Situation Report | June 14, 2021
On June 7, 2021, the state Department of Health posted a clarification for private duty nursing claims that follows a new edit 2304, set to be pended on June 1 for submission of documentation for zero-fill clams for all practitioners.
The clarification follows:
- If Prior Approval (PA)-submitted documents in the current calendar year contain a letter from the primary insurance or an Explanation of Benefits (EOB) showing that PDN is a non-covered service, the documentation requirement is met and no additional information is required during claims submission. Claims will initially show as being pended and will continue processing with status updates in the cycle. All subsequent claims should process without being pended for this edit.
- If the documentation has not been submitted in a PA for the current calendar year, the letter or EOB showing that PDN is not covered must be submitted as outlined in the May 3, 2021 All Provider LISTSERV here. Claims will initially show as being pended and will continue processing with status updates in the cycle. All subsequent claims should process without being pended for this edit.
- If PDN is a non-covered service, only one letter/EOB is required per calendar year. This will reset each January and providers will have to submit a new letter/EOB before claims will process.
- If PDN is a primary insurance covered benefit, documentation is required to show that each date of service was submitted to the primary insurer until the benefit is exhausted. These claims should not be zero-filled but should be submitted reflecting the amount paid by the primary insurer. This is the current procedure for claims submission for members with third-party insurance. Please see additional guidance in the December 2, 2020 Medicaid Update here.
- When the primary insurance EOB demonstrates that the PDN benefit is exhausted for the calendar year, subsequent claims should be submitted as a zero-fill claim, but no further documentation will be required for the remainder of the calendar year. Documentation will be required for each new calendar year as the primary insurance PDN benefit resumes and continue to be submitted until the benefit is exhausted.
General questions regarding claims submission should be directed to the eMedNY Call Center at 800-343-9000; questions regarding specific medical pended claims should be directed to the Bureau of Medical Review, Pended Claims Unit, at 800-342-3005 (option 3).