New York State

August 2007  
Volume 23, Number 8  

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


Important Information about Available Electronic Tools
The Medicaid Program has three electronic tools available for providers to interact with the Medicaid Program.

eMedNY Website Highlights: HIPAA Claim Denials
Did you ever get a claim denied but can't figure out why? Read this article to learn about HIPAA-compliant denials and what they mean!

Your Provider Manual is Online!...
Stay up to date with Medicaid policy by reading your provider manual.

Policy and Billing Guidance

Prior Approval Process for Enrollees Eligible for Both Medicare and Medicaid
Durable Medical Equipment, Prosthetic, Orthotic and Supply Item Providers are urged to review this change to Medicaid policy.

Dispensing Validation System Cancellations
This article provides information on how and when Pharmacy and Durable Medical Equipment Providers can cancel a request.

Preferred Drug Program News
Changes are coming effective August 28, 2007.

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

Claim Requirements When an Ambulette Vehicle is Used
Ambulette providers are reminded of claim requirements.

Clinical Psychologists: Reimbursement of New Procedure Codes
Three new procedure codes reimbursable effective September 1, 2007.

Traumatic Brain Injury Providers: New Billing Procedure for Services Without Established Fees
A new billing procedure takes effect October 1, 2007. Find out how this affects your program.

Inpatient Hospital Billing Guidelines
Guidelines were recently updated online.

Medicaid Payment for Undocumented Immigrants or Temporary Non-Immigrants
New Medicaid policy regarding the treatment of an emergency medical condition for this special population.

Sterilization and Hysterectomy Consent Forms Available Online
Now, nurse practitioners, midwives and physicians can obtain certain forms online.

General Information

Tools for the Evaluation, Ordering and Provision of Manual and Powered Wheeled Mobility Equipment
A template and guidelines for those involved with evaluating, ordering and providing this equipment to Medicaid enrollees.

Individual Provider Training is Available
Do you need help understanding the claims process? This article explains how to request assistance.

Seminar Schedule and Registration
If you have questions about billing the Medicaid Program, read this article and learn how to make a request for training.

Computer Sciences Corporation Call Center Contact Information
Learn how to navigate Computer Sciences Call Center with this article.

Provider Resources

Caduceus


News for All Providers....

Important Information about Available Electronic Tools
Return to Table of Contents

ePACES - Electronic Provider Assisted Claim Entry System

Computer

WHY ePACES? It's Free, Fast, Easy-to-use and Accurate!

  • Secure web-based application.
  • Free-of-charge to enrolled Medicaid providers.
  • HIPAA compliant transactions:
    • Claims (Professional, Dental and Institutional),
    • Claim status requests,
    • Eligibility requests,
    • Utilization Threshold (UT)/Service Authorization (SA) requests,
    • Dispensing Validation System (DVS) requests, and
    • Prior approval requests.
  • Professional "real-time" claims are processed instantly, therefore claim status and the amount paid are available immediately after submission (within seconds).
  • ePACES will speed up claims processing time.
  • ePACES can be accessed anywhere you have internet access.
  • The status of all claims, regardless of the mode of submission, is available via ePACES.

HOW DO I SIGN UP?

  • To start the enrollment process call the CSC Call Center at (800) 343-9000

Electronic Funds Transfer (EFT)

WHY EFT? No more waiting for your check to arrive in the mail!

  • Your Medicaid payments are directly deposited into the checking or savings account that you designate.

HOW DO I SIGN UP? It's Easy!

  • Complete the EFT Provider Enrollment Form, available online at: http://www.emedny.org/info/ProviderEnrollment/index.html
  • Multiple provider identification numbers? No problem, simply submit a separate EFT enrollment form for each provider identification number.
  • Provider Groups receiving payments under a Group identification number need only to complete a single enrollment form for the Group identification number.
  • Individual members of Provider Groups who bill individually may also enroll their individual Provider identification number.

Electronic Remittance Advice

WHY Electronic Remittance Advice? No more waiting for your paper remittance statement to arrive in the mail!

  • You'll receive your electronic remittance advice two-and-a-half weeks sooner than paper remittance statements.
  • Fast, secure delivery to your eMedNY eXchange or FTP (File Transfer Protocol) account.
  • HIPAA-compliant 835 (or 820 for Managed Care Plans) format.
  • A supplementary file provides the New York Medicaid edit error codes for denied and pended claims.
  • Dual remittance statements (paper and electronic) are available for up to four weeks while you transition.

HOW DO I SIGN UP? It's Easy!

Software is needed to process and interpret the electronic remittance statement.

Contact your software vendor, or for a list of software vendors, refer to http://www.emedny.org/hipaa/vendors/index.html

Questions about ePACES, Electronic Fund Transfer or Electronic Remittances?
Contact the CSC Call Center at:
(800) 343-9000.


eMedNY Website Monthly Highlights

This Month's Highlight:

Understanding HIPAA Claim Denials
(Electronic claim denials, including ePACES)
Return to Table of Contents

The eMedNY website contains an enormous amount of information for providers:

  • Provider Manuals,
  • documents that can assist providers with claim and other transaction submissions,
  • information to clarify messages and claim denials that are returned via the Medicaid Eligibility Verification System (MEVS) or the provider's remittances (electronic or paper).

Try This Search!

Go to: http://www.emedny.org/hipaa/

  • From the menu on the left choose Edit/Error Knowledgebase.
  • Then choose Edit Map for 835 in Order of Reason Code.

With the implementation of HIPAA standardized claim error reasons, in some cases, it can be difficult to pinpoint the specific reason for claim denial. HIPAA requires that denied claims be assigned a Claim Adjustment Reason Code. In some instances, to further define the denial reason, a HIPAA Remittance Remark Code may also be assigned to the denied claim.

The Edit Map referenced above will assist providers in pinpointing the specific eMedNY denial reason associated with the reported HIPAA reasons on the electronic 835 remittance or via ePACES. The last two columns in the mapping document will identify the specific eMedNY edit number and reason associated with the reported HIPAA denial codes.

Once the eMedNY edit number has been identified, additional information about the error causes and solutions can be found by accessing the Edit Drilldown Presented in Numeric Ranges document, on the same website page. This document will allow you to search by the eMedNY edit number for the cause(s) and possible resolution(s) to the denial.

For example: Your claim is denied for the following HIPAA codes:

  • Claim Adjustment Reason Code 16 - Claim Lacks Information That Is Needed for Adjudication.
  • Remittance Remark Code N259 - Missing/Incomplete/Invalid Billing Provider Secondary ID.

Access the document Edit Map for 835 in Order of Reason Code and search on Remittance Remark Code N259.

  • There are two possible eMedNY edit numbers associated with N259, but only one is mapped to Claim Adjustment Reason Code 16. The eMedNY Edit is Code 00098 - Locater Code Invalid.

If further instruction is required, access the document Edit Drilldown Presented in Numeric Ranges on the same website page. Select the edit range that includes 00098. Then click on the Edit Number link for 00098. There you will be given the potential causes and solutions for the denial.

If you are receiving HIPAA denial codes on your electronic remittance (835) or via ePACES, please take the time to visit http://www.emedny.org/ and become familiar with the Edit/Error Knowledgebase available to you.

Questions about the information on the website should be directed to the eMedNY Call Center at: (800) 343-9000.


Your Provider Manual is Online
Return to Table of Contents

As a provider, it is your responsibility to check and update your provider manual and review the Medicaid Update on a monthly basis to ensure you are current with the latest policy information.

Dot

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.


Policy and Billing Guidance.....

Prior Approval Process for Enrollees Eligible for Both Medicare and Medicaid

Durable Medical Equipment, Prosthetic, Orthotic, and Supply Items
Return to Table of Contents

Effective August 1, 2007, this article will serve as a revision to the policy and procedures outlined in the May 2000 Medicaid Update on this subject.

A. POLICY

Medicaid law and regulation require that when an enrollee is eligible for both Medicare and Medicaid benefits (i.e., dually eligible), the provider must bill Medicare first for covered services prior to submitting a claim to Medicaid for coinsurance and deductible. Prior approval from Medicaid is not required when billing Medicare coinsurance and deductible for services otherwise requiring prior approval for Medicaid-only enrollees.

B. EXCEPTIONS

When a Durable Medical Equipment, Prosthetic, Orthotic, and Supply (DMEPOS) item requires prior approval for Medicaid-only enrollees, a medical prior approval determination for a dually-eligible enrollee may be requested under the situations listed below. When required, the provider must furnish conclusive documentation with a Medicaid prior approval request that an appeal for reconsideration of a Medicare claims denial has been submitted to and denied by the Durable Medical Equipment Medicare Administrative Contractor (DME MAC).

  1. ITEM IS STATUTORILY NON-COVERED BY MEDICARE
    When a DMEPOS item is statutorily never covered by Medicare (e.g., bathing equipment) and is covered by Medicaid, a prior approval request may be submitted to Medicaid along with documentation of medical necessity. It is not necessary to submit claims to Medicare before requesting Medicaid prior approval in this situation.
  2. SAME OR SIMILAR EQUIPMENT
    When the DME MAC issues a claim denial because the Medicare beneficiary has received a product within the last five years which has the same or similar therapeutic benefit for the same medical condition, the provider must include documentation of the DME MAC denial with any Medicaid prior approval request. The prior approval request must include any information available to the provider about the item or items that caused the current Medicare claim to be rejected. Based upon this information Medicaid will make an independent determination of current medical necessity and appropriateness with respect to the requested item.
  3. PRODUCTS USED OUTSIDE THE HOME
    When the DME MAC issues a claim denial because a requested item is not being used "in the home", the provider must submit documentation of the DME MAC claim rejection with any Medicaid prior approval request. The prior approval request must also contain any information available to the provider about products supplied under Medicare reimbursement for the beneficiary's use in the home.
  4. PRODUCTS IN EXCESS OF THE ALLOWED MAXIMUM
    When the DME MAC issues a claim denial because the physician's order for a Medicare covered item requests quantities that exceed Medicare payment screens, the provider must submit documentation of the denial with any Medicaid prior approval. The provider must then proceed to appeal that denial to the DME MAC and maintain a copy of the DME MAC's determination on the appeal in the provider's records for any Medicaid post-audit purposes.
  5. ADVANCE DETERMINATION OF MEDICARE COVERAGE (ADMC)
    Unlike most services, certain customized or specialized wheeled mobility bases are eligible for a Medicare ADMC review prior to provision of service. When a negative ADMC decision communicates to the Medicare supplier and beneficiary that the beneficiary does not meet Medicare coverage criteria established for the base equipment, prior approval from Medicaid may be requested. The provider must submit with the prior approval request a copy of the ADMC and all the supporting documentation required by and submitted to Medicare*. This process is not to be utilized when the ADMC states that documentation submitted was not sufficient for a determination to be made. When a particular item is eligible for ADMC, all options and accessories ordered by the physician for that patient, along with the base HCPCS code, are eligible for ADMC. The current list of codes available for ADMC is:
    • Manual wheelchairs described by codes: E1161, E1231-E1234, K0005, and K0009.
    • Group 2, 3, 4 or 5 Single Power Option or Multiple Power Options wheelchair (K0835-K0843, K0856-K0864, K0877-K0891) - whether or not a power seating system will be provided at the time of initial issue.
    • Group 3 or 4 No Power Option wheelchair (K0848-K0855, K0868-K0871) that will be provided with an alternative drive control interface at the time of initial issue.
    • *Refer to the DME MAC medical policies and specific documentation requirements at the following websites:
      http://www.tricenturion.com/content/lcd_current_dyn.cfm; and
      http://www.medicarenhic.com/dme/dmemaca_sm_ch09-rev2007-01.pdf.

C. PAYMENT

  • If requests for major items of DMEPOS, such as powered mobility are approved, Medicaid will issue a prior approval in the amount of $1.00 pending resolution of the appeal of the adverse Medicare coverage determination to the DME MAC. Once a DME MAC denial is received in prior approval, Medicaid payment will be made according to the applicable Medicaid pricing policy.
  • If the DME MAC approves the major item of medical equipment on appeal, a bill may be submitted directly to Medicaid indicating the Medicare Approved and Medicare Paid amounts. When the DME MAC approves such a request on appeal, DO NOT enter the Medicaid prior approval number issued to you on your Medicaid claim.
  • If New York State Medicaid issues a prior approval and a subsequent decision by Medicare results in a Medicare payment to the provider, the provider is required to adjust any Medicaid paid claims to reflect the Medicare Approved and Medicare Paid amounts received in conformity with Department of Health Regulation at Title 18 of the New York Code of Rules and Regulations Section 540.6.

Questions? Please contact the Pre-Payment Review Group at: (518) 474-8161.


ATTENTION

Pharmacy and Durable Medical Equipment Providers

Dispensing Validation System Cancellations
Return to Table of Contents

Pharmacy and durable medical equipment providers may cancel a Dispensing Validation System (DVS) request for supplies within 24 hours of approval. Approvals for prescription footwear, orthotics, and prosthetics must be cancelled within 90 days.

Problems Cancelling a DVS Request?

Occasionally, providers may experience difficulty cancelling a DVS number using the OMNI 3750 Terminal or ePACES. In this situation, to obtain a copy of the cancellation request form, contact Computer Sciences Corporation's (CSC) Fax on Demand Line at: (800) 370-5809, and order document number 3018 to be faxed to you.

Once the completed form is returned to CSC, you will be notified via telephone within 24 hours that your DVS has been cancelled.

For questions about DVS cancellations, or if you prefer to request the cancellation form via telephone from a Customer Service Representative,
please contact the eMedNY Call Center at:

(800) 343-9000.


Preferred Drug Program News
Return to Table of Contents

Review of PDP Drug Classes

Effective August 28, 2007, the following drugs will be added to the list of "preferred" agents and will no longer require prior authorization:

  • Avalide®
  • Avapro®
  • Coreg®
  • Duetact®
  • fenofibrate
  • Pataday®
  • pravastatin
  • Relpax®
  • Tricor®
  • zolpidem

Also effective August 28, 2007, the following brand name drugs have been changed to "non-preferred" status. Generics for these medications remain preferred. Prescriptions written on or after August 28, 2007 for these drugs will require prior authorization:

  • Mavik®
  • Norvasc®
  • Uniretic®
  • Zocor®

The complete Preferred Drug List and Quick-list can be found at:
http://www.health.state.ny.us or https://newyork.fhsc.com/ or http://www.emedny.org/

To obtain prior authorization for a non-preferred drug, contact the clinical call center at (877) 309-9493 and follow the appropriate prompts. Requests for prior authorization of non-preferred drugs may also be faxed to (800) 268-2990. Faxed requests may take up to 24 hours to process.

The Preferred Drug List (PDL) has been reorganized to group similar or related drug classes together. For example, cardiovascular drugs are now grouped together, as are anti-infectives and gastrointestinal drugs.

Changes in PDL status for individual drugs are indicated by a "1" or a "2" next to the drug.

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.
Return to Table of Contents


ANALGESICS

 
Narcotics - Long ActingNarcotics - Long Acting
PREFERRED AGENTSNON-PREFERRED AGENTS
Duragesic®
fentanyl patch
Kadian®
morphine sulfate SR
Oramorph SR®
Avinza®
MS Contin®
Opana ER®
oxycodone HCL CR
Oxycontin®

