DOH Medicaid Update August 2004 Vol.19, No.8

Office of Medicaid Management
DOH Medicaid Update
August 2004 Vol.19, No.8

State of New York
George E. Pataki, Governor

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

Medicaid Update
is a monthly publication of the
New York State Department of Health,
Office of Medicaid Management,
14th Floor, Room 1466,
Corning Tower, Albany,
New York 12237

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As announced in last month's Medicaid Update, the Department has established the final deadline for accepting only HIPAA (Health Insurance Portability and Accountability Act) compliant transactions and claims. After October 6, 2004, ONLY HIPAA-compliant electronic transactions and claims will be processed. Electronic transactions and claims submitted in a non-HIPAA-compliant format will be rejected.

The Department and Computer Sciences Corporation (CSC) staff will continue to work with providers, vendors and provider organizations, offering technical assistance and support for testing and other efforts related to achieving HIPAA compliance. Recently, a new tool was introduced to help our trading partners identify edits/errors and the probable corrective action necessary. It allows claim submitters to see edit/error results of the prior week's claim cycle, and connects them to a web page describing the error, the potential cause and the solution. This new tool is available at under the News and Resources Tab, Edit/Error Knowledge Base.

Some of our trading partners still have not registered to test through the nyhipaadesk website and/or with CSC. If you are not yet testing, we urge you to expedite your compliance efforts, and begin the testing process as soon as possible. Any further delay may jeopardize your ability to successfully complete testing prior to October 6, 2004, which would result in an inability to submit HIPAA claims and receive payment. Information on the Medicaid HIPAA testing process is available at

Providers using clearinghouses or service bureaus to submit their Medicaid claims should be in constant contact with them to ensure they are proceeding aggressively with their HIPAA compliance program. Providers should not assume that these vendors will achieve timely HIPAA compliance, but should proactively monitor their progress. With the impending final deadline date for the rejection of non-compliant transactions and claims now set at October 6, 2004, less than two months away, providers must take all necessary steps to become HIPAA compliant as soon as possible to avoid any disruption in claims processing and payment flow.

For questions regarding HIPAA Medicaid compliance and this article please call CSC's HIPAA Support Helpline at (800) 522-5518.


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The Federal Drug Rebate Program requires pharmaceutical manufacturers to sign a rebate agreement in order to have their pharmaceuticals covered by state Medicaid programs. The actual rebate amount is based on the claim information transmitted by the pharmacy provider. Therefore, it is imperative that the dispensing pharmacy provides accurate drug information.


To assure accurate claiming:

  • The National Drug Code (NDC) must correspond to the actual prescription or over-the-counter drug being dispensed. You should be aware that preprogrammed NDCs do not guarantee the transmission of accurate information. It is considered a fraudulent billing practice to bill using a NDC other than that which is dispensed.
  • The 11 digits of the NDC must accurately reflect what is dispensed (package size matters).
  • The number of units dispensed must correspond to the correct reimbursement quantity (i.e., grams, milliliters or vials).
  • Do not bill for a particular manufacturer's product and dispense another manufacturer's product.

The benefits of accurate pharmacy coding include reduced audits and timely reimbursement. Provider payments are subject to recoupment if products are billed for and not dispensed.

Questions about this article can be directed to the Medicaid Pharmacy Unit at 518-486-3209.

To verify coverage of a particular NDC, please contact Computer Sciences Corporation at (800) 522-5535 or visit the following web site:

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In order to prepare for the implementation of eMedNY Phase II, (the replacement Medicaid system), Computer Sciences Corporation, under the direction of the Department of Health, is preparing new Companion Guides. Initial drafts, intended to give a preview of changes to help providers plan for the March 2005 deployment of the eMedNY Phase II, will be available beginning September 15, 2004 on the nyhipaadesk web site; Watch for more details in next month's Medicaid Update.


The replacement Medicaid system, commonly referred to as eMedNY Phase II, is well along in its development, and is scheduled to be implemented at the end of March 2005.

Most providers and other trading partners will be affected by the changes in Medicaid claims processing that eMedNY will bring!

A series of announcements aimed at informing providers of the differences between the current system and the new eMedNY system will appear each month in the Medicaid Update. Please share this information with your Information Technology personnel, vendors, suppliers and billing agents. These announcements are designed to inform you of the project milestones and give you details of changes you will be seeing in the new system. (If you would prefer to check on the progress of the project more frequently, please visit the eMedNY website at

  • Phase II is designed to make considerable improvements in Medicaid claims processing.
  • The Department will be issuing new Companion Guides (system specifications) for the eMedNY Phase II implementation. Please check the eMedNY and nyhipaadesk websites.
  • All electronic claims and other electronic transactions will be required to be in a HIPAA compliant format.
  • The following eMedNY changes will affect the way your electronic transactions will be transmitted:
    1. SNA connections will no longer be supported as a means of transmitting electronic messages into the system;
    2. RJE/NJE will no longer be supported for submitting files;
    3. No physical media (tapes, diskettes) will be supported for file submissions; and
    4. The "tilde" character will no longer be allowed as a segment terminator within the messages.

If you will be impacted by any of these changes, the Department encourages you to begin your efforts to change your systems now. Alternatives are currently available for all of the above changes. Go to the eMedNY website for additional information.

