Page 109 - CHHA Binder 2.3.20
P. 109
4/11/2019
Case Rate Payment
Single payment for ALL services provided during a “case”.
This rate does not vary based on amount of services provided
and is not based on the patient’s condition the way episodic
payment is. VNSNY Case Rate Episodes are 60 days.
VNSNY Care Managers (Clinical Utilization Managers)
handle case rate approval/authorizations.
23
Case Rate Contracts as of 3/1/2018
External Internal
Case Rate authorization authorization
Active payor Code Payor Group Effective Required Required Billing Type
HealthFirst
TFH HEALTH FIRST Medicaid 1-Jan No Yes Case Rate
T35 HF 65 PLUS Medicare 1-Jan No Yes Case Rate
THN HEALTH FIRST HEALTHY NEW YORK Medicaid 1-Jan No Yes Case Rate
TMA HEALTH FIRST MEDICARE ADVANTAGE Medicare 1-Jan No Yes Case Rate
MetroPlus
TMP METROPLUS ESSENTIAL PLAN Commercial 1-Jan No Yes Case Rate
TPG METROPLUS GOLD HEALTH PLAN Commercial 1-Jan No Yes Case Rate
TSN METRO+ PARTNERSHIP IN CARE Medicaid 1-Jan No Yes Case Rate
TMC METROPLUS Medicaid 1-Jan No Yes Case Rate
TPM METROPLUS CHP Medicaid 1-Jan No Yes Case Rate
TMF METROPLUS FHP Medicaid 1-Jan No Yes Case Rate
TPA METROPLUS MEDICARE ADVANTAGE Medicare 1-Jan No Yes Case Rate
1199*
J52 1199 CASE RATE Commercial 1-Jan No Yes Case Rate
Aetna*
J50 AETNA MEDICARE CASE RATE Medicare 1-Jan No Yes Case Rate
J51 AETNA COMMERCIAL CASE RATE Commercial 1-Jan No Yes Case Rate
CHOICE
FV1 CHOICE FIDA Dual Eligible 1-Jan No Yes Case Rate
MA8 VNS CHOICE MEDICARE Medicare 1-Jan No Yes Case Rate
MD1 CHOICE MEDICARE DUAL Medicare 1-Jan No Yes Case Rate
Montefiore
TG8 MONTE CMO MEDICARE Medicare 12/1 No Yes Case Rate
TC8 MONTE CMO MEDICAID Medicaid 12/1 No Yes Case Rate
TT8 MONTE CMO COMMERCIAL Commercial 12/1 No Yes Case Rate
TOM MONTE CMO MEDICARE/MEDICAID ADVANTAGE Dual Eligible 12/1 No Yes Case Rate
24
*Visit Based Case Rate
12
