DOH Medicaid Update February 2004 Vol.19, No.2

Office of Medicaid Management
DOH Medicaid Update
February 2004 Vol.19, No.2

State of New York
George E. Pataki, Governor

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

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



Technology

PHARMACISTS:
NEW NURSING HOME
ELIGIBILITY EDITS AND MESSAGING
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New edits have been developed to highlight recipient eligibility messaging. Previously, pharmacy claims for recipients, whose eligibility file designated them as residing in a residential facility, generated an "NH" warning in the message field. Effective January 3, 2004, the NH warning message was replaced with a denial message based on Edit 1493 (Pharmacy Service Included in In-State Facility Rate-Deny), Reject code 85, RX Denial 325.

If a prescription is needed by a patient discharged from a residential facility whose eligibility file still has this "NH" designation, the pharmacist has the option to fill the prescription by overriding these edits. To override the denial message, use the eligibility clarification code of 2 in field 309-C9 in the NCPDP 5.1 billing format. The claim will then pend for up to 30 days (Edit 1316, Reject code 85, RX Response code 310) awaiting the eligibility update.

Please note: If the eligibility update does not occur within the 30 days of claim submission, the claim will be denied for edit 1316 (Pharmacy Service Included in In-State Facility Rate).

It is important to be sure that the patient you are billing for has actually been discharged from a residential facility, as claims billed are subject to denial or recoupment.

For Eligibility Update Issues: Contact the recipient's local social services district.

For Billing Issues: Contact Computer Science Corporation at (800) 343-9000.


MANAGED CARE SPECIAL NEEDS PLANS
EXPANSION OF SERVICE AREAS
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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 code on VeriFone10 characters in eMedNY windowService Area
FidelisCare Healthier Life SNOFFIDELIS SNBronx, Brooklyn, SI, Manhattan, Queens
Healthfirst PHSP Inc SNOHHLTHFST SNBronx, Brooklyn, Manhattan
NYPS Select Health SN OGNYPSSEL SNManhattan, Bronx, Brooklyn
VidaCare Inc. SN ODVIDACARE SNManhattan, Bronx
MetroPlus Partnership in Care Plan SNOMMETROPLUS SNBronx, Brooklyn, Queens, Manhattan

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) FIDELIS
(888) 343-3547
MetroPlus Plan SN
Provider Relations Call Center
(800) 597-3380
  Healthfirst PHSP SN
Provider Relations
(800) 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 SNPs.

Additional Special Needs Plans billing information and exceptions for mental health and chemical dependency providers may be found in the August 2003 Medicaid Update at http://www.health.state.ny.us/health_care/medicaid/program/main.htm.

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


Reminder to All Providers

Time

TIMELY SUBMISSION OF CLAIMS TO MEDICAID
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Medicaid regulations require that claims for payment of medical care, services, or supplies to eligible recipients be initially submitted within 90 days of the date of service to be valid and enforceable, unless the claim is delayed due to circumstances outside the control of the provider. Acceptable reasons for a claim to be submitted beyond 90 days are:

  • Litigation
  • Medicare and other insurance processing delays
  • Delay in Medicaid eligibility determinations
  • Rejection or denial of the original claim for reason(s) other than the 90-days rule
  • Administrative delay in the prior approval process
  • Interrupted maternity care
  • IPRO denial/reversal.

If a claim is denied or returned for correction, it must be corrected and resubmitted within 60 days of the date of notification to the provider. Claims not correctly resubmitted within 60 days, or those continuing to not be payable after the second resubmission, are neither valid nor enforceable. In addition, all claims must be submitted to the fiscal agent and be payable within two years from the date the care, services or supplies were furnished in order to be valid and enforceable against the Department or a social service district.

CLAIMS OVER 90-DAYS OLD, LESS THAN TWO YEARS OLD

All claims initially delayed over 90 days must be submitted within 30 days from the time submission came within control of the provider. For paper claims, a cover letter must be attached which specifies one or more of the acceptable reasons noted above.

Resubmitted paper claim forms should be typed or printed legibly in order to reduce delays in processing. Claim forms including attachment(s) or required documentation may be submitted in batches (50 forms or less) and enclosed in a single envelope or package. The invoice number of each claim form in the batch must be specified on the cover letter.

