Thursday, August 16, 2018

When Medicaid Is Secondary Payer:

When Medicaid Is Secondary Payer:

When Medicare and other commercial insurance is involved and if the lab or radiology provider is required to bill Medicare or the commercial insurance directly, the ancillary provider should do so and then bill eMedNY for any balance due. The clinic should not report these ancillaries on their APG claim since they will not be paying the ancillary provider. If Medicare denies payment for the ancillary service because it is not covered by Medicare, the ancillary service provider should bill Medicaid directly.

Exceptions to the APG Ancillary Billing Policy: There are four exceptions to the uniform application of the APG billing policy for ancillary laboratory and radiology services provided on behalf of clinic patients. They include the following:

** Laboratory and radiology tests performed on behalf of Federally Qualified Health Centers that do not participate in the APG payment methodology;

** Procedure codes carved-out of APGs as specified in Section 4.20 (e.g. Coumadin, Clozaril, lead screen, HIV viral load, virtual phenotype, blood factors, etc.);

** Procedure codes which may be carved-out of APGS (optional carve-outs) as specified in Section 4.21 (e.g. pregnancy testing); and

** Laboratory and radiology services associated with specialty clinic rate codes carved-out of APGs as specified in Section 4.22, since these are not “APG” visits. Utilization Thresholds and Laboratory/Radiology Ancillary Services: Utilization threshold limits will not apply to laboratory or radiology services incorporated in APG claims. Note: see section below regarding billing for professional and technical component of radiology services.

The professional component of radiology services is carved-out of the APG payment to the hospital or D&TC clinic and may be billed separately by the radiologist using the Medicaid fee schedule. This applies when a clinic patient receives radiology services from a clinic and the clinic is billing Medicaid under APGs for the patient encounter as well as those situations when a patient has been referred from another hospital outpatient department or freestanding clinic to a clinic and that clinic is billing the referring hospital/free-standing clinic for the radiology service (the referring hospital/free-standing clinic must bill for the radiology procedures on their Medicaid APG claim).

** The radiologist should use the radiology fee schedule (physician component) for radiology procedures provided to patients referred by other hospitals or free-standing clinics.

** The facility that provides the radiology services should bill the referring hospital or free-standing clinic for the technical component.

** The referring hospital or free-standing clinic must include the radiology procedure in the APG claim for the visit in which the radiology procedure was prescribed.

Note: The ancillary vendor may not bill the professional component of the radiology service if the hospital practitioner is planning to read and bill for this professional service. If the hospital plans to bill for the professional component of radiology service, the hospital should tell the ancillary vendor not to bill for the professional component of this service.


Under APG payment rules, certain surgical procedures may only be performed in the hospital inpatient setting. These procedures may not be performed on an ambulatory surgery or clinic outpatient basis. These designated ‘inpatient only’ procedures will not be reimbursed under the APG payment methodology. They will continue to be paid through the Diagnosis Related Groups (DRG) payment methodology. The APG Grouper will automatically reject these procedures for payment. The list of these procedures is available at the Department’s Website at:

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