CHANGES TO THE UTILIZATION THRESHOLD PROGRAM AND ELIMINATION OF SERVICE AUTHORIZATION REQUESTS

This article pertains to services subject to Utilization Threshold (UT) in order to be reimbursed for services by New York Medicaid. The Laboratory Service category is subject to UT. With the implementation of the 5010 transactions, NYSDOH will be eliminating the current Service Authorization (SA) process. SA (278) transactions will no longer be supported. Instead, services subject to UT will be administered based upon the member’s status at the time the claim is processed and information reported in the eligibility response. • If the member is “At Limits” for any service category, the eligibility response will return an indication of “Limitations” for the applicable Service Type(s). If a “Limitations” message is returned, a Threshold Override Application (TOA) must be submitted to request an increase in the member’s allowed services as is done today. • If during claim adjudication the client is “At Limits”, the claim will pay if the SA units were available for that DOS when the eligibility request was processed. • If the provider did not perform an eligibility request for the date of service on the claim AND the member is “At Limits”, the claim will be denied. In addition, the member’s service counts for each service category will now be incremented based on claim adjudication instead of reservation of units by the SA. The provider number used when performing the eligibility request must match the provider number on the claim. The exception to this is for providers who submit claims with a group and rendering provider number. If either the group or rendering provider number was used to obtain the eligibility information and at least one of them match the claim, the UT edit will be bypassed. Source: NY State Medicaid Bulletin Volume 27-Number 2