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Section IV Stop-loss Policy and Procedure - eMedNY - emedny

Section IV Stop-loss Policy and Procedure - eMedNY - emedny 2025

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The document outlines the Stop-Loss Policy and Procedure for New York State's Medicaid Managed Care Program. It serves as a guide for managed care organizations to understand billing requirements related to stop-loss reinsurance, which limits their financial liability for high-cost enrollees. The manual details various types of reinsurance coverage, including general inpatient, mental health, substance abuse, and residential health care facility services. It also provides instructions on claim submission processes, common billing issues, and necessary documentation for audits.

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What is the objective of a stop loss provision?

Claims must be submitted within two years of the date of service. All claims submitted beyond the 90-day timely filing window must include Delay Reason Code 03.

What is the timely filing limit for New York Medicaid?

Medicaid provides free health insurance for low-income adults and children. It may also provide up to 90 days of retroactive coverage for unpaid medical bills if you request this coverage when you apply and were eligible during those 90 days.

What is the purpose of a stop loss provision?

To provide a safeguard for insureds, many major medical policies contain a stop-loss feature that limits the insureds out-of-pocket expenses. This means the insured is no longer required to pay coinsurance once expenses have reached a specific limit.

Is Medicaid retroactive coverage in NY?

Medicaid will not pay for services of a provider who has not registered in the Medicaid program. Providers are not required to participate in the Medicaid program. If they do, they must accept all Medicaid recipients as patients.

What is the objective of a stop loss prevention?

A stop-loss order is a tool used by traders and investors to limit losses and reduce risk exposure. With a stop-loss order, an investor enters an order to exit a trading position that he holds if the price of his investment moves to a certain level that represents a specified amount of loss in the trade.

What is the objective of a stop loss provision in major medical policies?

When employers chose to self-fund their medical benefits, they often chose to protect themselves from potential high-cost claims with stop-loss insurance. Stop-loss provides protection for high-cost claims over a predetermined threshold that fits each clients risk tolerance and preferences.

Section IV Stop-loss Policy and Procedure - eMedNY - emedny 2025

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What is the objective of a stop loss provision?

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What is the objective of a stop loss prevention?

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Section IV Stop-loss Policy and Procedure - eMedNY - emedny 2025

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How to edit Section IV Stop-loss Policy and Procedure - eMedNY - emedny online

Complete this form in 5 minutes or less

Got questions?

What is the objective of a stop loss provision?

What is the timely filing limit for New York Medicaid?

What is the purpose of a stop loss provision?

Is Medicaid retroactive coverage in NY?

What is the objective of a stop loss prevention?

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