ANTI-INFECTIVES

 
Anti-FungalsAnti-Fungals
PREFERRED AGENTSNON-PREFERRED AGENTS
Fulvicin U/F®
Grifulvin V® (tablet)
Gris-PEG®
griseofulvin (suspension)
Lamisil®
Grifulvin V® (suspension)
itraconazole (capsule)
Penlac®
Sporanox® (capsule, solution)
Anti-ViralsAnti-Virals
PREFERRED AGENTSNON-PREFERRED AGENTS
acyclovir (tablet, capsule, suspension)
Famvir®
Valtrex®
Zovirax® (tablet, capsule, suspension)
Cephalosporins - Third GenerationCephalosporins - Third Generation
PREFERRED AGENTSNON-PREFERRED AGENTS
Cedax®(capsule, suspension)
cefpodoxime proxetil (tablet)
Omnicaf® (capsule, suspension)
Suprax®
Spectracef®
Vantin® (tablet, suspension)
Fluoroquinolones Fluoroquinolones
PREFERRED AGENTSNON-PREFERRED AGENTS
Avelox®
Avelox ABC Pack®
Cipro®1(suspension)
ciprofloxacin (tablet, suspension)
ofloxacin
Cipro® (tablet)
Cipro XR®
ciprofloxacin ER
Factive®
Floxin®
Levaquin® (tablet, solution)
Maxaquin®
Noroxin®
Proquin XR®
Tequin®
Hepatitis C AgentsHepatitis C Agents
PREFERRED AGENTSNON-PREFERRED AGENTS
PEG-Intron®
PEG-Intron Redipen®
Pegasys®
Pegasys Convenience Pack®
None

CARDIOVASCULAR

 
Angiotensin Converting Enzyme Inhibitors (ACEIs) Angiotensin Converting Enzyme Inhibitors (ACEIs)
PREFERRED AGENTSNON-PREFERRED AGENTS
Altace®
benazepril
captopril
enalapril maleate
lisinopril
moexipril
trandolapril
Accupril®
Aceon®
Capoten®
fosinopril sodium
Lotensin®
Mavik®2
Monopril®
Prinvil®
quinapril
Univasc®
Vasotec®
Zestril®
ACEIs + Calcium Channel BlockersACEIs + Calcium Channel Blockers
PREFERRED AGENTSNON-PREFERRED AGENTS
Lotrel®
Tarka®
Lexxel®
ACE Inhibitors + DiureticAce Inhibitors + Diuretic
PREFERRED AGENTSNON-PREFERRED AGENTS
benazepril/HCTZ
captopril/HCTZ
enalapril maleate/HCTZ
lisinopril/HCTZ
moexipril/HCTZ
Accuretic®
Capozide®
fosinopril HCTZ
Lotensin HCT®
Monopril HCT®
Prinzide®
quinapril/HCTZ
Quinaretic®
Uniretic®2
Vaseretic®
Zestoretic®
Angiotensin Receptor Blockers (ARBs)Angiotensin Receptor Blockers (ARBs)
PREFERRED AGENTSNON-PREFERRED AGENTS
Avapro®1
Benicar®
Cozaar®
Diovan®
Micardis®
Atacand®
Teveten®
ARBs + DiureticARBs + Diuretic
PREFERRED AGENTSNON-PREFERRED AGENTS
Avalide®1
Benicar HCT®
Diovan HCT®
Hyzaar®
Micardis HCT®
Atacand HCT®
Teveten HCT®
Beta BlockersBeta Blockers
PREFERRED AGENTSNON-PREFERRED AGENTS
acebutolol
atenolol
betaxolol
bisoprolol fumerate
Coreg®1
labetalol
metoprolol tartrate
nadolol
pindolol
propranolol (tablet, solution)
propranolol ER (capsule)
timolol maleate
Coreg CR®
Corgard®
Inderal®
Inderal LA®
InnoPran XL®
Kerlone®
Levatol®
Lopressor®
metoprolol succinate
Sectral®
Tenormin®
Toprol XL®
Trandate®
Zebeta®
Beta Blockers + DiureticBeta Blockers + Diuretic
PREFERRED AGENTSNON-PREFERRED AGENTS
atenolol/chlorthalidone
bisoprolol fumerate/HCTZ
metoprolol tartrate/HCTZ
propranolol/HCTZ
Corzide®
Inderide®
Lopressor HCT®
Tenoretic®
Ziac®
Calcium Channel Blockers (Dihydropyridine)Calcium Channel Blockers (Dihydropyridine)
PREFERRED AGENTSNON-PREFERRED AGENTS
Afeditab CR®
amolodipine
DynaCirc ®
DynaCirc CR®
felodipine ER
isradipine
nicardipine HCL
Nifediac CC®
Nifedical XL®
nifedipine
nifedipine ER
nifedipine SA
Sular®
Adalat CC®
Cardene®
Cardene SR®
Norvasc®2
Plendil®
Procardia®
Procardia XL®
Cholesterol Absorbtion InhibitorsCholestrol Absorption Inhibitors
PREFERRED AGENTSNON-PREFERRED AGENTS
Zetia®None
HMG-CoA Reductase Inhibitors (Statins)HMG-CoA Reductase Inhibitors (Statins)
PREFERRED AGENTSNON-PREFERRED AGENTS
Advicor®
Altoprev®
Crestor®
Lescol®
Lescol XL
Lipitor®
pravastatin1
simvastatin
Vytorin®
Caduet®
lovastatin
Mevacor®
Pravachol®
Zocor®2
Triglyceride Lowering AgentsTriglyceride Lowering Agents
PREFERRED AGENTSNON-PREFERRED AGENTS
fenofibrate1
gemfibrozil
Lofirba®
Tricor®1
Antara®
Lopid®
Omacor®
Triglide

CENTRAL NERVOUS SYSTEM

 
Sedative Hypnotics/Sleep AgentsSedative Hypnotics/Sleep Agents
PREFERRED AGENTSNON-PREFERRED AGENTS
Ambien CR®
chloral hydrate
estazolam
flurazepam
temazepam
triazolam
zolpidem
Ambien®
Dalmane®
Doral®
Halcion®
Lunesta®
Prosom®
Restoril®
Rozerem®
Somnote®
Sonata®
Serotonin Receptor Agonists (Triptans)Serotonin Receptor Agonists (Triptans)
PREFERRED AGENTSNON-PREFERRED AGENTS
Imitrex® (tablet, nasal, injection)
Maxalt® (tablet, MLT)
Relpax®1
Amerge®
Axert®
Frova®
Zomig® (tablet, nasal, ZMT)

