DOH Medicaid Update October 2001 Vol.16, No.10
Office of Medicaid Management
DOH Medicaid Update
October 2001 Vol.16, No.10
State of New York
George E. Pataki, Governor
Department of Health
Antonia C. Novello, M.D., M.P.H., Dr. P.H.
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
Table of Contents
The Great American Smokeout
Hospital Reimbursement For Newborn Hearing Screening Program Services
Need Help Getting Answers to your Questions?
New Code for Reusable Hand Held Nebulizers
Smoking Cessation - How Practitioners Can Help
NEED HELP GETTING ANSWERS TO YOUR QUESTIONS?
PLACE THIS INFORMATION BY YOUR TELEPHONE!
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- Providers can access Medicaid recipient eligibility via the Electronic Medicaid Eligibility Verification System (EMEVS). Recipient eligibility status is available to providers 24 hours a day, 7 days a week via EMEVS. There are several methods to access eligibility via EMEVS. EMEVS is the only source of eligibility, with existing terms of coverage verification. Some of these terms might include managed care enrollment, Medicare and third party insurance coverage, and Restricted Recipient Program alerts. Questions concerning the use of EMEVS should be directed to (800) 343-9000.
- Computer Sciences Corporation (CSC) as fiscal agent for the State's Medicaid program has Inquiry Representatives available Monday through Friday from 9 AM to 5 PM to answer billing questions (eligibility information is not available from CSC's Inquiry Units). Questions concerning your billing problems should be directed to
Practitioner Services (800) 522-5518 (518) 447-9860
Institutional Services (800) 522-1892 (518) 447-9810
Professional Services (800) 522-5535 (518) 447-9830
- Do you wonder about the status of a claim? CSC issues remittance statements for all claims processed whether the status is paid, pending or denied. Medicaid remittance statements are distributed on a weekly basis and give details about a claim's adjudication, including the reason for denying or pending a claim. Providers are encouraged to review their remittances before contacting CSC with questions regarding the status of a claim.
- Need special onsite help? Providers making inquiries or requesting billing training by Regional Representatives should contact CSC by calling the appropriate number above.
How Practitioners Can Help
Third in a five part series
Tobacco dependence is a chronic condition that often requires repeated intervention. However, effective treatments exist that can produce long term or even permanent abstinence. Every patient who uses tobacco should be offered treatment. Patients willing to quit should be provided with assistance as part of a brief or intensive treatment program. Patients unwilling to quit should be motivated to quit by using the "5R's" motivational interventions: relevance,risks, rewards, roadblocks, and repetition.For more information on the "5R's," see the September 2001 edition of the Medicaid Update at:
Aiding your patients willing to stop smoking
|Action||Strategies for Implementation|
|Help the patient with a quit plan.||A patient's preparations for quitting:
|Provide practical counseling (problem solving/training)|
|Provide intra-treatment social support|
|Help patient obtain extra-treatment social support.||
|Recommend the use of approved pharmacotherapy, except in special circumstances.||
|Provide supplementary materials.||
Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. October 2000.
THE GREAT AMERICAN SMOKEOUT
November 15, 2001
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It's never too late to think about "kicking the habit." The American Cancer Society's volunteers and staff hold the Great American Smokeout every year to help smokers quit tobacco use for at least one day. More people quit smoking on this day than any other day of the year. Health care professionals have the ability to help patients stop tobacco usage.
- The Great American Smokeout is an opportunity for Americans to renew their commitment to a tobacco-free environment for themselves and family members.
- Smoking is an addiction and health care professionals can be very influential when they suggest smoking cessation to their patients.
- Please take time to mention this event as the first day towards a healthier lifestyle.
Encourage your patients to take part in the Great American Smokeout on
November 15, 2001.
For more information on tobacco cessation contact:
NYS Smokers Quitline 1-866-NYQUITS (1-866-697-8487)
American Cancer Society 1-800-232-1311
American Lung Association 1-800-586-4872
The NYS Smoker's Quitsite has
free information for you and your patients,
order online at
The New York State Medicaid Program is committed to assisting all Medicaid recipients who would like to stop tobacco use. Medicaid covers both prescription and over-the-counter smoking cessation agents.
For more information on Medicaid's Smoking Cessation policy, contact
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Twelve months from now, the requirements of the Federal Health Insurance Portability and Accountability Act (HIPAA) will take effect. Efforts continue to insure a smooth transition to the new requirements.
This article is the fourth to appear in recent Medicaid Update editions:
- An introduction to HIPAA and its requirements is in the March 2001 issue;
- An explanation of the privacy requirements is in the June 2001 issue;
- Website information, systems activities, and a list of members of the New York State HIPAA coalition is contained in the August 2001 issue.
These articles are contained in each edition available on the New York State Medicaid program website at:
This article will focus on those areas of New York's Medicaid program which currently may be "non-compliant" with HIPAA requirements, areas which diverge from general HIPAA guidelines. These "gaps"between what currently exists and what is required under HIPAA are the focus of staff energy.
The Health Insurance Portability and Accountability Act of 1996 was signed into law on August 12, 1996. The law is comprised of two legislative actions - health insurance reform and administrative simplification. The administrative simplification provisions in HIPAA impact the Medicaid program most significantly. HIPAA requires national standards for automated transfer of certain health care data between payers, plans and providers. The law is intended to simplify and encourage the electronic transfer of administrative and financial health care data by replacing the many non-standard formats now being used nationally with a single set of electronic standards to be used by the entire health care industry, including the Medicaid program.
The Analysis of Gaps
The HIPAA standards and implementation guides contain a number of data elements not currently included within our Medicaid Management Information Systems (MMIS) claims processing system. On the flip side, HIPAA transactions do not accommodate numerous data elements critical to our claims processing system. This gap between HIPAA and the Medicaid program's claims processing system will be analyzed and bridged for all HIPAA transactions.
To date, staff have completed the gap analysis for the three 837 transactions, Professional, Institutional, and Dental, and have identified a significant number of gaps. Staff are meeting regularly to review and resolve as many gaps as possible through mapping exercises and other work-around solutions.
Listed below are some of the more significant gaps we have uncovered between the HIPAA standards and the requirements of our Medicaid program.
CATEGORY OF SERVICE
The category of service data element is at the core of our claims processing system and is a crucial determinant for claims processing, pricing and payments. However, category of service is not included in the HIPAA standards and its exclusion has forced us to search for viable work-around solutions. For electronic claiming purposes, Medicaid will be replacing category of service with the national Health Care Provider Taxonomy coding structure. Taxonomy codes are ten character alphanumeric codes which classify providers into aggregate groupings around services, provider types and areas of specialization. We will be sharing much more information on the conversion to taxonomy codes with our provider community as we develop and finalize our HIPAA system specifications and claiming instructions.
The locator code, which is used by Medicaid to identify the address where the service is actually rendered, is not accommodated by theHIPAA standards. We are looking at different work-around solutions.
The HIPAA standards eliminate the use of locally developed codes. Effective October 16, 2002, we may only use nationally approved/accepted codes. Staff have been working with the other States and the Center for Medicare and Medicaid Services (the former Health Care Financing Administration) to crosswalk as many of our local codes as possible to nationally accepted codes. This process will continue for several more months.
We will share all gaps we identify and their proposed resolutions with you as we proceed with our analyses and review processes. It is anticipated that we will complete our gap analysis review process by the end of October.
Education and Training of Medicaid Providers
We are working with Computer Sciences Corporation Provider Relations staff to prepare a HIPAA education/training work plan and schedule. HIPAA will of course mandate very significant program/system changes for the Medicaid program and as such our compliance approach needs to include an extensive education component. We will be re-writing all our MMIS Provider Manuals to accommodate the HIPAA requirements. In addition, we will be scheduling regional education/training seminars across the state, to share with you all the Medicaid claiming changes required by the HIPAA standards. Location and dates have not been finalized, but it is anticipated that the seminars will be held sometimes in early 2002. We will provide sufficient advance notice through our Medicaid Update and other mediums.
In the meantime, we urge you to learn as much as you can about HIPAA and its impact on your business processes:
- Contact your vendor or clearinghouse to confirm they are, or will be, HIPAA compliant.
- If you maintain your own billing system and produce your own claims, you need to perform assessments and analyses of your system and functions and identify your gaps.
- If your information technology and system staff are not familiar with the HIPAA standards and requirements, you may wish to seek assistance from HIPAA consultants.
Whatever your situation may be, you need to take the necessary steps to assure your business processes will be HIPAA compliant by the October 16, 2002 date. You should not wait until we provide you with Medicaid claiming instructions, or until we hold our education/training sessions.
Our new electronic claim instructions will be HIPAA compliant and may not require extensive changes to a HIPAA compliant system.
If you have any questions regarding this article or on the Medicaid program's HIPAA effort, please contact Mario Tedesco at (518) 257-4496, Tim Shannon at (518) 257-4494, or Ligia Luccese at (518) 257-4503.
NEW CODE FOR REUSABLE HAND HELD NEBULIZERS
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For patients with respiratory conditions such as asthma, chronic lung disease or cystic fibrosis,reusable nebulizers can be an effective alternative to disposable nebulizers. Reusable nebulizers are the recommended delivery system for some drugs.
With proper care, reusable nebulizers will last 6-12 months.
Effective for dates of service on or after November 1, 2001, reimbursement is available to Pharmacy and Durable Medical Equipment providers for reusable nebulizers using the following specific billing code:
A7005# Administration set, with small volume nonfiltered pneumatic nebulizer, nondisposable $16.19
The set includes the nebulizer, tubing and tubing adapter.An Electronic Medicaid Eligibility Verification System (EMEVS) Dispensing Validation System (DVS) authorization number must be obtained prior to dispensing this item.
When an infant or toddler mask/elbow adaptation set is medically indicated:
- A prior approval request must be submitted for the adaptation set for review using the miscellaneous surgical supply code A4649.
- A DVS authorization for A7005 is also required.
Questions regarding this article may be referred to the Bureau of Medical Review and Payment at (518) 474-8161.
The Newborn Hearing Screening Program, effective October 20, 2001, requires all Article 28 (hospital) birth institutions with more than 400 births annually to directly administer a program to screen all newborns prior to discharge.
Hospital Reimbursement Newborn Hearing Screening Program Services
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Hearing loss is the most common congenital disorder in newborns. Early detection of hearing loss during infancy, followed with appropriate early intervention, can greatly enhance the language, cognitive and social development of these infants so that they may be on par with their hearing peers.
To identify newborns with significant hearing impairment, the New York State Department of Health (NYSDOH) has implemented a statewide comprehensive Newborn Hearing Screening Program. With input from health care providers, industry representatives, advocates, and parent representatives, a new Subpart 69-8 of Title 10 (Health) of the New York Codes, Rules, and Regulations was developed to implement the Newborn Hearing Screening Program. This regulation becomes effective October 20, 2001 and requires all Article 28 birth institutions with more than 400 births annually to directly administer a program to screen all newborns prior to discharge. Facilities with 400 births per year or fewer have the option to directly administer the Program or refer infants born in their facility to qualified providers in their communities.
For facilities that directly administer the Newborn Hearing Screening Program enhanced reimbursement for Medicaid eligible infants has been established to compensate for additional costs related to this newly mandated program. The 2001 newborn hearing screen rate amount is established at 27.95 This amount will be revised annually, with Division of the Budget approval, to reflect trending to the applicable rate year.
Effective October 20, 2001, facilities directly administering the Program may bill for the enhanced reimbursement in addition to the inpatient newborn DRG rate or birthing center rate. Also, as some newborns may be inadvertently missed while an inpatient or may require re-screening post discharge due to a failed initial screen, the newborn hearing screening rate will also be available for missed initial or re-screens provided to the facility's newborns in their outpatient clinic Where the infant is a registered clinic patient and receives additional outpatient services, such as a well baby visit, on the same day that the outpatient newborn hearing screen is provided, same-day billings will be permitted for the newborn hearing screening rate in addition to the general clinic visit rate.
The facility may also issue a prescription for the infant to obtain the missed initial or re-screening service from another provider in the community authorized to provide infant hearing screening services. In such circumstances, the actual provider of the referred newborn hearing screening service will be reimbursed based on the applicable New York State Medicaid Fee Schedule amount.
Rate Codes and Billing Issues
The rate codes established for billing the newborn hearing screening services are as follows:
- Rate Code 3138, HS (OUT) - For the initial screen provided while an inpatient (hospitals only). This rate code is billable as an outpatient claim in HCFA Version 5 format IN ADDITION TO the inpatient claim using the date of service on which the screen occurred.
- Rate Code 3139, HS (OutPat & D&TC) - For missed initial screens and required re-screens provided on an outpatient basis (hospitals and D&TC birthing center facilities). Hospital facilities must offer general outpatient clinic services to receive this rate code/rate amount.
The rate codes will initially be made available to all Article 28 hospitals/birthing centers certified for maternity beds/maternity services and will be added only to the specific locator code site(s) where maternity services are provided.
Rate codes for facilities with 400 or fewer births per year that elect the referral option will subsequently be zeroed out upon receipt of verification from the NYSDOH Early Intervention Program that the facility will not be directly administering the Program. Such facilities will issue prescriptions for the newborn to receive the service from a qualified provider in their communities and are not eligible for the enhanced reimbursement. The actual provider of the referred newborn hearing screen will bill for their service based on the appropriate NYS Medicaid Fee Schedule and applicable Current Procedural Terminology (CPT) code for the newborn screening service.
Any questions or concerns related to the enhanced reimbursement for newborn hearing screening services should be directed to the Bureau of Primary and Acute Care Reimbursement, NYSDOH (518) 474-3267.
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
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: http://www.health.state.ny.us/health_care/medicaid/program/main.htm