DOH Medicaid Update April 2003 Vol.18, No.4

Office of Medicaid Management
DOH Medicaid Update
April 2003 Vol.18, No.4

State of New York
George E. Pataki, Governor

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

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



Prescribers and Pharmacists! Important Information Below.
Prior Authorization Requirements for Second Generation Prescription Antihistamines!

Man and Hammer  

HIPAA-COMPLIANT BILLING FOR
EQUIPMENT REPAIR AND RENTAL
Prior Approval Not Required For Some Items

Effective with the April 1, 2003 revision to the MMIS Durable Medical Equipment (DME) Provider Manual, DME providers must bill using the following HIPAA-compliant modifiers when applicable:

  • "-RR"(rental); and,
  • "-RP" (repair and replacement).

Prior approval is required for these services, EXCEPT in the following circumstances:

  • The charge for the replacement or repair of an orthotic or prosthetic device is over $35 and is less than 10% of the price listed on the code for the device. Bill using the code for the device with the "-RP" modifier. If the device requires repair or replacement more than once per year, prior approval is required. For charges $35 and under, use L4210 or L7510. Use specific replacement and repair codes when available, instead of "-RP".
  • When "-RR" is noted under the code in the Manual, up to four months' rental at 10% of price listed is allowed. Bill using the code for the equipment with the "-RR" modifier. When more than four months rental is necessary in a two-year period, prior approval is required.

Questions may be referred to the Bureau of Medical Review and Payment at (518) 474-8161.


COMPOUND BILLING INFORMATION IS INCORRECT
PHARMACIST PAYMENT INSTRUCTIONS
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Important Billing Information

HCPCS code S9430, referenced on page 4-38 (Rev. 4/03) of the Pharmacy MMIS Manual 4/1/03 update for compound billing, is incorrect and should be deleted from your manual.

Z codes used for compound billing will no longer be available after March 31, 2003.

Effective 4/1/03, the only method for billing compounds is as follows:

  • Submit claims for compounded prescriptions using the NDC code for each ingredient. These claims are eligible for the Electronic Claim Capture (ECC) option when submitted through the NCPDP format.
  • Each ingredient must have a unique prescription number.
  • For on-line submitted claims, NCPDP Compound Code Field (406) must contain a 1.
  • Each drug ingredient payable by New York Medicaid will be reimbursed at AWP-10% plus a dispensing fee: $3.50 (if a brand drug) or $4.50 (if a generic drug).
  • The pharmacy will not be reimbursed for non-covered ingredients.
  • The patient may be responsible for multiple co-payments.
  • Each ingredient may impact the patient"s utilization threshold.

The Department is currently exploring options to allow billing when an integral ingredient of the compound is not found on the List of Medicaid Reimbursable Drugs or when the above method is not feasible.

Questions regarding this article can be directed to the Pharmacy Policy and Operations Unit at (518) 486-3209.


PATIENT EDUCATIONAL TOOLS
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Man and Report

The Medicaid Program's Bureau of Program Guidance (BPG) will now be providing educational tools to support the Medicaid disease management program. Medicaid's disease management program is dedicated to partnering with the provider community to promote quality of care in a cost effective and efficient manner. Our goal is to continue to provide educational tools on a routine basis.

This month, the focus is once again on diabetes. The following contains, a Testing Blood Glucose Information tool with a Glucose Log Sheet. It is hoped that the tools issued through the Medicaid Update will be useful to Medicaid practitioners.

BPG encourages practitioners to copy and distribute these materials to their patients and to share them with their colleagues.


TESTING BLOOD GLUCOSE
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Testing your blood glucose (sugar) levels is an essential part of controlling and treating your diabetes. Lowering your blood sugar by any amount reduces your chances of having eye, kidney and nerve problems.

Man and Question

The blood sugar test results will tell you whether your insulin and/or your pills, diet and activity are working to keep your blood sugar in normal ranges. This will help you and your doctor adjust many parts of your therapy. In addition, you will see what happens to your blood sugar levels after eating different types and amounts of food, after exercising, during illness, or after losing or gaining weight. The results of your blood sugar test may prompt you to take a snack if the result is too low, or take more insulin and/or walk, if the result is too high.

HOW TO TEST BLOOD GLUCOSE

You can test your blood sugar with an electronic blood sugar meter called a glucometer. Your doctor will show you how to use a glucometer.

