Medicaid to Implement New Claims Editing
Effective June 21, 2013, Medicaid will implement new claims edits designed to ensure that patient responsibility and Net Applied Monthly Income (NAMI) amounts are deducted from the appropriate hospital or nursing home inpatient payments. The new edits will also ensure that nursing home services (excluding bed hold days) are not reimbursed when the Medicaid beneficiary is in an inpatient hospital stay.
The new edit protocols include “Edit 02224 - Inpatient/Nursing Home Duplicate" to deny inpatient hospital or nursing home claims with overlapping dates of service unless the nursing home claim contains a revenue code for Therapeutic Leave, Hospital Leave or Therapeutic Leave Authorized by a Medical Professional.
NAMI reductions will be assessed to the entity in which the client "resides" on the first day of the month:
- When an inpatient claim is received for a client responsible for NAMI, the NAMI amount will be deducted from the hospital inpatient claim; or
- When a paid hospital inpatient claim: includes the first day of the month; is reduced by the NAMI; and a subsequent nursing home claim indicating leave of absence is processed, the nursing home claim will have the NAMI deducted and eMedNY will automatically process an adjustment to the hospital inpatient claim to reverse the NAMI deduction.
The one exception to this rule is the hospital will not be assessed the NAMI when a nursing home claim for a bed reservation spans the same first day of the month.
When a paid hospital inpatient claim: includes the first day of the month; is reduced by the NAMI; and a subsequent nursing home claim indicating leave of absence is processed, the nursing home claim will have the NAMI deducted and eMedNY will automatically process an adjustment to the hospital inpatient claim to reverse the NAMI deduction.
For more details, please click here.
Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827