DOH Medicaid Update August 2000 Vol.15, No.8

Office of Medicaid Management
DOH Medicaid Update
August 2000 Vol.15, No.8

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

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Several months ago, the provider enrollment seminar that was required as part of the enrollment process in the Medicaid program for practitioners in the New York City area was suspended. A booklet entitled "Introduction to the New York State Medicaid Program" is now included in the physician enrollment package and contains material that would have been covered at the seminar.

If you have a newly hired physician who needs to enroll in the New York State Medicaid program, please note that the physician enrollment package was revised in January 2000 to include the booklet and the signed attestation necessary for enrollment.

After October 1, 2000 all physician enrollments must be submitted using the new application that includes the attestation. If an application is received after October 1st on a previous version of the Physician Form DOH - 4129 (Rev. 1/00), it will be returned with a copy of the new application to be completed. Failure to use the new form will cause a delay in the enrollment process.

To obtain a copy of the new application form, please call the Bureau of Provider Enrollment at (518) 486-9440 or write to:

New York State Department of Health
Office of Medicaid Management
Bureau of Enrollment
99 Washington Avenue, Suite 611
Albany, NY 12210-2806

Reading Newspaper



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Influenza and pneumococcal diseases are responsible for approximately 60,000 deaths each year in the United States. 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 under utilized. 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.

Pneumococcal Conjugate Vaccine, Polyvalent (Prevnar)
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Effective for dates of service on and after August 15, 2000 the following procedure code will be available for billing:

90669 Pneumococcal conjugate vaccine, polyvalent, for intramuscular use - Claims for dates of service prior to August 15, 2000 must be submitted using code 90749 Unlisted immunization procedure. Claims using code 90749 must be submitted on a paper claim form and must include an itemized invoice.

Claims submitted using code 90669 for dates of service on and after August 15, 2000 may be submitted either electronically or on a paper claim form. No attachment is required. Reimbursement will be made at the administration fee for the Vaccine for Children's Program (VFC), $17.65. If claiming for vaccine purchased privately, append modifier "WD" to procedure code 90669 on your claim form in field 24D. Insert your acquisition cost plus a $2.00 administration fee in the amount charged field on your claim form. If you have any questions about New York State Medicaid reimbursement for this vaccine, contact the New York State Department of Health, Office of Medicaid Management at (518) 474-8161.

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Under Commissioner Novello's leadership, the Department of Health has made a commitment to assist Medicaid recipients in smoking prevention and cessation. Medicaid provides reimbursement for prescription and non-prescription smoking cessation drugs. Additional resources, including a cost-free Smoker's Quitline (1-866-NYQUITS (1-866-697-8487), are also available to all New Yorkers, including Medicaid recipients.

According to the Center for Disease Control, about 22 million adult women and at least 1.5 million adolescent girls smoke cigarettes in the United States. Among women, use of tobacco has been shown to increase the risk of cancer, heart and respiratory diseases, and reproductive disorders. More than 140,000 women die each year from smoking-related diseases (the most preventable cause of premature death in this country).

The Task Force for Tobacco-Free Women and Girls
The statewide Task Force for Tobacco-Free Women and Girls was formed in 1993 to investigate the problem of tobacco from womens' perspectives and to develop strategies for reducing the use of tobacco among women and girls. Annually, the Task Force provides funds and support for local tobacco coalitions to conduct activities to increase awareness of the problems associated with tobacco use by women and girls.

Educational Materials
The Task Force has released a new report detailing what middle and high school students believe can be effective strategies in encouraging girls to be tobacco-free. Other educational materials that are available include:

  • A slide show and table top display that review the history of tobacco advertising aimed at women and the impact this has had on women's health.
  • A slide show that illustrates how the cigar fad lures women into smoking.
  • A resource notebook that is available to assist community groups in planning activities that focus on women, girls and tobacco.
  • Computer screen savers that are available free of charge to schools and individuals

For more information on the Task Force for Tobacco-Free Women and Girls, contact:

Pat Hysert, Coordinator Task Force for Tobacco-Free Women and Girls
Roswell Park Cancer Institute
Elm and Carlton Streets
Buffalo, NY 14263
Phone: (716) 845-8080

Glucometers Now Covered For All Pregnant Women
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Glucose monitors are billable by pharmacies as a supply item effective July 1, 2000. This information is contained in the July 1, 2000 revision to the durable medical equipment (DME) and pharmacy manuals. This means that if pharmacies bill for glucose monitors using only the 0441 COS, the claim will be paid. Previously, glucose monitors were only billable as DME, which is not a covered service for women whose Medicaid cards produce the EMEVS message Perinatal Family. With this change, all Medicaid eligible pregnant women will be able to obtain glucose monitors when indicated. Questions should be directed to Susan Brownell, Bureau of Maternal and Child Health, at 518-473-5313.

Schedule of Medicaid Seminars for New Providers

Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid Management Information System (MMIS), announces the following schedule of Introductory Seminars. Topics will include:

  • Overview of MMIS
  • Explanation of MMIS Provider Manual
  • Discussion of Medicaid Managed Care
  • Overview of Billing Options
  • Explanation of 90-day Regulation
  • Explanation of Utilization Threshold Program

Please indicate the seminar(s) you wish to attend below:

October 12 [_______] 10 AM
Human Services Complex
Infirmary Road
Liberty, NY

October 26 [_______] 10 AM
Allegany County
(address to be announced - see below)
Belmont, NY

November 9 [_______] 10 AM
Suffern Free Library
210 Lafayette Ave.
Suffern, NY

November 13 [_______] 10 AM
Computer Sciences Corporation
800 North Pearl Street, 3rd Floor
Albany, NY

Other seminars may be scheduled as new programs are implemented or changes to existing billing procedures are announced.

Please complete the following registration information:
Provider Name:__________________________________Provider ID:__________________
Provider Category of Service:________________________________Number Attending:__________
Contact Name:____________________________________Phone Number:______________________

If the seminar address is not listed above, a CSC representative will contact you at least two weeks prior to the seminar date to confirm attendance and provide seminar address information. Each seminar will last approximately two hours.

Providers who have questions about these seminars can call CSC at the following numbers:

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

To register, please mail this completed page to:

Computer Sciences Corporation
Attn.: Provider Outreach
800 North Pearl Street
Albany, NY 12204

Or, you may fax a copy of the completed page to: 518-447-9240

Note: Please keep a copy of your seminar choice for your records. No written confirmations will be sent.

Thank you for participating in New York State's Medicaid program.

Information for Residential Health Care Providers and Long Term Home Health Care Providers
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Effective July 1, 2000 social services districts began making adjustments to a patient's participation amount (NAMI - Net Available Monthly Income) prospectively when a change in income or circumstances results in an increase/decrease in the amount that an individual should have paid toward the cost of care. An adjustment will be made to the individual's NAMI in a future month(s), following the issuance of a ten-day notice, to reflect the amount that should have been contributed for a budget period. Adjustments will be made for persons in permanent absence status in a medical facility. This includes certain participants in the Long Term Home Health Care program whose Medicaid eligibility is determined under the spousal impoverishment provisions. The following example illustrates how an adjustment will be made.

Example - In January, a patient receives a $50 increase in his/her pension. In February, when the social services district is notified of the increase, the district determines if the additional income renders the individual ineligible for Medicaid or results in a larger NAMI amount. The district determines that the increase results in a larger NAMI ($637 NAMI increased to $687). Timely and adequate notice is mailed to the patient and the medical facility at least ten days in advance of March 1st. The notice informs the individual that in addition to the increased NAMI amount of $687 effective March 1st, the patient is responsible to contribute $100 towards March's NAMI due to the $50 pension increase that was not budgeted for January or February. The total NAMI due for March is $787. Effective April 1st, the NAMI is changed to $687, the on-going NAMI amount.