Please send all paper claims less than two years old directly to:

CSC Healthcare Systems
P.O. Box 4444
Albany, New York 12204-0444

Be sure to send the original claim form and retain a photocopy for your files. Claims submitted via tape, diskette or modem must specify the appropriate late submission reason code. Refer to the MMIS electronic billing instructions issued by the Fiscal Agent or the HIPAA 837 Companion Documents available at: https://www.nyhipaadesk.com, for valid coding.

PROCEDURES FOR REQUESTING A WAIVER OF THE TWO YEAR BILLING REGULATION

Effective January 1, 2003, all claims over two years old MUST INITIALLY be submitted directly to Computer Sciences Corporation within 90 days of the date control was passed to you.

As part of the process, your claim will be denied. A denial message (Edit 01292, DOS Two Yrs Prior to Date Received) will appear on your remittance statement.

Requests for waiver of the regulation regarding submission of claims greater than two years from the date of service must then be submitted to the address below within 90 days of the Edit 01292 denial as noted on the remittance statement:

New York State Department of Health
Bureau of Medical Review and Payment
Two Year Review Unit
150 Broadway, Suite 6E
Albany, New York 12204-2736

Supporting documentation (cover letter of explanation, remittance statements, and notice of eligibility, fair hearing decision, evidence of agency error, etc.) must accompany your written request.

Any waiver requests received without a copy of the remittance statement documenting an Edit 01292 denial will be returned without further processing.

The Department will consider claims over two years old for payment if the provider can produce documentation verifying that the cause of the delay was the result of one or more of the following:

  • Errors by the Department,
  • Errors by a local social services district, or another agent of the Department, or
  • Court-ordered payments.

If you have any questions on the processing, review or disposition of claims over two years old, please call (800) 562-0856, menu #4.


PRESCRIBERS AND PHARMACISTS
CIALIS INFORMATION
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Effective March 1, 2004, Cialis will be added to the List of Medicaid Reimbursable Drugs.

This drug will be subject to the same rules and restrictions currently applied to Viagra and Levitra (note: there is a maximum of 6 tablets every 30 days and prescriptions are limited to an original one-month supply with up to 2 refills). Refer to the November 2003 Medicaid Update (page 11) for specific dispensing instructions and limitations.

The Medicaid Update may be accessed online at the New York State Department of Health website: http://www.health.state.ny.us/health_care/medicaid/program/main.htm

If you have any question please contact the Medicaid Pharmacy Unit at 518-486-3209.


DIAGNOSIS OF OCCUPATIONAL DISEASES
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Many Medicaid recipients may be working in environments that may expose them to harmful substances. This article is provided to assist health care providers in identifying patients whose conditions may be related to their work environment. Because occupational disease is under- recognized,1 failing to consider the workplace factors that may contribute to a patient's condition can result in the ordering of unnecessary tests, inappropriate referrals, and of equal or greater importance, a missed opportunity to protect others who may be at risk. 1,2,3

As time with the patient is limited, there are a few, simple questions that can assist in determining if a condition may be work-related.1 Providers should routinely ask their patients:

  • "What kind of work do you do?"
  • "Are you now or have you previously been exposed to dusts, fumes, chemicals, radiation, or loud noise?"
  • "Are your symptoms better or worse when you are at work?"
  • "Do you think your health problems are related to your work?"

If the replies to these questions rule out the likelihood of a condition being work-related, inquiries along this line can stop. But if something is stated that arouses suspicion, a full occupational health history should be taken.

Self-administered occupational history forms can be an efficient way to obtain this information and are available online at: http://www.atsdr.cdc.gov/HEC/CSEM/exphistory/exphist_form.htm

It should be remembered that many occupational factors act in concert with non-occupational factors to cause disease, so indication of other etiologic factors, such as smoking, does not necessarily rule out a disease as also having an occupational etiologic component. 2 For more information on taking an exposure history, go to: http://www.atsdr.cdc.gov/HEC/CSEM/exphistory/pdffiles/exposure_history.pdf.

If the initial evaluation raises the suspicion that the disease is related to the workplace, providers in New York State can utilize a statewide network of occupational health clinics for consultation and referral: http://www.health.state.ny.us/environmental/workplace/clinic_network.htm. Some diseases, such as occupational lung diseases, pesticide poisonings, and heavy metals poisonings are reportable to the New York State Department of Health (NYSDOH). NYSDOH's authority in statute and regulation enables it to access and obtain this information in accordance with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The NYSDOH provides information to health care providers and their patients, and with a patient's permission, will work with employers to identify and correct hazardous workplace conditions. Patients' interests are always put first and their confidentiality is maintained.

1Newman LS. Occupational Illness. New England Journal of Medicine, 333:1126-1134, 1995.
2Rosenstock L, Cullen MR. Clinical Occupational Medicine. WB Saunders Company, Philadelphia PA, 1986.
3 US DHHS, Agency for Toxic Substances and Disease Registry. Case Studies in Environmental Medicine. Taking an Exposure History. March 2000.

For more information contact Kitty Gelberg, Ph.D., MPH at (866) 807-2130 or e-mail her at khg01@health.state.ny.us.

Lungs

Reminder

Physicians are required, by law, to report suspected cases of occupational lung disease to the New York State Department of Health.
To file a report, call toll free: (866) 807-2130

More information about occupational lung diseases and physician reporting forms can be found at http://www.nyhealth.gov/environmental/workplace/lung_disease_registry/

  


List of
Top 20 DRGs

NOTICE TO NEW YORK STATE
HOSPITALS BILLING DRGs
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The Bureau of Health Economics of the New York State Department of Health has produced a new Diagnosis Related Group (DRG) table for Medicaid payments to New York State hospitals. The new table is effective for discharges beginning January 1, 2004.

Providers may request the table by sending an e-mail request to RBU@health.state.ny.us. Please include "2004 SIW Table" on the subject line of your e-mail.

Annually the Bureau of Health Economics determines the 20 most frequently billed DRGs. When payment for one of these DRGs is indicated, the remittance statement will list rate code 2996 rather than 2946.

Effective discharge date January 1, 2004, the Top 20 DRGs are:

 14      SPECIFIC CEREBROVASC DISORD EXC TIA & INTRACRANIAL HEMORRHAGE
 88      CHRONIC OBSTRUCTIVE PULMONARY DISEASE
 89      SIMPLE PNEUMONIA & PLEURISY AGE >17 W CC
121      CIRCULATORY DISORDERS W AMI & MAJOR COMP, DISCHARGED ALIVE
127      HEART FAILURE & SHOCK
139      CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC
143      CHEST PAIN
183      ESOPHAGITIS, GASTROENT & MISC DIGEST DISORD AGE >17 W/O CC
294      DIABETES AGE >35
296      NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W CC
359      UTERINE & ADNEXA PROC FOR CA IN SITU & NONMALIG W/O CC
371      CESAREAN SECTION W/O CC
372      VAGINAL DELIVERY W COMPLICATING DIAGNOSES
373      VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES
541      RESP DISORD EXC INFECTIONS, BRONCHITIS, ASTHMA W MAJOR CC
629      NEONATE, BWT > 2499G, W/O SIGN OR PROC, W NORM NEWB DIAG
745      OPIOID ABUSE OR DEPENDENCE W/O CC
751      ALCOHOL ABUSE OR DEPENDENCE W/O CC
775      BRONCHITIS & ASTHMA AGE <18 W/O CC
852      PERCUTANEOUS CARDIOVASCULAR PROC W NON-DRUG ELUTING STENT W/O AMI

If you have any questions, please contact the Bureau of Medical Review and Payment, Rate Based Provider Unit, at (518) 474-8161.


PATIENT EDUCATIONAL TOOLS
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Man and Report

   

This month's patient educational tools features an article on "How your Doctor Diagnoses Asthma".

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

   

HOW YOUR DOCTOR DIAGNOSES ASTHMA

Common Symptoms of Asthma

  • Wheeze
        A wheezing sound when you breathe. Sometimes this happens only when you have a cold.
  • Cough
        You may cough up mucus. The cough often comes back and may last longer than one week.
  • Shortness of breath
        Difficulty breathing may happen occasionally or often. It feels like you cannot get enough air into your lungs.
  • Chest tightness
        Your chest may feel tight in cold weather or during exercise. Chest tightness may be one of the signs that your asthma is getting worse.

The asthma symptoms alone are not enough to diagnosis asthma. You must see a doctor who will perform tests to make the correct diagnosis.

How Asthma is Diagnosed

To Diagnose Asthma, the Doctor Will Need to See if Three Criteria Are Met:

  • You have recurring episodes where your airflow becomes blocked (obstructed), resulting in at least one of the above asthma symptoms.
  • The blocked airflow can be at least partially reversed.
  • Other possible diagnoses are ruled out.

What the Doctor Will Do To Determine a Diagnosis of Asthma

Medical History

The Doctor Will:

Evaluate your medical history to identify:

  • What asthma symptoms you have had.
  • When your symptoms occur.
  • How long the symptoms last.
  • If there is a family history of asthma and allergies.

Ask about what triggers your asthma. Asthma triggers are things that irritate your airways and make breathing difficult.

Common Asthma Triggers:

  • Inhaled allergens & irritants
  • Medication
  • Weather
  • Exercise induced asthma symptoms
  • Illnesses such as viral infections
  • Emotions including fear, laughing or crying

Physical Examination

The Doctor Will:

  • Conduct a physical exam that focuses on the upper respiratory tract, chest, and skin.
  • Listen for wheezing during normal breathing.
  • Look for increased nasal secretions and nasal polyps.
  • Look at your skin for eczema and other allergic skin reactions.

Pulmonary (Lung) Function Testing

Spirometry

  • Spirometry is the most reliable test for diagnosing asthma.
  • Spirometry measures the amount and rate of air a person breathes in order to diagnose illness or determine progress in treatment.
  • A spirometer is an instrument that measures the maximum volume of air that you can exhale after breathing in as much as you can. The total volume you exhale is called "forced vital capacity", FVC.
  • The spirometer also measures the volume of air you exhale in the first second. This is called "forced expiratory volume in one second", FEV1.
  • In general, the more air you breath out during the first second of a full exhalation, the better.
  • The doctor may take several spirometry readings to compare your FVC and FEV1. These readings will allow the doctor to determine how much obstruction is in your airways.
  • The doctor may next give you a bronchodilating drug that will relax the muscles of your airways. After the drug has taken effect, spirometry testing will be performed again. If you are able to breathe out significantly more air during the first second that you could before, it indicates that your breathing obstruction is "reversible". This is a strong indication of asthma.

Additional Testing

Your doctor may order additional tests to help rule out other possible causes for your symptoms. These additional tests may include: additional pulmonary function tests; chest x-rays; allergy testing; examination for nasal polyps or sinusitis; and evaluation for gastroesophageal reflux (heartburn).

Remember: If your doctor diagnoses you with asthma, this does not mean you have to stop living a normal life. The good news is that with the right treatment, people with asthma can live with almost no limits to their activities.

Adapted from: Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (Bethesda, MD): National Institutes of Health, National Heart, Lung, and Blood Institute: 1997.

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, contact the Bureau of Program Guidance at (518) 474-9219. 2/04


ENTERAL FORMULA PRIOR AUTHORIZATION
POLICIES AND PROCEDURES FOR DISPENSERS
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BEFORE activating an enteral formula prior authorization, the dispenser must:

  1. Have the formula in stock;
  2. Notify the recipient if you plan to substitute a generically equivalent formula;
  3. Agree to dispense the formula for all refills;
  4. Begin to complete the Dispenser Worksheet:

WHILE activating an enteral formula prior authorization, the dispenser must:

  1. Validate that the caloric unit calculation authorized through the telephone system is correct per the written fiscal order. ( NOTE: once the dispenser activates an authorization, the prescriber cannot cancel it.)
    • Do not activate a prior authorization if the telephone system is reporting an amount less than the written fiscal order. Contact the prescriber to reconcile the prior authorization and written fiscal order. Through the telephone system, the prescriber can cancel a prior authorization that has not been activated and request another with the correct calories per day. The telephone system will then convert calories per day to caloric units per month for the dispenser call.
  2. Validate that the refills on the written fiscal order match the prior authorization.
    • Do not activate a prior authorization if the telephone system is reporting a different number of refills than is written on the fiscal order. Contact the prescriber to reconcile the prior authorization and written fiscal order. Through the telephone system, the prescriber can cancel a prior authorization that has not been activated and enter refills per written fiscal order on a new authorization, or a new written fiscal order can be provided by the prescriber to match the refills on the prior authorization.
  3. If the authorization is correct, answer accordingly on the telephone system and complete theDispenser Worksheet.

AFTER activating an enteral formula authorization, the dispenser must:

  1. Dispense all monthly refills in full as indicated on the written fiscal order for the approved period of service, until the expiration date of the prior authorization.
  2. Only dispense refills requested by the recipient. Further information on refills are available at: http://www.health.state.ny.us/health_care/medicaid/program/2003/sep2003.htm
  3. Bill with the same Prior Authorization Number, Recipient CIN, Provider ID, Category of Service and five or seven digit HCPCS code as entered and reported on the telephone system for the claim to be paid. Refills and caloric units (quantity) cannot exceed what has been authorized on the prior authorization record.

ENTERAL FORMULA PRIOR AUTHORIZATION
DISPENSER WORKSHEET
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ENTERAL PRODUCTS CLASSIFICATION LIST
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Packages

The following list of enteral formulae is provided as a guideline for prescribers and dispensers. This is not an all inclusive list, but it is meant to assist providers in prescribing and determining the correct item code for billing. For products not listed below, providers are to use their judgement in selecting the appropriate product classification based upon the prescriber's order, general categorical descriptions, and Medicaid coverage criteria (see December 2002 Medicaid Update for coverage criteria). Powdered, liquid, fiber-added, calcium-added and high protein forms of the same formula are billed under the same code. Please keep this information in the Enteral Therapy section of your MMIS Provider Manual Italicized products are subject to coverage by the Women, Infants, and Children (WIC) program.

