Provider Resources

These resources can save you time and help you to better care for your patients – and our valued Members.

Provider Forms

Inpatient/Outpatient Data Elements for UB04 Billing Reminder

Accurate and complete UB04 claim forms submission, either by electronic or paper means, helps us efficiently adjudicate claims and provide you with timely and accurate payments for your services.

The list of required data elements below is provided for quick reference.   Please ensure that your submissions include all of these critical elements.

Total Care, A Today’s Options® of New York Health Plan - Critical UB04 Data Elements

  • Name, Address and Phone Number of Facility

  • Billing Address (if different)

  • Federal Tax Identification Number

  • National Provider Identifier (NPI)

  • Type of Bill Code (no interim third-digit on DRG inpatient claims)

  • Statement Covers From and Through

  • Admission Date (Start of Care Date)

  • Type of Admission

  • Source of Admission

  • Patient Discharge Status

  • NDC Codes for all Administered Drugs

  • Neonate Birth Weight Value Code - When Applicable

  • Neonate Birth Weight in Grams – When Applicable

  • HCPCS Codes for all Service Lines on outpatient claims

  • Quantity of Units Submitted – Electronic Claims Zero Fill When Units Are Needed

  • Dollar Charge Amount

  • Principal/Primary Diagnosis Code

  • Inpatient Admit Diagnosis

  • Principal Procedure Code

  • Surgeon Identification Number (NPI) – For Inpatient & Outpatient Surgical Claims

  • Attending Provider Identification Number (NPI)

  • Maternity/Birth Condition Codes

As of August 1, 2014, Total Care, A Today's Options® of New York Health Plan began a system generated review of inpatient/outpatient UB04 electronic and paper claims based on the above list.  

Submissions that are missing required data elements or contain inaccurate or invalid data for the specific claim type will be returned to the submitter for completion.

If you have any questions, please contact our Provider Services Department at 1-877-872-4716 or 315-234-5901.

Prior Authorization

Total Care, A Today’s Options® of New York Health Plan (TC/TONY) has revised the prior authorization process as distributed in January 2015. TC/TONY has moved to a procedure and code based authorization format. As previously communicated in the Summer Provider Newsletter, the new prior authorization process will be for dates of service beginning September 15, 2015 and later.

A complete list of durable medical equipment, radiology and surgical procedure codes that require prior authorization are listed in the links below. Also, there are additional services that require an authorization such as physical therapy, mental health and nursing services.

Please note that TC/TONY has also revised the Prior Authorization Request Form. A Prior Authorization Form is required when requesting services. This new form can be found at the link below.

Claims and Adjustments

  • All Claims must be submitted within 120 days of the Date of Service.

  • If our Plan is secondary to another carrier, the claim with the Explanation of Benefits (EOB) or Explanation of Payment (EOP) must be submitted within 120 days of the receipt of the Carrier’s EOB or EOP. Also, all adjustments are subject to the 120 day submission time limit from the date on the Explanation of Payment (EOP).

  • Any claims denied for untimely filing will be identified by EX-24 on the EOP. If a Provider appeals a claim that was denied with the EX-24 on the EOP, the appeal will be reviewed by the Provider Relations Department to determine whether the appeal should be upheld or reversed based on additional information submitted with the appeal such as Coordination of Benefit information. Providers will be notified by mail of the resolution.

  • Providers may also submit an appeal for payment adjustments to a paid claim within 120 days of the EOP by using the Request for Claim Adjustment Form available below.

    • Please submit the form along with a timeline submission record and any supporting documentation related to the request for an adjustment to the Claims Department at the address listed below or fax to: 315-234-9812.

    • The Claims Department will review the appeal to determine whether the 120 day limit for appeals has been met, and will respond to you by mail.

Request for Claim Adjustment Form

Please mail or fax all correspondences and all supporting documentation to:

Total Care, A Today’s Options® of New York Health Plan
5232 Witz Drive
North Syracuse, New York 13212-6501
Attention: Claims Department
Fax: 315-234-9812

Statutory Reference Notice

STATUTORY REFERENCE: Chapter 551 of the Laws of 2006
Notice to Physicians on Software Product used to accept/edit claims

NOTICE
In accordance with Insurance Law Sections 3224-b and 4803(a) and Public Health Law Section 4406-d(1), as amended by Chapter 551 of the Laws of 2006, the claims processing software product utilized by Total Care, A Today's Options® of New York Health Plan is AMISYS, Version 6.4.3. This software incorporates CPT -CM 9 2014 in editing procedure codes and for claim pricing determinations.  If you have any questions or need additional information, please contact our Provider Relations Department at (315) 234-5901, Toll Free at (877) 872-4716, or TTY: New York Relay 1-800-662-1220.

ICD-9 to ICD-10 Transition

All healthcare providers must transition to ICD-10 on October 1, 2015, including those who do not deal with Medicaid or Medicare claims. Click here for answers to Frequently Asked Questions.

Appointment Availability Guidelines

Provider Updates

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