New York State

May 2007     
Volume 23, Number 5

Medicaid Update

The official newsletter of the New York Medicaid Program

Eliot Spitzer, Governor
State of New York

Richard F. Daines, M.D. Commissioner
New York State Department of Health

Deborah Bachrach, Deputy Commissioner
Office of Health Insurance Programs

 

News for All Providers

National Provider Identifier Implementation: All Providers Need to Take Action!
Every provider in New York's Medicaid Program must register their National Provider Identifier number with eMedNY by May 23, 2007.

Policy and Billing Guidance

Paper Claim Forms No Longer Contain Pre-printed Information
Do you submit paper claims to eMedNY? Identifying information is no longer printed on your claim form--and some providers are submitting claims with no identification number.

Converting to the UB-04 Paper Claim Form
As of May 23, 2007, the UB-92 claim form will no longer be accepted, and will be replaced by the UB-04 claim form.

Drug Utilization Review Override Documentation
The Medicaid Program recommends two methods to document why you override a drug utilization conflict.

Prescription Requirements for Carve Out Drugs
Pharmacists, should be documenting necessary information when dispensing drugs to residents of health care facilities.

Record-Keeping Requirements for Telephone Pharmacy Orders
Prescribers and Pharmacists need to be aware that certain documentation is required when an order for drugs is made via the telephone.

Hospital Prescribing Exemption Update (Revision)
The exemption from the requirement for hospital practitioners to prescribe on official New York State prescriptions will expire on April 19, 2007.

Preferred Drug Program News
Effective May 1, 2007, non-preferred drugs in five categories require prior authorization. Also, an appeal is made to prescribers to judiciously prescribe antibiotics.

Preferred Drug List
Print this seven page guide to New York's list of preferred drugs.

Mandatory Generic Drug Program Update
Prescriptions for the brand name drugs Adoxa and Estraderm, made after June 1, 2007, require prior authorization before they can be dispensed.

Your Provider Manual is Online
Providers should check on a monthly basis to ensure they are current with latest policy information.

You Must Bill Medicare First!
Advisory of a new edit coming into effect on July 2, 2007 when a pharmacist bills for supplies provided to a Medicaid enrollee who is also enrolled in Medicare.

Certified Home Health Agency - Medicaid Rate for Shared Home Health Aide
Clarification of the use of Medicaid rate code 2499 for home health aides who provide short home visits within close proximity of each other.

Revised List of CPT-4 Family Planning Codes
Clinic, practitioner and laboratory providers are advised of new Family Planning Benefit Program codes, to be used on or after May 17, 2007.

Medicare Coinsurance Claim Adjustments
Claims for services provided to Medicaid enrollees dually eligible for Medicare that were inappropriately paid at reduced coinsurance amounts will be automatically reprocessed.

General Information

Hospice Coverage Under Medicaid
A description of Medicaid hospice services and eligibility for the program.

What You Should Know about 1099 Forms: Impact on Group Providers
Do you belong to a group practice? Be sure that payments are claimed correctly, so that year-end 1099 amounts accrue properly.

Electronic Funds Transfer: The EFT Advantage
Get your payments faster and reliably through an electronic funds transfer.

Would You Like to Receive your Prior Approval Rosters Electronically?
Benefits of using the eMedNY eXchange.

Save the Date: "Planning Today for Tomorrow"
Announcing a symposium offered on June 21, 2007 where attendees can discuss Long Term Care restructuring activities and discuss plans for the future of Long Term Care in New York State.

DOH Toll-Free Helplines
Do you have a question that can only be answered by the Health Department? This guide contains contact numbers for various programs operated by the DOH.

Provider Services

 

Caduceus


National Provider Identifier Implementation
Return to Table of Contents

Urgent

You are required to register your National Provider Identifier(s) (NPI) with the corresponding MMIS Provider identification number(s) in the Department's NPI Registration System!

As of March 31, 2007, only 13% of New York's Medicaid providers have registered their NPI(s). To be ready for implementation, 100% registration is required before the mandated date of May 23, 2007.

If you have not yet registered your NPI, please visit:

https://npi.emedny.org/

To obtain an NPI, please visit:

www.cms.hhs.gov/NationalProvIdentStand

The actual NPI implementation target date is not known at this point, but will be communicated in a future Medicaid Update article.

The Department requires the MMIS Identification Numbers and/or License Numbers, when applicable, until the NPI system is implemented.

If you utilize a vendor in submitting electronic transactions to New York Medicaid, you should make sure they are aware of this condition.

Questions? Contact the eMedNY Call Center at:
(800) 343-9000.


Man

Editor's note...
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If you have any comments or suggestions about the new format of the Medicaid Update, please send an email to us at:

medicaidupdate@health.state.ny.us


Important
Information!
For Providers Who Submit Paper Claim Forms

PAPER CLAIM FORMS
No Longer Contain Pre-printed Information
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As you were previously notified, on March 1, 2007 Computer Sciences Corporation (CSC) stopped pre-printing the following paper claim forms with the Provider's Identification Number, Name and Address:

  • Claim Form A -- for Dentists and Transportation Providers;
  • Pharmacy Claim Form -- for Pharmacy Providers; and
  • HCFA-1500 Claim Form -- for Chiropractor, Clinical Psychology, Clinical Social Worker, Durable Medical Equipment, Hearing Aid, Laboratory, Midwife, Nurse Practitioner, Physician, Podiatry, Private Duty Nursing and Vision Care providers.

