NOTE: ***Ambulatory Patient Groups (APGs): OASAS certified outpatient clinic; outpatient rehabilitation and outpatient methadone programs are directed to see the Ambulatory Patient Groups (APGs) page for comprehensive APG guidance.
Medicaid - Public Health Program
Medicaid is a public health program that provides payment for certain medical services for individuals who are unable to afford health care. Medicaid is also often referred to as Title XIX for the section of the Social Security Act which created it. Medicaid financing involves a combination of Federal, state and local dollars.
Medicaid Client Eligibility
The New York State Medicaid program will only pay for Medicaid reimbursable services if the client is eligible for Medicaid on the date of service and the service is delivered by an authorized Medicaid provider. Clients should contact the Local Department of Social Services for help with Medicaid eligibility.
Medicaid Provider Enrollment Requirements for OASAS Providers
The NYS DOH is the single State agency responsible for administration of the New York State Medicaid program.
The DoH requires that chemical dependence treatment providers, be certified by OASAS and in possession of an OASAS operating certificate before the chemical dependence provider may apply for enrollment in the Medicaid program. For information on how to apply for an OASAS operating certificate and Medicaid provider status, go to How to Become a Medicaid Provider of OASAS Treatment Services.
OASAS Provider Participation in Medicaid
Most OASAS certified chemical dependence treatment services are eligible for reimbursement under the New York State Medicaid program.
Chemical dependence services are certified under Article 32 of the New York State Mental Hygiene Law and OASAS Chemical Dependence Regulations. Additionally, chemical dependence services can be certified and delivered in Article 28 settings. Chemical dependence services operated by Article 28 facilities may be certified by both OASAS and the DOH. For Medicaid reimbursement rates/fees and other information for specific chemical dependence service types please select from the following list of OASAS certified services:
- Medically Managed Detoxification (updated 9/09)
- Medically Supervised Inpatient/Outpatient Withdrawal
- Chemical Dependence Inpatient Rehabilitation/Residential Short-Term Chemical Dependence for Youth
- Chemical Dependence Outpatient Clinic ***
- Chemical Dependence Outpatient Rehabilitation ***
- Outpatient Chemical Dependency for Youth ***
- Methadone Treatment Program ***
- OASAS Buprenorphine Treatment ***
- Residential Rehabilitation Services for Youth
- Vivitrol Billing for OASAS Certified Programs
How to Bill Fee for Service Medicaid
- The New York State DOH assigns enrolled Medicaid providers a series of billing codes that vary by provider and service type. The NYS DoH assigned billing codes include:
- Medicaid providers will also need to use procedure codes for Medicaid billing. Procedure codes describe the billed service and either Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes may be used.
- Providers will need to use diagnosis codes from the ICD 9 CM (International Classification of Diseases, 9th Clinical Modification.) Billing staff must obtain these codes from the clinician who assigned the diagnosis.
Additional Billing Information for Chemical Dependence Medically Supervised Outpatient Clinic and Outpatient Chemical Dependency for Youth Programs
Correct completion of the service provider ID field is necessary for claim payment. If the staff person providing the billable service has a State Education Department (SED) license number, enter this number in the service provider ID field and enter the license type. If the staff person providing the billable service does not have an SED license, e.g a CASAC, then enter ID number 02249145, which represents an OASAS unlicensed practitioner. In these cases, the license type field must be left blank. For additional information see the July 2002 letter sent to Outpatient and MMT Providers.
- Providers submit claims for payment to Computer Sciences Corporation (CSC) through eMedNY, New York’s electronic Medicaid payment and information system. EMedNY is a claims processing system that pays providers on behalf of the New York State Medicaid program.
- OASAS certified providers must submit claims electronically. Providers may submit electronic claims using: the free internet based Electronic Provider Assisted Claim Entry System (ePACES); the provider’s own HIPAA compliant software; or providers may contract with a claims processing agent.
- Within four weeks from submission, information on the processed claim will usually be received by the provider from CSC and indicated as paid, pended or denied. In some instances a pended or denied claim may be resubmitted for payment consideration. For assistance with denied claims providers may call CSC at (518) 447-9810 or 1-800-522-1892.
- CPT Codes - Current Procedural Terminology - A national coding standard used for HIPAA billing. Procedure codes are the same for commercial and Medicaid covered services. (e.g. 90853 = the procedure code for group psychotherapy.) CPT coding books are issued by the American Medical Association and can be purchased by calling 1-800-621-8335.
- DRG - Diagnosis-Related Group - Developed by the NYS Department of Health to categorize patient records for reimbursement. DRG codes are used for a case based rate of payment for discharges from a hospital inpatient service. (e.g. 0744 is the DRG payment code for Opioid Abuse or Dependence treatment w/co –occurring complications).
- HCPCS Codes - Healthcare Common Procedure Coding System - A national coding standard used for HIPAA billing that describes a medical or diagnostic service.
- ICD-9-CM - International Classification of Diseases Clinical Modification, 9th Edition - A world wide diagnosis and procedure coding system used by hospitals and other health care providers. (e.g. 303.01 = alcohol dependence continuous). For purchasing information call 1-800-464-3649 (INGENIX Co.)
- Locator Code – A three digit code assigned by DOH to indicate each of the provider’s OASAS certified, Medicaid authorized billing locations E.g. 003 = 123 Main Street.
- Rate Code - A four digit code assigned by DOH to identify the reimbursement rate that Medicaid will pay for that OASAS certified service (e.g. 4215 = chemical dependence individual counseling in a freestanding clinic.
- Revenue Code - A four digit code that Identifies a specific billable service. HIPAA requires a revenue code on all inpatient and outpatient claims.
- Specialty Code - A three digit code assigned by the DOH to indicate the Medicaid provider’s area of expertise. (e.g. 986 = the specialty code for the chemical dependence medically supervised outpatient clinic, inpatient providers do not use specialty codes).