If you are a NY FQHC w/(PPS) payment that provides denture services (not DME itself) for the Medicaid members with a third party insurance? Then the following blog post is for you!
Medical Billing: coordination of benefits
- In order to ensure proper coordination of benefits the FQHCs should bill the third-party insurance and/or commercial insurance as primary and receive the PPS per visit payment
Secondary Insurance payment NYS Medicaid
- The NYS medicaid payment is calculated as a difference between the FQHCs PPS rate and the primary payer pro-rated payment amounts- ONLY up to 5 visits
- Please note that if the primary payer payment equals or exceeds the PPS rate then no additional amount will be paid by NYS Medicaid
Coding: the following codes apply
- D5110: Complete denture – maxillary
- D5120: Complete denture – mandibular
- D5211: Maxillary partial denture – resin base
- D5212: Mandibular partial denture – resin base
- D5213: Maxillary partial denture – cast metal framework with resin denture bases
- D5214: Mandibular partial denture – cast metal framework with resin denture bases
- D5225: Maxillary partial denture – flexible base
- D5226- partial denture – flexible base (including any clasps, rests and teeth
Find this information useful? Follow for more!
- NYS Medicaid: Billing for denture services (FQHCs) patients with third party insurance
- Fidelis: corrected claim submissions
- BCBS Highmark NY:
- NYS OMH ACT services- new rate codes for 2027
- Aetna trauma response reimbursement
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