Issue #11-02

This Medicaid Alert serves as notification that, effective immediately, school districts, counties and §4201 schools may bill for school supportive health services with a date of service on or after September 1, 2009. Appropriately documented claims submitted by school districts, counties and §4201 schools that have met the relevant employee training requirement will be forwarded for payment beginning with cycle 1765, as outlined in the 2011 Monthly Claiming and Billing calendar on the Medicaid-in-Education website.

As the past year’s mandatory relevant employee compliance training sessions have clarified, school districts, counties and §4201 schools will utilize an encounter-based billing methodology (one claim submitted for each visit) for service dates of September 1, 2009 and later. Current Procedure Terminology (CPT) codes must be used to identify/describe the service provided. Please note that Medicaid regulations require the submission of claims within two years of the date of service (18 NYCRR 540.6(a)(3)) for both public and non-public providers. School districts, counties and §4201 schools are encouraged to submit SSHSP claims in a timely manner, and no later than 22 months after the date of service, in order to ensure that claims are filed within the two-year limit.

Documentation supporting the provider’s right to bill Medicaid for services must be in place prior to the submission of claims for Medicaid reimbursement. Documentation includes:

• Verification of medical necessity (e.g., written order/referral),
• Verification that the service was provided by a Medicaid qualified provider, including fulfillment of “under the direction of” or supervision requirements,
• A contemporaneous record of each encounter, and
• An Individualized Education Program (IEP) which identifies the service being billed.

For more information on the encounter-based billing methodology and documentation requirements, visit Billing & Claiming Guidance. If you have any questions or comments regarding this alert, please contact your local Regional Information Center representative or the NYS Education Department, Medicaid-in-Education Unit at medined@mail.nysed.gov.