Since March 1, 2007, CSC has received claim forms with no identifying information for the provider. In some cases, even the envelope in which the claim forms were sent had no return address.

PLEASE NOTE: without identifying information for the provider, CSC cannot process the claim forms nor can CSC return the claim forms to the providers.

It is imperative that providers examine the paper claim forms they are submitting to make sure the Provider Information is complete. Without this information, claims cannot be processed or returned. This means that there will be no record of the claims in the eMedNY system nor will a remittance statement be issued.

Questions? Please call the eMedNY Call Center at (800) 343-9000.


Paper airplane

Do you Receive the Medicaid Update Electronically?
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Send an email to MedicaidUpdate@health.state.ny.us to get on our email list.


Important Information!
For Institutional Providers
Who Submit the UB-92 Paper Claim Form

Converting to the UB-04
Paper Claim Form
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As of May 23, 2007, Computer Sciences Corporation (CSC) will discontinue processing the UB-92 paper claim form.

Any UB-92 claim form submitted on or after May 23, 2007 will be returned to the provider

On May 23, 2007:

  • Only UB-04 forms will be accepted for Institutional rate-based claims. (Hospital Inpatient, Outpatient and Free-standing Clinic providers cannot use a paper claim; you must continue to submit all claims electronically);
  • CSC now accepts and processes the UB-04 claim form.
  • UB-04 forms must be obtained from national vendors.
  • Specific billing instructions for the UB-04 claim form are posted in the Billing Guidelines section of your Provider Manual, at:

http://www.emedny.org/ProviderManuals/index.html

The UB-92 billing guidelines will be available at the same website until on or around May 22, 2007, and then removed.

New Requirement for UB-04 Submitters

Providers who submit only paper UB-04 forms will need to make sure they have an active Electronic/Paper Transmitter Identification Number (ETIN) on file with CSC before submitting the UB-04 form, or the claim will be denied.

If you are a provider who already submits claims electronically, including via ePACES, you already have an active ETIN on file and no additional ETIN is necessary. If you are a provider with multiple provider ID numbers, each ID for which you submit a UB-04 form must have a valid ETIN on file.

The ETIN Application and associated Certification Statement required to obtain an ETIN can also be found on the eMedNY website at:

http://www.emedny.org/info/ProviderEnrollment/index.html

Questions about billing on the UB-04 claim form? Need to verify if you have an active ETIN on file with CSC?
Please call the eMedNY Call Center at:
(800) 343-9000.


Pills

Drug Utilization Review
Override Documentation
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If a pharmacist overrides a rejected Drug Utilization Review (DUR) conflict, especially if consulting with the prescriber, it is recommended that:

  • the pharmacist write the date, reason for override, and his/her signature or initials on the back of the prescription; or
  • if the software permits, comment and electronically store the reason for the override in the patient profile for the specific prescription filled.

You may be asked to provide documentation as part of ongoing program integrity activities.

     

Questions? Please contact the Bureau of Pharmacy Policy and Operations at: (518) 486-3209.


Attention
Pharmacists

Prescription Requirements for
"Carve Out" Drugs
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Drugs carved out of residential health care facilities' inclusive Medicaid rates and billed directly to Medicaid, are subject to Medicaid prescription requirements, as well as State and federal prescription requirements. These requirements include refill, quantity and prior authorization and prior approval, as described in the Policy Guidelines Pharmacy Provider Manual at:

http://www.emedny.org/ProviderManuals/Pharmacy/PDFS/Pharmacy-Policy_section.pdf

Pharmacy claims must be supported by appropriate prescription documentation and/or prescription information. Specifically, there must be a prescription or fiscal order on file, as well as all information necessary on a prescription to support the claim (i.e. quantity, directions).

Failure to comply with policy and regulation may result in disallowances and/or sanctions imposed on the provider.

Questions? Please call the Office of the Medicaid Inspector General, Bureau of Medicaid Audit at:
(518) 474-9747.


Attention
Pharmacists and Prescribers

Record-Keeping Requirements for Telephone Orders
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Phone

The Office of the Medicaid Inspector General's (OMIG) Bureau of Medicaid Audit performs pharmacy audits to ensure overall compliance with Medicaid regulations.

The increasing practice of using pharmacy computer generated labels as the only prescription documentation on file may not meet Medicaid compliance regulations.

This practice becomes a noncompliance issue with Medicaid regulation (at Title 18 NYCRR (New York Code of rule and Regulation) Section 505.3 (b)) when, due to a lack of information on these labels, auditors are unable to determine:

  1. whether the labels represent documentation for a telephone order;
  2. whether the labels represent unauthorized automatic regeneration; or
  3. whether the signed written order from a qualified prescriber is missing.

Medicaid regulation 18 NYCRR Section 505.3(b)(5) requires that a telephone order must be recorded by the pharmacy in the format required by subdivision (4) of Section 6810 of the Education Law, recording:

  • the time of the call; and,
  • the initials of the person(s) taking the call and the dispenser, prior to dispensing the drug.

Medicaid policy requires that the format used to record the telephone order must conform to requirements of the NYS Education Law with regard to permitting substitution or dispensing as ordered. This information is included in the Pharmacy Provider Manual, online at:

http://www.emedny.org/ProviderManuals/Pharmacy/index.html

  • Prescribers must document, in the patient record, support for prescriptions and oral orders [18 NYCRR 505.3(c)],
  • Pharmacists must assure the accuracy of information contained on Medicaid pharmacy claims, particularly prescriber information.

Failure to comply with policy and regulation may result in disallowances and/or sanctions imposed on the provider.