It is important that providers use the exact contribution amount and effective date that has been approved by the social services district when submitting a claim to Medicaid. To notify providers of an adjustment to a patient's NAMI, a copy of a new notice entitled "Important Information Concerning Your Contribution Toward Cost of Care" will be sent to the provider and the Medicaid recipient. Questions concerning this change in procedures may be referred to Wendy Butz, Office of Medicaid Management, Bureau of Medicaid Eligibility, at (518) 474-9130.

Billing for Commercial Insurance Deductible and Coinsurance
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The following provides clarification to the instructions for hospital providers included in the May 2000 Medicaid Update regarding billing for commercial insurance deductible and/or coinsurance amounts due from Medicaid.

As stated previously, only one deductible/coinsurance amount per claim can be billed regardless of the number of payers involved in the claim. Each payer must still have a '30' record indicating the amount paid by the carrier; however, the deductible/coinsurance amount (in the '41' record) may only be entered for one of the payers.

If Medicare is the primary payer, providers should continue to bill claims as in the past. Therefore, if Medicare's payment leaves a $776 deductible and Payer B pays $576 of that deductible, $200 is due from Medicaid. To receive this payment, the hospital's claim would have three '30' records: Sequence 01 is Medicare, Sequence 02 is Payer B and Sequence 03 is Medicaid. The Medicare record would indicate the correct number of covered days with $0 payment, Payer B's record would indicate '0' covered days and list the amount paid ($576), and the Medicaid record would indicate '0' covered days and $0 payment. Since Medicare is primary on this case, the '41' record should contain value code A1 (from Sequence 01 in the 30 record) and the value amount $776. MMIS will subtract the $576 from the $776 and pay $200. NOTE: This represents no change to billing procedures for Medicare-primary deductible payments.

Some provider claims have been denied in cases where Medicare is primary. Denial notice 00843, Calculated Payment Amount Less than Zero, will result if, using the example above, the '41' record lists value code B1 and the value amount of $200. The system recognizes that $200 is requested from the hospital but also recognizes that $576 has already been received. Therefore a negative amount is calculated causing the claim to fail.

Using the same example, if the claim contains two '41' records - A1 for $776 and B1 for $200, the claim will fail edit 01320 because multiple deductibles are being claimed.

When a commercial payer is primary and Medicaid is secondary, the hospital claim should include two '30' records: Sequence 01 is the Primary Payer and Sequence 02 is Medicaid. The Primary Payer's record would include the number of covered days and the amount paid. The Medicaid record would list '0' covered days and $0 payment. The '41' record should contain value code A1 (from Sequence 01 in the '30' record) and the value amount should equal the deductible amount sought. MMIS will calculate the Medicaid-only amount and compare it to the deductible sought and pay the amount that is less. If the commercial insurer payment exceeds the amount Medicaid would have paid if Medicaid were primary, no payment is due from Medicaid (and the patient cannot be billed).

If a claim involves two commercial payers and a payment is due from Medicaid, the claim should include three '30' records: Sequence 01 is Payer A, Sequence 02 is Payer B and Sequence 03 is Medicaid. Example: Payer A pays $19,500 and leaves a $500 deductible; Payer B pays $300 and leaves $200 due from Medicaid. Payer A's '30' record would indicate the appropriate number of covered days and a payment of $19,500; Payer B's '30' record would indicate '0' covered days and a payment of $300; Medicaid's '30' record would indicate '0' covered days and $0 payment. The '41' record would only include one record, B1 for $200. Assuming the Medicaid-only payment on this case is $21,000, MMIS will compare the difference between the Medicaid-only payment and the commercial payments ($21,000 - $19,800) to the amount requested ($200) and pay the lesser amount, $200

If additional clarification is needed for commercial deductible/coinsurance claiming, please contact the Provider Relations Unit of Computer Sciences Corporation at 1-800-522-1892 or 518-447-9810.

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Medicaid reimbursement to an independent clinical laboratory will only be made for laboratory tests ordered individually. For purposes of this ordering requirement, a panel defined by a single procedure code in the MMIS Laboratory Manual is considered to be an individual test. No payment will be made to a clinical laboratory for tests ordered as groupings or combinations of tests. As a reminder, effective July 1, 2000, the following groupings of automated chemistry tests may be ordered as a panel:

  • Basic metabolic panel: this panel must include the following: Calcium, Carbon dioxide, Chloride, Creatinine, Glucose, Potassium, Sodium, Urea nitrogen
  • Electrolyte panel: this panel must include the following: Carbon dioxide, Chloride, Potassium, Sodium
  • Comprehensive metabolic panel: this panel must include the following: Albumin, Bilirubin total, Calcium, Carbon dioxide, Chloride, Creatinine, Glucose, Phosphatase alkaline, Potassium, Protein total, Sodium, Transferase, alanine amino, Transferase, aspartate amino, Urea nitrogen
  • Lipid panel: this panel must include the following: Cholesterol, serum, total, Lipoprotein, direct measurement, high-density cholesterol, triglycerides
  • Renal function panel: this panel must include the following: Albumin, Calcium, Carbon dioxide, Chloride, Creatinine, Glucose, Phosphorus, inorganic, Potassium, Sodium, Urea nitrogen
  • Hepatic function panel: this panel must include the following: Albumin Bilirubin, total, Bilirubin, direct, Phosphatase, alkaline, Protein, total, Transferase, alanine amino, Transferase, aspartate amino.

If additional clarification is needed for commercial deductible/coinsurance claiming, please contact the Provider Relations Unit of Computer Sciences Corporation at 1-800-522-1892 or 518-447-9810.

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The Office of Medicaid Management is implementing a series of license verification edits that will verify the validity of servicing and referring practitioners. Beginning in late Fall, edits will be activated that identify servicing and referring practitioners, and verify that practitioner license or MMIS ID numbers reported on clinic claims are accurate and legitimate. The servicing/referring ID field on clinic claims will be matched against the State Education Department's (SED) license file and the Department of Health's (DOH) MMIS ID number file. Any claim failing the match will be denied. However, corrected claims may be resubmitted. There has been a similar edit in place for practitioner claims for a number of years.

Prior to activating these edits, the DOH will test reported license numbers and MMIS numbers against a cycle of paid claims to give clinics an opportunity to purge their computer files of incorrect licenses or MMIS ID numbers. During September, the DOH will send each facility and freestanding clinic its listing of reported license numbers and MMIS numbers that would have failed the new edits. The facilities and freestanding clinics will also be given a claim number as reference for each failed license/MMIS number. This information will allow the billing offices to identify servicing/referring practitioners to obtain their correct number. As an alternative, billing offices can also contact SED on line at to obtain or verify license numbers.

Facilities and freestanding clinics are also urged to consult the NYS MMIS Provider Manuals for instructions on completing the servicing/referring ID field. The instructions describe the proper completion of the fields that identify the SED license number and license type, and show examples of how these must be entered. These fields will be reviewed and edited for accuracy. Listed below is a chart identifying the primary SED license types currently in use by the DOH.

Remember, when the MMIS identification number is used to identify the servicing/referring practitioner, be certain to leave the license type code field blank.

License TypeType Code
Physician (MD or DO)01
General Surgeon04
Orthopedic Surgeon05
Other Physician Specialist08
Physician Assistant09
Out of State Physician (MD or DO)11
Out of State Dentist12
Out of State General Surgeon14
Out of State Orthopedic Surgeon15
Out of State Physiatrist16
Out of State Otolaryngologist17
Out of State Other Physician Specialist18
Out of State Physician Assistant19
Oral Surgeon21
Other Dental Specialist23
Speech Pathologist28
Nurse Practitioner/midwife29
Out of State Oral Surgeon31
Out of State Other Dental Specialist33
Out of State Opthamologist34
Out of State Optometrist35
Out of State Podiatrist36
Out of State Audiologist37
Out of State Speech Pathologist38
Out of State Nurse Practitioner/Midwife39
Occupational Therapist41
Certified Social Worker45
Physical Therapist46
Out of State Occupational Therapist51
Out of State Certified Social Worker55
Out of State Physical Therapist56

If you have any questions, you can contact Sal Medak, Bureau of Performance Assessment and Reporting, at (518) 474-2239.

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: