State OMIG Resumes Semiannual TPL Demand Billing Requests to Medicare
The Situation Report | April 28, 2025
The state Office of the Medicaid Inspector General (OMIG) has resumed its semi-annual demand-billing process for the second half of Federal Fiscal Year (FFY) 2024, as part of the Third Party Liability (TPL) appeals initiative.
Unlike the last 3 or 4 semi-annual TPL demand bill processes, approximately half of the Medicare-certified home care providers in New York received a letter from the state OMIG and its TPL contractor from the University of Massachusetts Medical School (UMMS), identifying which cases have been selected to undergo the current round of appeals (through demand billing). The dates of service span the third and fourth quarters of FFY 2024 only (April 1, 2024 through September 30, 2024) or the end of the episodic period billed to Medicaid.
UMMS’s letter also says providers should continue monitoring the status of their demand bill claim(s) once submitted. Providers are required to correct any claims that are rejected or suspended by the NGS. In addition, providers are required to timely submit a complete medical record to NGS once the Additional Development Request (ADR) is issued.
A final remittance advice for each episode billed (by demand bill) will be issued within 60 days of the final bill submission to Medicare. Upon receipt of the final remittance advice, providers must send copies of the following documents to UMMS within 10 business days:
- The original claim submitted to the MAC for each 60-day episode billed.
- The final claim remittance advice sent to you from the MAC.
- Each medical record your agency submitted to the MAC upon the ADR request.
Under Medicare requirements, all claims for services must be filed within one calendar year (12 months) after the date of service. In order to comply with this requirement, all demand bills must be submitted within one calendar year from the end date of the certification period identified in the OMIG’s case selection report included with your letter.
HCANYS CHHA members are reminded that Medicare initiated a new billing requirement for claims with periods of care beginning on or after January 1, 2022. For these claims, Medicare requires providers to submit a Notice of Admission (NOA) within 5 calendar days of the admission date. If the NOA was not previously submitted, your agency must submit the NOA followed with a demand bill to Medicare with a KX modifier. In addition, you must indicate “late NOA due to Medicaid TPL demand billing request” within the Remarks section of the claim for all identified services. (Medicare Claims Processing Manual, Chapter 10- Home Health Agency Billing).
HCANYS members interested in knowing whether they should have received a letter from OMIG or not can e-mail