NY Medicaid EHR Incentive Program

Pre–Payment Review Scenarios

Common Pre–Payment Review Scenarios

During pre–payment review, additional information may be requested to validate Medicaid Patient Volume. The four scenarios listed below are the most frequently occurring but do not encompass all possible scenarios. This page is meant to serve as a guidance only. Please contact NY Medicaid EHR Incentive Program Support for assistance.

Individuals over 100% (EP18–L)

Scenario

The Medicaid encounters on file with NY Medicaid are greater than the Medicaid encounters that the provider has attested with.

Why might this happen?

The provider could render care at multiple locations, could have minimal patient interaction, or could supervise other providers that bill under their NPI.

How can we remediate this?

If the provider renders care at multiple locations, they need to provide the location addresses with ZIP+4 code. If the provider supervises other providers who bill under their NPI the provider will need to send a list with those providers and their NPIs. If the provider has minimal patient interaction, the provider will need to send an explanation of the types of services they included or excluded in the attestation.

Home Health Encounters (EP20–L)

Scenario

The Medicaid encounters on file with NY Medicaid show home health encounters which lead to a discrepancy with the Medicaid encounters the provider attested to.

Why might this happen?

A provider may or may not have included home health encounters in their attestation. An example of a home health encounter would be a physician who refers a certified home health care agency to provide care in a patient´s home. A home health encounter may be due to a provider referring/ordering the care despite not rendering the care themselves. Depending on if the provider did or did not include home health encounters in their attestation, the discrepancy may require additional remediation to validate.

How can we remediate this?

The provider needs to indicate whether or not home health encounters were included in their attention patient volume. Any additional remediation will be determined based on analysis of the provider´s response.

Organizations under 30% (EP24–L)

Scenario

The Medicaid Encounters on file with NY Medicaid are less than the Medicaid Encounters the group has attested to.

Why might this happen?

A potential reason may be that the encounters are billed under the servicing provider´s individual NPI rather than the organization NPI.

How can we remediate this?

More information is needed about the group´s billing practices. NY Medicaid might request that providers complete an organization template.

Individuals under 30% (Medicaid Encounter Documentation Packet)

Scenario

The Medicaid Encounters on file with NY Medicaid are less than the Medicaid Encounters that the provider has attested to.

Why might this happen?

If NY Medicaid is unable to validate patient volume based on claims data, providers may be required to complete the Medicaid Encounter Documentation (MED) Packet to support their encounters.

How can we remediate this?

The provider will need to furnish a list of their Medicaid encounters during their 90–day reporting period to match their attestation.