To test your own blood glucose using a glucometer:

  • Stick your finger with a lancet (a device to get a drop of blood);
  • Squeeze your finger to get a small drop of blood;
  • Place the drop of blood on a test strip;
  • Insert the test strip into your glucometer;
  • Wait for the glucometer to give you a number;
  • This number is your blood sugar level.

Good blood sugar levels are usually in the following ranges:

  • 80 - 120 mg/dl on waking and before meals
  • 180 mg/dl or less - 2 hours after meals
  • 100 - 140 mg/dl at bedtime

YOUR DIET, MEDICINES, PHYSICAL ACTIVITY, SICKNESS AND STRESS
CAN AFFECT YOUR BLOOD SUGAR LEVELS

Your doctor will decide how often you should test your blood sugar. For many people it is either once daily before breakfast, or twice a day before breakfast and at bedtime. If the doctor also wants to judge how your diet and activity, as well as medicines, are affecting your blood sugar levels, you may be asked to test your blood sugar before each meal and at bedtime.

Do extra blood glucose tests when:

  • Your doctor is trying to determine the correct dosage of your insulin and/or pills
  • You start taking new medication that could affect your glucose levels
  • You think that your glucose may be too high or too low
  • You are sick
  • You are pregnant
  • You are traveling
  • You have eaten unusual foods or have drunk alcoholic beverages
  • Before or after exercising
  • Before driving

REMEMBER TO RECORD YOUR BLOOD GLUCOSE RESULTS AND BRING THEM
WITH YOU TO YOUR DOCTOR APPOINTMENTS

Prepared by the NYSDOH, Office of Medicaid Management, Bureau of Program Guidance, 4/03

Please contact the Medicaid Bureau of Program Guidance at (518) 474-9219 with your comments and suggestions on these and future patient educational tools.


GLUCOSE LOG SHEET

(Use this log sheet to keep a record of your daily blood glucose levels)

Daily Log________________________________________________Week Starting____________

Log Sheet For Daily Blood Glucose Levels
  BREAKFAST LUNCH DINNER BEDTIME OTHER NOTES
  Insulin DoseBlood SugarInsulin DoseBlood Sugar Insulin DoseBlood SugarInsulin DoseBlood Sugar Insulin DoseBlood Sugar 
Mon             
Tues           
Wed           
Thurs           
Fri            
Sat           
Sun           

Oral MedicationsTypes of Insulin
              
              
              
              
              
              
              

Source: http://ndep.nih.gov/get-info/info-control.htm

Prepared by the NYSDOH, Office of Medicaid Management, Bureau of Program Guidance, 4/03


HIPAA
             NEWS

POINT OF SERVICE DEVICE USERS
Current Devices Soon To Be Obsolete
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With the implementation of new HIPAA regulations, the Point of Service (POS) device you are currently using will become obsolete.

Due to upcoming software code changes associated with HIPAA, you will be required to replace your VeriFone TRANZ 330 POS device (or switch to an alternate access method) to comply with HIPAA regulations. The NYS Department of Health and Computer Sciences Corporation (fiscal agent for eMedNY contract) have chosen the VeriFone Omni 3750 as the replacement device for the TRANZ 330s. The Omni 3750 will support current transactions while the transition to the new HIPAA application progresses.

Next Steps:

The deadline by which all electronic transactions must comply with HIPAA standards is October 16, 2003; therefore, it is critical that you stay current with the future editions of the Medicaid Update where you"ll see:

  • instructions on how to obtain your new HIPAA capable Omni 3750
  • details on a special donation program for your old Tranz 330s

Verifone

Introducing the VeriFone Omni 3750

  • Small footprint
  • Integrated printer
  • Easier-to-use ATM keys
  • Smart Card Reader

Visit our web site at www.eMedNY.org for more information.


World Asthma Day will be celebrated on May 6, 2003. World Asthma Day was established in 1999 by the Global Initiative for Asthma, and is a joint project of the World Health Organization and the National Institutes of Health. Organizations throughout the world are working together to develop special activities to increase public awareness of the asthma epidemic.

