View the New York Medicaid OP Expected Reimbursement Detail (PAS or Fee for Service)

Use the following procedure to view the New York Medicaid Expected Reimbursement Detail for outpatient accounts using PAS or Fee for Service.

Note: If the Expected Reimbursement Detail is incomplete, click a Service Type link.

  1. Access the Expected Reimbursement Detail page for a New York Medicaid OP account. For more information, refer to View the Expected Reimbursement Details .
  2. Review the expected reimbursements.
  3. Optionally, you can perform the following actions:

The following table describes the fields on the Expected Reimbursement Detail page for New York Medicaid OP claims using PAS or Fee for Service.

Field

Description

Error Code

At Claim level the reason for rejection or return, if applicable.

Provider Number

The provider number.

State ID

The two-letter state identifier.

Rate Code

The rate code for the claim.

Rate Amount

The rate amount for the claim.

Effective Date

The effective date of the claim.

Reimbursement Type

The reimbursement type, either expected reimbursement or RA, if applicable for each line item. The latest RA is shown if there are multiple RAs.

Service Date

The date the service was rendered for each line item.

Revenue Code

The revenue code for each line item.

Billed HCPC/CPT Code

The associated CPT or HCPC codes for each line item.

Billed Units

The number of units billed for each line item.

Paid Units

The number of unites paid for each line item.

Covered Charges

The amount of charges covered by Medicaid for each line item.

Ordered Ambulatory Fee

Payment is made for ordered ambulatory goods or services only on a fee-for-service basis and is limited to the lower of the actual cost of the goods or the New York State Medicaid approved fee rate.

1st Adjustment Amount

Medicaid reimburses with a reduced amount for CPT codes without a modifier, or with a modifier on certain charges. If the charges are the highest on the claim, or if the detail line is the first line, one adjustment is applied to the total expected reimbursement. A second reduction is applied to the remainder.

2nd Adjustment Amount

Medicaid reimburses with a second reduced amount for CPT codes with or without a modifier. If the detail line is not the highest charge on the claim, or if the detail line is not the first line, two adjustments will be applied to the total expected reimbursement.

Total Expected Reimbursement

The calculated reimbursement based on the predefined contract terms and conditions and service type definitions in the system and the repriced claims data.

Action/Error Code

A Message Code is displayed based on how Medicaid reimburses the outpatient detail line, with a description below the reimbursement total explaining the reduction.

Error Code

The reason for rejection or return for each line item, if applicable.