DOH Medicaid Update September 2003 Vol.18, No.9

Office of Medicaid Management
DOH Medicaid Update
September 2003 Vol.18, No.9

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



A fiscal order for medical-surgical supplies may be refilled when the prescriber has indicated on the order the number of refills and the recipient has requested the refill. The recipient or representative must request each refill because their medical condition and/or living situation may change over the course of the fiscal order. Examples of medical-surgical supplies include: diabetic supplies, enteral formulas, incontinence products and wound dressings.

The following are unacceptable practices:

  • Automatic refilling and claiming for medical-surgical supplies;
  • Refilling in excess of the number of refills indicated on the fiscal order;
  • Knowingly making a claim for unnecessary medical-surgical supplies;
  • Claiming for medical-surgical supplies when a recipient is hospitalized
    or moves into a skilled nursing facility, because medical-surgical
    supplies are included in the Medicaid rate paid to the facility.

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

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This article provides clarification about continued use of the Welfare Reform Exception Code 83 for Medicaid fee-for-service (FFS) recipients and Medicaid managed care enrollees who have been ordered by the Local Department of Social Service (LDSS) to receive chemical dependence services as a condition of eligibility for Public Assistance/Medicaid.

Effective December 1, 1998, Medicaid managed care organizations were no longer responsible for LDSS ordered chemical dependence services delivered to Public Assistance/Medicaid recipients. Implementation of this policy included requiring the LDSS to use the Exception Code 83 to identify all those Public Assistance and/or Medicaid recipients mandated by the LDSS into chemical dependence services. Entering the code 83 for all LDSS mandated individuals was intended to provide a mechanism for counties to track mandated clients. Additionally, for Medicaid managed care enrollees, the exception code 83 permits Medicaid FFS reimbursement for Office of Alcohol and Substance Abuse Services (OASAS) certified providers who deliver LDSS mandated OASAS services.

Use of the Welfare Reform Exception Code 83 for Medicaid Fee-For-Service Recipients
Effective immediately, counties are no longer required, but have the option, to use the Code 83 on all mandated recipients for tracking purposes.

Use of the Welfare Reform Exception Code 83 for Medicaid Managed Care Enrollees
The LDSS must continue to enter Code 83 for Medicaid managed care enrollees who have been ordered by the LDSS to receive uncomplicated medically managed acute detoxification, chemical dependence inpatient rehabilitation or medically supervised inpatient or outpatient withdrawal services. Use of Code 83 will enable OASAS providers to submit claims to the Medicaid Management Information System (MMIS) and get paid directly on a FFS for these mandated services.

Outpatient chemical dependence treatment services ARE NOT included in the managed care benefit package. Accordingly, the LDSS does not need to enter Code 83 when ordering a managed care enrollee into only one or more of the following services: Methadone Maintenance Treatment Program (MMTP), medically supervised ambulatory chemical dependence programs, chemical dependence outpatient rehabilitation programs and outpatient chemical dependence for youth programs.

Under any of the following five circumstances, the managed care plan is responsible for the delivery and payment of the chemical dependence services even if the LDSS has ordered services as a condition of eligibility for Public Assistance and/or Medicaid:

  1. An evaluation visit when an enrollee requested evaluation visit from an Managed Care Organization (MCO) network provider;
  2. Evaluation and treatment services when the prepaid capitation plan or other designated MCO practitioner refers the patient to a provider for evaluation and/or treatment;
  3. Court ordered services;
  4. Chemical dependency services when the MCO is already providing the services and the LDSS is satisfied with the level of care and treatment plan; or
  5. Complicated Medically Managed Acute Detoxification.

If you have any questions, please call Ms. Barbara Frankel, Office of Managed Care, at (518) 473-7467.

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As a result of HIPAA national coding standards, the procedure codes for Private Duty Nursing services requiring prior approval will be changed, effective September 1, 2003.

When submitting a Prior Approval Request (form DSS-3615) for dates of service on or after September 1, 2003, the following procedure codes should be used:

RN: S9123 (replaces W9046)

LPN: S9124 (replaces W9045)

The modifier "T T" must be added to the above "S" codes to indicate "concurrent/shared" cases (one nurse providing service to two or more recipients at the same time).

RN shared: S9123 TT (replaces W9052)

LPN shared: S9124 TT (replaces W9051)

The modifier "U I" must be added to the above "S" codes to indicate Care at Home (CAH) waiver services.

RN shared: S9123 UI (replaces W9050)

LPN shared: S9124 UI (replaces W9049)

Claims filed for dates of service on or after September 1, 2003 but covered by prior approvals issued before September 1, should continue to reflect the "W" codes in order to match the prior approval through the indicated expiration date.

Please direct any questions to the Private Duty Nursing Unit at (518) 474-3575 or (800) 342-3005. For questions on the CAH program, call (518) 486-6562.


