Billing Changes Announced for NHTD/TBI Waiver Programs

(May 19, 2025) In an update in eMedNY and the Department of Health’s (DOH) listserv for waiver providers, it was announced that effective July 1, 2025, DOH will be implementing a billing change that will allow claims for Nursing Home Transition and Diversion (NHTD) and Traumatic Brain Injury (TBI) Waiver programs to be paid based on the county in which services were provided. Currently, providers are billing based on the participant’s county of fiscal responsibility, or, in some cases, on the provider’s corporate headquarters or central office address. This change will align waiver billing with the Centers for Medicare and Medicaid Services (CMS) requirements, which specify that services must be reimbursed based on the location of services provided. It will also standardize locator codes for all NHTD and TBI Waiver providers statewide.

A Federal Information Processing Standards (FIPS) code and corresponding locator code has been assigned to each county in NYS. The applicable five-digit FIPS (if submitting electronically) or three-digit county locator code (if submitting on paper) indicates the location (county) where the services were provided. This must be included on all NHTD and TBI claims submitted for dates of service on or after July 1, 2025.

Submitting Electronic Claims

When submitting an electronic claim for NHTD or TBI services effective for claims with dates of service on or after July 1, 2025, providers must enter Value Code 85 plus the applicable five-digit FIPS code from this crosswalk in the Value Code box of the claim. Providers must continue to include any other Value Code that is necessary to accurately report the claim (e.g., Value Code 24) in this box.

Submitting Paper Claims

When submitting paper claims for NHTD or TBI services effective for claims with dates of service on or after July 1, 2025, providers must enter Value Code 61 plus the applicable proxy locator code from the crosswalk in the Value Code box of the claim. Providers must continue to include any other Value Code that is necessary to accurately report the claim (e.g., Value Code 24) in this box.

System Updates

The eMedNY system has been reconfigured to associate FIPS codes to the correct proxy locator codes to ensure that the correct reimbursement amount is paid for each Fee-for-Service claim, and the Division of Finance and Rate Setting (DFRS) has been transitioning providers' rate codes over to the new locator codes for the last few weeks. The NHTD and TBI Manuals will be updated to reflect this change in billing practice.

DFRS will be emailing a webinar invitation to providers shortly.

Questions regarding this change can be sent to 1915CR@health.ny.gov.

Contact: Meg Everett, meverett@leadingageny.org, 518-867-8871