ProductCode
80056 powderB4154
AccupephaB4153
AcerflexB4154
Advantage 10+B4151
Advantage 60+B4151
AdveraB4154
AlimentumB4153
Alitraq PowderB4154
Amin-Aid PowderB4154
Analog formulasB4154
Apple FiberB9998
Aquasol EB9998
ATMFB4150
AttainB4150
BCAD-2B4154
Bio-careB4150
BoostB4150
Boost BreezeB4150
Boost High ProteinB4150
Boost PlusB4152
Boost PuddingB4150
Boost w/FiberB4150
Calcilo XDB4154
Calories PlusB4152
Casec PowderB4155
Choice DMB4154
CompleatB4151
Compleat PediatricB4151
ComplyB4152
Criticare-HNB4153
CrucialB4153
Cyclinex-1B4154
Cyclinex-2B4154
Deliver 2.0B4152
DiabetisourceB4154
Diabetisource ACB4154
DuocalB4154
Egg/Pro PowderB4155
EleCare PowderB4153
Elemental 028 ExtraB4154
ElementraB4155
Enfamil ARB9998
EnliveB4150
Enriched Antioxidant FormulaB4155
EnsureB4150
Ensure HNB4150
Ensure LightB4150
Ensure PlusB4152
Ensure Plus HNB4152
Ensure PuddingB4150
Ensure w/ FiberB4150
EnteraB4150
Entera IsotonicB4150
Entera OPDB4154
Enteralife HNB4150
Enteralife HN-2B4150
Entrition HNB4150
Entrition 1.5B4152
EpulorB4155
Essential Pro PlusB4155
Essential ProteinB4155
FiberlanB4150
FibersourceB4150
Fibersource HNB4150
FlavonexB9998
Forta DrinkB4150
Forta ShakeB4150
FortisonB4150
Gevral ProteinB4155
GlucernaB4154
Glucerna SelectB4154
Gluco-ProB4154
Glutamine-PlainB4155
Glutamine Rapid ReleaseB4155
Glutapak-10 B4155
Glutarex-1 B4154
Glutarex-2B4154
GlutasolveB4155
Glutasorb RTUB4153
GlytrolB4150
Hearty BalanceB4150
Hepatic-Aid Powder IIB4154
Hominex-1B4154
Hominex-2B4154
HOM 1B4155
HOM 2B4155
HPF PlusB4155
Immun-AidB4154
Immune System BoostB4155
ImmunocalB4155
Imu-PlusB4155
ImpactB4154
Impact 1.5B4154
Impact GlutamineB4153
Impact RecoverB4154
IntensiCalB4153
IntroliteB4150
IsocalB4150
Isocal-HNB4150
Isocal HN Plus B4150
Isocal IIB4150
IsofiberB4150
IsolanB4150
Isomil & Isomil DFB4150
IsosourceB4150
Isosource 1.5B4152
Isosource VHNB4154
Isosource-HNB4150
I-Valex-1B4154
I-Valex-2B4154
Jevity 1 CalB4150
Jevity 1.2 CalB4150
Jevity 1.5 CalB4152
JuvenB4155
KetoCalB4151
Ketonex 1B4154
Ketonex 2B4154
KindercalB4150
LactAid tabletsB9998
LactofreeB9998
L-EmentalB4153
L-Emental HepaticB4154
L-Emental PediatricB4153
Lipisorb B4154
LipomulB4155
LofenelacB4154
LonalacB4150
Lorenzo OilB4154
Magnacal RenalB4154
Maxamaid formulasB4154
Maxamum formulasB4154
MCT OilB4155
Meritene PowderB4150
MicrolipidB4155
Moducal PowderB4155
Modulen IBDB4154
MSUD DietB4154
MSUD-1B4154
MSUD-2B4154
NaturiteB4150
Naturite PlusB4152
NeocateB4153
Neocate JuniorB4153
Neocate One +B4153
NeproB4154
Nestle Flavor PacketsB9998
Neutra-PhosB9998
Newtrition B4150
Newtrition HNB4150
Newtrition IsofiberB4150
Newtrition IsotonicB4150
Newtrition 1.5B4152
NitrolanB4150
NovaSource 2.0B4152
NovaSource PulmonaryB4154
Novasource RenalB4154
NuBasicsB4150
NuBasics Juice DrinkB4150
NuBasics PlusB4152
NuBasics VHPB4150
Nutri-DrinkB4150
NutramigenB4150
Nutrassist-1.5B4152
Nutren JuniorB4150
Nutren-1 B4150
Nutren-1.5B4152
Nutren-2B4152
Nutrifocus B4152
NutriHealB4150
NutrihepB4154
NutrilanB4150
NutriRenal B4154
NutriVentB4154
NutriVirB4153
NutriVir NSAB4153
OptimentalB4153
OS 1B4154
OS 2B4154
OsmoliteB4150
Osmolite-HNB4150
Osmolite-HN PlusB4150
Pediatric E028 B4153
PediasureB4150
Pepdite One + B4153
Peptamen B4154
Peptamen 1.5 Diet B4153
Peptamen JrB4154
Peptamen VHPB4154
Peptinex B4153
Peptinex DT B4153
PepticalB4153
PerativeB4154
Periflex B4154
PFD-2 B4155
Phenex 1B4154
Phenex 2B4154
PhenylAde Amino AcidB4155
PhenylAde Drink MixB4154
Phenylfree 1B4154
Phenylfree 2B4154
Phenylfree 2HPB4154
Phlexy-10 CapsulesB4155
Phlexy-10 Drink MixB4155
PKU1B4154
PKU2B4154
PKU3B4154
PolycoseB4155
PortagenB4150
PregestimalB4154
ProBalanceB4150
ProCelB4155
Product 3232AB4155
Profiber B4150
PromixB4155
ProModB4155
PromoteB4150
Propac B4150
Pro-PeptideB4154
Pro-Peptide VHNB4154
Pro-PhreeB4155
Propimex 1 B4154
Propimex 2 B4154
ProSobeeB4151
Pro-Stat B4155
Pro-Stat 101B4155
ProSure B4155
Protain XLB4154
ProvideB4154
ProViMin B4155
PulmocareB4154
ReabilanB4153
Reabilan-HNB4154
ReGain PlusB4154
RenalcalB4154
Re-Neph/Re-Neph Free B4154
Replete B4154
Resource B4150
Resource ArginaidB4155
Resource Arginaid ExtraB4154
Resource DiabeticB4150
Resource DiabetishieldB4150
Resource for Kids B4150
Resource Fruit BeverageB4150
Resource GlutasolveB4155
Resource Instant Protein PowderB4155
Resource PlusB4152
Resource SupportB4150
RespalorB4152
Restore-X B4155
Resurgex B4155
Ross Carbohydrate FreeB4155
Sandosource PeptideB4154
Scandi ShakeB4152
Similac PM 60/40B4154
SLDB4154
SoyProB4155
StressteinB4154
SubdueB4153
Subdue PlusB4153
SumacalB4155
SuplenaB4154
SustacalB4150
Sustacal Pudding4150
Sustagen PowderB4150
Sympt-X GlutamineB4155
Tarvil (paper PA required)B4155
Tolerex B4156
TraumacalB4154
Traum-Aid HBCB4154
Travasorb Hepatic4154
Travasorb-HNB4153
Travasorb-MCTB4154
Travasorb RenalB4154
Travasorb StandardB4156
TwoCal-HNB4152
Tyrex-1 B4154
Tyrex-2B4154
UCD-1 B4154
UCD-2B4154
UltracalB4150
Ultracal HN Plus B4150
UltralanB4152
Ultracare KidsB4154
VHC 2.25 B4152
Vari-Flavors B9998
Vital-HNB4153
VitaneedB4151
Vivonex flavor packetsB9998
Vivonex Pediatric B4153
Vivonex PlusB4154
Vivonex RTFB4153
Vivonex-TENB4154
  • Use code B4100 #Food thickener, administered orally, per ounce for products such as Thick-It, Thick-n-Easy and Thicken-Up. A Dispensing Validation System (DVS) authorization number is required, obtained through the Medicaid Eligibility Verification System (MEVS). (For questions on obtaining a DVS authorization through MEVS, call Computer Sciences Corporation at (800) 343-9000.)
  • Paper prior approval is required for code B9998, when the prescriber orders greater than 2000 calories per day for any combination of formula(s), or over 1000 calories per day for code B4155.

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


Mortar

Revised Pharmacy Billing Procedure for
Compounded Prescriptions
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Currently, the New York State Medicaid program provides reimbursement for compound prescriptions using the NDC code for each ingredient as described in Option 1 -- Billing for Individual Components by NDC Number.

Effective February 18, 2004, a revised method of billing compound prescriptions, Option 2 -- Billing for a Compound as a Single Entity, may be used.

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

Billing Guidelines for Compound Prescriptions

Option 1 -- Billing for Individual Components by NDC Number using NCPDP 3.2 or 5.1

  • This option must be used when billing compounded controlled substances to comply with the Bureau of Controlled Substances standards.
  • Submit claims for compounded prescriptions using the NDC code for each ingredient. These claims are eligible for the Electronic Claim Capture (ECC) option when submitted through the NCPDP format.
  • Each ingredient must have a unique prescription number.
  • For on-line submitted claims, NCPDP Compound Code Field (406-D6) must contain a value of 1.
  • Each drug ingredient payable by New York State Medicaid will be reimbursed at AWP-12% plus a dispensing fee: $3.50 (if a brand drug) or $4.50 (if a generic drug).
  • Each ingredient may impact the patient's utilization threshold.
  • Payment will only be made for NDCs covered on the List of Medicaid Reimbursable Drugs.

OR

Option 2 -- Billing for a Compound as a Single Entity using NCPDP 5.1

  • The entire prescription must have one unique prescription number.
  • For on-line claims capture, Compound Code Field (406-D6) must contain a value of 2.
  • In the Product Service ID Field (407-D7), enter NDC Code of all "9s".
  • In the Product/Service ID Qualifier Field (436-E1) a value of 03 must be entered.
  • A value of 1 must be entered in the Quantity Field.
  • Reimbursement for each compound prescription billed using Option 2 is restricted to the usual and customary price charged to the general public for the total sum of the ingredients, up to the maximum reimbursable amount (MRA) for this option ($50.00), plus a dispensing fee of $3.50 and a compounding fee of $0.75.
  • There is no co-payment assessed using this option.
  • The pharmacy must retain the prescription and documentation of ingredients, amounts and costs.
  • Pharmacy claims for compounds will be reviewed on a regular basis and those found non- compliant with New York State Medicaid policy will be subject to denial and/or recoupment.

Don't Forget

Policy Reminder

  

A compound is considered reimbursable only when the following conditions have been met:

a.) A combination of any two or more legend drugs found on the List of Medicaid Reimbursable Drugs; or
 
b.) A combination of any legend drug(s) included on the List of Medicaid Reimbursable drugs and any other item(s) not commercially available as an ethical or proprietary product, or
 
c.) A combination of two or more products which are labeled: "Caution: For Manufacturing Purpose only."

For example: The combination of Aquaphor® and Hydrocortisone Cream 2.5% is NOT considered a compound.

Reconstitution of a commercially available product is not considered compounding.

If you have any questions or require further information, contact Pharmacy Policy Staff at (518) 486-3209.


Mail Box

Providers! Are You Changing Your Correspondence Address or Pay to Address?
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If you change your address, it is your responsibility to notify the Medicaid program in writing. Keeping your file current will ensure you receive all updates and announcements.

Your request should include your:

  • provider name;
  • provider identification number;
  • category of service;
  • new address;
  • new telephone number; and,
  • provider's signature.

Signature stamps, photocopies, etc., are not acceptable.

Indicate if your new address includes changes to both your correspondence address and pay to address. Mail information to:

Bureau of Enrollment
Office of Medicaid Management
New York State Department of Health
150 Broadway, Suite 6E
Albany, New York 12204-2736

Satellite

LIVE SATELLITE VIDEOCONFERENCE
On

DIABETES PREVENTION

The New York State Diabetes Prevention and Control Program presents:

The Diabetes Epidemic: Preventing the Preventable

Tuesday, March 9, 2004    9:00 - 10:30 AM EST

This live satellite videoconference (presented in collaboration with the University at Albany School of Public Health) will be broadcast free to participating hospitals and organizations.

Who should attend?

Primary care and family physicians, endocrinologists, physician assistants, nurse practitioners, nurses, dietitians, health psychologists, exercise specialists, social workers and other health care professionals who care for people with or at risk for diabetes.

Program Objectives

As a result of viewing this satellite broadcast, participants will be able to:

  • Identify three factors that put patients at high risk for developing type 2 diabetes.
  • Describe three overall behavioral changes that health care providers can discuss with their patients to reduce the transition from impaired glucose tolerance to type 2 diabetes.
  • Identify specific individuals and programs within and outside of your practice environment that can become part of a diabetes prevention team for your patients.
  • Identify three key behavioral strategies that patients can use to get started losing weight.
  • Identify available resources to assist health care providers in meeting clinical practice recommendations for people already diagnosed with diabetes.

Presenters:

  • James Desemone MD, FACE -- Associate Professor of Medicine, Director, Goodman Diabetes Service - Division of Endocrinology and Metabolism, Albany Medical Center
  • Elizabeth Venditti, Ph.D., Director, Lifestyle Resource Core for the Diabetes Prevention Program/Diabetes Prevention Program Outcomes Study, University of Pittsburgh Medical Center and Assistant Professor of Psychiatry, Department of Behavioral Medicine, University of Pittsburgh

Moderator:

  • Benita Zahn -- Television news anchor and Health Reporter for Albany-based NewsChannel 13's Live at 5 and Live at Noon.

Questions and Answers -- Phone in questions toll-free.

Free Continuing Education Credits

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Medical Society of the State of New York (MSSNY) through the joint sponsorship of the School of Public Health, University at Albany, SUNY; Bureau of Chronic Disease Services - Diabetes Prevention and Control Program, NYS Department of Health. The School of Public Health is accredited by the MSSNY to provide continuing medical education (CME) for physicians. The School designates this educational activity for a maximum of 1.5 hours of category one credit towards the AMA/PRA. Each physician should claim only those hours of credit that he/she actually spent in the educational activity.

This Educational Activity is presented by the School of Public Health Continuing Education, which has been approved as a provider of continuing education by the New York State Nurses Associations' Council on Continuing Education, which is accredited by the American Nurses' Credentialing Center's Commission on Accreditation. It has been approved for 1.5 contact hours and has been assigned approval code 54NLRE-PRV-02-067.

  • Continuing education for dietitians pending.
  • CME/CEU awarded at no charge to participants at certified downlink sites.

Registration online: http://www.albany.edu/sph/coned/diabetes.html

Listing of viewing sites available: http://www.albany.edu/sph/coned/sites.pdf


Reminder

You now have the opportunity to receive the Medicaid Update electronically and the benefits are numerous:

  • You will receive the electronic version about 3 weeks earlier than the mailed hardcopy
  • You will be able to disseminate internally via your own e-mail system, and forward to staff articles that are pertinent to your practice.
  • You will have the flexibility to copy, highlight and print articles as needed.

To request the electronic version, just send an email to the Medicaid Update Mailbox at:

Please provide the following information:

  • Name
  • Medicaid Provider ID Number
  • Email address (or multiple addresses, if desired)


The Medicaid Update: Your Window Into The Medicaid Program

The State Department of Health welcomes your comments or suggestions regarding the Medicaid Update.

Please send suggestions to the editor, Timothy Perry-Coon:

NYS Department of Health
Office of Medicaid Management
Bureau of Program Guidance
99 Washington Ave., Suite 720
Albany, NY 12210
(e-mail MedicaidUpdate@health.state.ny.us )

The Medicaid Update, along with past issues of the Medicaid Update, can be accessed online at the New York State Department of Health web site: http://www.health.state.ny.us/health_care/medicaid/program/main.htm

Please Note

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