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.











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                                      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

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