In addition to these changes, there will be modifications to the paper claim & PA forms implemented with Phase II. Details of those changes will also be available on the websites.

This policy statement is a reiteration of existing policy, intended to remind hospitals on proper claiming of services.

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When an original admitting hospital sends a Medicaid inpatient to another hospital for purposes of obtaining a diagnostic or therapeutic service not available in the admitting hospital, the original admitting hospital is responsible for the provision of those services. Neither hospital may bill the Medicaid program separately for these services.

The Medicaid payment for inpatient care is considered to include all procedures and services regardless of where they were performed. The original hospital is responsible for reimbursing all other hospitals, clinics or ambulatory surgery centers which provide the services not available at the admitting hospital.

This policy includes reimbursement of any transportation expenses, when the originating hospital must send the patient to other facilities for diagnostic or therapeutic services. The hospital should reimburse the ambulance or other transportation service for the transport of the patient, as the Medicaid inpatient rate is inclusive of all services provided to the Medicaid patient. The transport will not be authorized by the local social services district and paid fee-for-service.

For example, your hospital arranges for the round-trip transport of a Medicaid inpatient by an ambulance for a diagnostic, magnetic resonance imaging (MRI) test; therefore your hospital should reimburse the transportation service for the transport of the patient. The Medicaid inpatient rate is inclusive of all services provided to the Medicaid patient.

If you have any questions, please contact the Provider Resources Unit at (518) 474-9219.

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Medicaid enrolled pharmacies that are not yet enrolled in Medicare as pharmacy providers should enroll in Medicare now!

Medicare enrollment information is available at:


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As announced in the July 2004 Medicaid Update, Medicaid providers will begin to see Medicaid Eligibility Verification System (MEVS) messages associated with new coverage codes for applicants who are not seeking coverage of long-term care services beginning August 23, 2004. Individuals will be allowed to attest to the amount of their resources, rather than provide proof. Individuals may also attest to the amount of their resources and qualify for short-term rehabilitation services.

To support this new policy, six new Medicaid Coverage Codes have been created. For included and excluded services associated with each new coverage code and other pertinent information, please refer to the July issue of the Medicaid Update. The following new coverage codes will be valid for payment retroactive to April 1, 2003.

  1. Coverage Code 19: "Community Coverage With Community-Based Long-Term Care"
    For individuals who document their current resources.
  2. Coverage Code 20:"Community Coverage Without Long-Term Care"
    For individuals who attest to the amount of their resources, rather than provide proof.

    The next three Medicaid Coverage Codes are for individuals who meet a spenddown requirement.

  3. Coverage Code 21: "Outpatient Coverage With Community-Based Long-Term Care"
    For individuals who document their current resources.
  4. Coverage Code 22: "Outpatient Coverage Without Long-Term Care"
    For individuals who attest to the amount of their resources, rather than provide proof.
  5. Coverage Code 23: "Outpatient Coverage With No Nursing Facility Services"
    For individuals who provided resource documentation for the past 36 months (60 months for trusts) and have made a prohibited transfer of assets.
  6. Coverage Code 24: "Community Coverage Without Long Term Care"
    Same coverage as Coverage Code 20.


New Medicaid Coverage Codes and MEVS Response
Beginning August 23, 2004

Coverage CodeARU Eligibility Reason MessageOMNI 3750/ePaces Eligibility ResponseNON-NCPDP HIPAA Batch/PC/CPU Eligibility ResponseALL NON-NCPDP HIPAA TRANSACTIONS (EB05) Plan Cov Desc NON-HIPAA Reason Code NCPDP EMEVS Response Code
19Community Coverage with Community Based Long Term CareLimitationsFCommunity Coverage W/CBLTC 034034
20Community Coverage without Long Term CareLimitationsFCommunity Coverage No LTC035 035
21Outpatient Coverage with Community Based Long Term CareLimitationsFOutpatient Coverage W/CBLTC036036
22Outpatient Coverage without Long Term CareLimitationsFOutpatient Coverage No LTC037037
23Outpatient Coverage with No Nursing Facility ServicesLimitationsF Outpatient Coverage No NFS038038
24Community Coverage without Long Term Care LimitationsFCommunity Coverage No LTC035035

If you have any questions concerning pharmacy claims and/or MEVS in general, contact (800) 343-9000.
If you have any questions concerning any other claim type, contact Computer Sciences Corporation staff at (800) 522-5518.

