Required Data for Claim Forms (CMS-1500 & UB-04) Claim Submission Instructions (MLTC) Care Healthcare and VNSNY CHOICE Transition

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1 2018 Provider Manual VNSNY CHOICE Appendix V Claims CMS-1500 Form (Sample) UB-04 Form (Sample) Required Data for Claim Forms (CMS-1500 & UB-04) Claim Submission Instructions (MLTC) ICD-10 FAQ Care Healthcare and VNSNY CHOICE Transition VNSNY Provider Remittance Guide Billing Instructions for Nursing Home Providers Universal Billing Codes for Home and Community Long Term Care Claims layout information (Chores, Adult Day Care, Home Delivered Meals)

2 Sample CMS-1500 Professional Claim Form A-8

3 Sample CMS-1450/UB-04 Institutional Claim Form A-9

4 VNSNY CHOICE Required Data Elements and Claim Forms Required Data Elements CMS-1500 UB-04 Patient Name Patient Date of Birth Patient Sex Subscriber (Member) Name/Address Member ID Number Coordination of Benefits (COB)/other insured s information Date(s) of Service ICD-10 Diagnosis Code(s), highest level of specificity CPT-4 Procedure Code(s) HCPS Code(s) Service Code Modifier (if applicable) Place of Service Service Units Charges per Service and Total Charges Provider Name Provider Address / Phone Number National Provider Identifier (NPI) / Provider ID Numbers submitted on HIPAA standard transactions( Tax ID Number

5 VNSNY CHOICE Required Data Elements and Claim Forms, (cont.) Required Data Elements CMS-1500 UB-04 Provider Number (For Paper Claims Only) VNSNY CHOICE Payer ID Number -For EDI Claims Only Hospital/Facility Name and Address Type of Bill Admission Date and Type Patient Discharge Status Code Condition Code(s) Occurrence Codes and Dates Value Code(s) Revenue Code(s) and corresponding CPT/HCPCS Codes when billing Principal, Admitting, and Other ICD-10 Diagnosis Codes Present on Admission (POA) Indicator (if applicable) Attending Physician Name and NPI VNSNY CHOICE Authorization Number CMS-1500 forms and UB-04 s can be used to bill fee-for-service encounters. The UB-04 form should be used by facilities and by facilities billing on behalf of employed providers

6 2017 Provider Manual VNSNY CHOICE Claim Submission Instructions for Managed Long Term Care Providers Billing Instructions Claims should contain the following information: Complete Name, Address, and Telephone Number of the Provider Contact Person Provider ID (assigned by VNSNY CHOICE) Tax Identification Number Authorization Number (3 digits to the right of the member s VNSNY CHOICE ID/Case Number on the order) Date of Service Procedure Code (refer to your contract for list of codes) Modifier for code, if applicable. (Refer to your contract for list of codes) Member ID Number Member Full Name (first, middle and last) Date of Birth Invoice Number (provider s internal number) Units billed Total charges for each service Total dollar amount of the invoices 2. VNSNY CHOICE will reconcile each claim to the services that were authorized and the rates that are outlined in the provider's contract. 3. VNSNY CHOICE adheres to the prompt payment provision of Section 3224-a of the New York State Insurance Law. It is the policy of VNSNY CHOICE to pay providers in accordance to NYS Prompt Pay Laws after the receipt of a "clean" claim for services. 4. Once your claims have been adjudicated, VNSNY CHOICE issues a Remittance Advice with payment informing you of the decision made on the claims submitted. Remittance Advices will also be issued for denied claims, indicating the reason for the denial. 5. If there are questions about any aspect of the VNSNY CHOICE billing requirements, please contact VNSNY CHOICE s Provider Relations Department at the telephone number listed in Section 1 of this provider manual. 6. Questions about specific claims may be directed to the Claims telephone number listed in Section 1 of this provider manual.

7 VNSNY CHOICE ICD-10 Frequently Asked Questions Last Updated: September 23 rd, 2015 ICD-10 Frequently Asked Questions (FAQs) This information is intended to provide a general overview of what can be expected with the transition from ICD-9 to ICD-10 as it impacts VNSNY CHOICE providers. VNSNY CHOICE identifies the provider community to include: Fee-for-service providers, who submit claims for all contracted services. Capitated providers, who submit capitated encounters and are paid per member per month. Claim delegates who contract with VNSNY CHOICE and pay/process claims on behalf of VNSNY CHOICE. The delegates contract independently with physicians and hospitals and submit delegated encounters to VNSNY CHOICE. If after reviewing this FAQ you have questions about VNSNY CHOICE and ICD-10 contact Provider Services on Background 1. What is ICD-10? ICD-10 stands for the International Classification of Diseases, 10th Edition. It is the international standard for diagnostic classification. The United States (US) adapted the ICD-10 coding system as the official system of assigning codes to diagnoses used in all health care settings and to procedures associated with hospital utilization in the US. ICD-10-CM: Diagnosis codes used in all health care settings in the US. ICD-10 PCS: Procedure codes associated with hospital utilization in the US 2. When will ICD-10 replace the current coding system, ICD-9? ICD-10 codes must be used if the date of service is on or after October 1 st, What changes are occurring in ICD-10? Significantly more codes have been added and the codes provide more specificity. There have also been changes to the structure of the codes to allow for future expansion. Document1 Page 1

8 VNSNY CHOICE ICD-10 Frequently Asked Questions Last Updated: September 23 rd, 2015 Diagnosis Codes Characteristic ICD-9 Diagnosis ICD-10 Diagnosis Code Set Name ICD-9-CM Vol 1 and 2 ICD-10-CM Number of Codes ~ 14,000 ~ 69,000 Number of Characters Example 3 to 5 Numeric (+ V & E codes) Unspecified pleural effusion V02.61 Hepatitis B carrier 3 to 7 Alphanumeric A69.21 Meningitis due to Lyme disease S52.131a Displaced fracture of neck of right radius, initial encounter for closed fracture Procedure Codes Characteristic ICD-9 Procedure ICD-10 Procedure Code Set Name ICD-9-CM Vol 3 ICD-10-PCS Number of Codes ~ 4,000 ~ 72,000 Number of Characters 3 to 4 Numeric 7 Alphanumeric Example Suture of duodenal ulcer site 0DQ10ZZ Repair upper esophagus, open approach 4. Will ICD-10 replace Current Procedural Terminology (CPT) procedure coding? No. The switch to ICD-10 does not affect CPT coding for outpatient procedures. Like ICD-9 procedure codes, ICD-10 PCS codes are for hospital inpatient procedures only. Claims Processing 5. Will VNSNY CHOICE accept ICD-9 codes after October 1 st, 2015? VNSNY CHOICE will follow CMS guidance and will only accept ICD-10 codes for dates of service on or after October 1st, For inpatient claims, ICD-10 codes must be used for a date of discharge on or after October 1st, Is there a transition period where I can use either ICD-9 or ICD-10 codes without having my claims rejected? No. ICD-9 and ICD-10 codes are dependent on the date of service (DOS) for outpatient services and date of discharge (DOD) for inpatient services. ICD-9 codes must be used if the DOS/ DOD is prior to October 1st, ICD-10 codes must be used if the DOS/ DOD is on or after October 1st, Will VNSNY CHOICE accept a claim that has both ICD-9 and ICD-10 codes? No. VNSNY CHOICE will follow CMS guidance and will require that only one version of ICD codes be submitted on a claim. If both ICD-9 and ICD-10 codes are submitted on a claim, the claim will be rejected as a claim submission error. Document1 Page 2

9 VNSNY CHOICE ICD-10 Frequently Asked Questions Last Updated: September 23 rd, Will ICD-10 apply to claims submitted to VNSNY's OPS (and SCP) Systems? No, claims submitted to through the OPS system will not be affected and will continue to be processed in the same manner. 9. Will VNSNY accept 837 batches with both ICD-9 and ICD-10 claims spanning the conversion deadlines? Yes. VNSNY CHOICE will accept 837 batches containing both ICD-9 and ICD-10 claims as long as each claim uses the correct coding. 10. Can I drop my claims to paper and continue using ICD-9? No. The current professional and facility claim forms have been revised to support ICD-10. The UB-04 facility claim form includes the FL 66 Diagnosis and Procedure Code Qualifier field. The qualifier field value for ICD-9 is 9 and for ICD-10 is 10. The CMS-1500 version 02/12 professional claim includes an ICD version indicator in field 21. The value for ICD-9 is 9 and the value for ICD-10 is 0 (zero). 11. Will there be extensions given for timely filing during the ICD-10 transition time? No. VNSNY CHOICE does not anticipate extending timely filing deadlines. 12. How do I submit a claim for services that span the ICD-10 compliance date? For an outpatient claim, the claim should be split based on the date of service. Services performed prior to October 1st, 2015 should be billed on one claim using ICD-9 diagnosis codes and services performed on or after October 1st, 2015 should be billed on another claim using ICD-10 diagnosis codes. For an inpatient claim, ICD-10 codes should be used if the date of discharge is on or after October 1st, VNSNY CHOICE is following CMS guidance on institutional services that span the October 1st, 2015 compliance date. Refer to the CMS guidance published in MLN Matters Number SE1325 for specific billing scenarios. 13. What do I do if my claim is rejected? If you attempt to submit a claim electronically and it is rejected it is because there is an issue with the information billed. For example if you have used ICD-9 codes for outpatient dates of service after October 1st, 2015, the claim would be rejected. Review the claim carefully for billing errors relating to diagnosis code or other issues, and resubmit. 14. What do I do if my claim is denied or I believe the amount paid is incorrect? Firstly review the Explanation of Payment (EOP) to determine why the claim denied. Often claims are denied due to billing errors. If this is the case, submit a corrected claim. Document1 Page 3