Questions? Please call the Office of the Medicaid Inspector General, Bureau of Medicaid Audit at:
(518) 474-9747.


Hospital Prescribing Exemption Update
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The exemption from the requirement for hospital practitioners to prescribe on official New York State prescriptions will expire on April 19, 2007 for those hospitals that have not implemented:

  1. An electronic prescription system to transmit prescriptions from a computer to a pharmacy computer or fax machine; or
  2. A computerized provider order entry system that generates printed prescriptions.

In those facilities that have not implemented one of the above systems, all written prescriptions-for both controlled and non-controlled substances-must be issued on an official New York State prescription after April 19, 2007.

Prescribing Exemption Continues

The prescribing exemption will continue after April 19, 2007 for those hospitals and their affiliated clinics and health services that have implemented an electronic prescription system to transmit prescriptions to pharmacies capable of receiving them.

The exemption will also continue after April 19, 2007 for those facilities that have implemented a computerized provider order entry system that generates printed prescriptions.

Such facilities must first be approved by the Department of Health for the prescribing exemption to continue.

Pharmacists can access a listing of facilities that have been approved for the prescribing exemption online at: http://www.nyhealth.gov/professionals/narcotic or by calling the Bureau of Narcotic Enforcement at: 1-866-811-7957.

Prescriptions Issued Under the Prescribing Exemption

Facilities that have been approved for the prescribing exemption may issue prescriptions for non-controlled substances on the prescription form of the facility. In the near future, the Department of Health will issue secure serialized authentication labels to these facilities. Prescribers in approved facilities must then affix such labels to all prescriptions for non-controlled substances that are issued on the prescription form of the facility.

Important Note: The prescribing exemption applies only to the prescribing of non-controlled substances. Written prescriptions for controlled substances must be issued on an official New York State prescription.


Preferred Drug Program News
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Pills

Expansion of the Preferred Drug Program

The Medicaid Preferred Drug Program (PDP) is expanding to include additional drug classes.

Prescriptions written on or after May 1, 2007, for non-preferred drugs in the following drug categories, will require prior authorization:

  • Cholesterol Absorption Inhibitors;
  • Immunomodulators (injectable);
  • Ophthalmic Antihistamines;
  • Ophthalmic Quinolones; and
  • Otic Quinolones.

Prescribers are required to complete the prior authorization process before prescribing non-preferred drugs. To obtain prior authorization for a non-preferred drug, contact the Clinical Call Center at (877) 309-9493 and follow the appropriate prompts.

The current Preferred Drug List is available online at:

https://newyork.fhsc.com/providers/PDP_about.asp

Antibacterial Resistance and the Judicious Use of Antibiotics

To help reduce the appearance and spread of antibiotic resistance, prescribers are encouraged to:

  • be familiar with local data on resistance,
  • prescribe antibiotics that target only a narrow range of bacteria, and,
  • reserve broad spectrum antibiotics as second line therapy.

For more information on antibiotic use and resistance, please refer to the Centers for Disease Control and Prevention website at:

http://www.cdc.gov/drugresistance/

For clinical concerns or preferred drug program questions, contact (877) 309-9493.

For billing questions, contact (800) 343-9000.

For Medicaid pharmacy policy and operations questions, call (518) 486-3209.


New York State Medicaid
Preferred Drug List

All non-preferred drugs in these classes will require prior authorization.
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ACE InhibitorsACE Inhibitors
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 6/28/06
Altace®
benazepril
captopril
enalapril maleate
lisinopril
Mavik®
moexipril
Accupril®
Aceon®
Capoten®
fosinopril sodium
Lotensin®
Monopril®
Prinivil®
quinaprill
Univasc®
Vasotec®
Zestril®
ACE Inhibitors + Calcium Channel BlockerACE Inhibitors + Calcium Channel Blocker
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 6/28/06
Lotrel ®
Tarka®
Lexxel®
ACE Inhibitors + DiureticAce Inhibitors + Diuretic
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 6/28/06
benazepril/HCTZ
captopril/HCTZ
enalapril maleate/HCTZ
lisinopril/HCTZ
Unieretic®
Accuretic®
Capozide®
fosinopril HTC
Lotensin HCT®
Monopril HCT®
Prinzide®
quinapril/HCTZ
Quinaretic®
Vaseretic®
Zestoretic®
Angiotensin Receptor Blockers Angiotensin Receptor Blockers
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 6/28/06
Benicar®®
Cozaar®
Diovan®
Micardis ®
Atacand®
Avapro®
Teveten®
Angiotensin Receptor Blocker + DiureticAngiotensin Receptor Blocker + Diuretic
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 6/28/06
Benicar HTC®
Diovan HTC®
Hyzaar®
Micardis HCT®
Atacand HCT®
Avalide®
Teveten HCT®
Anti-Emetics - OralAnti-Emetics - Oral
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Kytril®(tablet, solution)
Zofran®(tablet, solution, ODT)
Anzemet®
Anti-FungalsAnti-Fungals
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Fulvicin U/F®
Grifulvin V® (tablet)
Gris-PEG®
griseofulvin (suspension)
Lamisil®
Grifulvin V® (suspension)
itraconazole (capsule)
Penlac®
Sporanox® (capsule, solution)
Antihistamines - Second Generation Antihistamines - Second Generation CC
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
OTC loratadine
OTC loratadine-D
Allegra® (tablet, capsule, suspension)
fexofenadine
Allegra-D®
Clarinex®
Clarinex-D®
Semprex-D®
Zyrtec®CC
Zyrtec-D®
Anti-Virals Anti-ViralsCC
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
acyclovir (tablet, capsule, suspension)
Famvir®
Valtrex®
Zovirax® (tablet, capsule, suspension)
Beta BlockersBeta Blockers CC
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 6/28/06
acebutolol
atenolol
betaxolol
bisoprolol funerate
labetalol
metoprolol tartrate
nadolol
pindolol
propranolol
timolol maleate
Blocadren®
Coreg®CC
Coreg CR®CC
Corgard®
Inderal LA®
Inderal®
InnoPran XL®
Kerlone®
Levatol®
Lopressor®
Sectral®
Tenormin®
Toprol XL®CC
Trandate®
Zebeta®
Beta Blocker + DiureticBeta Blocker + Diuretic
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
atenolol/chlorthalidone
bisoprolol funerate/HCTZ
metoprolol tartrate/HCTZ
propranolol/HCTZ
Corzide®
Inderide®
Inderide LA®
Lopressor HCT®
Tenoretic®
Timolide®
Ziac®
Bisphosphonates - OralBisphosphonates - Oral
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 6/28/06
Fosamax®(tablet, solution)
Fosamax®Plus D
Actonel®
Actonel®with Calcium
Boniva®
Calcitonins - NasalCalcitonins - Nasal
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Miacalcin® Fortical®
Calcium Channel Blockers (DHP)Calcium Channel Blockers (DHP)
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 6/28/06
Afeditab CR®
Dynacirc ®
Dynacirc CR®
felodipine ER
isradipine
nicardipine HCL
Nifediac CC®
Nifedical XL®
nifedipine
nifedipine ER
nifedipine SA
Norvasc®
Sular®
Adalat CC®
Cardene®
Cardene SR®
Plendil®
Procardia®
Procardia XL®
Cephalosporins - Third GenerationCephalosporins - Third Generation
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Cedax®(capsule, suspension)
cefpodoxime proxetil (tablet)
Omnicaf®(capsule, suspension)
Suprax®
Spectracef®
Vantin® (tablet, suspension)
Cholesterol Absorbtion Inhibitors (CAIs)Cholestrol Absorption Inhibitors (CAIs)
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Zetia®None
Fluoroquinolones (Oral)Fluoroquinolones (Oral)
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Avelox®
Avelox ABC Pack®
ciprofloxacin (tablet, suspension)
ofloxacin
Cipro® (tablet, suspension)
Cipro XR®
Factive®
Floxin®
Levaquin® (tablet, suspension)
Maxaquin®
Noroxin®
Proquin XR®
Tequin®
Hepatitis C AgentsHepatitis C Agents
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
PEG-Intron®
PEG-Intron Redipen®
Pegasys®
Pegasys Convenience Pack®
None
HMG-CoA Reductase Inhibitors (Statins)HMG-CoA Reductase Inhibitors (Statins)
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Advicor®
Altoprev®
Crestor®
Lescol®
Lescol XL
Lipitor®
Vytorin®
Zocor®
Caduet®
lovastatin
Mevacor®
Pravachol®
prevastatin
PravigardPAC®
Immunomodulators (Injectable)Immunomodulators (Injectible)
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Enbrel®
Humera®
Kineret®
Immunomodulators (Topical)Immunomodulators (Topical)
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Elidel®
Protopic®
None
Inhaled AnticholinergicsInhaled Anticholinergics
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Atrovent®
Atrovent HFA®
Combivent®
ipratropium
Spiriva®
Duoneb®
Inhaled beta2Adrenergic Agents - Long ActingInhaled beta2Adrenergic Agents - Long Acting
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Foradil®
Serevent Diskus®
None
Inhaled beta2Adrenergic Agents - Short ActingInhaled beta2Adrenergic Agents - Short Acting
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
albuterol
Maxair Autohaler®
Proventil HFA®
Ventolin HFA®
Xopenex®
Xopenex HFA®
Accuneb®
Alupent®
metaproterenol
ProAir HFA®
Proventil®
Inhaled CorticosteroidsInhaled Corticosteroids
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Advair Diskus®
Advair HFA®
Asmanex®
Azmacort®
Flovent HFA®
Qvar®
Aerobid®
Aerobid-M®
Pulmicort Turbuhaler®CC
Leukotriene ModifiersLeukotriene Modifiers
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Accolate®
Singular®
None
Narcotics - Long ActingNarcotics - Long Acting
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Duragesic®
fentanyl patch
Kadian®
morphine sulfate SR
Oramorph SR®
Avinza®
MS Contin®
Opana ER®
oxycodone HCL CR
Oxycontin®
Ophthalmic AntihistaminesOphthalmic Antihistamines
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Patanol®Elestat®
Emadine®
ketotifen®
Optivar®
Zaditor®
Ophthalmic QuinolonesOphthalmic Quinolones
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
ciprofloxacin
ofloxacin
Vigamox®
Ciloxan®(solution, ointment)
Ocuflox®
Quixin®
Zymar®
Otic QuinolonesOtic Quinolones
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Ciprodex®
Floxin®
Cipro HC®
Phosphate Binders/RegulatorsPhosphate Binders/Regulators
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Fosrenol®
Phoslo
Renagel®
None
Proton Pump InhibitorsProton Pump Inhibitors
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Nexium®
Prevacid®(capsule)
Prilosec®OTC
Aciphex®
omeprazole
Prevacid
NapraPAC®
Prevacid® (solutab, suspension)
Prilosec®
Protonix®
Zegerid® (capsule, packet)
Sedative Hypnotics/Sleep AgentsSedative Hypnotics/Sleep Agents
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Ambien CR®
chloral hydrate
estazolam
flurazepam
temazepam
triazolam
Ambien®
Dalmane®
Doral®
Halcion®
Lunesta®
Prosom®
Restoril®
Rozerem®
Somnote®
Sonta®
Serotonin Receptor Agonists (Triptans)Serotonin Receptor Agonists (Triptans)
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Imitrex®(tablet, nasal, injection)
Maxalt®(tablet, MLT)
Amerge®
Axert®
Frova®
Relpax®
Zomig® (tablet, nasal, ZMT)
Steroids - IntranasalSteroids - Intranasal
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Nasacort AQ®
Nasonex®
Beconase AQ®
Flonase®
flunisolide®
fluticasone®
Nasarel®
Rhinacort Aqua®
ThiazolidinedionesThiazolidinediones
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Actos®
Actoplus met®
Avandia®
Avandamet®
Avandaryl
Duetact®
Triglyceride Lowering AgentsTriglyceride Lowering Agents
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
gemfibrozil
Lofirba®
Antara®
fenofibrate®
Lopid®
Omacor®
Tricor
Triglide