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Prior approval for home infant apnea monitors for children less than one year of age is not required if the monitor is ordered by a Physically Handicapped Children's Program (PHCP)/Children with Special Health Care Needs (CSHCN) Program Infant Apnea Specialty Center. Effective for order dates on and after August 1, 2004, the following facilities are designated as PHCP/CSHCN Infant Apnea Specialty Centers (please note the list carefully, as there are some changes from the previous list):

CapitalAlbany Medical Center Hospital
CentralCayuga Medical Center at Ithaca
 United Health Services Hospitals, Inc. - Wilson Hospital Division
 St. Joseph's Hospital Health Center
MetropolitanBellevue Hospital Center
 Brooklyn Hospital Center Downtown Campus
 Coney Island Hospital
 Flushing Hospital Medical Center
 Good Samaritan Hospital (West Islip)
 Interfaith Medical Center - St. John's Episcopal Hospital Division
 Jacobi Medical Center
 Jamaica Hospital Medical Center
 Kings County Medical Center
 Lenox Hill Hospital
 Long Island Jewish Medical Center (Schneider Children's Hospital)
 Maimonides Medical Center
 Mercy Medical Center
 Metropolitan Hospital Center
 Montefiore Medical Center, Jack D. Weiller Hospital
 Mount Sinai Hospital
 Nassau University Health Center
 New York Hospital Medical Center of Queens
 New York Presbyterian Hospital at Columbia Presbyterian Center
 New York Presbyterian Hospital at Weill Cornell Center
 New York University Hospitals Center
 North Central Bronx Hospital
 North Shore University Hospital
 Northern Westchester Hospital
 Our Lady of Mercy Medical Center
 St. Luke's Cornwall Hospital
 Staten Island University Hospital North
 SVCMC - St. Vincent's Manhattan
 SVCMC - Staten Island
 University Hospital (SUNY Health Sciences Center - Stony Brook)
 University Hospital of Brooklyn
 Westchester Medical Center
 Winthrop University Hospital
 Woodhull Medical and Mental Health Center
WesternStrong Memorial Hospital
 Women and Children's Hospital of Buffalo


  • Rental Policy:
    The Medicaid program will not reimburse the purchase of Apnea monitors. The Medicaid program will only provide reimbursement to rent Apnea monitors.
    As with all rentals, the monthly fee includes all necessary features and equipment, delivery, maintenance and repair costs, parts, supplies and services for equipment set-up, maintenance and replacement of worn essential accessories or parts, loading or downloading software, and backup equipment as needed.
  • Billing:
    When billing for the apnea monitor rental, enter the Medicaid Provider Identification Number for the PHCP/CSHCN Infant Apnea Specialty Center in the "Ordering/Referring Provider ID" field. Effective for order dates on and after August 1, 2004, the Center must be on the above revised list. The correct billing code, E0619 Apnea monitor, with recording feature is reimbursed at a rate of $190 per month.
    (For more information see page 4-45 of the MMIS Durable Medical Equipment Provider Manual, Rev. 4/04).
  • Ordering:
    For children less than one year of age, the child must be seen at an approved PHCP/CSHCN Infant Apnea Specialty Center, or the primary physician (even if a pediatric pulmonologist) must obtain an order from an approved center (this can be done via phone, faxing/mailing the record, or teleconference). If this is impossible, a six-month prior approval may be issued if all the necessary documentation from the primary physician to medically justify the equipment is submitted. Please note that all orders for apnea monitors are valid for up to six months.
  • Facilities interested in becoming an approved PHCP/CSHCN Infant Apnea Specialty Center may contact the Children with Special Health Care Needs Program at (518) 474-0570.
  • For questions on claim form completion, call CSC Provider Services at (800) 522-5535.
  • For questions on coverage and prior approval, call the Medicaid Bureau of Medical Review and Payment at (518) 474-8161.

This is an overview of Medicaid's vision care services currently available to eligible recipients.
Please share this article with your staff and insert a copy of it in your Provider Manual.

Sun With Glasses

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  1. Eye Examination:    Complete Optometric Eye Examination (medical exam and evaluation with initiation of diagnostic and treatment program, including refractive state.) Also see Sections B & C.
    Frequency: Once in Two Years (24 months)
  2. Lenses:    Plastic or glass lenses due to a change in optical prescription issued by a licensed optometrist or ophthalmologist. Limited to monofocal (single vision for reading or distance), bifocal (standard lined lenses offered) or multifocal (trifocal when medically necessary). Also see Sections B & C.
    Frequency: One (1) Pair in Two Years (24 months)
  3. Frame:     NYC Recipients: A frame from a selection of styles, colors and materials (plastic, metal) offered to Medicaid patients. Upstate (Non-NYC) Recipients: A frame from the Sample Frame Kit available from the Medicaid optical lab contractor, Wallkill Optical Laboratory. (Phone # (800) 836-2636; Fax # (800) 836-2637). Also see Sections B & C.
    Frequency: One (1) in Two Years (24 months)
  4. Fitting Service:     The fee for the professional service of fitting and dispensing eyeglasses is paid to the ophthalmic dispenser. The fees are $10 or $15, depending on the type of lens and/or frame.
  5. Medical Necessity & Prior Approval:    Prior approval is required for certain medically necessary materials or services.
    Examples are:
    • Contact Lenses,
    • Orthoptic/Pleoptic Training,
    • Polycarbonate Lenses (for children & adults),
    • Tinting,
    • Special frames, not listed in the MMIS Provider Manual.

    A supply of Prior Approval Request Forms may be ordered from Computer Sciences Corporation (CSC), our fiscal agent, at:

    Practitioner: (800) 522-5518 or (518) 447-9860
    Professional: (800) 522-5535 or (518) 447-9830

    Questions about the Prior Approval process may be directed to the Medicaid Prior Approval staff at: (800) 342-3005 or (518) 474-3575.

