DOH Medicaid Update October 1999 Vol.14, No.10

Office of Medicaid Management
DOH Medicaid Update
October 1999 Vol.14, No.10

State of New York
George E. Pataki, Governor

Department of Health
Antonia C. Novello, M.D., M.P.H., Dr. P.H.

Medicaid Update
is a monthly publication of the
New York State Department of Health,
Office of Medicaid Management,
14th Floor, Room 1466,
Corning Tower, Albany,
New York 12237

Enteral Therapy
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Effective immediately, the maximum quantity allowed per month (without paper prior approval) for code B4084 #Gastrostomy/jejunostomy tubing has changed. When medically necessary, up to two per month may now be dispensed.

Codes B4154 #Enteral Formulae; Category IV and B4155 #Enteral Formulae; Category V are listed as "BR " (By Report). Do NOT bill online for codes listed "BR ". An EMEVS dispensing validation number must be obtained and recorded on a paper claim form. Amounts charged should be the lower of either the acquisition cost (by invoice to provider) plus 50% OR the usual and customary charge to the general public. The cost invoice must be attached to claim.

Note: The calculation for pricing all Enteral Therapy formulae is as follows: Number of calories per can, divided by 100, equals the number of caloric units per can. Claims will be denied if caloric units are not used to bill.

Questions concerning this article should be directed to the Bureau of Medicaid Review and Payment at (518) 474-8161.

Since April 1, 1999, co-payments have been inadvertently deducted by the Medicaid Management Information System from provider payments for some recipients who have reached the $100 co-payment limit. An EMEVS message had advised providers that the recipient was at the co-payment cap and that no co-payment should be collected or deducted. This systems problem is being corrected, and providers who have had co-payments deducted in error will receive a retroactive adjustment in their checks dated October 11, 1999, which will be released on October 27, 1999. Providers who may have collected co-payments from recipients who have reached their $100 cap should also refund those payments to recipients.

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On August 9, 1999, Governor Pataki signed legislation (Chapter 412 of the Laws of 1999) requiring the New York State Department of Health (DOH) to ensure the timely enrollment of infants born to women who are receiving Medicaid into the Medicaid program. The new statute takes effect July 1, 2000.

The recently enacted statute requires DOH to assign a client identification number, and issue an active Medicaid identification card as soon as possible, but no later than ten (10) business days from the notification of the birth by the hospital. The legislation mandates that hospitals report live births to women in receipt of Medicaid to DOH or its designee within five (5) business days of the birth. Hospitals may face a financial penalty if they fail to comply with this provision.

The new law expands on existing Medicaid policy for newborns. Infants born to mothers who Medicaid recipients are automatically eligible for Medicaid. This Medicaid coverage continues until the child is age one. Consequently, we recommend that providers encourage the mother to notify the local Department of Social Services about the birth of the child. Providers are assured that Medicaid will pay for all medically necessary services provided under the Medicaid program to such infants.

Hospitals also must notify each mother, in writing upon discharge, that her newborn is considered enrolled in the Medicaid program and that she may access care, services, and supplies available under the program for her baby, provided that she herself is in receipt of Medicaid. (DOH will provide language to be used for this notification, and identify procedures to be used to notify mothers.) A Medicaid provider that furnishes medical assistance to such a child whose mother is in receipt of Medicaid will be eligible for Medicaid reimbursement whether or not the child has an identification card or a client identification number, in accordance with the applicable provisions of the Medicaid program with respect to care and services provided, and the claim submitted.

DOH is developing a process that uses existing computer systems to allow hospitals and DOH to meet the mandated time frames. Consequently, hospitals will not be required to develop separate systems to address the new statutory requirements. DOH, along with several other state agencies,will be working over the next several months to develop an automated system for registering newborn children in Medicaid within the time frames specified in the statute. The proposed automated system will use information received electronically from hospitals through the DOH Statewide Perinatal Data System to update Medicaid program computer systems.

We are requesting the cooperation of all hospitals across the State in complying with the new legislation to ensure the timely enrollment of newborns into the Medicaid program.

Additional information about activities to implement this new legislation will be provided in future issues of the Medicaid Update.

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The New York State Medicaid program will provide reimbursement for prescription smoking cessation products effective October 1,1999. Products covered include nicotine patches such as Habitrol and Nicotine TDS (not over the counter brands), Zyban and Nicotrol Inhaler. Prescriptions will be limited to an original one-month initial supply with up to two refills, for a total of a 90-day supply. In the near future, approval through the Dispensing Validation System (DVS) will be required prior to dispensing smoking cessation agents. Additional information will be provided to pharmacists regarding the use of this system shortly. For further information, contact the Pharmacy Policy Unit at (518) 486-3209.

The Department of Health is committed to assisting all Medicaid recipients who are attempting to stop smoking. Manufacturers of these products often include support and assistance to those receiving the products, and recipients should be encouraged to use these aids. Also, community based groups may offer free behavioral modification programs which may be available in your area.

Timing Is Everything
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During the process of billing or rebilling Medicaid claims, questions about time constraints arise. Some of the most common of these questions relate to "how long " information is on the Medicaid system and "how long " a claim is pended. As a reference source, listed below are some time frames categorized by the following: less than 30 days, 30 days, 60 days, 90 days, and greater than 90 days.

  • Less Than 30 Days
    • 24 hours - Length of time a pharmacy has to reverse (credit) an Electronically Captured Claim
    • Medicaid checks and remits are held for two weeks and two days before mailing
  • 30 Days
    • Time allowed to return a Claim Correction Form (CCF) to Computer Sciences Corporation (CSC)
    • Approximate payment time for claims (This may vary with claim type)
    • Length of time a pharmacy claim is pending for "NO UT SERVICE AUTHORIZATION ON FILE "
  • 60 Days
    • Length of time the status of a claim remains on file for CSC Inquiry Staff
    • Length of time a pharmacy has for the Electronic Claim Capture (ECC) of a filled prescription or fiscal order
    • Length of time a claim (excluding pharmacy) is pending for "NO UT SERVICE AUTHORIZATION ON FILE "
    • Length of time a provider has to resubmit a denied claim that has not been previously resubmitted.
  • 90 Days
    • Length of time to submit claims without a valid 90-day reason
    • Length of time a UT Service Authorization stays on file for pharmacy transactions
  • Greater than 90 Days
    • 120 days (4 months) - Length of time a UT Service Authorization stays on file, excluding pharmacy (see above)
    • Up to 2 years - Length of time to submit a new claim with a valid 90-day reason attached
    • Up to 6 years - Length of time to submit an adjustment or void to a previously paid claim

Providers making inquiries or requesting billing training by regional representatives should contact CSC by calling the appropriate number below. Please be prepared to supply your Medicaid Provider ID number.

Practitioner Services: 1-800-522-5518 or (518) 447-9860
Institutional Services: 1-800-522-1892 or (518) 447-9810
Professional Services: 1-800-522-5535 or (518) 447-9830

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Pricing for insulin vials, cartridges and pens has been updated effective September 1,1999. In the future, pricing changes on these products will be automatically updated using a methodology based upon pricing information supplied by our drug pricing contractor. For further information, contact the Pharmacy Policy Unit at (518) 486-3209.

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Influenza and pneumococcal diseases are responsible for approximately 60,000 deaths each year in the United States (U.S.). As many or more deaths are attributable to influenza and pneumonia than AIDS, breast cancer, all U.S. motor vehicle accidents, diabetes or Alzheimer disease. Persons who are at great risk for complications from these diseases, including all adults 65 years and older, residents with chronic medical conditions living in long term care facilities, anyone who has a serious long-term health problem (heart, kidney, lung or metabolic disease, asthma, anemia or other blood disorder) or weakened immune system, should receive a pneumococcal vaccine and a yearly influenza vaccine.

Although clinically safe and effective vaccines are available and there have been long-standing recommendations for vaccination, they are still underutilized. The current influenza immunization rate for adults 65 years and older in the U.S. is 43.3% and 39.9% in New York State. For pneumococcal vaccine, the immunization rate is even lower. In the U.S. it is 20.7% and 18.5% in New York State. The national Healthy People 2000 goal for influenza and pneumococcal immunization rate among non-institutionalized high-risk populations is at least 60% by the year 2000.

The New York State Department of Health will be undertaking a new initiative to promote adult immunization. The goal is to increase immunization coverage in adults 65 years and older to 60% for influenza and 40% for pneumococcal vaccines through the use of community-based coalitions. These coalitions include individuals and organizations working toward the common goal of ensuring that those at risk and the providers who care for them have access to information, vaccines and effective vaccine delivery systems.

To help ensure that all at risk patients obtain immunizations, all Medicaid enrolled medical providers are urged to immunize their patients over 65 years of age. As a reminder-reimbursement for influenza virus vaccine and pneumcoccal vaccine under Medicaid may be billed by a clinic as a threshold visit. If provided in an office, physicians and nurse practitioners may claim code 90724, influenza vaccine, and 90732, pneumococcal vaccine in addition to the appropriate evaluation and management code for the day. Reimbursement for the immunization injection will be at acquisition cost of the antigen. Insert acquisition cost per dose, plus a two-dollar administration fee, in the amount charged field on the claim form. For a complete list of immunization injections, please refer to the procedure code section of your MMIS Provider Manual.

(Medicare Crossover Lawsuit)
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Instructions to those providers who had been named plaintiffs in the above-cited action.

  • This is to remind providers that the June 1999 purge cycle [cycle #139] was the final cycle in which Medicare lawsuit claims would be processed for payment.
  • Providers are also reminded that all unresolved lawsuit claims remaining after the June purge cycle would be denied and reported out in remittances, in a regular cycle soon after that purge cycle. Unresolved Medicare lawsuit claims denied in cycle #140 were reported out to providers in remittances from that cycle.
  • This is also a reminder that all edit correction and data submission opportunities ended with the May 11, 1999 deadline. All opportunities for corrections, adjustments, and other changes, except voids, ended at that time. Voids continued to be processed as per established lawsuit claiming instructions, until the September purge cycle.

Important note: With the conclusion of the September purge cycle, all previously established lawsuit claims processing procedures, including those for voids, ceased to be operational. Providers may no longer submit voids for processing using the method previously established for lawsuit claims processing. Instead, providers who may still need to submit a void for a lawsuit claim must now first contact Computer Sciences Corporation (CSC) for necessary instructions.

For assistance, please call your CSC Healthcare Systems representative at:

Practitioner Services: 1-800-522-5518 or (518) 447-9860
Institutional Services: 1-800-522-1892 or (518) 447-9810
Professional Services: 1-800-522-5535 or (518) 447-9830

The Medicaid Update: Your Window Into The Medicaid Program

The State Department of Health welcomes your comments or suggestions regarding the Medicaid Update.

Please send suggestions to the editor, Timothy Perry-Coon:

NYS Department of Health
Office of Medicaid Management
Bureau of Program Guidance
99 Washington Ave., Suite 720
Albany, NY 12210
(e-mail )

The Medicaid Update, along with past issues of the Medicaid Update, can be accessed online at the New York State Department of Health web site: