';
CLOSE
Tags Posts tagged with "Claims"

Claims

0 283

The Office of Child Development & Early Learning (OCDEL) notified all County Early Intervention (EI) Programs and Providers that they will perform one final Mass Claims Adjustment on April 21, 2026.

As a result of the final analysis of the denied claims file, they were able to identify that many of the denied claims can be processed again and should result in a Paid claim. This final Mass Claims Adjustment will significantly reduce the manual efforts for both the County and EI Provider.

Immediately following this final Mass Claims Adjustment, a revised and final report of denied claims will be issued to all County EI programs to distribute to their contracted providers. 

Reminder of Next Steps:

  • Using the newly published Fiscal Year 2025/26 Fee Schedule — File NEW claims on or after March 9, 2026, that contain a date of service on or after July 1, 2025.
  • Using the newly published Fiscal Year 2025/26 Fee Schedule — Adjust claims filed on or after March 9, 2026, that contain a date of service on or after July 1, 2025, if the OLD fee schedule was used.

The Bureau thanks all stakeholders for their patience as they work to streamline the process and expedite the payments for provided Early Intervention services.

0 409

The Office of Child Development & Early Learning (OCDEL) has completed the Mass Claims Adjustment for all PAID CLAIMS of Early Intervention (EI) services that contain a date of service between July 1, 2025 – March 8, 2026 and were filed on or before March 8, 2026.

Due the high volume of claims, the Mass Claims Adjustment was processed in daily batches with a summary of claims below:

  • Week 1: March 16, 2026
    • Claims Adjusted for Speech Therapy
    • Claims Adjusted for Occupational Therapy
    • Claims Adjusted for Physical Therapy
  • Week 2: March 23, 2026
    • Claims Adjusted for Special Instruction
    • Claims Adjusted for Audiology/Evaluation/Teaming
    • Claims Adjusted for Service Coordination

A complete review of the Mass Claims Adjustment was performed during the week of March 30, and a final batch of claims were processed on April 7, representing claims with a date of services of July 1, 2025.

Reminder of Next Steps:

  • Using the newly published Fiscal Year 2025/26 Fee Schedule, file NEW claims on or after March 9, 2026, that contain a date of service on or after July 1, 2025.
  • Using the newly published Fiscal Year 2025/26 Fee Schedule, adjust claims filed on or after March 9, 2026, that contain a date of service on or after July 1, 2025, if the OLD fee schedule was used.

IMPORATANT:

As expected, OCDEL reports that there are many ICNs that failed the Mass Claims Adjustment. The Bureau is preparing a document for each County to distribute to their contracted providers that includes the original ICN that did not successfully Mass Adjust. Detailed instructions will be included with this document for how the Infant Toddler program and EI Provider can work together to resolve the claims errors. After successful resolution of the claims error, providers will be responsible for performing their own Claims Adjustment for the claims that failed the Mass Claims Adjustment.

View the following links for more information:

0 2309

ACTION NEEDED to Continue Submitting Claims and Eligibility Requests Electronically and Receiving EDI Transaction Responses with PROMISe™

The Pennsylvania (PA) PROMISe™ EDI as a Service (EDIaaS) Communication Plan details what is required by Trading Partners for registration and the X12 batch file naming standard, contains guidelines for Trading Partners on how to create certain segments within an X12 batch file, and provides the response files returned to Trading Partners who submit X12 batch files using EDIaaS to PROMISe™ for processing.

For Questions or Additional Information
Please contact the PROMISe EDI Help desk for any follow-up or inquiries related to this update.

0 8296

The purpose of this bulletin is to provide guidance on documentation needed to substantiate a claim as well as provide guidance on the service documentation processes. This information is applicable to providers and Supports Coordination Organizations (SCO) that render services through the Consolidated, Community Living, P/FDS, and Adult Autism Waivers as well as Targeted Support Management (TSM) and base-funded services.

Documentation to provide a record of services delivered to an individual must be prepared and kept by the provider, SCO, or common-law employer for the purposes of substantiating a claim and documenting service delivery. The Office of Developmental Programs (ODP) has developed Technical Guidance for Claim and Service Documentation for providers of services in the Adult Autism Waiver and providers of services for all other waivers and base-funded services, which provide specific information for providers and SCOs on the documentation that must be kept for each service in order to support a claim and to document service delivery. These apply to services rendered by providers and SCOs that have enrolled directly with ODP, organized health care delivery systems, and services delivered through both self-directed services models, Agency with Choice, and Vendor Fiscal/Employer Agent.

Providers are encouraged to review and consider using the Medical Assistance Provider Self Review Protocol to proactively identify and address any claim documentation-related problems. The protocol can be found here.

0 2837

The Office of Developmental Programs (ODP) has shared the message that the Provider Electronic Solutions software, commonly referred to as PES, will be sunset on June 15, 2022. PES was distributed free of charge to providers as a method of submitting HIPAA-ready transactions such as claims and eligibility to the PROMISe system.

Effective June 15, 2022, the software will not work with Microsoft Edge or other commonly used internet browsers. The Department of Human Services (DHS) will no longer upgrade PES due to the product’s age, limited configurability, and end-user experience. The Provider Assistance Center (PAC), which was maintained by Gainwell Technologies, will no longer provide user support for PES effective June 15. 2022.

Providers are encouraged to use the PROMISe Provider Portal to submit claims, validate eligibility, conduct claim inquires, and access their weekly remittance advice. The PROMISe Provider portal is available free of charge and allows single-entry interactive submissions. Additionally, users can purchase certified software from software vendors or contract with a clearinghouse to handle ongoing HIPAA transaction needs.

0 2329

ODP Announcement 22-021 provides guidance on the upcoming rate increases for the Adult Autism Waiver. Compensation is beginning March 1, 2022; the new rates will be implemented in the Home and Community Services Information System (HCSIS) on March 1, 2022. All Individual Support Plans (ISPs), including ISPs in draft, pending review, or pending approval status, will be updated with the new rates for each of the applicable services. An additional fiscal segment will automatically be added on each ISP for each service that is impacted by the rate change.

Providers are strongly encouraged to review Service Authorization Notices or the Provider Service Detail report in HCSIS to confirm the new rates were loaded, authorized, and that they are billing the increased Fee Schedule Rate before attempting to bill for any services rendered March 1, 2022, and after.

Compensation for the Period July 1, 2021, through February 28, 2022

Providers should bill normally for any services rendered from July 1, 2021, through February 28, 2022. ODP will be compensating providers, via gross adjustments, for the difference between the rate billed and the updated fee schedule rate for dates of service rendered during the period July 1, 2021, through February 28, 2022. This is intended to eliminate the provider’s effort of voiding and re-billing claims.

ODP anticipates processing gross adjustments during the April to May 2022 timeframe to ensure all billing for dates of service July 1, 2021, through February 28, 2022, has been completed. Because the rates will be loaded into HCSIS effective July 1, 2021, and the gross adjustment compensation will be issued by ODP, providers should not adjust any claims after April 1, 2022, submitted for services rendered on July 1, 2021, through February 28, 2022.

Adjustment of a claim(s) for services delivered during these dates will result in a duplication of payment that will need to be repaid. Providers are strongly encouraged to bill in a timely manner to minimize the need for corrections.

For questions on how to resolve billing errors for services that were rendered on July 1, 2021, through February 28, 2022, contact Amber Bennett.

Correction to Rates for Small Group Employment and Residential Habilitation Ineligible Fees

Because of an internal editing error, the rates for Small Group Employment and Residential Habilitation: Community Home Ineligible published in the Pennsylvania Bulletin (52 Pa.B. 1326, February 26, 2022) were incorrect. The correct rates, with the corresponding procedure codes, are higher than what was published. The corrected rates are also available on the Department of Human Services’ website.

© 2021 - Rehabilitation & Community Providers Association