  6. Non-Covered Items:   Optical items or services that are not covered by Medicaid include, but are not limited to: sunglasses (prescription or non-prescription); and photogray, transitional and/or progressive (multifocal) lenses.
  7. Medicaid Managed Care Enrollees:   For recipients who are enrolled in a Medicaid Prepaid Capitation Plan Care Enrollees: (PCP) that covers optical/vision care (Coverage Code 'Z' on MEVS) the PCP must provide, at a minimum, the same vision care services as fee-for-service Medicaid. The recipient must obtain services from optical providers that participate in the Managed Care Provider's network.

Eye Exam


The Medicaid recipient's county of fiscal responsibility determines what vision care services may be provided and billed by an optometrist, optician (ophthalmic dispenser) and/or optical establishment that are enrolled in the Medicaid Program.

  1. County Code 66 (NYC)    Providers serving NYC recipients may provide and be paid for eye exams, (NYC): lenses and frames from their own stock and the professional fitting and dispensing service. In addition, since October, 2003 they have the option of ordering eyeglass materials (lenses and frames) from the Wallkill Optical Lab and billing Medicaid for only the fitting/dispensing fee.

  2. County Codes 01 through 55 (Albany-Westchester):    Providers serving Upstate (Non-NYC) recipients may provide and be paid for eye exams and the professional fitting/dispensing service. Dispensers are required to order prescription lenses, frames and complete pairs of eyeglasses from the Wallkill Optical Lab, Medicaid's sole-source contractor. See Exception below. The Wallkill Optical Lab makes the finished lenses and/or eyeglasses, returns them to the dispenser and bills Medicaid for these materials.
    Exception: When Part B of Medicare is the primary payer and covers the first pair of eyeglasses (post-cataract surgery), non-NYC optical providers may fill the order from their own stock. When billing us for Medicare deductible or coinsurance amount, enter the letter 'S' in the "SA Exception Code" field on the claim.
  3. County Codes 97 and 98 (OMH & OMRDD)   Providers serving recipients whose county code is one of these two may provide and bill for eye exams and the professional fitting and dispensing service. Also, they have the option of providing and billing for lenses and frames from their own stock or ordering eyeglass materials from the Wallkill Optical Lab.

  4. County Code 99 (Breast & Cervical Cancer Treatment)     Recipients whose county code is 99 are eligible for all medically necessary vision care services.



  1. Eye Examination:   When medically indicated, an additional complete eye exam(s) may be covered in the two-year period. The vision care provider must submit, with the claim form, a detailed description of the medical reason(s) for another exam. The explanation must be "patient-specific", e.g., patient relates frequent episodes of headaches, bouts of nausea and eye strain after reading. Also, the eye exam must show a significant change in visual acuity of a .50 diopter or greater in sphere or cylinder in one or both eyes (include on the claim the prescriptions from both the previous and the current eye exams.)
    Note: Periodic office visits to evaluate and manage a new or existing condition (i.e., diabetes, glaucoma, cataracts, etc.) in an optometrist's office should be billed under Evaluation & Management (E&M) procedure codes 99201, 99202, 99211 or 99212. The fee is the same as the fee for a complete eye examination.
  2. Lenses:    Within a two-year period, a recipient may experience a change in his/her vision and need a new prescription for monofocal lenses for reading or distance (not both) or to change from monofocal to bifocal lenses. An additional pair(s) of lenses may be covered if the new prescription confirms a change in visual acuity of a .50 diopter or greater in sphere or cylinder in one or both eyes. To document the "significant" change in a patient's vision, the prescriptions for the previous and the current lenses should be identified in the Procedure Description field of the claim form.

    Bifocal Lenses vs. Two (2) Pair of Eyeglasses:

    a) For patients less than 70 years of age: For certain eligible recipients, in lieu of bifocal lenses, two (2) complete pair of eyeglasses (for both distance and reading) may be covered when the following conditions are met, and a "patient-specific" explanation of the reasons for two pair is submitted with the claim form:

    • Two pair of eyeglasses, instead of bifocals, may be ordered/dispensed when medically necessary, e.g., medical, physical and/or psychological condition(s) may preclude a patient from wearing a bifocal lens; past attempt(s) in using bifocal lenses was unsuccessful; patient has a condition which results in frequent falls and injuries.
    • In addition to the new prescription, an eye doctor should provide the recipient with a written "patient-specific" explanation of the medical need for two pair. Both documents should be given to the ophthalmic dispenser when new eyeglasses are ordered.
    • Both pairs of eyeglasses should be ordered and dispensed at the same time and billed on the same claim form. Also, the prescriptions for both pairs must be listed in the Procedure Description field of the claim form.

    b) For patients 70 years of age or older: Eligible recipients who are at least 70 years of age may receive two (2) complete pair of eyeglasses (for both distance and reading), instead of bifocal lenses. They should be ordered, dispensed and billed at the same time. In addition, in the Procedure Description field of the claim form, please clearly identify the following three items:
    • The patient's age (must be 70+ years old);
    • No recent history of bifocal use (within at least 24 months); and
    • The prescriptions for both pairs of lenses (reading & distance).

    Note: When ordering two pair of eyeglasses from the Wallkill Optical Lab, the above information should be clearly written on or submitted with the order form.

