Dear Stakeholders,

We would like to make you aware of a new directive from New York State Office for People With Developmental Disabilities (OPWDD) that will limit ISS’ ability to submit multiple claims each month. At the end of May we received this notification and have taken some time to research and understand its impact.

Here is the link to the complete information on the eMedNY New Edit 02292 Billing Changes:

https://www.emedny.org/Listserv/eMedNYGeneralUpdates/New_Edit_02292_-_5-14-26.pdf

To summarize, starting June 1, 2026, Medicaid will enforce Edit 02292 (Claim Submission Limit Exceeded) to cap the number of times a provider can submit a claim for the same service. Providers are allowed a maximum of 5 total submissions (the original claim plus 4 subsequent resubmissions). Claims will automatically deny after the 5th attempt. Medicaid will be reducing the number down to 3 total submissions at some unknown date in the future.

As an example, expenses are reimbursed to the family at the beginning of the month and a claim is then sent to Medicaid. That claim reimburses ISS for most of what we paid to the family. A week goes by and more expenses are reimbursed and an adjustment claim is submitted to reimburse ISS again. That is now our second attempt. Continue on throughout the month with multiple reimbursements hitting a single budget line from the family, staff, direct bill vendors, etc. Each round of reimbursements to the ISS stakeholders generates billing claims which are now going to be limited to a total of 5 for each budget line each month.

Important things to note that impact ISS’ billing:

  • IDGS categories can include camp, community classes, coaching education for parents, clinical non-direct and clinical direct clinicians, health club/organizational memberships, household-related items and services, paid neighbor, self-directed staffing support, transition programs, transportation, and interpretation services. Each expense reimbursement to an IDGS sub-budget line rolls up to a single IDGS billing claim. IDGS is just one example of how this billing structure works.
  • A Participant’s Medicaid eligibility.
  • Medicaid is going to reduce the claim count from 5 to 3 at an unknown date in the future.

This also effects Self-Hired Comm Hab, SEMP and Respite staff. It is important that staff clock in and out in eTime each shift and submit their time according to the agency’s payroll schedule (every two weeks).

ISS needs to carefully evaluate how this new mandate is going to impact our ability to continue to reimburse everyone timely and still be able to get reimbursed for what ISS pays out.

Currently, ISS is reviewing our billing and claim history to determine how this will impact us. Additionally, management will be reviewing our business rules, expense submission and reimbursement policies and processes to ensure alignment with the new requirements.

At this time, we are not changing anything for our stakeholders. You should continue to follow existing procedures and submit all staff shifts and expenses, all expense reimbursement requests, and broker and vendor invoices on time and with all required documentation as usual, in order for ISS to continue to reimburse and bill timely.

Rest assured, we understand the impact these changes may have, and we will continue to work diligently to achieve the best possible outcomes for you. We will send out additional eblasts in the future if we need to modify our business rules. Thank you.