Mandatory Generic Drug Program Update
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Pills

The New York State Medicaid Mandatory Generic Drug Program requires prior authorization for brand-name prescriptions with an A-rated generic equivalent.

Effective June 1, 2007, new prescriptions for the brand-name drugs below will require prior authorization.

ADOXA PAK TABLETLOESTRIN 21 1.5/30 TABLET
ESTRADERM 0.05 MG, 0.1MG PATCHZONEGRAN 25 MG CAPSULE

Prescriptions written prior to June 1, 2007, but filled on or after June 1, 2007, including refills, will not require prior authorization. When the current prescription expires, however, a prior authorization will be required for the patient to continue to receive the brand-name drug.

NOTE: Brand-name drugs that are on the Medicaid Preferred Drug List do not require prior authorization and are not subject to the Medicaid Mandatory Generic Program prior authorization requirements.


Dot

Your Provider Manual is Online!
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As a provider, it is your responsibility to check and update your provider manual on a monthly basis to ensure you are current with the latest policy information.

Provider manuals are available online at

http://www.emedny.org/ProviderManuals/index.html

To receive a hard copy of your Manual, if you do not have access to the internet, you must contact Computer Sciences Corporation at:

(800) 343-9000.


Attention
Pharmacy Providers

Edit 152 message:

Recipient file Indicates Medicare/No. Medicare Present [i.e., while the enrollee has Medicare coverage, you have not entered any information on your claim regarding Medicare payment.]

You Must Bill Medicare First!
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For an enrollee with both Medicare and Medicaid coverage, all charges for Medicare covered drugs and supplies must be billed to Medicare first.

New Claim Edit for Pharmacies

Effective July 2, 2007, Medicaid will implement claims processing Edit 152 for supplies, to ensure that Medicaid is billed as a last resort when an enrollee is both Medicare/Medicaid dually eligible (dual eligibles) and the drug or supply is covered by Medicare.

Drugs will be added in the near future; providers will be notified through the Medicaid Update.

Billing for Medicare/Medicaid Dual Eligibles

Papers

Pharmacies must be enrolled in Medicare in order to bill Medicaid for drugs or supplies provided to dually eligible enrollees. Pharmacies must indicate the Medicare paid amount on the submitted Medicaid claim or payment will be denied.

Pharmacies not enrolled in Medicare and attempting to bill Medicaid for drugs and supplies for dual eligibles will not be paid.

Information on Medicare enrollment can be found at: http://www.cms.hhs.gov

For billing questions, please call Computer Sciences Corporation at:
(800) 343-9000.

For information on pharmacy policy, please call the Bureau of Pharmacy Policy and Operations at:
(518) 486-3209.


Fraud impacts all taxpayers.
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Do you suspect that a recipient or a provider has engaged in fraudulent activities?

Please call:

1-877-87FRAUD

Your call will remain confidential.

You can also complete a Complaint Form available at: www.omig.state.ny.us.


CERTIFIED HOME HEALTH AGENCY
MEDICAID RATE FOR SHARED HOME HEALTH AIDE
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The purpose of this article is to clarify the use of the Medicaid rate code for shared home health aide (2499) established for all Certified Home Health Agencies (CHHA) in 1995.

Shared home health aide is a method of providing home health aide services to individuals in need of home health aide services who are located within geographic proximity to one another.

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  • Geographic proximity of individuals is defined as two or more individuals, related or unrelated, residing in the same household, apartment complex or adult home.

New York State regulation (18 NYCRR 505.23(b)(3)) requires that a CHHA must consider whether the functional needs, living arrangements and working arrangements of an individual are such that the individual can be maintained appropriately by home health services provided by shared home health aides. Shared home health aide should be used for individuals residing in close geographic proximity who are capable of being maintained by short visits to each individual.

The shared home health aide rate code 2499 is billable in quarter hourly increments/ units with a rate established to be one-fourth of the hourly rate in a CHHA for a home health aide. For those CHHAs that have retained a per visit rate for home health aide, the shared home health aide rate is equated to a quarter hourly rate instead of one fourth of the per visit rate.

When completing a claim for shared home health aide services, rate code 2499 is used. The number of units claimed is the total number of 15 minute interments of time spent by the shared home health aide with the Medicaid recipient.

For example:

A shared home health aide is providing services intermittently over a 6.5 hour span of time to three individuals in the same apartment complex and may visit each individual 2-3 times during the day. The aide spends an overall total of an hour and 15 minutes with individual A, an overall total of 2 hours and 45 minutes with individual B, and an overall total of 2 hours and 30 minutes with individual C providing care. The claim for individual A is submitted for 5 units of rate code 2499, the claim for individual B is submitted for 11 units of rate code 2499, and the claim for individual C is submitted for 10 units of rate code 2499. The total of the three claims equals 26 units or 6.5 hours of shared aide time.

Questions? Please contact the Bureau of Long Term Care at:
(518) 474-6580.


Attention
Providers Who Render Family Planning Services to Enrollees Eligible for the Family Planning Benefit Program Only

Revised List of CPT-4
Family Planning Codes
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The Centers for Medicare and Medicaid Services (CMS) has mandated that Medicaid ensure that all Family Planning Benefit Program (FPBP) claims submitted for payment are limited to family planning services.

The February 2007 Medicaid Update advised family planning providers that effective May 17, 2007, all claims processed for FPBP recipients must contain a family planning procedure code from the approved list that was published in that article. The implementation date for the claims processing procedure code editing has been moved to July 1, 2007.

All clinic, practitioner, and laboratory claims for FPBP enrollees processed on or after July 1, 2007, must contain a family planning procedure code from the revised procedure code list on the following page.

In addition, the primary diagnosis code must be in the V25 (contraceptive management) series.

Clinic claims must include both the rate code and a corresponding family planning procedure code(s). Therefore, all claims submitted for FPBP enrollees must contain:

  • A "Y" in the family planning box.
  • A primary diagnosis code in the V25 series (contraceptive management), and;
  • The appropriate code for the procedure or procedures performed, from the revised list below, of approved family planning services or medical supplies.

Claims for an FPBP enrollee processed on or after July 1, 2007 will be denied if the above information is not on the claim form.

The following list was revised because some of the previously listed CPT-4 codes are inactive for Medicaid reimbursement, or are not family planning. These inactive codes can usually be reported under another CPT-4 code on the list. This list contains the family planning codes approved by CMS as eligible for reimbursement under the Family Planning Benefit Program.

The codes deleted from the previously published list in the February 2007 Medicaid Update article are:

8743088155
8753693041
87850Z2351
88154 

    

APPROVED CODES FOR SERVICES UNDER THE FAMILY PLANNING BENEFIT PROGRAM MAY 2007 LIST

1197581007870818759199070A4268
1197681025870868780099201J1055
1197782465871028814199202J1056
5525084703871108814299203J7300
5545085013872058814799204J7302
5830085014872078814899205J7303
5830185025872108815099211J7304
5856586592872528815399212T5999
5860086593872548816099213 
5861586631872708816299214 
5867086689872738816499215 
5867186696872748816599241 
7101086701873208817499242 
7101586702873908817599243 
8100086703874908932199244 
8100186762874919300099245 
81002867818753593010A4266 
81003870708759093040A4267 

Remember, this requirement will affect claims processed by Medicaid on or after July 1, 2007.

Questions? Please contact the Bureau of Policy Development and Agency Relations at: (518) 473-2160.


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Medicare Coinsurance
Claim Adjustments
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For dates of service on and after April 1, 2005, some claims for services provided to enrollees dually eligible for both Medicaid and Medicare were inappropriately paid at reduced coinsurance amounts.

The affected claims were for care and services covered by Medicare, but not covered for enrollees with Medicaid as their only coverage.

In mid-May, all claims for services that fit the criteria will be automatically reprocessed by Medicaid and additional monies will be paid to providers.

Questions? Please contact the Bureau of Policy Development and Agency Relations at: (518) 473-2160.


Hospice Coverage under Medicaid
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Description of Program

Hospice is a coordinated program of home and inpatient care which treats a terminally ill individual and family as a unit, employing an interdisciplinary team acting under the direction of an autonomous hospice administration.

Caduceus

The program provides the individual and family with palliative and supportive care to meet the special needs arising out of physical, psychological, spiritual, social and economic stresses which are experienced during the final stages of illness, and during dying and bereavement.

Services Included in Hospice

Hospice care may be provided by a hospice agency certified under Article 40 of the Public Health Law and approved by Medicare. Services may be provided in the home, a nursing home, assisted living facility, free standing hospice, hospital or a hospice residence.

Services must be provided according to a written plan of care and are focused on easing the symptoms rather than curing the disease. The individual and family receive medical, psychological and social services, and bereavement and pastoral care related to the individual's terminal diagnosis.

Hospice includes the following services as the needs of the patient dictate:

  • Nursing, Physician,
  • Physical Therapy,
  • Occupational Therapy,
  • Speech and Language Pathology,
  • Medical Supplies and Equipment,
  • Home Health Aide and Homemaker,
  • Bereavement,
  • Pastoral Care,
  • Pharmaceutical/Laboratory,
  • Social Work,
  • Nutrition,
  • Psychological,
  • Audiology, and
  • Respiratory therapy.

Eligibility

In order to be eligible for Hospice, the individual's physician and the hospice medical director or designee must certify the individual as having a terminal illness (a medical prognosis for a life expectancy of six months or less if the illness runs its normal course).

Individuals choosing hospice must voluntarily choose to receive hospice care which precludes usage of other Medicare or Medicaid services for terminal illness and related conditions.

Individuals have the ability to rescind this choice and subsequently reapply for hospice benefits at a later date.

Medicaid Coverage

The hospice benefit, as required by federal regulation, includes all services necessary to meet the needs of the patient related to the terminal illness. It is the responsibility of the hospice to provide those services required under the Medicare hospice benefit.

Medicaid State Plan Personal Care Services (PCS) may be authorized by the Local Department of Social Services only if determined necessary and part of the plan of care unrelated to the terminal illness or which preceded the terminal illness and if the individual meets the PCS eligibility criteria.

Medicaid reimburses for hospice care as follows:

  • for routine home care using an all inclusive daily reimbursement rate,
  • continuous home care during periods of crisis,
  • general inpatient care for pain management or symptom management,
  • inpatient respite to relieve caregivers, and
  • room and board for individuals receiving hospice care in a skilled nursing facility or hospice residence.

Disallowed Services

Medicaid policy prohibits duplication of services with Medicaid always the payer of last resort; therefore, the following Medicaid services/programs are not allowed in combination with the hospice benefit:

  • Private Duty Nursing,
  • Long Term Home Health Care Program (LTHHCP)/Lombardi Program,
  • Certified Home Health Agency (CHHA) Services, and
  • Adult Day Health Care service.

Overpayment resulting from duplication of services will be recouped from the hospice provider.

Questions? Please call the Bureau of Long Term Care at: (518) 474-6580.


Attention
Group Practice Providers

WHAT YOU SHOULD KNOW ABOUT 1099s
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To have claim payments issued to a Group Practice, the Group Provider Identification Number must be submitted on the claim.

Medicaid will issue checks made payable to the group. These funds are then associated with the group's tax identification number and will appear on the group's, Internal Revenue Service 1099 Form for the year in which checks were issued.

If no Group Identification Number is submitted on the claim, payment is made to the individual Provider Identification Number and the individual's associated tax number.

Medicaid will issue a 1099 to the individual for the funds paid to that individual provider and his/her associated tax identification number.

If checks are made payable to an individual provider, but the checks are deposited into a group bank account, the individual provider will still be issued a 1099 for funds paid to the individual's Provider Identification Number and associated tax number.

Please note: The 1099 should not be returned to Computer Sciences Corporation as the 1099 can not be reissued under the group's tax number.

How do I correct claims paid to the individual provider that should have been paid to the group?

Step 1: To correct the payment for these claims, voided claim transactions will need to be submitted for the individual provider. This will cause the payments to be negated and taken from subsequent payment made to the individual.

Step 2: The Group practice then must resubmit original claims with the Group Identification Number entered on the claims. Medicaid will then make payment to the Group and the funds will be associated with the Group's tax identification number and the 1099 issued to the Group.

Any voided and re-billed claims as described above will only impact the 1099 amounts when the voids and re-billed claims are submitted in the same year the original payments were made.

For example, a voided claim submitted in the year 2007 will not impact the 1099 amount issued for the year 2006.

Questions about claim submissions? Please call the eMedNY Call Center at (800) 343-9000.


Electronic Funds Transfer
The EFT Advantage
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Electronic Funds Transfer (EFT) allows providers to have their Medicaid payments directly deposited in their checking or savings accounts. Over 4,000 Medicaid Providers have already signed up for EFT, and are enjoying the convenience of this service.

With EFT enrollment, providers no longer have to rely on the Postal Service to deliver Medicaid checks.

Providers do not have to submit claims electronically to take advantage of the convenience of EFT.

Medicaid funds issued to a provider as a result of paper or electronic claims submission can be electronically transferred to your bank account.

If you would like to enroll in EFT, complete the EFT Provider Enrollment Form, available online at:

www.emedny.org/info/ProviderEnrollment/index.html

Prior to completing the form, read and follow the instructions.

After sending the EFT Provider Enrollment Form to CSC, please allow four to six weeks for processing. During the interim, you should review your bank statement and look for an EFT transaction in the amount of $0.01, which CSC will submit as a test. Approximately 10 days later, your next payment will be sent electronically to your bank account.

If you have any questions about eMedNY EFT enrollment process, please call CSC Provider Enrollment Support at: (800) 343-9000 select option 5.


Would You Like to Receive Your
Prior Approval Rosters Electronically?
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If you currently receive hardcopy Prior Approval (PA) Rosters, you should consider switching to the Electronic PA Roster.

ADVANTAGES OF ELECTRONICALLY DELIVERED PRIOR APPROVAL ROSTERS

  • No additional expense for providers.
  • Electronic Rosters are delivered in advance of hard-copy rosters so claims may be submitted and paid earlier.
  • Electronic storage of PA Rosters on a personal computer makes for easy retrieval of historical information.
  • If you are already an ePACES or eXchange user, you already have what you need in place to receive electronic PA rosters.
  • You will no longer need to rely on the Postal Service to deliver your rosters.

Electronic PA rosters are delivered in Portable Document Format (PDF) and can be viewed via Adobe Acrobat, available free of charge. The roster can then be printed and saved on your personal computer for future reference or as a means to save an electronic record.

Since the rosters are not in a HIPAA-compliant format, providers have no need to purchase additional software to read or interpret the roster information.

Electronic PDF-formatted rosters are delivered via the eMedNY eXchange on a weekly or daily basis, depending upon provider type.

Weekly rosters for transportation and personal care services providers are posted to eXchange every Monday.