  3. Frame: During a two-year period, a recipient may change the frame size, style or material only when medically necessary. A written, "patient-specific" explanation of the medical/ophthalmic necessity for such a change should be submitted with the claim form. Examples of general reasons might include:
    • The new prescription requires a larger frame;
    • Recipient being treated for an allergic reaction to certain frame material;
    • Patient has had a recent growth spurt or a significant loss/increase in weight.

      Note: When ordering a different frame from the Wallkill Optical Lab, the written patient-specific explanation should accompany the order form.

  4. Repair or Replacement    The repair or replacement of a frame, one or more lenses or a complete of Eyeglasses or pair of eyeglasses due to loss, theft or breakage is covered. The vision Eyeglass Materials: care provider must dispense replacement eyeglasses or with the materials same lens prescription and the same frame (or one as similar as possible to the original) in order to duplicate what was originally dispensed within the past two-year period.

    When a provider replaces a complete pair of eyeglasses, the appropriate "Fitting of Eyeglasses" procedure code 92340 through 92353 should be billed. In addition, optical providers replacing eyeglasses for NYC recipients may bill for the appropriate codes for the lenses and frame.

    To identify eyeglass replacement, the modifier "RP" must be added to each code billed, including to code for the fitting/dispensing service.

    When a provider repairs or replaces part (lens, frame, temple, bow) of the eyeglasses, the appropriate "Repair and Refitting of Eyeglasses" code 92370 or 92371 should be billed. In addition, optical providers replacing eyeglass parts for NYC recipients may bill for the appropriate code for the part that was replaced. The modifier "RP" must be added to the frame or lens code(s) of the part billed to identify replacement.

    Note: Prior approval or authorization is not needed to replace a lens, frame or pair of eyeglasses, unless the original material (e.g., polycarbonate lenses, a special frame or tinted lenses) required prior approval.

  5. Frequency Limitations: Once in 24 months is the usual and customary frequency for optical services. However, since the basis of Medicaid's coverage is "medical necessity", additional services during the two-year period may be payable if the optical provider submits "patient-specific" information, which documents that the service(s) is medically necessary and/or when the criteria outlined above in Section C (1) - (4) are met. Service utilization often varies greatly from recipient to recipient. A child may need to change his/her eyeglass prescription annually or to replace lost or broken eyeglasses frequently. An adult may need to change from single vision to bifocal lenses or to have lost or stolen eyeglasses replaced in less than two years. As a result, optical materials should be changed or replaced based on an individual's medical/ophthalmic needs. If additional services are required, prior approval/authorization is not needed, unless it was required before ordering or dispensing the original material (i.e., polycarbonate or contact lenses, a special frame or tinting).

    For comprehensive information about vision care policy, claim submission, procedure codes and fees, please consult your MMIS Vision Care (Ophthalmic) Services Provider Manual. Questions about this article should be directed to DOH/OMM Bureau of Policy Development & Agency Relations at (518) 473-2160.

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You Must Remain The Provider of Service!

Medicaid rules allow only the provider of service (or the billing agent for that provider) to submit claims for services rendered.

Due to mechanical breakdowns or other circumstances, transportation providers will face times when the number of available vehicles does not meet the demand for services. At these times, providers may choose to lease vehicles from another operator, or subcontract with another provider:

When another provider's vehicles are being used to transport your own recipients, your company name must be on the vehicle (for example, magnetic sign) as the operator of that vehicle.

  • It is expected that the leased/subcontracted vehicle will have current required inspection stickers.
  • The driver of the leased/subcontracted vehicle must be in compliance with all applicable regulations.


  • The provider must maintain adequate records to support billing for Medicaid regardless of whether the trip is subcontracted.

In essence, you remain the provider of service and the transportation service provided is clearly identified with your company. When these conditions are met, then you are allowed to bill Medicaid for rendered transportation services.


The practice of subcontracting trips to another provider for a certain percentage or amount of the resulting Medicaid reimbursement, without identifying the vehicle as yours, is prohibited under Medicaid. This ad hoc subcontracting practice subverts Medicaid's role to insure that only enrolled providers who meet all regulatory requirements are allowed to deliver Medicaid transportation services.

If you have any questions, please contact the Provider Resources Unit at (518) 474-9219, or email your question to


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New Edits and Messaging

Effective September 1, 2004, approval through the Dispensing Validation System (DVS) will no longer be required prior to dispensing Viagra, Cialis, Levitra, and other erectile dysfunction (ED) drugs (e.g., Muse, Caverject, etc.).

Previously established frequency limits of six dosage units every 30 days remain in effect.

Claims for these drugs are subject to an additional DUR edit of 0710, entitled "Procedure/Formulary Code Exceeds Service Limits" to prevent Therapeutic Duplications.

Drug Utilization Review Rejections

When dispensing ED drugs and a DUR rejection message is received, do NOT override. The DUR rejection messages are meant to protect patients and pharmacists from inappropriate and potentially dangerous drug-drug or drug-disease interactions, as well as alert pharmacists to potential policy violations. If an ED drug DUR message 0710 is received and the drug is dispensed, Medicaid will not reimburse for the inappropriately dispensed drugs. Pharmacists that routinely override DUR rejection messages may be subject to administrative action, which may include fines.