10 VNSNY CHOICE ICD-10 Frequently Asked Questions Last Updated: September 23 rd, 2015 If after reviewing the EOP you are still unsure why the claim was denied, or you believe it was denied incorrectly, call VNSNY CHOICE Provider Services on Our representatives are available to help you Monday through Friday, 8am-8pm. If after consulting with Provider Services you still believe the claim was incorrectly denied you can submit a written dispute/appeal. Fill out the dispute form ( %28UPDATED% %29.pdf) and make sure to explain clearly why you believe the claim was incorrectly processed and provide supporting documentation. Disputes must be submitted in writing to the address on the form. For Medicare non-contracted provider appeals, in accordance with CMS mandates, appeals can only be considered if accompanied by a signed waiver of liability statement. You can find the waiver of liability form at: Remember to submit the dispute/appeal in line with the timeframes specified in your contract with VNSNY CHOICE and in the Provider Manual. Provider Reimbursement 15. Do you anticipate any delays in processing or payments due to the switch to ICD-10? VNSNY CHOICE does not expect delays in processing or payment of a claim due to ICD-10 if the claims are properly coded based on the latest CMS guidelines. Rejection or denial due to misuse of new codes is possible. 16. Do you expect that ICD-10 will have an impact on capitation payments to providers? VNSNY CHOICE does not expect an impact to capitation. Providers who have entered into a capitated agreement with VNSNY CHOICE receive a check per member per month (pmpm) regardless of whether they submit claims for that member. Authorizations 17. How will VNSNY CHOICE handle authorization of services that occur on or after the ICD- 10 compliance date of October 1st, 2015? VNSNY CHOICE will issue authorizations based on the request date. All authorization and referral requests prior to and including September 30 th, 2015, are required to use ICD-9 codes. All authorization and referral requests submitted on or after October 1st, 2015 are required to use ICD-10 codes. 18. How will VNSNY CHOICE handle authorization of services that span the ICD-10 compliance date of October 1st, 2015? VNSNY CHOICE will provide two authorizations, one for services up to and including September 30 th, 2015 and another for services on and after October 1 st, Separate claims should be submitted for services before and after the compliance date. Document1 Page 4

11 VNSNY CHOICE ICD-10 Frequently Asked Questions Last Updated: September 23 rd, 2015 More Information Centers for Medicare and Medicaid Services: Workgroup for Electronic Data Interchange: ICD-10-CM official guidelines for coding and reporting: American Health Information Management Association: American Medical Association checklist for tips on preparing provider offices for ICD-10 (registration required): checklist.pdf IMPORTANT: The information contained in this document is designed to provide a general overview of what can be expected with the transition from the International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, (ICD-9) to ICD-10 as it impacts VNSNY CHOICE s business. The information provided is not intended to address all of the Centers for Medicare & Medicaid Services (CMS) requirements and implications mandating the use of ICD-10 and should not be used as legal advice for implementation activities. We encourage you to seek any professional advice you may need, including legal counsel, regarding how the new requirements will affect your specific practice. VNSNY CHOICE is providing this information for general informational purposes only. Document1 Page 5

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13 Provider Remittance Fact Sheet 1. Servicing Provider Information 2.Payee Name 3. Patient Information 4. Claim Information Dates of Service Procedure Code or Revenue Code Amount billed on the claim Allowed Amount Adjusted Amount/Disallow Amount Primary Payor Payment- Coordination of Benefits Patient Responsibility o Co Payment o Co-Insurance o Deductible o Non Covered Amount Interest Owed 4 Plan Payment/Benefit Amount Remark Codes/Explanation Codes 5. Claim Totals Current Payment Amount Provider Withhold Amount - Risk withhold amounts and/or Sequestration Prior Paid Amount- Any amount that have been paid on this claim previously Net Payments Amount - Current Payment less Provider Withhold Amount and Prior Paid Amount

14 6. Explanation of adjusted claims- This will display under a adjusted claim. This details the original claim number, amount paid and date the original claim was paid. 7. Provider Total- Total amounts for all claims listed on the Remittance Advice. 8. Payee mailing information 9. Payment Summary - The below headings are for all claims listed on the Remittance Advice Date Payment is being made Check Number Who payment is being made to Payee tax ID Reference ID Total Charges Total Cons Charged- Total Considered Charges. This is the larger of contracted amounts and charges Total Denied Total Allowed Non Paid- Total of Coordination of Benefits and Member responsibility Prior Paid- Total of amount previously Interest Owed- Total interest paid Provider withhold- Total Risk withhold amounts and/or Sequestration Gross Paid - Total Charged less Total Denied, Non Paid, Prior Paid, and Provider Withhold. Reductions- Total amount of all original claims payments when the reprocessed claim on the Remittance Advise is paid less than the prior paid

15 Automatic Recovery- Amount recovered from medical overpayment Other Recoveries Net Check Amount- Gross Paid less and any Recoveries 10. Explanation of Claims Handling- Remark Codes with descriptions 11. Payment Reduction and Recovery Summary Previous Balance- Existing Medical Overpayment Balance Recoveries on this Remittance- Medical Overpayment amount being recovered on this Remittance Reductions on this Remittance- Medical Overpayment amount being added to the total on this Remittance New Balance 12. Payment Recoveries and Reductions made in this Remittance Cycle- This provides details the claims that was originally overpaid and when the overpaid amount for that claim was recovered

16 2018 Provider Manual VNSNY CHOICE Billing Instructions for Nursing Home Providers 1. All nursing homes must submit invoices to VNSNY CHOICE no later than 90 days after the end of the month in which services are provided or from the date of the Medicare explanation of benefits (EOB), whichever is greater. 2. If payment is obtained from other sources to offset some or all of VNSNY CHOICE billing responsibilities, documentation of these payments must be included with the claim. 3. VNSNY CHOICE MLTC will pay all undisputed claims in accordance with New York State Prompt Pay regulations. 4. Medicare rules are unchanged, even if an individual is a member of VNSNY CHOICE MLTC. Bedhold VNSNY CHOICE follows New York State Medicaid Program policy regarding payment for bedholds. Upon member admissions to nursing facilities when VNSNY CHOICE is the primary payer, VNSNY CHOICE representatives provide the Care Manager with contact names and numbers. See Section 1 of this provider manual for contact information. It is essential that a nursing home notify the appropriate VNSNY CHOICE regional office when a member is hospitalized. This allows the Care Manager to discuss bedhold with the facility and to follow the member s care while in the hospital. The member must be in the facility for a minimum of thirty (30) days to be eligible for bedhold payment, subject to a vacancy rate on the first day of the member s absence of not more than 5%. VNSNY CHOICE must be notified at the time of member hospitalizations in order to authorize and approve bedhold payments. Payment to a facility for reserved bed days provided for temporary hospitalizations may not exceed twenty days. The twenty days are reset based on when the member s 12-month period began.

17 2018 Provider Manual VNSNY CHOICE Billing Instructions for Nursing Home Providers General Procedure: 1. On a monthly basis, the nursing home submits claims to VNSNY CHOICE for services provided on a UB-04 CMS (HCFA) A separate invoice must be submitted for each member. For members enrolled in Medicare or Medicare Managed Care Organizations ( MCO ), the Explanation of Benefits (EOB) must also be attached. 3. If Medicare or a Medicare MCO was NOT billed prior to billing VNSNY CHOICE, then the Nursing Home must attach a copy of the "Ineligibility for Medicare Benefits form to the invoice. 4. Depending on the type of health insurance the member has and the location of the member immediately prior to the nursing home admission, one of the following procedures should be followed: If the member is admitted from a hospital: A. The member has both Medicare Part A and Institutional Medicaid If the member was an inpatient of a hospital for at least 3 consecutive days and was admitted to the nursing home within 30 days of hospital discharge, then Medicare is usually the primary payer and VNSNY CHOICE is the secondary payer. Medicare rules do not change when an individual is a member of VNSNY CHOICE. The nursing home evaluates the member to determine if he/she meets Medicare coverage criteria. If so, Medicare or the Medicare MCO should be billed following the nursing home's standard procedures. A. During days 1 through 20, Medicare covers 100 percent of the charges, with no co-payment B. During days 21 through 100, Medicare pays a portion of the charges. For these days, VNSNY CHOICE is responsible for all co-payments. The nursing home should submit an invoice to VNSNY CHOICE and attach the Medicare or Medicare MCO remittance advice showing the co-payment that is due. If this is not attached, the invoice will be denied and returned to the nursing home with a request that Medicare be billed first. C. It is understood that Managed Medicare plans may have a different cost sharing structure that Medicare fee for service. In those cases, the Managed Care s Remittance Advice will be used to determine what if any cost sharing will be reimbursed by VNSNY CHOICE MLTC. B. The member has Institutional Medicaid and there is no other eligible payer (including individuals who do not have Medicare Part A and those who are assessed as having no rehabilitation potential) If the member does not have Medicare Part A or is not expected to benefit from rehabilitation therapies, then VNSNY CHOICE is responsible for paying all nursing home costs, beginning on the date of admission. The nursing home should submit its invoice to VNSNY CHOICE at their current rate. The nursing home should submit documentation of its Medicaid rate as updated by the New York State Department of Health. The "Ineligibility for Medicare Benefits" form should be attached to the invoice.

18 2018 Provider Manual VNSNY CHOICE Billing Instructions for Nursing Home Providers If the member is admitted from a hospital (cont.) C. The member does not have Institutional Medicaid A member without Institutional Medicaid is only eligible for nursing home care if they have Medicare Part A and meet the conditions for coverage under the Medicare program. The nursing home should bill Medicare or the Medicare MCO for its services and VNSNY CHOICE for any co-payments, as described in section A above. If nursing home services are required beyond 100 days, the member will be required to disenroll from VNSNY CHOICE and his/her family will have to pay privately for any ongoing care. A member without Institutional Medicaid is not eligible for long term nursing home care through the VNSNY CHOICE program. If a nursing home placement is the only appropriate setting to care for this member, he/she will be required to disenroll from VNSNY CHOICE and his/her family will have to pay privately for nursing home care. If the member is admitted from the community: D. The member has Institutional Medicaid VNSNY CHOICE is responsible for paying all nursing home costs, beginning on the date of admission. The nursing home should submit its invoice to VNSNY CHOICE at the agreed upon rate. The "Ineligibility for Medicare Benefits" form should be attached to the invoice. E. The member is not eligible for Institutional Medicaid A member ineligible for Institutional Medicaid is not eligible for long term nursing home care through the VNSNY CHOICE program. If a nursing home placement is the only appropriate setting to care for this member, he/she will be required to disenroll from VNSNY CHOICE and his/her family will have to pay privately for nursing home care.

19 2018 Provider Manual VNSNY CHOICE Medicaid Eligibility and NAMI (Net Available Monthly Income) Nursing Home Medicaid Eligibility The New York City Human Resources Administration (HRA) published guidelines addressing nursing home admissions when a resident is a member of a Managed Long Term Care (MLTC) program. The guidelines direct the MLTC programs to coordinate Medicaid eligibility functions with the nursing facility. In order for HRA to properly capture NH days/stays, it is advised that your facility submit a Medicaid conversion for every long-term (permanent) placement admission and a discharge form when appropriate. (This is the same process that nursing homes use for all Medicaid admissions.) This will allow HRA to track admissions and days for MLTC members. HRA will process the admission, but the member will remain on VNSNY CHOICE s roster. The resident will not appear on the nursing home s Medicaid roster. VNSNY CHOICE is the payer for the Medicaid portion of the nursing home bills of its members instead of Medicaid. As such, VNSNY CHOICE coordinates all other Medicaid eligibility activities for its members with HRA, such as annual recertification. VNSNY CHOICE may coordinate some of the necessary documents for financial recertification with the nursing home s staff but, again, VNSNY CHOICE staff will manage the Medicaid eligibility issues with HRA. Net Available Monthly Income (NAMI) VNSNY CHOICE will continue to collect any Medicaid surplus for its members placed in nursing homes until the placement becomes permanent. Once it is confirmed that the member is to remain in the nursing home for long-term care, the nursing home will be notified of the NAMI application and to begin the process of re-routing monthly income. VNSNY CHOICE determines the NAMI amount and will coordinate with the nursing home s billing department regarding the timing and amount of the NAMI. Each month, VNSNY CHOICE sends contracted nursing homes a roster listing members who were residents in the facility during the previous month. The roster indicates: Member name Placement status, e.g. short-term or long-term NAMI amount (if applicable) VNSNY CHOICE Care Manager s name Contact telephone numbers for VNSNY CHOICE regional staff and Claims Department.

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27 2018 Provider Manual VNSNY CHOICE General Claims Layout Information and Provider Codes Chore Services Providers Column Field Name Description Field Length Data Type A Provider Invoice Number The provider s own invoice number. You can use whatever combination of letters and numbers you wish, either generated by your billing Up to 20 characters Text &/or numeric B Member ID VNSNY CHOICE Member ID for example: V , total of 9 positions, 1 st left most position always should equal a V (must be upper case) Next right most 8 positions must be numeric. 9 characters Alpha Numeric C Member Last Name VNSNY CHOICE member s (patient) last name (Not case sensitive) Up to 35 characters Text D Member First Name VNSNY CHOICE member s (patient) first name (Not case sensitive) Up to 35 characters Text E DOS Date of Service(s): the date the provider performed the services. 8 characters Date format MM/DD/YY F TOS Type of service: Provider must specify CHORE 5 characters Text G Authorization Number This is a 3-digit number from the VNSNY CHOICE Order Processing Order entry form to the right of the Agency Name, e.g The left group of numbers represent the member s VNSNY Case number ID and to the right, is a 3-digit sequence number. You must include only the digits to the right. *NOTE: An Authorization number may remain the same for multiple dates of service for the same member.

28 2018 Provider Manual VNSNY CHOICE General Claims Layout Information and Provider Codes Adult Day Care Providers Column Field Name Description Field Length Data Type A Provider s Invoice Number The provider s own invoice number. You can use whatever combination of letters and numbers you wish, either generated by your billing system or manual created, e.g A Up to 20 characters Text &/or numeric B Member ID VNSNY CHOICE Member ID for example: V , total of 9 positions, 1 st left most position always should equal a V (must be upper case) Next right most 8 positions must be numeric. 9 characters Alpha Numeric C Member Last Name VNSNY CHOICE member s (patient) last name (Not case sensitive) Up to 35 characters Text D Member First Name VNSNY CHOICE member s (patient) first name (Not case sensitive) Up to 35 characters Text E DOS Date of Service(s): the date the provider performed the services. 8 characters Date format MM/DD/YY F TOS Type of service: Provider must specify SDY. 3-5 characters Text G Authorization Number This is a 3-digit number from the VNSNY CHOICE Order Processing Order entry form to the right of the Agency Name, e.g The left group of numbers represent the member s VNSNY Case number ID and to the right, is a 3-digit sequence number. You must include only the digits to the right. 3 digits Numbers

29 2018 Provider Manual VNSNY CHOICE General Claims Layout Information and Provider Codes Home Delivered Meals Providers Column Field Name Description Field Length Data Type A Provider s Invoice Number The provider s own invoice number. You can use whatever combination of letters and numbers you wish, either generated by your billing system or manual created, e.g A B Member ID VNSNY CHOICE Member ID for example: V , total of 9 positions, 1 st left most position always should equal a V (must be upper case) Next right most 8 positions must be numeric. C Member Last Name VNSNY CHOICE member s (patient) last name (Not case sensitive) Up to 20 characters Text &/or numeric 9 characters Alpha Numeric Up to 35 characters Text D Member First Name VNSNY CHOICE member s (patient) first name (Not case sensitive) Up to 35 characters Text E DOS Date of Service(s): the date the provider performed the services. 8 characters Date format MM/DD/YY F TOS Type of service: Provider must specify MOW. 5 characters Text G Authorization Number This is a 3-digit number from the VNSNY CHOICE Order Processing Order entry form to the right of the Agency Name, e.g The left group of numbers represent the member s VNSNY Case number ID and to the right, is a 3-digit sequence number. You must include only the digits to the right. 3 digits Numbers NOTE: An authorization number may remain the same for multiple dates of service for the same member.