What is reimbursable

Two questions decide whether a school-based health service can be billed to Medicaid in New York. Is the service one the SSHSP fee schedule covers, delivered by somebody qualified to deliver it? And can the district still produce the evidence, on the day an auditor asks, that it was ordered, mandated, consented to, and actually performed? A service can fail the second test long after it passed the first.

Services that carry a rate

SSHSP covers nine categories of service. Within them the fee schedule sets rates by CPT and rate code, distinguishing individual from group delivery and evaluation from ongoing therapy, so two sessions of the same therapy can pay differently depending on how they were delivered.

• Speech therapy and speech-language evaluationIndividual and group sessions, plus the evaluations that establish the need for them.
• Occupational therapyIndividual and group sessions, and OT evaluation.
• Physical therapyIndividual and group sessions, and PT evaluation.
• Psychological counselingIndividual and group counseling delivered against an IEP mandate.
• Psychological evaluationDiagnostic examination and psychological testing, billed per session or per hour depending on the code.
• Medical evaluationThe physician examination that supports an IEP recommendation.
• Audiological evaluationHearing assessment. Hearing services are billed under this category rather than separately.
• Skilled nursingNursing services delivered by qualified nursing staff under an IEP mandate.
• Special transportationTransportation on a specially adapted vehicle, on a day the student received another billable service.

Rates change, and the current figures belong in the fee schedule rather than on a marketing page. The published SSHSP handbook and its appendices are the authority on what each code pays; districts using Apollo Claims see the current codes and rates in the app.

Who has to deliver the service

Medicaid pays for a service on the basis of who furnished it, not which department employed them. A speech session delivered by somebody without recognized speech qualifications is not a cheaper claim; it is not a claim. Three things have to hold.

The provider must be qualified for that service type. Qualifications are specific to the service, so a licensed professional in one discipline does not thereby become billable in another.

The provider needs an NPI. The furnishing provider’s National Provider Identifier goes on the claim, and so does the NPI of the practitioner who wrote the order. A missing NPI on either side stops the claim at submission rather than at audit.

Providers who work under supervision need a co-signature. Where a service is delivered by somebody who practises under direction, the supervising provider must be qualified to direct that work and must attest to it. A supervisor who is themselves supervised cannot serve as one, and nobody can supervise their own work: the point of the co-signature is that a second person reviewed it.

What has to be on file before it pays

An eligible service delivered by a qualified provider is still not a billable claim until the record behind it is complete. Each of these is a condition, not a formality, and each one is a place districts routinely lose money they have already spent:

• An IEP mandate covering the dateThe service must appear in an IEP whose effective period covers the day it was delivered, and the sessions billed must stay inside the frequency the IEP mandates for that period.
• A Medicaid-enrolled studentThe student needs a valid Client Identification Number, with eligibility in force on the date of service.
• Written parental consentA one-time written consent to bill public benefits and to disclose records for billing must be on file before any claim goes out. This is a requirement of IDEA at 34 CFR 300.154(d), separate from anything Medicaid asks for.
• A written order or referralFor the service types that require one, an order from a qualified practitioner must exist before the service is furnished, and it must be valid for the date of service. The ordering practitioner’s NPI travels on the claim.
• A qualified providerThe person who furnished the service must hold qualifications recognized for that service type, and must have an NPI on record.
• A signed, contemporaneous session noteThe note records the actual start and end time of the session and is signed by the furnishing provider, with credentials and date. A session dated in the future is not a record of anything.
• Coding that matches the serviceAt least one ICD-10 diagnosis code appropriate to the service, and the CPT procedure code designated for that service and encounter type.

Where the money is usually lost

Almost none of it is lost on the question of coverage. The services are plainly covered and the students are plainly eligible. What goes missing is the written order that was never obtained, the consent form nobody can locate, the session note signed three months late or not at all, the mandate that expired mid-year while sessions carried on. The service was delivered either way, and the district paid for it either way. The only thing in question is whether the evidence survives to support the claim.

That is the problem Apollo Claims exists to solve: assembling the evidence as the work happens, and checking each claim against the program’s rules before it is filed rather than after it is denied.

Sources

This page summarizes program requirements in general terms. It is not compliance advice, and it is not a substitute for the published guidance. Where this page and the handbook differ, the handbook governs.

• Medicaid in Education (SSHSP)New York State Education Department
• SSHSP Handbook and provider guidanceNew York State Education Department
• Delivering Services in School-Based Settings: A Comprehensive Guide to Medicaid Services and Administrative ClaimingCenters for Medicare & Medicaid Services, 2023
• Medicaid Funding for School-Based ServicesU.S. Department of Education & CMS, 2024
• Parental consent for billing public benefits, 34 CFR 300.154(d)U.S. Department of Education