Girl Clapping

Asthma has reached epidemic proportions in the United States, affecting approximately 15 million people of all ages and races, particularly children. To address this important health issue, the Environmental Protection Agency (EPA) has prepared an Asthma Day Event Planning Kit , and a number of other educational materials to assist public health educators, health care organizations, providers of health care, and other interested parties to prepare for Asthma Awareness Month and World Asthma Day. The focus of these materials is to raise awareness in communities of the indoor and outdoor pollutants that can trigger asthma episodes. Hundreds of asthma awareness events will take place across the United States during May. Make sure that your activities are included and listed on the EPA website.

For more information about Asthma Awareness Month and World Asthma Day:

  • Contact the EPA Region 2 Representative, Matt Hiester, at (212) 637-4004
  • Go to the EPA Website at www.epa.gov/asthma
  • Call (800) 438-4318 to order a free kit and other asthma materials
  • Request a kit electronically at iaqinfo@aol.com
  • Fax in the following free Materials Order form to (703) 356-5386

World Asthma Day
Materials Order Form

To order materials for your World Asthma Day activities, fax both pages of this order form to:

IAQ INFO at (703) 356-5386 (Allow 2-3 weeks for delivery)

NAME_______________________________________DATE________________________________

SPONSORING ORGANIZATION______________________________________________________

MAILING ADDRESS________________________________________________________________

CITY___________________________ STATE________________________ ZIP _______________

PHONE_________________________FAX _____________________________________________

E-MAIL__________________________________________________________________________

NAME/TYPE OF EVENT PLANNED__________________________________________________

DATE, TIME, LOCATION OF EVENT_________________________________________________

Quantity

             "Clear Your Home of Asthma Triggers: Your Children Will Breathe Easier"
______English................................402-F-99-005
______Chinese................................402-F-99-005A
______Vietnamese..........................402-F-99-005B
______Korean..................................402-F-99-005C
______Spanish................................402-F-99-005D

______"Health at Home: Controlling Asthma Triggers" Video (English/Spanish)
Order up to 5...................402-V-01-006

______"A Brief Guide to Mold, Moisture, and Your Home"..............402-K-02-003

______"Take the Smoke-Free Home Pledge" Brochure ...................402-K-00-004

______"Take the Smoke-Free Home Pledge" Poster......................402-H-01-002

______"Secondhand Smoke Community Action Kit" CD-ROM................402-H-02-002

______"Secondhand Smoke: Poisoning Our Children" Video (English)....402-V-92-003

______"Secondhand Smoke: Poisoning Our Children" Video (Spanish)... 402-V-02-002

______"If You Must Use a Pesticide, Follow These Rules".............735-F-98-015

______"Help! It's A Roach" Activity Book for Kids...................735-F-98-016

______ARTHUR®"Hooray for Health! All About Asthma" - order up to 100 ....402-K-02-009
(To download the guide in English and Spanish or individual sections in English, Spanish, Chinese, Tagalog, and Vietnamese, go to http://pbskids.org/arthur/grownups/teacherguides/health/index.html#asthma.)

______ARTHUR® "Hooray for Health!"stickers (order one box of 50 stickers)

Tips to Protect Children from Environmental Threats - order up to 100
______English and Spanish....................100-F-02-004

Tips to Protect Children from Environmental Threats Growth Chart (6 foot)
______English - order up to 25........................................................100-F-02-005
______Spanish - order up to 25........................................................100-F-02-009
______English with picture of President Bush - order up to 25............100-F-02-008
______Spanish with picture of President Bush - order up to 25.............100-F-02-010

______Children"s Environmental Health: A Call for Global Protection - order up to 25....100-F-02-006

______AAFA Child Care Asthma & Allergy Action Cards - order one set of 20

Air Quality Guide for Ozone - order up to 100
______English.........................................456-F-99-002
______Spanish........................................456-F-00-003

Ozone and Your Health - order up to 100
______English.........................................452-F-99-003
______Spanish........................................452-F-00-001

Smog-Who Does It Hurt? - order up to 100
______English.........................................452-K-99-001
______Spanish........................................452-K-00-001

Copies of the asthma and secondhand smoke public service announcements (TV, radio, print) in English and Spanish may be ordered on line at: http://www.tvaccessreports.com/epapsa.

"Buster's Breathless" is available on the ARTHUR® home video, Arthur Goes to the Doctor, which can be purchased ($9.95) by calling (800) 315-8056.

Health professionals may also order one shipment of spacers and/or peak flow meters. No EPA endorsement implied. When ordering, please provide the name of the health professional.

______Spacers (180 count) donated by the American Respiratory Care Foundation at the Asthma and Allergy Foundation of America

______Peak Flow Meters (100) donated by the American Respiratory Care Foundation

Materials may be ordered through May 31, 2003.

Supplies are limited and are available on a first come basis.


Phone

HELPFUL HINTS FOR PROVIDERS USING THE
ENTERAL VOICE INTERACTIVE TELEPHONE
PRIOR AUTHORIZATION SYSTEM
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After reading this article, further assistance is available for specific questions:

  1. Billing:    Pharmacy providers:  (800) 343-9000
                      DME providers:  (800) 522-5535
  2. Policy questions, coverage criteria, HCPCS codes:      (518) 474-8161
  3. When medical necessity for enterals cannot be authorized by the voice interactive prior authorization system, prior approval may be required:
    Obtaining prior approval forms:          (800) 522-5518
    Completing prior approval forms:        (800) 342-3005
  • Listen carefully to all voice prompt directions provided on the Enteral Prior Authorization Call Line at (866) 211-1736.
  • The prescriber of enteral formula must initiate the prior authorization: process by calling the Call Line to verify medical necessity. If the enteral formula is authorized, the system will provide a prior authorization number that must be written on the fiscal order.
  • The dispenser receives the fiscal order and completes the prior authorization process by calling the Call Line and coding the enteral product with the appropriate HCPCS "B-code". The prior authorization number is effective for the original dispensing and up to five refills. Prior authorization is not required for orders written prior to April 1, 2003, but dispensed on or after April 1, 2003. When these orders expire, a new prior authorization will be required.
  • Prior authorization is not required when claiming the Medicare co-insurance and deductible for enteral formulas.

IMPORTANT BILLING INFORMATION

Follow Up to "Timely Submission Of Claims To Medicaid" Article
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In the February 2003 Medicaid Update, the article "Timely Submission of Claims To Medicaid" indicated the seven valid reasons for submitting claims more than 90 days old. There are no other acceptable reasons for billing beyond 90 days. There is no appeal process. Instructions for requesting an appeal can be found in some Provider Manuals, but that information is no longer valid and will be replaced in updated revisions.

When submitting paper claims that are more than 90 days old, a letter must accompany the claims indicating the reason for late submission.

The following page contains a sample 90-day letter that can be used when submitting valid paper claims more than 90 days old.

----------------------------------------------------------------------------------------------

Computer Sciences Corporation
P.O. Box 4444
Albany, NY 12204-0444

The claim(s) listed below is/are for services, which were provided more than 90 days ago. The reason for late submission is:

_______Litigation

_______Medicare and other insurance processing delays

_______Delay in Medicaid eligibility determination

_______Rejection or denial of the original claim for reason(s) other than the 90-days rule

_______Administrative delay (enrollment process, prior approval process, rate changes, etc.) by the
             department or other State agency

_______Interrupted Maternity Care

_______IPRO denial/reversal

Sincerely,

Enclosure
Invoice#:


HIPAA
             NEWS

HIPAA TESTING TO BEGIN
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The Medicaid HIPAA testing process will begin by April 16, 2003. Initially, we will conduct a beta testing with a selected number of providers and vendors. We encourage all providers to expedite their HIPAA compliance efforts to ensure you will be able to test successfully with us. We strongly recommend that all providers seek certification from a third party prior to submitting test transactions to Medicaid. New York Medicaid testing will be based on Version 4010A of the HIPAA ANSI X12 implementation guides.

MEDICAID PROVIDER TRAINING SESSIONS

Medicaid HIPAA provider training is scheduled to begin in April 2003. The training will be held regionally and will focus on Medicaid billing requirements under HIPAA. Attendees to these training sessions are expected to have knowledge of the HIPAA implementation guides that may pertain to their area of service.

Additional information related to registration, dates, and location will be forthcoming and will also be posted on the Medicaid website as soon as they become available.

ePACES

Department of Health - Office of Medicaid Management and Computer Sciences Corporation (CSC) have initiated a project to develop a HIPAA compliant replacement for the current PACES software. ePACES is a web-based application that will replace targeted EMEVS software capabilities and existing PACES applications. All Medicaid providers that are currently using PACES will be asked to switch to ePACES, or some other HIPAA compliant format, prior to October 16, 2003. Additional ePACES information will be available on the Medicaid HIPAA website in the near future. We anticipate that ePACES will be available to the provider community by the end of June 2003.

HIPAA SUPPORT

CSC will provide HIPAA inquiry support through their Provider Relations Department. Providers with questions related to NYS Medicaid HIPAA compliance requirements may call the toll-free number (866) 840-3445 for assistance. (CSC staff will only answer questions related to New York State Medicaid HIPAA requirements.) Inquiry Representatives are available, Monday through Friday, 9:00 am to 5:00 pm.

NEW YORK STATE MEDICAID HIPAA WEBSITE

Please visit the New York State Medicaid HIPAA website at:

At this website, you will find among other general HIPAA information, the following:

  • Companion Guides
  • Crosswalk from Category of Service to Provider Type and Transaction Companion Guide type
  • Trading Partner Agreement
  • Current MMIS System Edits crosswalk to HIPAA Claim Adjustment Reason Codes
  • ePACES training schedule
  • Medicaid HIPAA Transaction and code sets training schedule

Pills

PRESCRIBERS AND PHARMACISTS!
Beginning April 30, 2003
Second Generation Prescription Antihistamines
Must Be Prior Authorized
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Effective April 30, 2003, the New York State Medicaid Program will require prior authorization for prescribing and dispensing prescription second generation antihistamines including Clarinex®, Zyrtec®, Allegra®, and Semprex D®.

Over the counter (OTC) second generation antihistamines, such as loratadine (Claritin®, AlavertTM, etc.), DO NOT require prior authorization. With these less expensive OTC versions of second generation antihistamines available, prescribers are encouraged to use these comparable products.

Note: Medicaid does not require the use of first generation antihistamines (Benadryl, etc) prior to prescribing a second generation antihistamine. Approval to use the prescription version is based on treatment failure, or patient characteristics, which preclude the use of an over the counter version of second-generation antihistamines. These circumstances should be documented in the patient record.

Unlike many insurers, Medicaid covers the costs for over the counter second generation antihistamines. Patients will not have to pay for these products themselves. The prescriber simply writes a fiscal order for the OTC second generation antihistamine and gives it to the patient to present to the pharmacist for filling. The Medicaid patient will only be responsible for 50-cent co-pay for the OTC antihistamine instead of the $2.00 co-pay for the brand name prescription product. First generation antihistamines also do not require prior authorization.

If you are prescribing a prescription second generation antihistamine, you must obtain a prior authorization number by calling the toll free prior authorization telephone number and answering questions regarding the patient. The eight-digit prior authorization number must be entered on the face of the prescription.

Information on how to obtain prior authorization for prescription second generation antihistamines is found below.


Phone in Hand

Information for Prescribers
How to Obtain a Prior Authorization for
Second Generation Prescription Antihistamines
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  1. Prior authorization is required for second generation prescription antihistamines effective April 30, 2003.
  2. No prior authorization is required when ordering first generation antihistamines or second generation over the counter (OTC) antihistamines. The Medicaid Program pays for OTC products including first and second generation antihistamines. A written order is still necessary.
  3. The prescriber, or their authorized agent, must call the Prior Authorization Call Line to initiate the prior authorization process.
  4. Once authorization has been given and a prior authorization number is obtained, the prior authorization number must be written on the prescription and documented on the Prior Authorization Worksheet.
  5. The patient's medical record must include documentation of the rationale for requesting the prior authorized drug. The completed prior authorization worksheet may be included in the patient's medical chart.
  6. Prior authorization is required for each new prescription. It is effective for the life of the prescription (up to five refills within six months). An agent of the prescriber (an employee such as a medical assistant) may complete the prior authorization call and write the prior authorization number on the prescription.
  7. If a prior authorization number is not written on a prescription for products requiring prior authorization, the pharmacy will be prohibited from filling the prescription. The pharmacy will need to contact the prescriber to ask that the prior authorization process be initiated, or that the prescription be changed. If this does not occur, the patient may have to return to your office, or call your office to get the necessary prior authorization number.

Remember that for prescriptions ordered prior to April 30, 2003, no prior authorization is required. When the current prescription (including refills) expires, prior authorization will be required.

Prior Authorization Requirements For Second Generation Antihistamines
Affected DrugStatus effective April 30, 2003
ClarinexPrior authorization required
Allegra/Allegra DPrior authorization required
Zyrtec/Zyrtec DPrior authorization required
Semprex-DPrior authorization required
loratadine (Claritin, Alavert, etc.)No Prior authorization
diphenhydramine (Benadryl, etc.)No Prior authorization
brompheniramine (Bromphed, etc.)No Prior authorization
chlorpheniramine (Chlor-Trimeton, etc.)No Prior authorization

For billing questions, contact (800) 343-9000.

For clinical or policy questions, contact the Pharmacy Policy and Operations Staff at (518) 486-3209.


ANTIHISTAMINE PRIOR AUTHORIZATION REQUEST
PRESCRIBER WORKSHEET AND PRESCRIBER INSTRUCTIONS

The NYS Medicaid Program Antihistamine Prior Authorization Request Prescriber Worksheet and Prescriber Instructions is available only as a portable document format (PDF) file. Requests for the NYS Medicaid Program Antihistamine Prior Authorization Prescriber Worksheet and Prescriber Instructions in an alternate format should be made by sending an e-mail note to: MedicaidUpdate@health.state.ny.us.


Antihistamine Information for Pharmacists
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Pharmacists

  1. Effective April 30, 2003, second generation prescription antihistamines require prior authorization.
  2. Also effective on April 30, 2003, Claritin® will be reimbursable as an OTC product only. Existing prescriptions for Claritin® should be filled as an OTC product. For refills, the existing prescription is considered the fiscal order.
  3. The prescriber initiates the prior authorization process and obtains the prior authorization number.
  4. The prior authorization number must be written on the prescription before the prescription can be billed to Medicaid.
  5. To complete the prior authorization process, the pharmacist must call the Prior Authorization Call Line at (877) 309-9493 to validate the prior authorization number prior to dispensing. Failure to validate the prior authorization number will result in the claim not being paid.
  6. Multiple prior authorizations for multiple patients may be validated in a single phone call.
  7. Initial dispensing must occur within 60 days of the date prior authorization was obtained (subject to other State laws and Medicaid restrictions).
  8. A prior authorization number is valid for the original dispensing and up to five refills within a six month period (subject to other State laws and Medicaid restrictions).
  9. The pharmacist must include the prior authorization number on the submitted electronic or paper claim before the claim can be paid. This prior authorization number must also be included on claims for refills.
  10. For prescriptions ordered prior to April 30, 2003, no prior authorization is required. When the current prescription (including refills) expires, prior authorization will be required.
  11. Prior authorization does not guarantee payment. Payment is subject to patient eligibility and other Medicaid guidelines.
Prior Authorization Requirements For Second Generation Antihistamines
Affected DrugStatus effective April 30, 2003
ClarinexPrior authorization required
Allegra/Allegra DPrior authorization required
Zyrtec/Zyrtec DPrior authorization required
Semprex-DPrior authorization required
loratadine (Claritin, Alavert, etc.)No Prior authorization
diphenhydramine (Benadryl, etc.)No Prior authorization
brompheniramine (Bromphed, etc.)No Prior authorization
chlorpheniramine (Chlor-Trimeton, etc.)No Prior authorization

Antihistamine Prior Authorization Validation Pharmacy Worksheet and Pharmacy Instructions

The NYS Medicaid Program Antihistamine Prior Authorization Validation Pharmacy Worksheet and Pharmacy Instructions is available only as a portable document format (PDF) file. Requests for the NYS Medicaid Program Antihistamine Prior Authorization Validation Pharmacy Worksheet and Pharmacy Instructions in an alternate format should be made by sending an e-mail note to: MedicaidUpdate@health.state.ny.us.


PRESCRIBERS AND PHARMACIES
FAX ORDERS FOR OTC PRODUCTS ALLOWED
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Fax

To support the use of over-the-counter (OTC) products when medically indicated, the Medicaid Program will allow fax fiscal orders for OTC products, effective April 30, 2003. The requirements have been aligned with policies related to the allowable use of a fax for prescription products for ease of administration.

Fax fiscal orders for OTC products must meet the following requirements

  • Receipt of the hard copy fiscal order by the pharmacy within thirty (30) business days only if there are refills for the OTC product.
  • Fax orders must originate from an unblocked fax number (that is, the source fax number is clearly visible on the fax that is received).
  • The fax fiscal order must include the physician stamp and signature.
  • Each page of a fax fiscal order may include only one (1) product. Lists of products are not acceptable as faxed fiscal orders.

This change is being implemented to assist and support the use of cost-effective OTC products, when appropriate.

This change in policy is being implemented on a temporary basis through April 2004, in order to assess the impact of the policy change.

Prescribers and pharmacists will be advised in October 2003 whether this change will be made permanent.

Please direct any questions to the Pharmacy Policy and Operations Unit at (518) 486-3209 or ppno@health.state.ny.us.


PHARMACY POLICY REMINDERS
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The maximum quantity of Viagra every 30 days is SIX tablets.

Traffic Lite

DO NOT fill or refill prescriptions for Viagra before the 31st day as the claim will reject as a therapeutic duplication. DO NOT override. Medicaid will recoup reimbursement for those claims inappropriately paid.

PHARMACY PROVIDERS - CAUTION!

The NDC number of the drug dispensed must match the NDC number of the drug that is billed.

Be careful of your software making a "switch" to a preferred NDC. This is typically not visible to the dispensing pharmacy as it occurs at the corporate level; however it can result in "NDC not covered"/payment denied.


MANDATORY GENERIC
PROGRAM REMINDERS

Prescriptions for brand name drugs that have an "A" rated generic equivalent ordered prior to November 17, 2002 did not require prior authorization for the life of that prescription. These prescriptions were "grandfathered" in for six months. It is important to remember that when a new prescription is issued to the patient, it will require a prior authorization. The generic equivalent of the brand-name drug does not require prior authorization.

When a prescriber writes a brand-name prescription for DAW/Brand Medically Necessary but does not get a prior authorization number, the pharmacy must contact the prescriber. Dispensing a generic drug because there is no prior authorization when the prescription is written DAW/Brand Medically Necessary is a violation of NYS Education Law.

Numbers


The Department's Web Site Offers Easy Access
For You and Your Consumers!
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This is to remind providers that useful information about the New York State Medicaid Program is available on the Department's web site at:

Among the items posted is the Medicaid pamphlet "Need Help Paying for Medical Care? How Medicaid Helps You & Your Family," that may be accessed at:

Medicaid Income and Resource Levels, providing consumers a benchmark in the eligibility process, as well as guidance for consumers on how to apply for Medicaid are included at this site.

Applications for Medicaid are made at the local department of social services in the applicant's county of residence:

To assist your consumers, the complete listing of county offices, including address and telephone number, may be found at:

If the applicant resides in New York City, the New York City Human Resources Administration's web site will link the individual to the Medicaid offices in New York City at:

Applicants must provide documentation of all available or potentially available income and resources and other eligibility requirements when applying for Medicaid. A review by local department of social services staff of the documentation determines whether an applicant qualifies for Medicaid.

Consumers are welcome to write to us. Questions may be submitted to the Medicaid Mailbox at:

(Please note that this Department will not make a determination as to anyone's eligibility for assistance. The local department of social services in the applicant"s county of residence makes this determination.)

Both providers and consumers can make use of the Department's listing of Important Telephone Numbers at:

Included are the toll-free numbers to report Medicaid fraud, inquire about co-payment requirements or Medicaid managed care issues, or to receive help on Medicaid billing questions.

We encourage providers to visit this web site for useful information and encourage you to share information with your consumers. The Department will continue to update and enhance this web site to provide up-to-date information


IN ADDITION TO ASTHMA AWARENESS MONTH
DID YOU KNOW...

THE MONTH OF MAY IS...

Hepatitis Awareness Month
Contact: Hepatitis Foundation International
(800) 891-0707
www.hepfi.org

National Arthritis Month
Contact: Arthritis Foundation
(800) 283-7800
www.arthritis.org

National Osteoporosis Prevention Month
Contact: National Osteoporosis Foundation
(202) 223-2226
www.nof.org

National Stroke Awareness Month
Contact: National Stroke Association
(800) STROKES
www.stroke.org

For a complete calendar of all national health observances,
call the National Wellness Institute at (715) 342-2969, or visit the Internet at www.nationalwellness.org

 


Have you been asked to pay money to another individual in order to receive Medicaid referrals?

 

Please call: 1-877-87FRAUD

Your call will remain confidential!

 


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 MedicaidUpdate@health.state.ny.us )

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

Please Note

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