Alert 07-2


New York State Office of the Medicaid Inspector General (NYS OMIG)

School/Preschool Supportive Health Services Program (SSHSP/PSHSP)

Medicaid in Education Unit

Issue #07-2

TO:                      All SSHSP/PSHSP Medicaid Providers


FROM:                NYS OMIG SSHSP/PSHSP Medicaid in Education Unit


DATE:                February 21, 2007


SUBJECT:          Follow-up to the NYS Education Department Letter entitled

                             Medicaid Reimbursement Billing Requirements –

                             SSHSP/PSHSP dated February 6, 2007


This is to inform all school districts, counties and 4201 schools of the seriousness of the above-referenced letter (copy attached) from NYSED.  Effective immediately, no Medicaid claims should be submitted for payment, regardless of the service periods, which do not comply with the requirements contained in the letter.  Failure to comply with these requirements will put such claims at risk for disallowances as well as the U.S. Department of Justice potentially charging federal False Claims Act violations against the school district, county or 4201 school.  False Claims Act penalties range from a minimum of $5,500 to $11,000 per claim in addition to three times the amount of each claim as well as attorneys’ fees and costs.


In response to these requirements, effective immediately, school district and 4201 school claims for rate codes 5322 - Psychological Evaluation – Basic, 5305 - Psychological Evaluation – Comprehensive, 5329 - Psychological Counseling, 5326 - Speech Therapy, and 5496 - Special Transportation and county claims for rate codes 5306 and 5307 - Psychological Counseling, 5308 - Psychological Evaluation - Basic, 5309 - Psychological Evaluation - Comprehensive, 5323 and 5331 - Speech Therapy and 5327 - Special Transportation have been pended in payment cycle 1540 under Medicaid Management Information System (MMIS) edit 01141.  This means that the claims will not be processed but will be held until decisions can be made about their pay ability.  All future claims for these rate codes will continue to be pended until further notice.


A previous attempt to pend these claims for these rate codes was not made in time.  Accordingly, all claims for these rate codes were voided by MMIS edit 01999 in payment cycle 1539 and immediately resubmitted for MMIS to pend the claims.


School districts, counties and 4201 schools should not submit claims for these rate codes until they can verify that they meet the requirements stated in the February 6, 2007 SED letter.  Additional information will be provided to clarify which counseling titles meet CMS credentialing requirements.


For any questions/comments regarding this alert, please contact your Regional Information Center representative, NYS Education Department Medicaid Coordinators, or NYS OMIG, Medicaid in Education Unit staff.


Last Updated: June 5, 2009