ENDOCRINE AND METABOLIC AGENTS

 
BisphosphonatesBisphosphonates
PREFERRED AGENTSNON-PREFERRED AGENTS
Fosamax® (tablet, solution)
Fosamax® Plus D
Actonel®
Actonel® with Calcium
Boniva®
Calcitonins - IntranasalCalcitonins - Intranasal
PREFERRED AGENTSNON-PREFERRED AGENTS
Miacalcin®Fortical®
Thiazolidinediones (TZDs)Thiazolidinediones (TZDs)
PREFERRED AGENTSNON-PREFERRED AGENTS
Actos®
Actoplus Met®
Avandia®
Avandamet®
Avandaryl
Duetact®1
none

GASTROINTESTINAL

 
Anti-EmeticsAnti-Emetics
PREFERRED AGENTSNON-PREFERRED AGENTS
Kytril® (tablet, solution)
Zofran® (tablet, solution, ODT)
Anzemet®
Proton Pump InhibitorsProton Pump Inhibitors
PREFERRED AGENTSNON-PREFERRED AGENTS
Nexium®
Prevacid® (capsule)
Prilosec OTC®
Aciphex®
Nexium Packet®
omeprazole
Prevacid® (solutab, packet)
Prevacid NapraPAC®
Prilosec®
Protonix®
Zegerid® (capsule, packet)

IMMUNOLOGIC AGENTS

 
Immunomodulators -InjectableImmunomodulators -Injectible
PREFERRED AGENTSNON-PREFERRED AGENTS
Enbrel®
Humira®
Kineret®
Immunomodulators -TopicalImmunomodulators -Topical
PREFERRED AGENTSNON-PREFERRED AGENTS
Elidel®
Protopic®
None

OPHTHALMICS

 
Antihistamines - OphthalmicAntihistamines - Ophthalmic
PREFERRED AGENTSNON-PREFERRED AGENTS
Patanol®
Pataday®1
Elestat®
Emadine®
ketotifen RX
Optivar®
Fluoroquinolones - Ophthalmic Fluoroquinolones - Ophthalmic
PREFERRED AGENTSNON-PREFERRED AGENTS
ciprofloxacin
ofloxacin
Vigamox®
Ciloxan® (solution, ointment)
Ocuflox®
Quixin®
Zymar®

OTICS

 
Fluoroquinolones - OticFluoroquinolones - Otic
PREFERRED AGENTSNON-PREFERRED AGENTS
Ciprodex®
Floxin®
Cipro HC®

RENAL AND GENITOURINARY

 
Phosphate Binders/RegulatorsPhosphate Binders/Regulators
PREFERRED AGENTSNON-PREFERRED AGENTS
Fosrenol®
Phoslo
Renagel®
None

RESPIRATORY

 
Anticholinergics - InhaledAnticholinergics - Inhaled
PREFERRED AGENTSNON-PREFERRED AGENTS
Atrovent®
Atrovent HFA®
Combivent®
ipratropium
Spiriva®
Duoneb®
Antihistamines - Second Generation Antihistamines - Second Generation CC
PREFERRED AGENTSNON-PREFERRED AGENTS
OTC loratadine
OTC loratadine-D
Allegra® (tablet, capsule, suspension)
Allegra-D®
Clarinex®
Clarinex-D®
fexofenadine
Semprex-D®
Zyrtec®CC
Zyrtec-D®
Beta2Adrenergic Agents - Inhaled Long ActingBeta2Adrenergic Agents - Inhaled Long Acting
PREFERRED AGENTSNON-PREFERRED AGENTS
Foradil®
Serevent Diskus®
Brovana®
Beta2Adrenergic Agents - Inhaled Short ActingBeta2Adrenergic Agents - Inhaled Short Acting
PREFERRED AGENTSNON-PREFERRED AGENTS
albuterol
Maxair Autohaler®
Proventil HFA®
Ventolin HFA®
Xopenex®
Xopenex HFA®
Accuneb®
Alupent®
metaproterenol
ProAir HFA®
Proventil®
Corticosteroids - InhaledCorticosteroids - InhaledCC
PREFERRED AGENTSNON-PREFERRED AGENTS
Advair Diskus®
Advair HFA®
Asmanex®
Azmacort®
Flovent HFA®
Qvar®
Aerobid®
Aerobid-M®
Pulmicort ® (Flexhaler, Turbuhaler)CC
Symbicort®
Corticosteroids - IntranasalCorticosteroids - Intranasal
PREFERRED AGENTSNON-PREFERRED AGENTS
Nasacort AQ®
Nasonex®
Beconase AQ®
Flonase®
flunisolide®
fluticasone®
Nasarel®
Rhinacort Aqua®
Vermyst®
Leukotriene ModifiersLeukotriene Modifiers
PREFERRED AGENTSNON-PREFERRED AGENTS
Accolate®
Singular®
None

1Preferred as of 8/28/07

2Non-preferred as of 8/28/07

CC Clinical Criteria


Attention
Ambulette Providers

Claim Requirements When an Ambulette Vehicle is Used
Return to Table of Contents

At times, an ambulette vehicle is used to transport Medicaid enrollees in need of livery service (category of service 0605) or in day treatment group ride situations (category of service 0606). Since personal assistance is not required nor provided for the enrollee, the ambulette provider bills the livery/day treatment transportation fee and/or appropriate livery/day treatment procedure codes.

Reminder

Claim Requirements

In the November 2005 Medicaid Update, ambulette providers were reminded that the driver's license number and vehicle license plate number must be submitted on claims for ambulette service.

Ambulette providers must follow the guidelines established for the ambulette category of service whenever an ambulette vehicle is used to transport Medicaid enrollees. The subsequent claim should include:

  • the driver's license number; and
  • the vehicle license plate number.

If a different driver and/or vehicle returns the enrollee from the medical appointment, the license number of the driver and vehicle used for the origination of the trip should be reported on the claim.

The Office of the Medicaid Inspector General will monitor claims for this as well as other appropriate claim information and documentation.

Questions? Call the Transportation Unit at (518) 474-5187 or email medtrans@health.state.ny.us


Attention
Clinical Psychologists

Reimbursement of New Procedure Codes
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Effective dates of service on or after September 1, 2007, three new procedure codes will be reimbursable to clinical psychologists.

To bill for these procedures, you must provide documentation of board certification or eligibility to participate in the board examination in Clinical Neuropsychology.

The new codes are:

  • 96111    Developmental testing; extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments) with interpretation and report.
  • 96116    Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report.
  • 96118    Neuropsychological testing (e.g., Halstead-Reitan neuropsychological battery, Wechsler memory scales and Wisconsin card sorting test), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report.

The fee for each of these procedures is $150.

Acceptable documentation includes proof that you:

  • are board certified in Clinical Neuropsychology by the American Board of Professional Psychology (ABPP)/American Board of Clinical Psychology (ABCN);

    or

  • have been deemed eligible to participate in the board examination in Clinical Neuropsychology by the American Board of Professional Psychology (ABPP)/American Board of Clinical Psychology (ABCN).

Submit this documentation, with your Medicaid provider identification number, to:

Computer Sciences Corporation
P.O. Box 4610
Rensselaer, NY 12144-4610

Following a review of your submitted document(s), you will be notified in writing of acceptance, denial, or need for additional documentation.

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


Attention
Traumatic Brain Injury Providers

New Billing Procedure For Services Without Established Fees
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A new billing procedure for claiming charges for services without established fees will be established for providers in the Traumatic Brain Injury (TBI) program. This new process will take effect on October 1, 2007.

Woman

  • Payments for such services were previously processed using a series of multiple rate codes with specific dollar amounts (i.e., $1, $10, $100, etc.).
  • One such service that was billed with a series of rate codes is Community Transitional Services. These services used the rate code series 9864 thru 9867. System changes will allow providers to bill their total charges under one rate code for the specific service rendered.

The new total charges rate codes for each noted service will be:

  • 9857 TBI Special Equipment/Supplies;
  • 9867 TBI Community Transitional Services; and,
  • 9874 TBI Environmental Modifications.

The fields to be completed on your claim form all remain the same. Payment will be made based on the amount recorded in the "Total Charges" field.

Questions pertaining to this new billing policy may be addressed to the Rate Based Provider Unit of the Pre-Payment Review Group at: (518) 474-8161.


Have you been asked to pay money to another individual to receive Medicaid referrals?
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Please call:

1-877-87FRAUD

Your call will remain confidential.


Inpatient Hospital Billing Guidelines
Recently Updated!
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Billing personnel and billing agents for inpatient hospital providers are advised that billing guidelines were recently posted to: http://www.emedny.org.

Hospital

Although the Inpatient Hospital Billing Guidelines document does not change any previously issued billing instructions, it organizes the instructions into one document to make it easier for billers to reference and locate billing procedures.

The guidelines information covers such topics as:

  • General Inpatient Billing Procedures
    • Calculating and submitting the appropriate number of days.
  • Diagnosis Related Groups (DRGs)
    • DRG payment calculations and "split-billing" situations.
  • Non-DRG (DRG-exempt) Claims
    • DRG-exempt "split-billing" situations.
  • Medicaid - Payer of Last Resort
    • Billing after Medicare and other insurance payments.
  • Special Instructions for Other Inpatient Claims
    • Alternate level of care claims, graduate medical education (GME) claims, "pass-days" claims, and cost outlier claims.
  • Supplemental Inpatient Billing Information
    • Inpatient services paid "offline", replacement/void of previously paid claims; Medicaid managed care clients, hospital responsibility for outside care.

Please take the opportunity to become familiar with these instructions, available at:

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

Comments or questions about the instructions should be submitted to the eMedNY Call Center at: (800) 343-9000; or
via email at: emednyproviderrelations@csc.com


Medicaid Payment
for Undocumented Immigrants or Temporary Non-Immigrants

Treatment of an Emergency Medical Condition
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The purpose of this article is to inform providers of new Medicaid policy when submitting claims for treating undocumented (illegal) immigrants or temporary non-immigrants (i.e., foreign students, visitors, workers) for an emergency medical condition.

Recent Audit Findings

An audit of claims billed for care and services to treat emergency medical conditions was conducted by the Centers for Medicare and Medicaid Services (CMS). The audit identified provider claims for emergent care and services provided to undocumented immigrants and/or temporary non-immigrants which were not true medical emergencies.

These claims were billed with the emergency indicator set to "Yes". This billing error resulted in inappropriate payments to the provider and in the State inappropriately claiming federal funds. This has also resulted in services being paid for by Medicaid for this enrollee population, which are not true medical emergencies, as defined under federal law.

Emergency

The Office of Health Insurance Programs is developing payment edits to correct the claiming errors.

New Payment Edits

The CMS audit concluded that certain services do not fall under the definition of treatment of an emergency medical condition. Therefore, Medicaid will no longer cover the costs for the following services or transportation to these services:

  • rehabilitation services, (including physical therapy, occupational and speech therapies), and
  • encounters for chemotherapy.

Additionally, encounters for:

  • radiation therapy, and
  • most durable medical equipment/supplies and services,

do not fall under the definition of treatment of an emergency medical condition.

CMS told New York to cease claiming federal expenditures for these non-emergency services. Edits are being developed to deny the above mentioned services when billed as emergency services.

Not all services that are medically necessary meet the federal definition of an emergency medical condition.

  • Emergency medical conditions do not include debilitating conditions resulting from an initial event, which later requires ongoing regimented care.

  • Certain types of care provided to chronically ill persons are beyond the intent of the federal laws and implementing State laws, and are not considered "emergency services" for the purpose of Medicaid payment. Such care includes:

    • › alternate level of care in a hospital,
    • › nursing facility services, home care (including private duty nursing), and
    • › personal care.

  • Also, care and services related to an organ transplant procedure are not included in the federal definition of treatment for an emergency medical condition.

Certification of Treatment of Emergency Medical Condition Forms: The DSS-3955 (Upstate) or MAP-2151 (NYC)

The treating physician must complete, date, sign and submit the DSS-3955 or MAP-2151 form for any undocumented or temporary non-immigrant who has received and is applying for Medicaid coverage for the treatment of an emergency medical condition.

A new DSS-3955 or MAP-2151 must be obtained from the treating physician for each new episode requiring treatment of an emergency medical condition. An individual may reapply whenever he or she needs treatment of an acute emergency medical condition and the treating physician provides a new DSS-3955 or MAP-2151.

To obtain the DSS-3955, go to:

http://health.state.nyenet/docs/2007gis/07ma006.pdf

To obtain the MAP-2151, call the New York City Human Resources Administration at:

(212) 630-1193.

If you have provided medical treatment to an individual who appears to meet the above criteria and who indicates he/she has no means of paying for the services, he/she may be referred to a local department of social services for a determination of Medicaid eligibility.

The local department of social services will notify you of the acceptance/denial of the application, the period of coverage and the individual's Client Identification Number (CIN) when appropriate. If the immigrant is found eligible for Medicaid, you can receive reimbursement for the emergency services by billing eMedNY.

Billing instructions, provider manuals and sample paper claim forms are available at:

http://www.emedny.org/

If you have questions related to the billing process for these services, you can call CSC Provider Services at:

(800) 343-9000.

Questions regarding immigrant eligibility for Medicaid may be directed to the Office of Health Insurance Programs, Bureau of Medicaid and Family Health Plus Enrollment at:

(518) 474-8887.


Attention
Nurse Practitioners
Midwives
Physicians
Hospitals
Clinics

Sterilization and Hysterectomy Consent Forms Available Online
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The following forms will no longer be available via written request:

FORM NUMBER FORM TITLE
LDSS-3113Acknowledgement of Receipt of Hysterectomy Information (English)
LDSS-3113S Acknowledgement of Receipt of Hysterectomy Information (Spanish)
LDSS-3134 Sterilization Consent Form (English)
LDSS-3134S Sterilization Consent Form (Spanish)

These forms may be obtained online at:

http://www.health.state.ny.us/health_care/medicaid/publications/ldssforms

Website access problems?

Contact Michael Margiasso in the Office of Health Insurance Programs at: (518) 473-4852.

Questions on the completion of these forms?

Contact our fiscal agent, Computer Sciences Corporation at: (800) 343-9000.


General Information.....

Tools for Evaluation, Ordering, and Provision of Manual and Powered Wheeled Mobility Equipment
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After an extensive collaboration with practitioners, therapists, medical equipment providers, advocates and Medicaid medical review staff, and utilizing State and national standards; guidelines for wheeled mobility equipment and a sample evaluation for wheeled mobility have been developed.

Updated Wheeled Mobility Equipment Guidelines

  • Provides detailed clinical, documentation and coverage criteria, including the new powered mobility code set.

Sample evaluation template for wheeled mobility

  • Encompasses appropriate elements for practitioners to evaluate and consider when ordering wheeled mobility equipment and seating.

These resources are intended to assist providers in collecting and formalizing all necessary information to support Medicaid approval and/or payment for this equipment.

The documents are available at: http://www.emedny.org/ProviderManuals/DME/index.html

Questions? Please contact the Pre-Payment Review Group at: (518) 474-8161.


Question

Do You Receive Multiple Copies of the Medicaid Update?
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If you are enrolled in more than one category of service, you are receiving more than one Medicaid Update. We can eliminate this duplicate mailing. Please mail to us the address page of the duplicate copies of the Medicaid Update to:

Medicaid Update

NYS Department of Health

Office of Health Insurance Programs

99 Washington Ave., Suite 720

Albany, New York 12210

Or email the list of duplicate numbers to: medicaidupdate@health.state.ny.us


Individual Provider Training Is Available
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Computer Sciences Corporation (CSC) has Regional Representatives available to assist individual providers in resolving a variety of Medicaid claiming difficulties they may be experiencing. This service is provided to Medicaid enrolled providers free-of-charge!

CSC Regional Representatives can help providers with issues/problems such as:

Computer

  • Paper or electronic billing.
  • ePACES usage.
  • Prior Approval completion.
  • Eligibility verification or service authorization response.
  • Remittance interpretation (review solutions for pending and denied claims).

How to Make the Request

Providers may request to be contacted by a Regional Representative to schedule an individual training session by calling the Call Center at:

(800) 343-9000; or

via email at:
emednyproviderrelations@csc.com

If using the email method to request a call from a Regional Representative, please include your provider identification number, the nature of your request, and contact information.

A CSC Regional Representative will contact you either via email or telephone to discuss your needs.


Seminar Schedule and Registration
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  • Do you have billing questions?
  • Are you new to Medicaid billing?
  • Would you like to learn more about ePACES?

If you answered YES to any of these questions, please consider registering for a Medicaid seminar. Computer Sciences Corporation (CSC) offers various types of seminars to providers and their billing staff. Many of the seminars planned for the upcoming months offer detailed information and instruction about Medicaid's web-based billing and transaction program - ePACES. ePACES seminars are designed for specific provider types.

Class

ePACES is the Electronic Provider Assisted Claim Entry System that allows enrolled providers to submit the following type of transactions:

  • Claims
  • Eligibility Verifications
  • Utilization Threshold Service Authorizations
  • Claim Status Requests
  • Prior Approval Requests

Professional providers such as physicians, nurse practitioners and private duty nurses can even submit claims in "REAL-TIME" via ePACES. Real-time means that the claim is processed within seconds and professional providers can get the status of a real-time claim, including the associated paid amount, without waiting for the remittance advice to be delivered.

Seminar locations and dates are available at the eMedNY website. Seminar registration is fast and easy. Seminars are free to enrolled Medicaid providers. Go to: http://www.emedny.org/training/index.aspx, to find and register for the eMedNY Training Seminar appropriate for your provider category and location.

Review the seminar descriptions carefully to identify the seminar appropriate to meet your training needs. Registration confirmation will be instantly sent to your email address.

If you are unable to access the Internet to register, you may also request seminar schedule and registration information by contacting CSC's Fax on Demand at:

(800) 370-5809

Request document number 1002 for a list of seminars and registration information to be faxed to you.

CSC Regional Representatives look forward to meeting with you at upcoming seminars!

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


Computer Sciences Corporation
Call Center Contact Information

Main Telephone Number
(800) 343-9000
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Hours of Operation

Phone

For provider inquiries pertaining to non-pharmacy billing or claims, or provider enrollment:

      Monday through Friday

7:30 a.m. - 6:00 p.m. Eastern Standard Time

For provider inquiries pertaining to eligibility, service authorizations, DVS, and pharmacy claims:

      Monday through Friday

7:00 a.m. - 10:00 p.m. Eastern Standard Time

     Weekends and Holidays

8:30 a.m. - 5:30 p.m. Eastern Standard Time

 

Call Center Telephone Tree

 

Option 1: For Paper, Electronic and ePACES billing, remittance information and prior approval inquiries other than NYC Transportation.

  • Sub-option 1: For Pharmacy questions, not including DME.
  • Sub-option 2: For Institutional providers such as hospitals, long term care facilities and clinics.
    • Option 1: For hospital providers inquiring about an inpatient claim.

           All Others: Hold for next available representative.

  • Sub-option 3: For Practitioner providers such as doctors' offices, nurses, dentists and ophthalmic providers.
    • Option 1: For Dental providers.
    • Option 2: For Nursing providers.

           All Others: Hold for next available representative.

  • Sub-option 4: For Professional providers such as DME, labs and transportation.

Option 2: For eligibility questions, UT service authorizations and DVS transactions including POS device support.

Option 3: For MOAS, threshold-override application provider support and NYC Transportation prior approvals.

  • Sub-option 1: For MOAS or threshold override application support.
  • Sub-option 2: For NYC Transportation prior approvals.

Option 4: For ePACES enrollment and ePACES Administrator password resets only.

Option 5: For new Provider enrollment, enrollment status and electronic transmission certifications such as TSN Applications or Security Packets.

Option 6: For batch file verification or support such as eMedNY eXchange, FTP and the eMedNY gateway.

Option 7: Reserved for messages concerning new developments or other information. Subject to change and may not always be active.

  • Sub-option 1: Provider is routed to main menu.
    Call is disconnected after repeating option 7 message twice and if sub-option 1 is not selected.

Man

Reminder:
The Medicaid Update is Available Electronically!
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Do you want to receive your copy of the Medicaid Update three weeks sooner? Sign up today for the electronic version!

Simply send an email to medicaidupdate@health.state.ny.us designating the email address or addresses you'd like the Medicaid Update sent to!

If you do not want the hard copy, please provide your Medicaid provider identification number and confirm that you do not want the hard copy.


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, or via e-mail at: emednyproviderrelations@csc.com

Provider Training
To sign up for a provider seminar in your area, please enroll online at: http://www.emedny.org/training/index.aspx or call CSC at (800) 343-9000.

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/index.html

Rate-based/Institutional Provider Enrollment
A change of address form is available at:
http://www.emedny.org/info/ProviderEnrollment/index.html

Comments and Suggestions Regarding This Publication?
Please contact the editor, Timothy Perry-Coon at MedicaidUpdate@health.state.ny.us

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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