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Commissioner Michael F. Hogan, PhD
Governor Andrew M. Cuomo

Clinic and Ambulatory Restructuring

The Office of Mental Health (OMH) has implemented new regulations, rates and services for all OMH licensed mental health clinics. This site is intended to be a quick reference guide for all stakeholders looking for information on clinic services as well as information regarding the restructuring of other ambulatory programs.

News

  • Update: Seriously Emotionally Disturbed (SED) Clinic Claims/Supplemental Security Income (SSI) Client Claims: Issues Resolved

    This is an update to the posting regarding claims being denied when submitted to Medicaid using the SED rate codes. The problem has been fixed and claims using the SED rate codes will now be accepted. This issue affected SED claims with dates of service of January 1, 2012 and after.

    SED claims that have been denied will need to be resubmitted.

    The SED Rate Codes are:

    • Non-hospital: 1510, 1513, 1477, 1585
    • Hospital: 1522, 1525, 1591, 1582

    Additionally, OMH became aware that Mental Health (MH) clinic claims for SSI individuals enrolled in "health-only Medicaid Managed Care" were also being denied. This issue was also resolved today and claims for these individuals will now be accepted. Claims that have already been denied will need to be resubmitted.

    The two other Ambulatory Patient Groups (APG) reimbursement problems that have been identified, the incorrect blend % for non-hospital MH clinics and the inappropriate withhold of a $3 co-pay per visit, will not be resolved until later this month. All claims submitted until resolution will likely be subject to these inaccuracies. However, when they are resolved, the claims will be automatically reprocessed and the corrections included in a remittance.

  • Medicaid Claims and Reimbursement (January 10, 2012)
    • APG payments will now be paid prospectively starting with date of service January 1, 2012. This applies to all mental health clinics licensed under Article 31 of the New York State Mental Hygiene law. All services delivered on or after January 1, 2012 must be claimed using the APG methodology.
    • Procedures provided prior to January 1, 2012 should continue to be claimed using the interim payment methodology PDF (123kb). This includes continuing to hold the health services claims and eligible off-site services claims for all of those services provided prior to January 1, 2012.
    • OMH expects to begin reprocessing claims using the APG methodology for procedures delivered October 1, 2010 through December 31, 2011 starting April, 2012. This plan also includes the processing of claims that OMH has instructed providers to hold (health services and eligible off-site services).
  • Medicaid Reimbursement Rates for Mental Health Clinics - includes provider-specific blend rates and APG base rates for both hospital and non-hospital clinics (December 27, 2011)
  • December 2011 Statewide Clinic Trainings
  • Psychotropic Medication Injection - Commonly used J-codes for claiming Medicaid (December 21, 2011)
  • Behavioral Health Organizations (BHO) Notices of Conditional Awards (September 12, 2011)
  • Medicaid Billing Issue: When submitting claims to Medicaid using a Healthcare Common Procedure Coding System (HCPCS) code, the HCPCS database requires that alphanumeric codes must contain capital letters. For example, H2010 will fail if entered as h2010. (September 6, 2011)
  • Selection of Regional BHO is now available. (June 24, 2011)
  • Update - Medicare/Medicaid Crossover Payments for Offsite Clinic Services (May 24, 2011)
  • Instructions for Interim Claiming and Test Billing APGs

    Part 599 program regulations went into effect on October 1, 2010. OMH licensed clinic providers did not transition to APG claiming until January 1, 2012. OMH expects to begin reprocessing claims using the APG methodology for dates of service 10/1/10-12/31/11 in April 2012. Continue to use the interim claiming methodology for all services provided prior to January 1, 2012.

    Letter to the Office of Medicaid Inspector General (OMIG) - Co-signed by OMH and New York State Department of Health (DOH) to OMIG

    • This letter in part temporarily waives the 90 days claims submission requirement and gives clinics 3 months from the date of federal Medicaid State Plan approval to adjust all claims and make any corrections as appropriate. The letter also requests that OMIG allow a time-limited moratorium on Article 31 clinic audits and disallowances.
    • Please note: When submitting claims more than 90 days from date of service during the period the waiver is in effect, clinics must enter reason code 3 (Authorized Delays - Delays previously approved). In addition, you should keep a copy of the attached letter in your files.

    Instructions for interim claiming and test billing APGs PDF (123kb) are now available.

    Interim Claiming Issues: Problems & Solutions PDF (109kb) - Materials from October 6, 2010 webinar.

  • Prescribing Clozapine – Guidelines available now.
  • Sample Clinic Encounter Form PDF (114kb) – This form is not required. It was developed for clinics to use if they so choose.

Comments or questions about the information on this page can be directed to the Bureau of Financial Planning.