NYS Medicaid Codes - What do they Mean?

This article has links to references for various codes for Medicaid eligibility and billing.  

1.  ELIGIBILITY CODES 

When you prepare for a fair hearing and obtain an evidence packet, and in some other instances, you obtain screenshots from the eMedNY system - the computer system that stores Medicaid eligibility information,  which providers use to look up eligibility of their  patients.  Local Medicaid offices or the NYSofHealth enter these codes into the system.

Here are a few references that might shed light on what some of these codes mean:

•   2023 Welfare Management System Worker’s Guide to Codes. (6-17-23)   

  • Chapter 4 is Medicaid - Use "bookmarks" in  PDF

  • (Compare to 2018 version  NYS DOH-OTDA WMS Workers' Guide to Codes 6-17-2018)  

• eMedNY MCE 834 Companion Guide (version 3.4)   (8/1/2024)- guide published for Medicaid  providers but that can be useful for consumers  and advocates to understand the mysteries of eligibility codes.  

  • This is one of  many guides posted on a webpage called eMedNY 5010/D.0 Transaction Instructions which is in turn posted on the eMedNY.org support webpage.

• Guide to Restriction Exception (RE) Codes and Health Home Services (7/2/2024)

Down the road we hope to post more helpful guides to understanding the most common eligibility codes.  

2.  BILLING CODES for Home Care and Adult Day Health

• MLTC and managed care plan notices often use strange-looking codes to describe the approved shift for home care.  These codes can be found in  Universal Billing Codes for Home Care and Adult Day Health Care Services  (NYS DOH) - has billing codes for live-in, mutual cases, CDPAP vs. personal care, private duty nursing, etc.  Note that some codes look the same but have a different "modifier" - such as for mutual cases (oen aide is assigned to care for two people in the household)..  
• Annoyingly, home care is billed in 15-minute increments.  That makes notices difficult to read.