DOH Medicaid Update January 2003 Vol. 18, No.1

Office of Medicaid Management
DOH Medicaid Update
January 2003 Vol.18, No.1

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


The Provider Outreach staff at Computer Sciences Corporation (CSC) contributes this CSC Billing Bulletin to the Medicaid Update to give providers reminders and helpful hints about a variety of Medicaid billing topics. If you have suggestions for topics, or have billing questions you would like to see addressed in future CSC Billing Bulletin articles, please send your suggestions to the following address:

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

Or, you may fax your suggestions to:

Provider Outreach
(518) 447-9240

Suggested topics and billing questions will be addressed in future CSC Billing Bulletin articles.

Questions regarding policy and enrollment should be directed to the appropriate phone numbers or addresses in the Inquiry section of the New York State Medicaid Management Information System Provider Manual.

Questions regarding the Medicaid Eligibility Verification System (MEVS) should be directed to (800) 343-9000.

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 (800) 522-5518 or (518) 447-9860
Institutional Services (800) 522-1892 or (518) 447-9810
Professional Services (800) 522-5535 or (518) 447-9830
Pharmacies contact: eMedNY Provider Services at (800) 343-9000

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  • Procedure Code 08670 Periodic orthodontic treatment visit (as part of contract).

    This code can be billed quarterly for a maximum of three years and can only be billed four (4) times in a 12 month period beginning 90 days after the date of service on which orthodontic appliances have been placed for active treatment.

    Claims billed more frequently than the allotted four times per year will result in an automatic systems denial for Edit Reason 00710 - Procedure exceeds service limits.

  • Procedure Code 09920 Behavior management (OMRDD client identification form required)

    This is a per visit incentive to compensate for the greater knowledge, skill, sophisticated equipment, extra time and personnel required to treat this population. This fee will be paid in addition to the normal fees for specific dental procedures. For purposes of the Medicaid program, the developmentally disabled population for which procedure code 09920 may be billed is limited to those who receive ongoing services from community programs operated or certified by the New York State Office of Mental Retardation and Developmental Disabilities (OMRDD). These include, among others, family care programs, programs operated directly by the State, programs operated by agencies such as the Association for Retarded Children (ARC), and private schools. To identify patients who are eligible for services billed under MMIS procedure code 09920, OMRDD has provided these individuals with special identification forms. In order to ensure the proper use of this procedure code, a copy of the completed OMRDD client identification form must be attached to each claim submitted to MMIS under procedure code 09920. You also should maintain a copy of this form with the patient's record.

If you have any questions, please call the Bureau of Medical Review and Payment at (800) 342-3005, option #3.

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The Medicaid program reimburses for drugs furnished by physicians to their patients on the basis of the acquisition cost to the practitioner of the drug dose administered to the patient. For all drugs furnished in this fashion, it is expected that the physician will maintain auditable records of the actual itemized invoice cost of the drug, including the numbers of doses of the drug represented on the invoice.

To facilitate electronic claim submission and timely payment to physicians, the Medicaid program consults national pricing references such as First DataBank to establish a maximum reimbursable amount (MRA) on its procedure code reference file. Claims submitted for most physician-supplied drugs will be paid automatically up to the MRA price. However, drugs listed in the Medicaid Physician Fee Schedule with a notation of BR (By Report) under the Maximum Fee column must be submitted on a paper NYS MMIS HCFA 1500 Claim Form, with a copy of the itemized invoice as documentation.

It is important to remember that, regardless of whether a particular drug is designated as BR (By Report) in the Medicaid Physician Fee Schedule, Medicaid does NOT intend to pay more than the acquisition cost of the drug dosage, as established by invoice, to the practitioner. Regardless of whether an invoice must be submitted to Medicaid for payment, the physician is expected to limit the charged amount to the actual invoice cost of the drug dosage administered.

If you have any questions, please call the Bureau of Medical Review and Payment at (518) 474-8161.

No Smoking

According to a study conducted by the Pediatric Asthma Care Patients Outcomes Research Team (PORT) exposure to household asthma triggers continues to be a significant problem, with few parents adopting environmental control measures to reduce allergen exposure. In the PORT study of 638 children (ages 3 to 15 years) with asthma, 30 percent lived in households that included a smoker, 18 percent had household pests (cockroaches or mice), and 59 percent had furry pets. Also noted, 45% of the parents had received instructions about avoiding asthma; unfortunately, receipt of instructions about how to reduce environmental triggers was not associated with efforts to do so.


Asthma rates have increased in the past two decades and are highest among poor, urban and minority populations. Mounting evidence suggests that indoor allergens and irritants contribute to childhood asthma. Exposure to environmental tobacco smoke has consistently been shown to increase asthma risk for children. Studies have also implicated dust mites, cockroaches, mice, cats and other furry pets.

The National Asthma Education and Prevention Program (NAEPP) guidelines, first disseminated in 991, highlight the reduction of environmental triggers as part of a comprehensive approach to asthma treatment. Recent asthma care improvements have focused predominately on appropriate Pharmacotherapy. Less attention has been focused on reinforcement and follow through on the need to minimize asthma patients exposure to environmental triggers.

Cockroach Exposure to potential environmental triggers is common, and parents of children with asthma infrequently adopt recommended trigger avoidance measures. While specific exposures may vary with demographic and socioeconomic variables, all children are at risk. These results confirm the need to further develop effective educational strategies to utilize with parents of children with asthma to reduce indoor environmental triggers.


For successful long-term asthma management, it is essential to identify and reduce exposures to relevant allergens and irritants and to control other factors that have been shown to increase asthma symptoms and/or precipitate asthma exacerbations. Using the correct medications, reducing exposure to triggers and learning how to manage asthma as a chronic disease can reduce the frequency and severity of asthma symptoms.

Source: Archives of Pediatric and Adolescent Medicine March 2002, 156, pp.258-264.

The Medicaid program reimburses for medically necessary care, services and supplies needed in the diagnosis and treatment of asthma. For information regarding Medicaid payment of these services, please contact the Bureau of Program Guidance at (518) 474-9219.

More information on asthma and asthma triggers may be found on the following websites:

National Asthma Education and Prevention Program
Centers for Disease Control & Prevention
New York State Department of Health

In November 2002, the U.S. Department of Health and Human Services (HHS) launched the first national diabetes awareness and prevention campaign designed to promote lifestyle changes as a way to prevent the onset of adult-onset diabetes among all people, but particularly among Hispanics and other minorities. The campaign called, "Small Steps, Big Rewards", encourages daily physical exercise and a healthier diet to prevent type 2 diabetes.

Nationally, 17 million people have diabetes, 16 million of which have type 2 diabetes. An additional 16 million people have pre-diabetes, a condition that raises a person's risk of developing type 2 diabetes. The diabetes rate nationwide has increased 50% in the past decade and is expected to increase to an additional 165% by 2050 if the current rate continues.


The new campaign is jointly sponsored by the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC) and will be run by the National Diabetes Education Program (NDEP). The "Small Steps, Big Rewards" campaign grew out of the finding of HHS' Diabetes and Prevention Program (DPP) clinical trial. The study, sponsored by NIH, showed that people with pre-diabetes can delay and possibly prevent type 2 diabetes by losing five to seven percent of their body weight through moderate changes in diet and exercise. The NDEP involves more than 200 public and private sector partners who work at the national, state, and local level.

The "Small Steps, Big Rewards" campaign will include tools to help people make lifestyle changes, a kit to assist providers educate patients about diabetes, web-based resources for providers and consumers, and public awareness announcements on TV, radio and in print.

The NDEP is seeking partners to educate people with diabetes and their families on how to control their diabetes. You can help spread the message about healthy living with diabetes by distributing campaign materials to your members, constituents, patients, health professionals, local media and other community organizations.

Free Materials

Small Steps

Just go to the National Diabetes Education Program website for valuable free materials and information on how to join the campaign:

The Medicaid program reimburses for medically necessary care, services and supplies for the diagnosis and treatment of diabetes. For information regarding Medicaid coverage of services related to diabetes, please contact the Bureau of Program Guidance at (518) 474-9219 or go to:


Approximately 4.7 million adult New Yorkers suffer from a form of arthritis.
Of those, 1.7 million are aged 65 or older.
This number will only increase as New Yorkers age.

Arthritis is the leading cause of disability in New York State and in the nation. It accounts for enormous health care and costs for individuals, their families, and the State. Unfortunately, many people with arthritis believe that there is nothing that they can do to manage their disease, but there is.

Physical activity, weight control, and self-management can help people with arthritis function better and stay productive. Research has suggested that diet and exercise choices can help reduce pain and improve mobility. Contrary to popular belief, regular exercise helps, not hurts, most older adults. Those with chronic diseases, such as arthritis, may actually improve or maintain their functioning level, but should first check with their physician before embarking on a physical activity regimen.

The Surgeon General states that significant health benefits can be obtained by including physical activity in your routine on most days of the week and recommends that adults achieve 30 minutes of moderate physical activity per day. For those beginning a physical activity routine, it may be helpful to break the recommended amount of time into intervals, such as three 10-minute segments of time. The Surgeon General reports that regular physical activity is necessary to maintain normal muscle strength, joint structure, and joint function. Walking and bicycling are particularly good activities for people with arthritis because these are aerobic/endurance activities, which, if done regularly, strengthen the heart and control weight.

The five Arthritis Foundation chapters across New York State offer a variety of services and programs that are available to people with arthritis, their families, and others who want to increase their knowledge of this disease. Each chapter offers the Arthritis Self Help Course (ASHC). ASHC is a six-week course that teaches people how to manage their arthritis and lessen its effects. ASHC has been proven to reduce the pain associated with arthritis by 40% and reduce physician visits for arthritis by 20%.

For more information about ASHC or other programs and services contact your local chapter. For more information about arthritis and other rheumatic conditions, visit the New York State Department of Health website at or call the Arthritis Program at (518) 408-5141.

New York Chapter
122 East 42nd St., 18th Floor
NY, NY 10168
(212) 984-8700

Serving: the five Boroughs of New York City, Westchester, Sullivan, Rockland, Orange, Dutchess, Ulster, and Putnam Counties

Hudson Valley Branch
Burke Rehab Center
785 Mamaroneck Rd.
White Plains, NY 10605
(914) 683-8462

Upstate NY Chapter
3300 Monroe Ave., Suite 319
Rochester, NY 14618
(585) 264-1480

Serving: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Livingston, Monroe, Niagara, Ontario, Orleans, Schuyler, Seneca, Wayne, Wyoming, and Yates Counties

Buffalo Branch
462 Evans St.
Williamsville, NY 14221
(716) 626-0333

Long Island Chapter
501 Walt Whitman Rd.
Melville, NY 11747
(631) 427-8272

Serving: Nassau and Suffolk Counties

Central NY Chapter
5858 East Molloy Rd. #123
Syracuse, NY 13211
(315) 455-8553

Serving: St. Lawrence, Jefferson, Lewis, Oswego, Cayuga, Onondaga, Madison, Oneida, Herkimer, Cortland, Tompkins, Chenango, Broome, Tioga, Steuben, and Chemung Counties

Broome County Branch
Lourdes Hospital
161 Riverside Dr., Rm. M02
Binghamton, NY 13905
(607) 798-8048

Northeastern NY Chapter
1717 Central Ave., #105
Albany, NY 12205
(518) 456-1203

Serving: Albany, Columbia, Delaware, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, and Washington Counties



Medicaid Developing HIPAA Compliant PACES Software

The Office of Medicaid Management and its fiscal agent, Computer Sciences Corporation, have initiated a project to develop a HIPAA compliant replacement for the current PACES software. The replacement software, ePACES, is a web-based application that will provide targeted Medicaid Eligibility Verification System (MEVS) capabilities as well as and the existing PACES application. The ePACES application will allow submission of HIPAA 'Dental' 'Professional' and 'Institutional' claim formats. New York Medicaid providers using the PACES software will be asked to switch to the new ePACES application or another HIPAA compliant format if they prefer.

ePACES pilot testing with a selected number of providers will begin in April 2003. We intend to begin ePACES implementation when testing is complete for ePACES, the MMIS and eMedNY processing systems. We will continue to accept claims via PACES until October 16, 2003. After this date we will only accept HIPAA compliant transactions. These can be produced with either the new ePACES application or any other process you may have that will generate HIPAA compliant transactions.

The framework of the ePACES application will be on a browser base. No software will be installed on the providers' computers. Accordingly, providers will need Internet access as well as an Internet browser that will support encryption of 128-bit (Internet Explorer 4.01 and above, Netscape 4.7 and above). You must have a minimum connection speed of 28.8K.

ePACES functionalities will support the following HIPAA transactions:

270 & 271    Eligibility (Inquiry & Response)
276 & 277   Health Care Claim Status (Inquiry & Response)
278             Service Authorizations and DVS (Inquiry & Response)
837            Claims (Institutional, Professional, Dental)

Additional information will be provided on ePACES as we proceed with its development. Please check our HIPAA website for updates on ePACES and other Medicaid HIPAA activities.

HIPAA Timelines

Companion Guides - Drafts of the 837, 834, 835, 820 and 276/277 companion guides should be available on the HIPAA website by early January, 2003. Draft versions of the rest of the transactions will be available late January, early February. Please remember that these documents will be in draft form and are subject to change.

Testing - The HIPAA transactions testing process will begin by, or prior to, April 16, 2003. Initially we will conduct pilot testing with a selected number of providers. Between April and October 2003, we expect to test with all our providers. We encourage providers to expedite their HIPAA compliant efforts to insure that they will be able to test successfully with Medicaid. If you use the services of a vendor, make sure to maintain regular communications and monitor his/her compliance progress.

Medicaid Training - Medicaid HIPAA provider training is scheduled to begin in early March 2003. The training will be held regionally and will focus only on changes in Medicaid billing requirements necessitated by the HIPAA legislation. The training will be fairly intensive and we expect attendees to have knowledge of the HIPAA implementation guides that may pertain to their area of service. A tentative schedule will be posted on our HIPAA website as soon as it becomes available.

New York Medicaid website is

Medicaid Seminar for New Providers
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Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid Management Information System (MMIS), announces the following schedule of Introductory Seminar. 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

The scheduled seminar will be held:

February 13, 2002 - - 10:00 AM
Westchester Department of Social Services
Basement Conference Room A
143 Grand Street
White Plains, NY

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

The seminar will last approximately two hours . Direct questions about these seminars to CSC as follows:

Practitioner Services (800) 522-5518 or (518) 447-9860
Institutional Services (800) 522-1892 or (518) 447-9810
Professional Services (800) 522-5535 or (518) 447-9830
Pharmacies contact: eMedNY Provider Services at (800) 343-9000

Please complete the registration information using the link to the form below:

To register, please mail the completed page to:

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

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

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

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

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Did you miss a pertinent article during the year 2002? Listed below is an index of articles, by provider specialty or subject area. These articles can be located:

Please note that articles containing invitations to date-specific events are not listed, as these events have already occurred.


All Providers



Comprehensive Case Management



Durable Medical Equipment

Family Health Plus    


Home And Community Based Waiver



Managed Care


Nurse Practitioner

Nursing Home



Ordered Ambulatory



Portable X-Ray

Private Duty Nursing

Tobacco Cessation


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Woman at Desk

Who Do I Call?

Onondaga County Department of Social Services has chosen Rural-Metro to process requests for transportation of Onondaga County Medicaid recipients.

For dates of transport on or after January 1, 2003, ordering practitioners should call:

(315) 701-7500

Questions regarding this article should be addressed to the Provider Resource Unit at (518) 474-9219.


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On Saturday, November 16, 2002, the New York State Department of Health (DOH) and Computer Sciences Corporation(CSC) implemented Phase I of eMedNY. eMedNY is the new Medicaid system that will consolidate the Medicaid Management Information System (MMIS) with the Medicaid Eligibility Verification System (MEVS).

Phase I of eMedNY, the MEVS replaced the functionality previously provided by EMEVS and offers enhanced electronic claim capture and online adjudication capabilities for pharmacy claims. Online adjudication provides an immediate status response at the time of submission that allows pharmacy providers to determine if a claim is approved for final payment.

The DOH and CSC wish to take this opportunity to extend our appreciation to the Medicaid provider community who participated in, or who were impacted by, the implementation. Despite extensive testing, there were some system implementation issues that, in some instances, prevented providers from making full use of the new eMedNY functionality. The provider community reacted with the highest levels of patience and professionalism. DOH and CSC further wish to acknowledge those providers that continued to render medically necessary services to Medicaid clients during the eMedNY implementation period. Be assured that DOH and CSC representatives worked around the clock to quickly bring the new eMedNY system to its full capacity and functionality.

For more information about eMedNY, visit the website at The website contains the MEVS Provider Manual and the ProDUR/ECCA Manual. These manuals can be downloaded from the website. Other information available at the website includes: Medicaid news, frequently asked questions and answers, formulary file information, and DOH and CSC contact information.

Questions about MEVS transactions, pharmacy claims, connectivity, POS terminals and software should be directed to eMedNY Provider Services (Monday - Friday from 7:00 a.m. to 10:00 p.m., and Saturdays, Sundays and holidays from 8:30 a.m. to 5:30 p.m.) at the following telephone number: eMedNY Provider Services, (800) 343-9000.

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Prescribers (doctors, nurse practitioners, dentists, etc.) and pharmacists are reminded of policies they must adhere to when prescriptions are transmitted to a pharmacy by telephone or fax for Medicaid recipients.

Prescribers may telephone or fax prescriptions directly to pharmacies for Medicaid recipients unless otherwise prohibited by federal or State laws or regulations.

A follow-up signed written prescription must be on file at the pharmacy within five (5) business days for:

  1. Prescriptions with refills.
  2. Prescriptions for multi-source brand name drugs requiring "brand necessary" or "brand medically necessary".

Note: Telephone or faxed orders for OTC (over-the-counter) drugs are not permitted.

  • PRESCRIBERS are responsible to provide the original written prescription within five (5) business days of a telephoned or faxed order.
  • PHARMACISTS are required to have the original signed written prescription on file within five (5) business days of a telephoned or faxed order.

Don't Forget    

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When electronically billing for a prescription drug, the prior authorization number must be entered into the prior authorization field for the claim to be paid. This field has 12 values (NCPDP format). Pharmacists are reminded to enter into the prior authorization code field a "1", followed by the eight-digit prior authorization number, followed by three zeroes/copay exemption values. Claims that do not follow this format will be denied.

For billing questions, contact (800) 343-9000. For policy questions, contact the Pharmacy Policy and Operations staff at (518) 486-3209.


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  • Entering the client identification number

Some providers have expressed difficulty in entering the client identification number (CIN) into the automated pharmacy prior authorization telephone response system. Providers are reminded to listen carefully to the voice prompt directions and follow the steps below:

  • Verify that the format of the CIN is 2 letters, 5 numbers, 1 letter - e.g. AB12345C.
  • USE THE KEYPAD TO ENTER ALL 8 VALUES AT ONCE. For letters, enter the corresponding number on the keypad. For Q, use 7 and for Z, use 9 (These letters are not visible on all keypads).
  • AFTER ALL EIGHT VALUES HAVE BEEN ENTERED, the caller must define the first, second and eighth value by entering the number that represents the letter of the CIN. For example, the voice prompt will say "The first number you pressed was 2 - If you wanted an A, press 1. If you wanted a B, press 2".

Please contact us at (518) 486-3209 if you have questions after following these instructions.

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: