DOH Medicaid Update May 2004 Vol. 19, No.5

Office of Medicaid Management
DOH Medicaid Update
May 2004 Vol. 19, No.5

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 our February 6, 2004 letter, the Department will soon re-examine the status of trading partner testing and claims submission as of June 1 to develop the final deadline for submitting HIPAA compliant claims.

For the last few months, Department and Computer Sciences Corporation staff have been working with providers, vendors and provider organizations, offering technical assistance and support for testing and other efforts to achieve HIPAA compliance. We have been monitoring the progress and are encouraged by the aggressive compliance efforts undertaken by many of you. Regardless of the final deadline date, however, please be aware that effective March 2005, only HIPAA-compliant electronic claims will be processed through eMedNY, the new Medicaid system.

A significant number of our trading partners have not registered to test through EDIFECS 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. Further delay may jeopardize your ability to successfully complete testing prior to the final deadline for compliance, which could result in delays in claims processing and payment.

Information on the Medicaid HIPAA testing process is available at

Providers using clearinghouses or service bureaus to submit Medicaid claims should be in close contact with these entities to assure they are proceeding aggressively with HIPAA compliance. We will announce the final compliance deadline in the near future. Providers must take all necessary steps to become HIPAA compliant as soon as possible to avoid any disruption in claims processing and payment flow.

If you have questions regarding this article, please contact the CSC HIPAA Inquiry Unit at (800) 522-5518.

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Paper and Pen Pharmacy

Effective May 1, 2004, the Medicaid program allows multiple drug orders on a single patient specific prescription document, in certain circumstances.

This policy applies only to drugs administered in nursing homes which:

  •   are not controlled substances; and,
  •   are reimbursed by Medicaid outside the facility's all-inclusive Medicaid payment rate (i.e., drugs which are paid on a fee-for-service basis).

The dispensing pharmacist must be employed by or providing services under contract to nursing homes. Pharmacists providing services under contract to nursing homes will no longer be required to obtain separate prescriptions for non-controlled, carve-out drugs in these settings.

The policy for written hard copy follow-up prescriptions for telephone orders and fax orders remains in effect, and all New York State Education Department rules and regulations apply.

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

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We notified you in a letter dated April 1, 2004, that the New York State Medicaid program will soon begin systems enforcement of the requirement that pharmacies bill Medicare first for Medicare-covered drugs before billing Medicaid.

We remind pharmacy providers who have not yet enrolled in Medicare to enroll in Medicare now, to avoid any problems with claims processing and payment.

Medicare enrollment information is available at:

Additional information will be forthcoming in future Update issues and by direct mailing as we move closer to implementation.

This article clarifies payment policy stated in the August and November 2003 editions of the Medicaid Update.

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The August and November 2003 editions of the Medicaid Update included articles about the revision in State policy on the Medicaid program's payment of Medicare coinsurance for Part B services, in the limited number of instances when the Medicaid fee for a service is equal to or higher than the Medicare paid amount.

To reiterate State policy:

  • When the Medicaid fee is equal to or higher than what Medicare pays for a Part B service, the Medicaid program will pay the full coinsurance amount, as indicated in the example below:
    • Medicare Approved    100
    • Medicaid Fee               90
    • Medicare Pays             80
    • Medicare Coinsurance  20
    • Medicaid Pays          $ 20

This revises the previous State policy stated in the August 2003 Medicaid Update, of paying only up to the Medicaid fee in such instances.

This policy does not affect the law reducing the Medicaid coinsurance payment that was passed by the Legislature last May. This law, effective July 1, 2003, requires the Medicaid program to pay 20% of the coinsurance for Medicare Part B services (except psychology, ambulance, and clinic) when the Medicare paid amount is higher than the Medicaid fee.

If you have any questions, please call the Department of Health at (800) 541-2831.


Reimbursement for Drugs on Claims with Medicare
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This article addresses physician billing errors on Medicaid claims that involve Medicare.


For most physician-provided drugs given to a Medicaid recipient who also has Medicare, Medicaid will pay the full coinsurance amount for those drugs after Medicare has approved the claim.


Due to billing errors, many Medicare coinsurance payments to physicians for drugs they administer are being reduced to 20% of the coinsurance liability. These errors became evident after changes were made to our system, pursuant to the legislation that became effective on July 1, 2003 affecting Medicaid payment on claims where Medicare is primary.

Prior to the legislative change, the Medicaid claims payment system simply subtracted the amount Medicare paid from the amount Medicare allowed and paid the full coinsurance.

Resolution of the Problem:

In order to generate a correct payment, the system must compare the Medicare paid amount with the Medicaid fee. The Medicaid fee on file is a single unit fee.

  • If the "Times Performed/Units" field is not properly completed on the claim submission, the amount Medicare paid is compared to a single unit Medicaid fee. If no units appear on the claim, the system defaults to 1. This results in a coinsurance payment reduced to 20% of the full coinsurance liability.
  • When the "Times Performed/Units" field contains the correct number of units, usually the full coinsurance is paid.

Research has revealed that when this error has occurred, the "Times Performed/Units" field is blank on the electronic submission. This may indicate a vendor software problem and should be investigated.

If you think you have been inappropriately paid for physician-provided drugs because of incorrect "Units" you may adjust those claims. For assistance in billing adjustments, contact Computer Sciences Corporation, Provider Relations at (800) 522-5518.

Policy questions regarding this article may be directed to the Bureau of Policy Development and Agency Relations at (518) 473-2160.
Specific payment issues should be addressed to the Bureau of Medical Review and Payment at (518) 474-8161.


Man with Report

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This month's patient educational tool features an article on "The Main Types of Asthma Medications."

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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"Controllers" or Long-Term Control Medication

"Controllers" or long-term control medication is taken to PREVENT asthma attacks.

  1. "Controllers" are taken every day over an extended period of time.
  2. Take your long-term control medication just as your doctor tells you to, EVEN if you are feeling fine to prevent asthma symptoms.

Types of Long-Term Control Medications

  • A. Anti-Inflammatory Medications- prevent and reduce swelling of the airways and buildup of mucous, making breathing easier. Continuous use makes airways less sensitive to asthma triggers.
  • B. Long-Acting Bronchodilators - generally used with inhaled corticosteroids. They relax the muscles around the airways, allowing them to open more fully so you can breathe more freely. They do not act as quickly, but they last longer than "Rescue" or quick-relief medications.
  • C. Methylxanthine Bronchodilators - are used for long-term control of asthma symptoms, especially nighttime symptoms. They help to keep the airways relaxed and open, so breathing is easier.

A. Anti-Inflammatory Long-Term Control Medications

TypeName Sold Under
Inhaled corticosteroids- (steroids) inhaled form
is the anti-inflammatory drug of choice for persistent asthma.
Inhaled non-steroidals that reduce inflammation.INTAL®TILADE® 
Combination of inhaled corticosteroid and
inhaled long-acting bronchodilator.
Leukotriene modifiers-sometimes used
as an alternative to steroids, taken as a pill.

B. Long-Acting Bronchodilators

TypeName Sold Under
Inhaled Long-acting beta2 agonistsSEREVENT®FORADIL®

C. Methylxanthine Bronchodilators

TypeGenericName Sold Under
Alternative bronchodilator, taken orally as a pill or liquid theophyllinetheophyllineTHEODUR®THEOLAIR®

Note: Long-term control medications should never be used to treat sudden symptoms. They cannot act fast enough to provide relief.

"Rescuers" or Quick-Relief Medications

"Rescuers" or quick-relief medications are used DURING an asthma attack or when you first start having asthma symptoms:

Coughing, Wheezing, Shortness of Breath or Tightness in Your Chest

  1. "Rescuers" are inhaled for quick relief; they usually start working within 5-15 minutes.
  2. "Rescuers" or quick-relief medications are bronchodilators. They relax and open (dilate) your airways and make breathing easier.

"Rescuers" or Quick Relief Medications

TypeGenericName Sold Under
Inhaled Short-acting beta2 agonistsalbuterolPROVENTIL®VENTOLIN®

Note: If you find that you are using a quick relief inhaler more than 2 or 3 times per week, this may be a sign that your asthma is not under control. You should tell your doctor.

Systemic Corticosteroids

Systemic Corticosteroids are used to treat severe asthma episodes and prevent recurrence of severe asthma attacks.

  1. Systemic Corticosteroids are usually prescribed on a short-term basis (3-10 days); they start working within 3 hours and work best after 6-12 hours.
  2. Systemic Corticosteroids may be given in a high dose "burst" for a few days and a reduced dose until the end of the course of treatment.

Systemic Corticosteroids

TypeGenericName Sold Under
Systemic corticosteroid- anti-inflammatory
taken orally as a pill or liquid or as an injection.

Note: It is important to take your systemic corticosteroid exactly as your doctor has prescribed, including amount of medication and length of time.

Please note this information is presented for patient education; it is not meant to serve as a recommendation or guideline for treatment. This does not necessarily include all possible treatments for asthma.

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


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This article is a follow-up to the February 2004 Medicaid Update article on "Timely Submission of Claims to Medicaid." Please note the additional information for stop-loss claim billing and claims over two years old.

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 finally 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 Submitted for Stop-Loss Payments:

Claims for stop-loss payment must be finally submitted to the Department, and be payable, within two years from the close of the benefit year in order to be valid and enforceable against the Department. That is, 2002 payable claims must be finally submitted no later than December 31, 2004 with corresponding cutoff for future years.


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

Please 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: for valid coding.


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

As part of the process, those claims will be automatically denied. A denial message (Edit 01292, DOS Two Yrs Prior to Date Received) will appear on the provider's remittance statement. The Department will consider claims over two years old for payment only 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.

Requests for waiver of the regulation regarding submission of claims greater than two years from the date of service must then be received at the address below within 90 days of the release of the Medicaid remittance statement confirming the Edit 01292 denial.

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, notice of eligibility, fair hearing decision, evidence of agency error, etc.) and a copy of the remittance statement documenting an Edit 01292 denial must accompany your written request. Any waiver requests received without the required information will be returned without further processing.

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

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Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid Management Information System (MMIS), announces the following schedule of Introductory Seminars. Topics will include:

  • Overview of MMIS
  • Overview of Billing Options
  • Discussion of Medicaid Managed Care
  • Explanation of Utilization Threshold Program
  • Explanation of 90-day Regulation
  • Overview of HIPAA
  • Explanation of MMIS Provider Manual

Please indicate the seminar you wish to attend below:

*July 7, 2004  10:00 AM
Suffolk County DSS
3085 Veterans Memorial Hwy
Ronkonkoma, NY 11779

*July 13, 2004  10:00 AM or 1:30 PM
Broome County DSS
36-42 Main Street
Binghamton, NY 13905


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

Please complete the following registration information:

Provider Name:____________________________________________Provider ID:________________________

Provider Category of Service:_________________________________Number Attending:___________________

Contact Name:____________________________________________Phone Number:______________________

Please provide the names of all attendees on the lines provided below:



Please register early to attend sites marked with (*) because seating is limited. Each seminar will last approximately two hours.

If there are any questions about these seminars please contact the CSC Call Center at 800-522-5518 or 518-447-9860.

To register, please mail this completed page to:

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

or, fax a copy of the completed page to:     (518) 447-9480

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

Thank you for participating in the New York State Medicaid program.

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Provider/Subject                 Article                Month

All Providers


Care At Home




Disease Management

Durable Medical Equipment

Enteral Formulas

Family Health Plus


Home & Community Based Waiver



Managed Care


Nurse Practitioner

Nursing Home





Private Duty Nursing

Rehabilitation Services

Social Work

Substance Abuse Services

Tobacco Cessation


Happy Man

Prior Authorization Tips For Prescribers...
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When a prescription requires a prior authorization number, an agent of the prescriber (an employee, such as a medical assistant) may complete the prior authorization telephone call and write the prior authorization number on the prescription. The prescriber is not required to do this. Multiple prior authorizations for multiple patients may be obtained and validated with a single telephone call.

Prior Authorization for a Drug: (877) 309-9493
Prior Authorization for an Enteral Formula: (866) 211-1736

The Prior Authorization Voice Interactive Phone System (VIPS) must be used when prescribing the following:

  • Brand-name drugs where an A-rated generic equivalent is available;
  • Second-generation prescription antihistamines;
  • Zyvox;
  • Serostim; and
  • Enteral formula.


The VIPS cannot be used for overriding maximum quantities, overriding age or gender restriction indicators, or prescribing medications not listed on the New York State List of Medicaid Reimbursable Drugs (claims will be rejected or subject to recoupment).

If you have any questions concerning drugs covered by the Medicaid program, please call the Pharmacy Policy and Operations staff at (518) 486-3209. If you have any questions concerning enteral formula, supplies, or DME, please call the Bureau of Medical Review and Payment at (518) 474-8161.

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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:
Call Center (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
(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: