OASAS recognizes the importance of efficient, effective, and timely resolution to Provider's Reimbursement Concerns. The Revised Reimbursement Complaint Process outlined below informs OASAS Providers of the steps and information needed as part of the complaint resolution process. Providers should review and utilize the Common Complaint Troubleshooting as appropriate before filing a complaint.
Once the decision to file a formal complaint is made, Providers should provide accurate and detailed information as asked for in the Complaint Form. The better the information the more effective the process, the quicker the resolution.
Review Common Complaint Issues
- Authorization vs. Prior Authorization "Authorization" means notification which involves informing the individual's Medicaid Managed Care Plan that the person is seeking treatment. Prior authorization is a request for coverage of services prior to providing those services to the individual. In most instances, prior authorization is not allowed.
- Incorrect Rate Reimbursement: Can be due to correct rates not being loaded into the 3M Grouper or the Plan's electronic claims processing system. Rate Verification Steps:
- Check Rates in OASAS APG Clinical and Medicaid Billing Guidance, and/or
- Send NPI, Rate Code(s), and location to the OASAS for verification.
- Eligibility: Verify individuals coverage via ePACES.
- Denial of Access to treatment: For urgent individual issues of access to treatment, on-going issues for those experiencing insurance obstacles to obtaining treatment, and help filing an appeal for denial of treatment contact the NYS Ombudsman, Right to Treatment Program at 888-614-5400 or email: [email protected]
Fill out OASAS Complaint Form
Please download and fill out in detail the information requested on this form and submit to the Practice Innovation and Care Management mailbox.
Once the completed Complaint Form is reviewed PICM will contact you for clarification if needed, or request for further information, provide direction to other resources, or resolution to the issue.
If further claim information is needed, Providers will be required to fill out the Complaint Information Spreadsheet for each plan in question. The spreadsheet provides additional required information that must be transmitted in a password-protected or encrypted spreadsheet, to ensure PHI is protected. The spreadsheet password should be sent via a separate email. Delay in receipt, or lack of accuracy of the spreadsheet may result in extended resolution time. OASAS will receive and review all information and notify you of any further action.
The following information must be provided:
-Medicaid client identification number (CIN).
-Insurance coverage eligibility status e.g. Medicaid managed care; Medicaid FFS; or commercial insurance.
-Provider NPI, service address including zip+4 for each claim in question.
Contact Practice Innovation & Care Management Unit
Submission of an in inquiry/complaint to the PICM mailbox DOES NOT replace or initiate the internal/external grievance and appeal and/or fair hearing processes supported by either the NYS insurance/public health or OTDA laws and regulations.
If a service recipient is dissatisfied with their plan or any of its employees, providers, or contractors, or plan's services, determination of benefits, or the health care treatment received through the plan, they can file a complaint or grievance directly with their plan. Service recipients may make their complaint/grievance verbally or in writing. They may also designate someone to make the complaint/grievance for them.