Medicaid Policy for Dispensing ED Drugs

  • ED drugs include: Viagra, Cialis, Levitra, Muse, Caverject, etc.
  • Maximum quantity of any ED drug every 30 days is SIX dosage units.
  • Medicaid will reimburse for only one strength of ED drug per recipient, per month. Changes in dosage strength prior to the 31st day are NOT permitted.
  • ANY QUANTITY of ED drugs dispensed, up to and including six dosage units, is considered to be a 30 day supply.
  • Obtaining Prior Authorizations to increase frequency of dispensing will not be allowed for any reason, including lost or stolen drugs, replacements, and vacation supplies.
  • A diagnosis of ED is required and must be documented by the physician in the patient's medical record. However, a diagnosis of ED does not need to be written on the prescription blank.

ED Drug Dispensing Guidelines

  • DO NOT fill or refill prescriptions for ED drugs before the 31st day, as the DUR system will reject them as Therapeutic Duplications. Claims filled prior to the 31st day will be denied payment.
  • Therapeutic Duplications involving more than one ED drug will be denied payment. The system will not allow overrides for edit 0710. Do not override or dispense. If claims are somehow processed and paid, Medicaid will recoup reimbursement for those claims inappropriately paid.
  • Please do not call for permission to override any on-line rejection message.

Questions about the ED drug policy may be directed to Pharmacy Policy staff at (518) 486-3209.

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As stated in the previous article, the Medicaid program covers drugs for medically necessary treatment of erectile dysfunction (ED).

While ED drugs may help alleviate dysfunction, they do not protect against the spread of sexually transmitted diseases, including HIV. Since these drugs can help enable increased sexual activity, before prescribing ED drugs, risk reduction counseling should occur as part of the visit that results in this prescription. This counseling should include:

  • An evaluation of the individual's past sexual risk behavior and ways to modify/change those behaviors to make them safer;
  • An evaluation of the individual's knowledge of how to use a condom, as well as where to access condoms (many HIV/AIDS-related agencies provide condoms free and condoms are covered by the Medicaid program);
  • An exploration of issues surrounding use of condoms for sexual activities other than vaginal intercourse, including anal intercourse and oral sexual activity.

ED drugs should be prescribed only when medically necessary!

Questions about this policy may be addressed to the Bureau of Policy Development and Agency Relations at (518) 473-2160.

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Medicaid recipients in New York City now have the option to enroll in the following expanded service area for five Special Needs Managed Care Plans.

Medicaid Provider NameMEVS codeAbbreviated Plan Name Service Area
FidelisCare Healthier Life SNOFFIDELIS SNBronx, Brooklyn, Manhattan, Queens, SI
Healthfirst PHSP Inc. SNOHHLTHFST SNBronx, Brooklyn, Manhattan, Queens
NYPS Select Health SNOGNYPSSEL SNBronx, Brooklyn, Manhattan
VidaCare Inc. SNODVIDACARE SNBronx, Manhattan
MetroPlus Partnership in
Care Plan SN
OMMETROPLUS SNBrooklyn, Manhattan, Queens

Providers should make note of these codes in their MMIS Provider Manual under the heading "Recipient Other Insurance Codes."

Special Needs Plans: Provider Relations
NYPS SelectHealth SN
Provider Relations
(866) 469-7774
VidaCare Inc. SN
Provider Inquiry
(800) 556-0674
Fidelis Care HealthierLife SN
Provider Relations Call Center
(888) 343-3547
MetroPlus Plan SN
Provider Relations Call Center
(212) 908-8883
 Healthfirst PHSP SN
Provider Relations
(888) 801-1660

Please contact the health plans above for Special Needs Plans (SNP) benefit package information.

Enrollees can call the New York Medicaid CHOICE Helpline at (800) 505-5678 to find out more about SNP.


Mental Health Providers: Mental Health Services for SSI/SSI-related recipients enrolled in SNPs

Currently, SSI/SSI-related recipients enrolled in Medicaid managed care plans have mental health services carved out from the benefit package. An "S" is indicated on the MEVS for these SSI/SSI-related recipients when a provider conducts eligibility verification. Historically, providers have been advised to bill MMIS directly for mental health services for these recipients.

This policy will change for SSI/SSI-related enrollees in SNPs. For SSI/SSI-related SNP recipients, inpatient and outpatient mental health services (as described in "Covered Services" of Appendix K in the SNP model contract) are covered by the plan. Providers are advised that for specified plans ("OG" NYPS SelectHealth), these mental health services are the plan's responsibility when a recipient is indicated as SSI ("S") on the MEVS.

An exception is made for some SSI children in the SNPs. Mental health benefits for some SSI children will be carved out of the benefit package consistent with mainstream managed care for SSI recipients. Please check with the plan to determine status of these children.

Mental Health Specialty Services (as described in "Non-Covered Behavioral Health Services" in Appendix K of the SNP model contract) will remain carved out services for all SNP recipients, including SSI and SSI related SNP recipients. The SNP model contract is available at the following website:

This clarification of mental health services applies to all SNPs, including Healthfirst, MetroPlus, Fidelis HealthierLife and VidaCare, which were announced in previous updates.