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HIPAA open provider testing is in progress at Medicaid is using the EDIFECS validation tool. Providers must test successfully before they will be allowed to submit HIPAA transactions.

ePACES is the free alternative for submitting HIPAA compliant transactions to NY Medicaid. For extensive information, including enrollment instructions, visit Providers who are still billing Medicaid using our proprietary paper claim forms may wish to consider ePACES as a more efficient and effective method. National surveys have confirmed that electronic transactions are less prone to errors, require fewer resources to complete and submit, and are normally processed more quickly.


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The deployment of the new Omni 3750 has shown excellent results in performance and purchasing turnaround time since the July production rollout. Working with their VeriFone partner, Computer Sciences Corporation (CSC) has been able to forecast and maintain inventory levels to streamline requests and get the provider customer base up and running quickly and efficiently. VeriFone preloads and configures this easy to use device prior to shipping which has enabled providers to connect and transmit transactions with minimal assistance from the eMedNY support center.

About the Omni 3750 Warranty Service and Support Program
The Omni 3750 program was designed to focus on the efficiency and effectiveness of support, procurement, and warranty options in the best interest of the provider user base. This "one stop shopping" or central point of contact for ordering, warranty repairs, troubleshooting and ongoing support eliminates providers from dealing with multiple vendors and support centers to address their questions and technical issues. The warranty program for the Omni 3750 is one of the most significant features of this program. The Expedited Replacement Service (ERS) is a five-year warranty program that has been designed by VeriFone and CSC to support the large volume of Point of Service (POS) devices required for the Medicaid program. During this five year period, VeriFone uses overnight delivery of the replacement terminal to reduce downtime and involvement in the return/replacement process through one single point of contact.

What should I do with my old TRANZ 330 Device?
When you transition to the new Omni 3750 you may wish to dispose of your old device. To maintain the confidentiality of information stored in your device, you must first clear the memory of the device. The procedure to perform this operation follows:

  1. Press the *& "Clear" keys at the same time (Terminal should say enter password)
  2. Type in 8,alpha,0,alpha,5,3,6,1,0,4,1,alpha press "Enter" (Terminal should say "successful")
  3. Press the "Clear" key (Terminal memory has now been deleted)

Ordering Information
During the month of August, letters were mailed to each provider submitting transactions via a POS device. That letter contained instructions and forms for ordering the new device. If you are a POS user and have not received a letter please call the Provider Services POS Inquiry Line at (800) 343-9000 (Option 4). This line is available Monday through Friday between 9:00 AM and 5:00 PM. Providers with Internet access can also obtain this information at under "What's New".

About the Omni 3750 (Pricing/Features)

  • The Omni 3750 has been priced at $817 (includes shipping and handling) plus tax and includes features such as: five year warranty on hardware failures; Expedited Replacement Service (overnight replacement of damaged units); integrated printer; faster 14,400 bps modem for improved transmission speeds; and easier to use ATM keys.

Please note: As an alternative to using the POS device, the Medicaid Eligibility Field software replacement program called ePACES is referenced on page 3. ePACES will be available to providers at no cost.

Unless you act immediately to order, you may experience delays due to a potential last minute surge of orders prior to the October 16th deadline. CSC and VeriFone will do everything they can to minimize delays. Keep in mind that your new Omni 3750 can be used to access eMedNY just like the TRANZ 330, until such time as you receive instructions to download the new HIPAA software. The HIPAA software needs to be installed and working prior to October 16th or an interruption of service could result.

Medicaid will start accepting and processing HIPAA transactions on September 27, 2003. The Transactions and Code Sets Compliance date is October 16, 2003.

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Transportation Restriction Program

The New York City Human Resources Administration (HRA) is implementing the final phase of its program to assure Medicaid recipients travel via the most appropriate mode of transport needed. For several years, HRA has asked targeted ordering practitioners to submit to HRA pertinent information justifying the mode of travel ordered. With ensuing HRA feedback, practitioners are better able to more accurately assess the required mode of transport.

Beginning in late August 2003, HRA will electronically submit these decisions to the prior approval system. If an inappropriate mode of transportation is ordered, a message will be sent to the ordering practitioner and the transportation provider indicating the recipient is restricted from using that mode of transportation.

This message, sent on the prior approval roster of ordered trips, will read:

      "RECP RESTRICTED FROM TRANS SVC" (Recipient Restricted From Transportation Service).

The ordering practitioner should reassess whether the ordered mode of transportation is correct for the recipient's level of disability.

  • If the original assessment is incorrect, the ordering practitioner should reorder the trip at the appropriate mode.
  • If the original assessment is correct, the ordering practitioner should contact HRA at (212) 630-1417 to initiate a change to the initial restriction.

Bridge and Tunnel Toll Increase For Ambulette Providers

Reflecting the increase in the toll charged to all users of certain NYC bridges and tunnels, the reimbursement amount for an incurred toll (procedure code 66191) has been changed from $3 to $4 effective May 1, 2003.

Providers are allowed to claim a toll:

  •   When the toll is incurred while a passenger is in the vehicle.
  •   For only one toll per crossing, not multiple tolls based on a toll per passenger.

If you have questions, please call (518) 474-9219.


Man and Report

This month's patient educational tool features an article on "Laboratory Tests for Diabetes".

The Medicaid program encourages practitioners to copy and distribute the following information to their patients and to share them with their colleagues.


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Blood Work

Test Tubes

Keeping your blood glucose (sugar) within the normal range will make you feel better and will prevent or delay the start of diabetes complications such as nerve, eye, kidney, and blood vessel damage. There are many ways to keep track of your blood sugar.


You may test your own blood glucose level at home or wherever you may be several times a day. The self- monitoring of blood glucose (SMBG) test gives you your present blood sugar level.


You or your doctor may want an overall result of your blood sugar control. The A1C blood test gives an average of all the blood sugar results for the past 2-3 months. The A1C test is used to see how well your treatment plan (medications, activity and diet) is working to control your blood glucose levels.

  • So even though a person's blood glucose may be high on a certain day because of inactivity or too much food, the A1C test will tell the doctor that most of the time the blood sugar levels for the past 2-3 months have stayed within normal range.
  • On the other hand, the A1C results could be higher than normal, which would tell the doctor that one or more parts of your treatment plan will need to be changed or modified. In other words, there may be too many or too few calories, not enough or too much medication, or too little or too much activity in the daily plan.

Baseball Player

The best way to understand the A1C test is to compare it to a baseball player's season batting average.

The A1C test is the batter's overall rating for the entire season.

The self-monitoring blood glucose test could be compared to a batter's daily score.

Your doctor may want to measure your A1C level twice a year. Your doctor will measure A1C more frequently if your treatment plan changes, or you are not meeting goals.


The fasting plasma glucose test is the preferred way to diagnose diabetes. After you have fasted for at least 8 hours overnight, a single sample of blood is drawn in the doctor's office or laboratory.

  • Normal fasting plasma glucose levels are less than 110 mg/dl.
  • Fasting plasma glucose levels of more than 126 mg/dl on two or more tests on different days indicate diabetes.


For the oral glucose tolerance test, you must fast overnight for at least 8 hours and then go to your doctor's office or the laboratory in the morning.


  • A fasting plasma glucose test will be done first.
  • Then you will receive 75 grams of glucose in a sweet tasting drink.
  • Blood samples are then taken up to 4 times to measure your blood glucose results.

Prepared by the New York Department of Health, Office of Medicaid Management, Bureau of Program Guidance, 8/03

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Generally, eye care services under the Medicaid program include a bi-annual eye exam. However, when a recipient's medical condition, such as a diagnosis of diabetes, necessitates an eye exam more frequently, reimbursement will be made when the service is billed with medical justification. The Medicaid program encourages all primary care practitioners to refer patients with diabetes to eye care specialists.

As a public service, we wish to make you aware of a new program available to your diabetic patients who have Medicare coverage only. The Centers for Medicare and Medicaid Services (CMS) has recognized that some Medicare patients delay receiving necessary eye exams due to the cost of the resulting coinsurance and deductible. In collaboration with the American Academy of Ophthalmology (AAO) and the American Optometric Association (AOA), CMS has initiated the EyeCare AmericaSM - National Eye Care Project® to encourage Medicare beneficiaries with diabetes to get their eyes examined.

  • Medicare beneficiaries age 65 and older who have diabetes and haven't had a medical eye exam in the past three years, will be matched with a volunteer ophthalmologist in their area.
  • Beneficiaries will receive a free comprehensive eye exam and up to one year of follow-up care for any condition diagnosed at the initial exam.

To get the name of an ophthalmologist participating in the EyeCare AmericaSM-National Eye Care Project® in a specific area, beneficiaries can call the 24-hour toll-free number at (800) 222-3937.


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The American Lung Association of New York State, in conjunction with the American Lung Association of the City of New York, has launched "Back to School with Asthma," a statewide asthma education and awareness campaign.

This campaign will complement extensive ongoing activities by the New York State Department of Health and New York's regional Asthma Coalitions. The campaign will educate the public about asthma, including the causes and triggers of asthma, prevalence rates, hospitalization rates, direct and indirect costs of asthma and treatments for asthma. It will also suggest ways individuals and policymakers can prevent attacks and reduce the burden and societal costs associated with asthma.

"Back to School with Asthma" is designed to give parents working with doctors, teachers and school health professionals the tools they need as they prepare to send a child with asthma to school. "Back to School with Asthma" brochures and kits will offer parents information about asthma, asthma triggers, asthma management plans, and information about New York State's law that gives school-aged children the right to carry and use asthma inhalers while in school. The informational material will also explain the role that diesel emissions from school buses can play in worsening the health of a child with asthma and how to make sure school environments are "asthma-friendly."

For information about the "Back to School with Asthma" campaign, contact the American Lung Association at (800) LUNGUSA or visit their web site at

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: