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  • Fully Integrated Dual Advantage (FIDA) > Billing

    Providers may not balance bill participants in the FIDA Plans for the cost of any covered service, which includes any coinsurance, deductibles or financial penalties, or any other amount in full or in part.

    The FIDA Plans will not charge Medicare Part C or D premiums, nor assess any cost-sharing for Medicare Parts A and B services. All participants are currently eligible for $0 Part D copays in accordance with Section 1860D 14(a)(1)(D)(i) of the Social Security Act and 42 CFR Part 423.782(a)(ii). The FIDA Plans will not assess any cost-sharing for Medicare Part D or NYS Department of Health services.

    Practitioners who participate on an IDT may be eligible for additional compensation for IDT meeting attendance billed under the following CPT codes:

    IDT Meetings
    CPT CODE  PROCEDURE DESCRIPTION
    99366
    Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more, participation by nonphysician qualified health care professional
    99367
    Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician 
    99368Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by nonphysician qualified health care professional 
    99487Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with no face-to-face visit, per calendar month
    99488Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with no face-to-face visit, per calendar month
    99489Complex chronic care coordination services; each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)

    Required Use of Codes in Screening for Clinical Depression

    Effective January 2015, the Associated Dual Assurance Network primary care and behavioral health providers must include the G codes noted below in claims and encounter submissions as applicable to Screening for Clinical Depression and Follow-up Plan. CMS and DOH have developed data reporting requirements for all FIDA plans to measure the percentage of patients screened for clinical depression using an age appropriate standardized tool with appropriate follow-up plan documented in the medical record. Please see page 31 of the Medicaid Adult Core Set for a list of acceptable depression screening tools.

    Standardized screening tools help predict the likelihood of someone developing or having clinical depression. The purpose of using a standardized screening tool is to determine if the patient screens positive or negative for depression. If the patient has a negative screen for depression, no follow-up plan is required. If the patient has a positive screen for depression using a standardized screening tool, the provider must have a follow-up plan as outlined below. 

    Follow-up for a positive depression screening must include one (1) or more of the following: 

    • Additional evaluation
    • Suicide risk assessment
    • Referral to a practitioner who is qualified to diagnose and treat depression
    • Pharmacological interventions - if you decide to prescribe an anti-depressant for the patient, please make sure to schedule follow-up appointments as appropriate and provide the care and education necessary to support medication adherence
    • Other interventions or follow-up for the diagnosis or treatment of depression

    A patient is not eligible for depression screening if one or more of the following conditions exist:

    • Patient refuses to participate
    • Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status
    • Situations where the patient’s motivation to improve may impact the accuracy of results of nationally recognized standardized depression assessment tools. For example: certain court appointed cases
    • Patient was referred with a diagnosis of depression
    • Patient has been participating in on-going treatment with screening of clinical depression in a preceding reporting period
    • Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. For example: cases such as delirium or severe cognitive impairment, where depression cannot be accurately assessed through use of nationally recognized standardized depression assessment tools


    Codes to Identify Outpatient Visits
    CPT CodeHCPCS
    90791, 90792, 90832, 90834, 90837, 90839, 
    92557, 92567, 92568, 92625, 92626, 
    96150, 96151, 97003, 99201, 99202, 99203, 
    99204, 99205, 99212, 99213, 99214, 99215
    G0101, G0402, G0438, G0439, G0444

    Codes to Identify Outpatient Visits
    CPT CODE Description
    G8431Screening for clinical depression is documented as being positive and a follow-up plan is documented
    G8510Screening for clinical depression is documented as negative, a follow-up plan is not required

    Codes to Identify Exclusions
    CPT CODE Description
    G8433Screening for clinical depression not documented, documentation stating the patient is not eligible
    G8940Screening for clinical depression is documented as negative, a follow-up plan is not required

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    Glossary terms found on this page:

    Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

    A pattern of medical care that focuses on long-term care with chronic diseases or conditions.

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    The government agency responsible for administering the Medicare and Medicaid programs.

    A percentage of the allowed charge that is payable by the member, not EmblemHealth, for covered services rendered by an out-of-network provider. After the member has met his or her deductible, EmblemHealth will pay a percentage of the allowed charge for those covered services in accordance with the member's benefit program. The member is responsible to pay the remaining percentage of the allowed charge. This remaining percentage is the coinsurance charge.

    The fixed dollar amount members must pay for certain covered services. It is generally paid to a network provider at the time the service is rendered.

    A medically necessary service for which a member is entitled to receive partial or complete coverage under the terms and conditions of the benefit program, is within the scope of the practitioner's practice and the practitioner is authorized to render pursuant to the terms of the agreement.

    A portion of eligible expenses that an individual or family must pay during a calendar year before EmblemHealth will begin to pay benefits for covered services.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    Specific conditions or circumstances that are not covered under the benefit agreement or Certificate of Insurance. It is very important to consult the benefit contract to understand what services are not covered benefits.

    A managed care plan under contract with the Centers for Medicare & Medicaid Services and the State to provide the fully-integrated Medicare and Medicaid benefits under the FIDA demonstration. Also called fully-integrated duals advantage plan.

    The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.



    The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.



    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    A prepaid payment or series of payments made to a health plan by purchasers and often plan members for health insurance coverage.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

    A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

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