To speak to a Sandata Representative about the NYS OMIG Verification Organization mandate or to schedule a system demo, please contact:

Matthew Rose, Regional Vice President of Sales:
516-484-4400, ext. 4191 or mrose@sandata.com

NYS OMIG Frequently Asked Questions

1. What is the definition of a Verification Organization (VO)?

   "Verification organization" means an entity which uses electronic means including but not limited to contemporaneous telephone verification or contemporaneous verified electronic data to verify whether a service or item was provided to an eligible Medicaid recipient.

2. What is the definition of a participating provider?

   The legislation states that a participating provider “means a
   a. certified home health agency
   b. long term home health agency
   c. personal care provider
   with total Medicaid reimbursements exceeding fifteen million dollars per calendar year.”

3. How is the fifteen million dollars per calendar year calculated?

   This requirement will apply to Federal Employers (as defined by FEIN) with Provider ID’s which, in aggregate, directly submit Fee for Service claims as Certified Home Health Agencies, Long Term Home Health Agencies and/or Personal Care Agencies (excluding Consumer Directed).

4. Does a VO need to provide all services outlined in the VO diagram?

   No, however it is the VOs responsibility to ensure that all of the functions exist, and meet all of the requirements described herein. For each provider that employs the services of the VO, the VO must review and attest to the requirements being met in that particular implementation.

5. Can a CHHA be considered a VO if they are submitting their Medicaid claims directly to NY State if the meet the dollar threshold?

   No, part of the role of a VO is to be third party control organization.

6. Is Electronic Visit Verification required at the provider level?

   Yes. EVV must be employed and all resulting data must be collected and stored in a provider neutral repository which can be accessed by the DOH and the OMIG and their respective representatives.

7. Will the CHHA need to install EVV for skilled Medicaid workers?

   At this time it is believed that skilled workers will be exempt from EVV during the initial implementation period.

8. Are providers required to do compliance checking?

   Yes providers must ensure that all their employees are in compliance with regulations. The VO must verify that the providers systems have the appropriate checks and balances in place and checks against exceptions and sanction databases.

9. Are providers required to do exception handling / resolution prior to claims submission?

   Yes. The VO must verify that the providers’ systems prevents claims from being submitted with exceptions or that all exceptions have been properly resolved.

10. Are providers required to do conflict reporting?

    Yes. Any instance of caregiver location conflict (caregiver is at two locations at the same time) must be identified and reported.

11. Are providers ever considered a VO?

    No, providers are never the VO. Each covered provider must engage the services of a VO.

12. What happens when the VO’s client’s billing system is not a product of the VO nor directly under their control?

    The VO is required to review the interrelationships from the different systems and attest to the presence of the required checks and that there is no way for the provider to circumvent the controls.

13. What are authorization requirements?

    There are no specific requirements related to authorizations. However, there must be reasonable checks to ensure the continuum from authorization to plan of care to scheduling to the actual and provision of related services.

14. Are provider homegrown software solutions acceptable to the state?

    They would be considered a weak link in the verification process, but the state has not ruled their use out at this point. The VO will need to be familiar with the system and will need to focus on and speak to the controls in place to give reasonable assurance that requirements can’t be bypassed.

15. Are Consumer Directed Personal Care Services included?

    At the present time Consumer Directed Personal Care is being exempted from the calculation for covered providers. Professional services staff are not subject to the requirements at this time.

16. Is Managed Long Term Care included?

    Managed Long Term Care is not included, however fee for service managed care is included. With the exception of Consumer Directed, if fee for service claims are submitted for Home Health (COS 0260), Persona Care (COS 0264) or Long Term Home Health (COS 0388), they are used to determine covered providers. All of those services, with the exception of the professional component are subject to the EVV and cross edits.