For all other provider types, a roster is posted the day after PA(s) are approved.

eXchange works like email. A provider, who has requested an electronic roster, would sign on to the eXchange via the eMedNY website. After entering an assigned User Identification Number and password, the provider is able to print the roster and/or detach the roster file to save it on a personal computer for future reference.

What is included on the electronic roster?

The rosters contain information necessary to submit claims. The PA information is in order of patient last name and contains the following information:

Roster DateBilling Provider IDBilling Provider NamePatient Name
Patient Medicaid IDPatient GenderPatient Date of BirthPatient County
Procedure/Rate CodePA NumberOrdering Provider IDStatus of Request
Approved QuantityApproved TimesDates of ServiceApproved Amount

How do I get a User Identification Number and password for eXchange?

To obtain a User Identification Number and password for eXchange, providers must enroll in ePACES.

Providers already enrolled in ePACES, are automatically enrolled in eXchange. After successful ePACES enrollment, a provider calls the eMedNY Call Center at the number below to have his/her eXchange inbox activated.

Providers not enrolled in ePACES will need the following before contacting the Call Center to enroll:

  • Computer with internet access;
  • Valid email address;
  • Internet browser (Explorer v.4.01, Netscape v. 4.7 or higher);
  • Operating systems: Microsoft Windows, Macintosh, or Linux; and
  • NYS Medicaid Provider Identification Number.

The Electronic Prior Approval Request form is available at:

http://www.emedny.org/info/ProviderEnrollment/index.html

This form must be submitted to Computer Sciences Corporation when the provider is ready to receive rosters electronically, after the eXchange inbox is activated.

For questions or to sign-up for ePACES, eXchange or Electronic PA Rosters, please call the eMedNY Call Center at: (800) 343-9000.


Long Term Care

Save the Date

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The New York State Department of Health

Is pleased to announce

"Planning Today for Tomorrow"


A statewide symposium on

Long Term Care Restructuring

June 21, 2007

Please join us at the Empire State Plaza Convention Center in Albany, New York on Thursday, June 21, 2007.

"Planning Today for Tomorrow" participants will be updated on current New York State restructuring activities, examine the special needs of those requiring long term care, review the best practices and innovations of New York State counties and other states, and plan for future activities.

Registration is $50.00 per registrant.

For more information, please call Kelly Hull at (518) 473-8797 or e-mail Kelly at
keh04@health.state.ny.us.

We look forward to seeing you then!


DOH

Toll-Free Helplines
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Roswell Park Cancer Institute

Referral Services - (800) 767-9355
  • Physician referring patient to RPCI
  • Diagnosis or suspicion of cancer or want 2nd opinion
  • General or specific question about cancer or learn about trials
  • Will your insurance cover costs at RPCI
General Information Switchboard
(800) 685-6825

Gilda Radner Cancer Registry
(800) 682-7426
Food and Nutrition Programs

Child and Adult Care Food Program
(800) 942-3858

Growing Up Healthy Hotline
(800) 522-5006
    Adult Care & Assisted Living Complaints

(866) 893-6772
 Home Health Care
Certified Home Health Care Agencies


(800) 628-5972
  NYS Partnership for Long-Term Care

(888) NYS-PLTC
  Office of Professional Medical Conduct
Complaints and Inquiries


(800) 663-6114
AIDS

General Information
(800) 541-AIDS
General Information, Spanish Language
(800) 233-7432
AIDS Drug Assistance Program (ADAP)
(800) 542-2437

AIDS Counseling & Testing

Buffalo
(800) 962-5064
Nassau
(800) 462-6785
New Rochelle
(800) 828-0064
Rochester
(800) 962-5063
Syracuse
(800) 562-9423
Suffolk
(800) 462-6786
Troy
(800) 962-5065
Queens
(800) 462-6785
After Hours Hotline
(Monday-Friday 4 PM to 8 PM,
Saturday & Sunday 10 AM to 6 PM)
(800) 872-2777
Health Insurance

Child Health Plus
(800) 698-4KIDS

ELDERLY PHARMACEUTICAL INSURANCE COVERAGE PROGRAM (EPIC)
  • Fraud and Abuse Hotline
    (800) 542-0424
  • Participant Helpline
    (800) 332-3742
  • Provider Helpline
    (800) 634-1340
Family Health Plus

(877) 934-7587

Prenatal Care Assistance Program

(800) 522-5006

Info

PROVIDER SERVICES
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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:
http://www.nyhealth.gov/medicaid/program/update/main.htm
Hard copies can be obtained upon request by emailing: MedicaidUpdate@health.state.ny.us

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

Questions about billing and performing MEVS transactions?
Please contact CSC Provider Services at: (800) 343-9000.

Provider Training
To sign up for a provider seminar in your area, please enroll online at: http://www.emedny.org/training/index.aspx

Patient Eligibility
Call the Touchtone Telephone Verification System (800) 997-1111, (800) 225-3040 or (800) 394-1234.

Address Change?
Questions should be directed to CSC at (800) 343-9000, option 5.

Fee-for-service Provider Enrollment
A change of address form is available at:
http://www.emedny.org/info/ProviderEnrollment/Provider%20Maintenance%20Forms/6101-Address%20Change%20Form.pdf.

Rate-based/Institutional Provider Enrollment
A change of address form is available at:
http://www.emedny.org/info/ProviderEnrollment/Provider%20Maintenance%20Forms/6106-Rate%20Based%20Change%20of%20Address%20Form.pdf

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

The Medicaid Update is a monthly publication of the New York State Department of Health containing information regarding the care of those enrolled in the Medicaid Program.

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