pennsylvania, the county of Pike. Rates for facilities in these areas should be taken from "downstate" rates. All other areas fall under "upstate" rates. The case payment rate chart for out of state facilities contains a list of more than 1,000 out of state hospitals. If you match the case payment rate from the facility to the above rate chart, you can determine whether the facility is an upstate or downstate teaching/non-teaching facility.
  • For HCO calculations, use the HCO thresholds found in the Cost outlier tables on the NYS DOH website. Make sure they are date appropriate for the claim discharge date. The WEF column on the out of state rate sheet corresponds to the Institution specific adjustment factor (ISAF) - column 5 on the NYS inpatient rate sheet. The WEF value should be used on Line 18 on the high cost outlier page of the claims calculation when calculating out of state rates.

    Admission to a Non-teaching downstate facility - Admit date 2/1/10- Discharge 2/14/10, APR-DRG 140 Severity Level 4 (SIW- 2.3575) Plan´s payment $21,450.75.

    Stop Loss calculation:

    Downstate non-teaching rate code 2953 (2/14/10) - $6779.56 × 2.3575 (SIW) = $15,982.86 + $638.30 (Capital add-on per discharge Rate code 2990 downstate) = $16,621.16.

    Stop Loss total $16,621.16 compared to Plan´s payment of $21,450.75 = Maximum Stop Loss reimbursement is $16,621.16
  • Out of state hospital APR-DRG rate chart
Q. What is a plan´s responsibility for inpatient hospital discharges when an enrollee changes plans in the middle of the inpatient hospital stay? Who is responsible financially for the discharge and how is it determined?

A. The new plan is not liable for cost of a hospital stay for a Medicaid Managed Care (MMC) enrollee who is admitted to the hospital prior to the effective date of enrollment; unless the patient is:

  1. Transferred to another hospital.
  2. Unit 5 transferred from acute setting to a per diem setting such as psych/rehab or detox.
  3. Any time the case payment (usually DRG/AP/APR) changes from cost basis to a per diem basis.
  4. From a per diem rate to another per diem rate (detox to rehab for example).

Once the patient meets one of the four conditions above, the new plan picks up.

Q. What elements are used to verify an original and an adjustment stop loss claim?

A. The following are requirements necessary for all submissions and/or processing of claim types defined by rate codes; 2299 (IP), 2295 (MH), 2297 (RHCF), and 2296 (SNP):

  • The requirement of the Transaction Control Number (TCN) of the claim being replaced if submitting an adjustment claim. This field is column J of the electronic file specifications. This is the adjustment/replacement TCN of the claim being replaced ending with a "2," not the TCN of the claim being replaced.
  • Plans are required to have a corresponding encounter in the MEDS system for every discharge submitted for every claim excluding rate code 2297 (RHCF). Failure to do so may result in claim denial or underpayment. Plans are allowed to submit missing encounters and having verified encounter presence in the MEDS system, may submit claim adjustments for processing.
  • Encounters must have discharge dates for each stay as this date drives the payment for General Inpatient stays. This is imperative for intermittent billing since these dates are within the statement header dates and are billed as individual stays. Each "stay" must have its own encounter with an Admit and Discharge date. Examples of intermittent billing are Specialty Hospitals and some Inpatient Psych/Substance Abuse rehabilitation facilities.
  • The diagnoses and procedure codes on all encounters submitted by plans to the MEDS system must correspond to the claims submitted to the Stop Loss unit. Failure to do so may result in claim denial or underpayment. Plans are allowed to resubmit encounters and having verified encounter presence in the MEDS system, may submit claim adjustments for processing.
  • Plans must include a copy of the total charges and documentation as to how the payment was applied or your plan´s grouper calculation indicating that the claim paid as an HCO. This documentation should be in the form of a PDF version of the UB-04 CMS-1450 or 837I and accompany the .txt file submission.
  • The Hospital Medicaid MMIS ID, NPI and the Hospital Name must be included in all claims submitted by plans.
  • Plans are required to follow the format indicated in the electronic file specification. Additional columns should only be added after the last column.
  • The adjustment submission should include all the stays as if it was a new submission, and not just the additional or revised stays. The system will retract the original payment and calculate the new, all inclusive, rates. As stated above, the encounter must match this new submission’s additional/revised stay(s) for General Inpatient and Inpatient Psychiatric claims.

Q. NPI vs. MMIS - which do I use?

A. Both the NPI and the MMIS number are required. If there is discrepancy between the NPI and the MMIS, Stop Loss will use the NPI to identify the provider. This does not imply that you can eliminate the MMIS from our claim submission. If you do, the claim will fail and will be returned to you for resubmission.

  • If an MMIS is unavailable, please use the generic MMIS. Per the eMedNY Provider Manual/Managed Care MEDSIII - Data Element Dictionary, the MMIS for OON or OOS Inpatient is 01666086.
Q. What file format or specifications do I use for submitting claims to Stop Loss for HARP members?

A. The file specifications have not changed. Use the same import file specificationsas you use for all your Stop Loss claims.

Q. What part of a member stay is the responsibility of the plan and what part is the responsibility of Stop Loss?

A. Effective January 1, 2016 statewide for all individuals for whom psychiatric inpatient and/or Substance Use Disorder (SUD) inpatient services are a covered service, the psychiatric inpatient stop loss and SUD inpatient stop loss provisions will change.

This change will be phased in and fully realized in three years. The parameters of the Stop Loss program responsibility are clearly outlined in the:

Q. How are claims over $250,000 calculated for stop loss?

A. Stop loss claims over $250,000 are calculated as outlined below. This illustration is color-coded and uses fictitious data.

TCN CIN Discharge Date DOH Calc DRG Total Plan ChargeÚ Total DOH CalcÚ ClaimTotal Threshold Copay Total Claim Charge Total Due Plan
12345678910110 AB12340C 07/09/13 662.2 6,877.28 6,877.28          
12345678910110 AB12340C 07/18/13 662.3 11,890.50 11,890.50          
12345678910110 AB12340C 07/30/13 662.3 10,821.18 10,821.18          
12345678910110 AB12340C 08/06/13 662.2 6,877.28 6,877.28          
12345678910110 AB12340C 08/10/13 662.1 5,259.67 5,259.67          
12345678910110 AB12340C 08/15/13 662.2 7,090.25 7,090.25          
12345678910110 AB12340C 08/17/13 662.2 7,777.23 7,777.23          
12345678910110 AB12340C 08/23/13 662.2 6,702.03 6,702.03   Where is the surcharge?  
12345678910110 AB12340C 08/26/13 662.3 12,048.95 12,048.95          
12345678910110 AB12340C 08/31/13 662.2 6,825.83 6,825.83   * The 7.04% surcharge was added in to the Plan charge and in this case DOH paid the same amount to the Plan that the Plan paid
12345678910110 AB12340C 09/15/13 662.1 4,950.05 4,950.05
12345678910110 AB12340C 09/10/13 662.3 12,048.95 12,048.95  
12345678910110 AB12340C 09/26/13 662.3 10,975.08 10,975.08          
12345678910110 AB12340C 09/21/13 662.3 12,048.95 12,048.95          
12345678910110 AB12340C 10/13/13 662.3 10,975.08 10,975.08          
12345678910110 AB12340C 10/07/13 662.3 12,048.95 12,048.95          
12345678910110 AB12340C 10/29/13 662.2 4,954.89 4,954.89          
12345678910110 AB12340C 10/28/13 662.3 12,048.95 12,048.95          
12345678910110 AB12340C 11/05/13 662.2 7,289.46 7,289.46          
12345678910110 AB12340C 11/02/13 662.3 8,376.11 8,376.11          
12345678910110 AB12340C 11/12/13 662.3 10,975.08 10,975.08          
12345678910110 AB12340C 01/20/13 662.1 5,006.17 5,006.17          
12345678910110 AB12340C 11/27/13 662.3 10,975.08 10,975.08          
12345678910110 AB12340C 11/15/13 662.2 7,777.23 7,777.23          
12345678910110 AB12340C 11/29/13 662.1 5,619.88 5,619.88          
12345678910110 AB12340C 12/18/13 662.3 10,975.08 10,975.08          
12345678910110 AB12340C 12/21/13 662.2 7,294.14 7,294.14 513,391.58 100,000.00 30,000.00 399,534.33 383,391.58
  Your claim total is 513,391.58
anything over 250,000.00 will get 100% reimbursement
claim total
100% reimbursement 263,391.58 everything over 250,000.00 that we are working with
100,000.00 threshold now applied

not taken out of the calculation until now

20 percent copay
  100% reimbursement
Threshold - copay
added together = total due plan 383,391.58  

Updated May 26, 2021