Chemical Dependency (Alcohol and Substance Abuse) Providers: SSI/SSI-related recipients enrolled in SNPs will have inpatient chemical dependency services covered by the SNP.

Currently, SSI/SSI-related recipients enrolled in Medicaid managed care plans have inpatient and outpatient treatment and rehabilitation chemical dependency (alcohol and substance abuse) health services carved out from the benefit package (except for detoxification services, which are included in the managed care benefit package). An "S" is indicated on the MEVS for these SSI/SSI-related recipients when a provider conducts eligibility verification. Providers have been historically advised to bill MMIS directly for inpatient and outpatient chemical dependency (alcohol and substance abuse) services for these recipients.

This policy will change for SSI/SSI-related enrollees in SNPs. For SSI/SSI-related SNP recipients, inpatient chemical dependency (alcohol and substance abuse) services are covered by the plan. Providers are advised that for the specific plan ("OG" NYPS SelectHealth) inpatient chemical dependency services are the plan's responsibility when a recipient is indicated as SSI ("S") on the MEVS.

An exception is made for some SSI children in the SNPs. Consistent with mainstream managed care for SSI recipients, inpatient and outpatient treatment and rehabilitation chemical dependency (alcohol and substance abuse) benefits for some SSI children will be carved out of the benefit package (except for detox services which are included in the managed care benefit package). Please check with the plan to determine the status of these children.

Questions regarding this article can be directed to the Department of Health at (518) 486-1383.


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Under Commissioner Antonia Novello's leadership, the Department of Health is committed to assisting Medicaid recipients in smoking prevention and cessation. Since 1999, Medicaid has covered various smoking cessation agents to aid recipients in quitting tobacco. Below is a review of Medicaid's Smoking Cessation Policy and new information for pharmacists.

No Smoking            No Smoking            No Smoking            No Smoking            No Smoking            No Smoking


  • Smoking cessation therapy consists of prescription and non-prescription agents. Covered agents include inhalers, nasal sprays, Zyban (bupropion), and Over-The-Counter nicotine patches and gum.
  • Two courses of smoking cessation therapy per recipient, per year are allowed. A course of therapy is defined as no more than a 90-day supply (an original order and two refills, even if less than a 30 day supply is dispensed in any fill).
  • If a course of smoking cessation therapy is interrupted, it will be considered one complete course of therapy. Any subsequent prescriptions would then be considered the second course of therapy.
  • Multiple smoking cessation therapies, using different routes of administration, are allowed (e.g., Zyban and nicotine patches may be used concomitantly if warranted). Professional judgment should be exercised when dispensing multiple smoking cessation products.
  • Duplicative use of any one agent is not allowed (i.e., same drug/same dosage form/same strength).
  • For all smoking cessation products, the recipient must have an order. A prescription is the terminology for an order of a prescription product. A fiscal order refers to an order, which looks just like a prescription written on a prescription blank, for an over-the-counter product.


Pharmacy Provider Information

  • Effective September 1, 2004, the use of the Dispensing Validation System (DVS) will no longer be required to process prescriptions/orders for smoking cessation therapy.
  • Claims for smoking cessation therapy will continue to be subject to DUR editing.
  • Prescription nicotine patches will no longer be reimbursed. NYS Medicaid will only reimburse for over-the counter nicotine patches. The following NDCs will no longer be reimbursed:

    00364-2890-30 Nicotine 7mg/24hr patch
    00364-2893-30 Nicotine 14mg/24hr patch
    00364-2901-30 Nicotine 21mg/24hr patch

  • Refills of fiscal orders for these products written prior to September 1, 2004 can be filled and billed using the NDC of the dispensed OTC patches.


The New York State Smokers' Quitline is available to assist your patients free of charge.

NYS SMOKERS' QUITLINE 1-888-609-6292

For more information on the New York State Medicaid Smoking Cessation policy, please call (518) 486-3209. For questions regarding the on-line transmission of a smoking cessation claims, contact CSC at (800) 343-9000.

"Take Time to Care About..."

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The U.S. Food and Drug Administration's (FDA), Office of Women's Health developed the "Take Time To Care Program" in 1998 to disseminate information on subjects that particularly concern women. Since that time, the program has grown from a small grassroots effort into a massive national health campaign that reaches millions of women. The FDA message to women stresses the need to "Take time to care... for yourself...for those who need you".

In collaboration with the American Diabetes Association and other partners, the FDA launched their "Take Time to Care...About Diabetes Campaign" in early 2004. The diabetes materials available include a fact sheet and brochures on diabetes and other comorbid conditions, a medication record booklet, easy recipes and much more. These materials and all of the other "Take Time To Care Program" materials are free and are available in a number of languages.

For free materials and information about the FDA Office of Women's Health: Take Time to Care Program" please go to:

For the Take "Time to Care...About Diabetes Campaign", please go to:

The following fact sheet on diabetes is from the FDA "Take Time to Care...About Diabetes Campaign" and is available on their website.


Women's Health
Take Time To Care ... for yourself ... for those who need you

What is Diabetes?

  • Diabetes changes the way your body uses food. In your body, the food you eat turns to sugar.
  • Your blood takes this sugar all over the body. Insulin helps get sugar from the blood into the body for energy.
  • Your body does not get the fuel it needs, and your blood sugar stays high.
  • High blood sugar can cause heart and kidney problems, blindness, stroke, the loss of a foot or leg, or even kill you.

The Good News ... You Can Manage Diabetes

Watch what you eat and get exercise, use medicines wisely and check your blood sugar.

Types of Diabetes

  • Type 1--The body does not produce any insulin. People with type 1 diabetes must take insulin every day to stay alive.
  • Type 2 --The body does not make enough, or use insulin well. Most people with diabetes have type 2.
  • Some women get diabetes when they are pregnant.

Watch What You Eat and Get Exercise

  • There is no one diet for people with diabetes. Work with your team to come up with a plan for you.
  • You can eat the foods you love by watching serving sizes. Carbohydrates raise your blood sugar the most.
  • The "Nutrition Facts" label on foods can help. Many packaged foods contain more than 1 serving.
  • The foods we eat are made up of:
    • Carbohydrates (fruits, vegetables, breads, juices, milk, cereals and desserts)
    • Fats
    • Protein
    • Cholesterol
    • Fiber (fruits, vegetables, beans, breads, and cereals)
  • Be active at least 30 minutes a day most days of the week.
  • Exercise helps your body's insulin work better. It also lowers your blood sugar, blood pressure and cholesterol.

Use Medicines Wisely

  • Sometimes people with diabetes need to take pills or take a shot (insulin). Be sure to follow the directions.
  • Ask your doctor, nurse or pharmacist what your medicines do, when to take them, and if they have any side effects.

Have your doctor, pharmacist or nurse report serious problems with
medicines or medical devices to the FDA at 1-800-FDA-1088

Check Your Blood Sugar and Know Your ABCs

  • Help prevent heart disease and stroke by controlling your blood sugar, blood pressure, and cholesterol.
  • Make a plan with your doctor, nurse or pharmacist.
  • Check your blood sugar using a meter (home testing kit). This tells what your blood sugar is so you can make wise choices.
  • Ask your doctor for an A-1-C (A-one-see) blood test. It measures blood sugar levels over 2-3 months.
  • Talk to your health team about your ABC's:
    A - 1 - C
    Blood pressure

Women and Diabetes

  • In the U.S., 9.1 million women have diabetes and 3 million of them don't even know it.
  • Women who have diabetes are more likely to have a miscarriage or a baby with birth defects.
  • Women with diabetes are more likely to be poor which makes it harder to manage the disease.

Heart Disease and Stroke

  • Women with diabetes are more likely to have a heart attack and have it at a younger age.
  • Most people with diabetes die from heart attack or stroke.

Are You at Risk for Diabetes?

  • Are you overweight?
  • Do you get little or no exercise?
  • Do you have high blood pressure (130/80 or higher)?
  • Do you have a brother or sister with diabetes?
  • Do you have a parent with diabetes?
  • Are you a woman who had diabetes when you were pregnant OR have you had a baby who weighed more than nine pounds at birth?
  • Are you African American, Native American, Hispanic, or Asian American/Pacific Islander?

If you answered yes to any of these questions, ask your doctor, nurse, or pharmacist if you need a diabetes test.

Warning Signs

  • Going to the bathroom a lot
  • Feeling hungry or thirsty all the time
  • Blurred vision
  • Lose weight without trying
  • Cuts/bruises that are slow to heal
  • Feeling tired all the time
  • Tingling/numbness in the hands or feet

Most people with diabetes do not notice any signs.

This document was developed by FDA's Office of Women's Health (OWH), the National Association of Chain Drug Stores (NACDS), and the American Diabetes Association (ADA). The OWH, NACDS, and the ADA thank all of the participating organizations that have assisted in its reproduction and distribution.


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Missing Issues?
The Medicaid Update, now indexed by subject area, can be accessed online at the New York State Department of Health website:
Hard copies can be obtained upon request by calling (518) 474-9219.

Would You Like Future Updates Emailed To You?
Email your request to our mailbox,
Let us know if you want to continue receiving the hard copy in the mail in addition to the emailed copy.

Do You Suspect Fraud?
If you suspect that a recipient or a provider has engaged in fraudulent activities, please call the fraud hotline at: 1-877-87FRAUD. Your call will remain confidential.

As a Pharmacist, Where Can I Access the List of Medicaid Reimbursable Drugs?
The list of Medicaid reimbursable drugs is available at:

Questions About an Article?
For your convenience each article contains a contact number for further information, questions or comments.

Do You Want Information On Patient Educational Tools and Medicaid's Disease Management Initiatives?
Contact Department staff at (518) 474-9219.

Questions About HIPAA?
Please contact the HIPAA Support Helpline at (800) 522-5518 or (518) 447-9860.

Address Change?
Please contact the Bureau of Medical Review and Payment at:
Fee-for-Service Provider Enrollment Unit, (518) 486-9440
Rate Based Provider Unit, (518) 474-8161

Billing Question? Call Computer Sciences Corporation:
Provider Services (800) 522-5518 or (518) 447-9860.

Comments and Suggestions Regarding This Publication?
Please contact the editor, Timothy Perry-Coon at or via telephone at (518) 474-9219 with your concerns.

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: