New York State

November 2007  
Volume 23, Number 11  

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


eMedNY Website Highlight: Provider Enrollment and Maintenance/Update Forms Now Contain the National Provider Identifier Number
Guidance on navigating the eMedNY website.

eMedNY Call Center Contact Information
Recent changes to the eMedNY Call Center telephone prompts.

Seminar Schedule and Registration
Find out where to sign up for training seminars!

ePACES Update: Enhanced Prior Approval Inquiry
Learn how ePACES allows providers to inquire about their prior approval requests.

Critical Information for Pharmacy Providers

Department Launches New Public Website with Pharmacy Prices
Consumers will now be able to search and compare pharmacy prices on selected drugs online!

Policy and Billing Guidance

2008 Ambulette Survey: Required Information from Ambulette Providers
An advisement to ambulette providers that the 2008 Ambulette Survey is coming soon!

Separate Transportation Provider Number Required for Each Dispatching Operating Location
Transportation providers are reminded of enrollment requirements for multiple dispatching locations.

Durable Medical Equipment Providers: Provider Manual Changes
There are changes to the Durable Medical Equipment Fee Schedule.

Article 28 Clinics: Revised Instructions for the Billing of Implanon and Intrauterine Devices
This article provides billing instructions and CPT codes for clinics that provide Implanon and intrauterine devices to Medicaid clinic patients.

Costs of Laboratory Tests for End Stage Renal Disease Patients Are in Clinic Rate
A reminder to clinics providing dialysis services.

Proper Claim Completion for Abortion-Related Laboratory Testing
Medical practitioners and clinics are reminded that abortion-related services are not family planning services, and must not be claimed as such.

Backdating Prescriptions and Fiscal Orders
Prescribers and pharmacists should review this article regarding recent audit findings.

Mandatory Generic Drug Program Update
Certain drugs will require prior authorization effective December 1, 2007.

Group Providers: What You Should Know About Internal Revenue Service 1099 Forms
Correct claim submission for group practices.

Private Duty Nursing Providers: Fee Increase for Medically Fragile Children
Clarification regarding the intent of the fee increase and associated payments.

Prior Approval Submission Deadline for Care at Home Waiver Enrollees
A reminder to private duty nursing providers of new prior approval requirements.

Clarification on Reporting Critical Care Procedure Codes 99291 and 99292
When is it appropriate to use 99291 versus 99292? Answers to this question and more are in this article!

Electronic Remittances May Not Always Equal the Total Weekly Paid Amount
Providers who receive electronic remittances should review this article for clarification.

National Drug Code Required on Medicaid Claims
Reminder to physicians, nurse practitioners, licensed midwives, and Article 28 hospital based and freestanding clinics of this upcoming claim requirement.

Preferred Drug Program News
Steps to validate a prior authorization.

General Information

Free Influenza (Flu) Fact Sheets Are Available For Your Patients

Provider Services

Caduceus


News for All Providers.......

eMedNY Website Monthly Highlights

This Month's Highlight:

 

Provider Enrollment Forms and Maintenance/Update Forms
Now Include National Provider Identifier Number
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The eMedNY website contains an enormous amount of information for providers. In addition to Provider Manuals, there are other documents and forms for individuals and entities to enroll as new providers in the New York State Medicaid Program or update information on existing provider files.

Go to http://www.emedny.org/info/ProviderEnrollment/index.html. This page displays links to printable forms providers use to enroll in the Medicaid Program or to update information, such as an address change.

Enrollment Forms

The left-hand column of the web page contains enrollment forms for the following fee-for-service providers:

  • Physicians
  • Portable X-Ray;
  • Podiatrists;
  • Registered Physician's Assistants;
  • Laboratories;
  • Service Bureau;
  • Clinical Psychologists;
  • Group Enrollment;
  • Nurse Practitioners;
  • Optical Establishment;
  • Chiropractors;
  • Dentists;
  • Hearing Aid Dealers;
  • Clinical Social Workers;
  • Durable Medical Equipment Dealers;
  • Therapists;
  • Transportation;
  • Opticians and Optometrists; and
  • Nurses and Nurse Registries;
  • Midwives.
  • Pharmacies

Also contained in the left-hand column are enrollment packets for Enhanced Fee Programs such as HIV-Enhanced Fee Payment, Medicaid Obstetrical and Maternal Services (MOMS) and the Preferred Physicians and Children Program (PPAC).

Enrollment Maintenance/Update Forms

The right-hand column contains Provider Maintenance forms used by enrolled providers to update or add additional information to their Medicaid files. The forms include updates to the following types of information:

Provider Enrollment forms MUST contain the National Provider Identifier Number (NPI)!

Newly updated NPI forms were posted to the website in September, and were effective October 15, 2007.

After that date, only the NPI updated forms will be accepted.

Older versions of the forms will be returned to the provider.

  • Clinical Laboratory Improvements Amendment Certificates;
  • Supervising Pharmacist Agreement;
  • Collaborating Physician Form;
  • Supervising Physician Certification;
  • Application as a Specialist;
  • Fee for Service Address Change;
  • Rate-Based Change of Address Change;
  • Request for Participation in a Group Practice;
  • Drug Enforcement Administration (DEA);
  • Registered Physician's Assistant Questionnaire;
  • Medically Fragile Children Private Duty Nursing rate Enhancement;
  • Medicare Information; and
  • Tax Information.

Please take the time to visit http://www.emedny.org/ and become familiar with the information and forms available to you.

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


Your Provider Manual is Going Online!
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Books

As a provider, it is your responsibility to ensure you are current with the latest policy information.

Click on the link to your Provider Manual at http://www.emedny.org/providermanuals/index.html and you will find the archived versions and other important information regarding recent changes made to your Provider Manual.

Providers are also responsible for knowing the information included in the Information for All Providers sections, which include general Medicaid policy, general billing, inquiry and third party insurance information.

If you do not have access to the internet, contact the eMedNY Call Center at the number below to request a paper copy.

(800) 343-9000


Recent Changes to
eMedNY Call Center Telephone Prompts

eMedNY Call Center Contact Information

Main Telephone Number
(800) 343-9000
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Phone

In an effort to improve service to providers, Computer Sciences Corporation's eMedNY Call Center recently reorganized the prompts (selections) providers hear when they call our telephone number.

We understand how busy providers are and the goal of the reorganization is to help ensure that providers are directed to the correct Customer Service Representatives with the appropriate expertise to quickly respond to their inquiries.

While it may take a few extra moments at the beginning of the call, the reorganization will prevent unnecessary transferring of calls and wasting providers' valuable time.

Please listen carefully to the new prompts so the Call Center can put you in touch with the best representative to assist you with your inquiry. The new phone tree is described below:

Call Center Telephone Tree

Option 1: If you are a Physician, Dentist, Private Duty Nurse, Nurse Practitioner, Clinical Social Worker or Ophthalmic Provider:

  • Sub-option 1: For New Enrollment into the NYS Medicaid Program, ePACES Enrollment and TSN/ ETIN applications.
  • Sub-option 2: For explanation of eligibility response, UT service authorization, POS Device Support and questions regarding prescription prior approvals
  • Sub-option 3: For NYC Transportation Prior Approvals.
  • Sub-option 4: For Claims, Billing, remittance, form orders and non-pharmacy prior approval questions.

Option 2: If you are a Pharmacy Provider:

  • Sub-option 1: For New Enrollment into the NYS Medicaid Program, ePACES Enrollment and TSN/ ETIN applications.
  • Sub-option 2: For all other questions including explanation of eligibility response, claims, billing, remittance and prior approval questions including DIRAD.

Option 3: If you are a Hospital, Clinic, Long Term Care Facility, Nursing Agency, Child Care Agency or Home Health Agency:

  • Sub-option 1: For New Enrollment into the NYS Medicaid Program, ePACES Enrollment or TSN/ ETIN applications.
  • Sub-option 2: For explanation of eligibility response, UT service authorization, POS device support and questions regarding prescription prior approvals
  • Sub-option 3: For NYC Transportation Prior Approvals.
  • Sub-option 4: For claims, billing, remittance, form orders and prior approval questions.

Option 4: If you are a DME, Hearing Aid, Laboratory, or Transportation Provider:

  • Sub-option 1: For New Enrollment into the NYS Medicaid Program, ePACES Enrollment and TSN/ ETIN applications.
  • Sub-option 2: For explanation of eligibility response, UT service authorization or DVS Transactions including POS Device Support.
  • Sub-option 3: For claims, billing, remittance, form orders and prior approval questions.

Option 5: For MOAS and threshold override application provider support.


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.

Man

ePACES is the electronic Provider Assisted Claim Entry System which 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 and select "Training" 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 through CSC's Fax on Demand at:

(800) 370-5809; request document number 1003.

A list of seminars and registration information to be faxed to you.

Please contact the eMedNY Call Center at (800) 343-9000 if you have questions about registration.

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


ePACES Update!
Transportation, Personal Care and Other Providers!

Enhanced Prior Approval Inquiry
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A new feature has been added to ePACES that allows providers to inquire on the status of their prior approval (PA) requests! To access your prior approvals, click on the "PA Roster" link on the ePACES Welcome Page.

Providers can search for their outstanding prior approvals, such as transportation, personal care, dental and physician, regardless of how they were entered into eMedNY (not just the ones entered on ePACES). You can search for your prior approvals based on a wide range of criteria:

Computer

  • Client Identification Number,
  • Procedure Code,
  • Submitted Date Range,
  • Effective Dates, and
  • Many other criteria.

You may even specify the order that you want your items listed.

Prior approvals meeting the criteria will be listed, and by clicking on an individual PA on the list, you can get detailed information about that PA.

You can even request that the selected prior approvals be downloaded to your computer (PC). The downloaded file will be a comma delimited (.CSV) file that can be loaded directly into Microsoft Excel or your own program for further processing.

If you want instructions faxed to you on how to use this new function, please dial CSC's Fax on Demand at:

(800) 370-5809 and choose document 4024.

You will continue to receive your regular prior approval rosters by mail or electronically.

ePACES Providers may receive their prior approval rosters electronically in their eXchange mailbox by submitting an Electronic Prior Approval Request form, which is available at:

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

If you are not currently using your eXchange mailbox, you can have it activated by calling the CSC Call Center at the number below.

If you have questions about this new feature, of if you would like to enroll in ePACES, please call the eMedNY Call Center at:

(800) 343-9000.


Critical Information for Pharmacy Providers......

Department Launches New Public Website With Pharmacy Prices
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Section 276-a of Public Health Law requires the Department of Health to provide a database on its public web site which lists by pharmacy the usual and customary charge for the 150 most commonly prescribed drugs on the list created annually by the State Education Board of Pharmacy. The purpose of the website is to allow consumers to search and compare pharmacies prices on selected drugs. Development of the website is complete and it will soon become available to the public on the Department of Health's web site (www.nyhealth.gov)

As required by the law, the prices posted on the website will be based on the 'usual and customary price' submitted by the pharmacy in the "amount charged field" of its most recent (based on date of service) NCPDP claim submission to the Medicaid program.

  • The initial data displayed on the website will be based on claims submitted with dates of service beginning in April 2007.
  • Prices will be updated weekly.
  • Up to two prices, one for the brand name drug and one for the generic drug, if available, will be posted on the website.

Pharmacies are responsible for ensuring that the amount in the "amount charged field" of the claim submission is accurate. This information will automatically appear on the website as the price the pharmacy would charge consumers for the prescription.

Questions about the new website can be emailed to rxnyhealth@health.state.ny.us


Do you suspect that an enrollee or a provider has engaged in fraudulent activities?
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Please call:

1-877-87FRAUD

Your call will remain confidential.

Or complete a Complaint Form available at:

www.omig.state.ny.us


Policy and Billing Guidance......

ATTENTION
AMBULETTE PROVIDERS!

2008

Annual Ambulette Survey

Required Information from Ambulette Providers!
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Providers of Ambulette services are reminded that during January of each year they are required to submit vehicle information in accordance with Title 18 NYCRR 502.6(b):

Providers who fail to disclose this information will be subject to termination from the Medicaid Program.

"Each provider of ambulette services must, during the month of January of each year, disclose to the Office of the Medicaid Inspector General (OMIG), in writing, the information concerning those vehicles currently owned or leased by the provider.

The information to be disclosed must include at a minimum the name and address of the provider, each vehicle's license number and Department of Transportation identification number and a statement regarding whether the vehicle is owned or leased.

A provider of ambulette services which fails to disclose this information will have its participation in the medical assistance program terminated."

Survey Forms

The forms identifying the information to be disclosed and the return address will be included in the January 2008 Medicaid Update.

A response must be received by February 15, 2008.

It is strongly recommended that:

  • these forms be submitted via certified mail, return receipt and
  • a copy of both your submission and the proof of mailing be kept for your files.

Proof of mailing must be provided by the provider in the event of non-receipt by the Office of the Medicaid Inspector General.

Questions? Please call the Office of the Medicaid Inspector General at:

(518) 474-9722.


Transportation Providers

Separate Provider Identification Number
Required for Each Dispatching Operating Location
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To receive reimbursement from the New York Medicaid Program, transportation providers must be enrolled in the New York Medicaid Program and have a separate provider identification number for each dispatching operating location.

Ambulance

An additional dispatching operating location can no longer be added to an existing provider service address.

Providers must complete the appropriate forms to notify the Department of additional dispatching operating locations or any changes in their status, such as:

  • ownership change,
  • correspondence address,
  • pay-to address,
  • change of dispatching operating location (service address), or to obtain an enrollment package for a new dispatching operating location, etc.

The forms can be obtained online at:
http://www.emedny.org/info/ProviderEnrollment/index.html
or you may call Computer Sciences Corporation at:
(800) 343-9000.

Questions? Please call the Bureau of Provider Enrollment at (518) 402-7032.


Durable Medical Equipment Providers

Provider Manual Changes
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Please make the following corrections in your Durable Medical Equipment (DME) Procedure Code Section, (Rev. 7/1/07):

  • DVS (Dispensing Verification System) is not required for T4543 (p.17) or E0181 (p. 29).
  • T4543 requires paper Prior Approval and E0181 is direct bill.

The "#" next to these codes in the 07/01/07 Procedure Code Section is a typographical error.

Please make the following fee change in your DME Service Fee Schedule (Rev. 7/1/07):

  • T5001- # Positioning seat for persons with special orthopedic needs, for use in vehicles (prior approval required for age less than 2 or over 10) (up to 60 inches), (p. 59 of 103). Effective for dates of service (DOS) on or after October 1, 2007, the price will be $609.75.

Questions? Call the Pre-Payment Review Group at (800) 342-3005, option 4.


Attention
Article 28 Clinics

Revised Instructions for The Billing of Implanon and Intrauterine Devices
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Effective December 1, 2007, clinics providing Implanon and intrauterine devices (IUD) to registered Medicaid clinic patients are able to bill fee-for-service for the contraceptive device as well as bill the threshold clinic rate for the insertion or removal of the device. Previously, billing for the actual cost of these devices occurred when administered in a physician's office or an ordered ambulatory clinic when a Medicaid patient was referred by a physician or another clinic.

In order to bill fee-for-service for contraceptive devices for registered clinic patients, the clinic must be enrolled in Medicaid and have the designated category of service of 0163 (ordered ambulatory freestanding diagnostic and treatment center) or 0282 (ordered ambulatory hospital-based clinic). For clinics that have a family planning specialty code of 906 on file, Medicaid will automatically assign either COS 0163 or 0282 to their provider enrollment file.

If a clinic does not have a specialty code of 906 on file, they must request the addition of COS 0163 or 0282 to their Medicaid enrollment records, by faxing or mailing a letter on facility letterhead, including the Medicaid provider identification number and signature of an authorized representative to:

Prepayment Review Group
Rate Based Provider Services
150 Broadway, Suite 6E
Albany, New York 12204-2736


or

Fax: (518) 473-6705

Billing Instructions and HCPCS Codes

Two separate claims will be required for submission, one for reimbursement of the clinic visit and one for the contraceptive device.

Clinic Visit

  • For a freestanding diagnostic and treatment center, the clinic visit (for insertion or removal of the IUD or Implanon) must be billed under the clinic category of service 0160, using the clinic rate code of 1610.
  • For a hospital-based clinic, the clinic visit (for insertion or removal of the IUD or Implanon) must be billed under the clinic category of service 0287, using the clinic rate code of 2870.

Contraceptive Device

When billing for the contraceptive device, category of service 0163 or 0282 must be used.

HCPCS Codes for the billing of Implanon and intrauterine devices are:

  • S0180 Implanon
  • J7300 Intrauterine copper contraceptive
  • J7302 Levonorgestrel-releasing intrauterine contraceptive system

The reimbursement for Implanon or the IUD is limited to the actual acquisition cost by invoice to the provider. Claims for these devices do not require submission of an invoice, although the invoice must be maintained for audit purposes.

Medicaid Managed Care and Family Health Plus Enrollees

Medicaid managed care plans that cover family planning services must cover IUDs and Implanon. The cost of the device is never considered a pharmacy item and must always be included in the cost of the practitioner or clinic services.

  • Clinics and practitioners who have contracts with a patient's Medicaid managed care plan to provide family planning services may not bill Medicaid fee-for-service for Implanon or an IUD. Additionally, these clinics and practitioners may not refer health plan members to Medicaid fee-for-service providers for Implanon or an IUD.
  • Clinics and practitioners who do NOT have contracts with a patient's Medicaid managed care plan to provide family planning services may see patients and bill Medicaid fee-for-service when the patient requests Implanon or an IUD on a self referral basis only.

Family Health Plus (FHPlus) plans that cover family planning services must cover implantable contraceptives (Implanon) and IUDs. Enrollees in FHPlus plans that do not cover family planning services can obtain implantable contraceptives (Implanon) or IUDs from Medicaid clinics and practitioners.

Questions about enrollees not in a managed care plan may be directed to the Division of Financial Planning and Policy, Bureau of Policy Development and Coverage at:

(518) 473-2160.

Questions about enrollees in a managed care plan may be directed to the Division of Managed Care and Program Evaluation, Bureau of Managed Care Program Planning at:

(518) 473-7467.


Clinics Providing Dialysis Services

Costs of Laboratory Tests Provided to End Stage Renal Disease Patients Are in Clinic Rate
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The costs of laboratory services related to End Stage Renal Disease (ESRD) treatment are included within the dialysis clinic reimbursement rate-the clinic pays the laboratory directly for the laboratory services that are provided.

In some situations, the patient being treated for ESRD has other illnesses for which lab testing is appropriate. These non-ESRD lab services are not part of the dialysis clinic rate, so they can be provided by any lab enrolled in the Medicaid Program and can be billed by the lab, using the Medicaid fee-for-service laboratory fee schedule.

If you are unsure if laboratory services provided in a dialysis clinic setting are reimbursed within your clinic rate, please contact the Office of Health Insurance Programs, Bureau of Primary and Acute Care Reimbursement at:

(518) 474-3267.


REMINDER to

Medical Practitioners and Laboratories

Proper Claim Completion for Abortion-Related Laboratory Testing
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Abortion-related services are not considered family planning. If a laboratory test is related to an abortion as indicated by the medical practitioner on the requisition form, the laboratory must insert the appropriate abortion code in the abortion/sterilization field on the claim form for processing. Additionally, the family planning field must contain an "X"in the NO box.

Instructions for billing abortion-related services on paper claims and the appropriate codes can be found online in the Billing Guidelines section of the Laboratory Provider Manual at:

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

Billing instructions can be found in the 837 Professional Health Care Claim Companion Guide online at:

http://www.emedny.org/hipaa/emedny_transactions/transactions.html

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


Pharmacy Providers and Prescribers

Backdating Prescriptions and Fiscal Orders
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RX

The Office of the Medicaid Inspector General (OMIG) conducts audits of pharmacy providers to ensure overall compliance with Medicaid regulations.

One of the most common findings at audit is the lack of proper support documentation for a claim, which demonstrates non-compliance with Medicaid regulation Title 18 NYCRR Section 504.3.

Recent Audit Findings

Recent pharmacy audits have revealed the apparent efforts of some providers to reduce this audit finding by:

  • generating backdated documents; or,
  • recreating the "missing" prescriptions and/or fiscal orders.

The generation of new prescriptions/fiscal orders to refute audit findings is illegal and an unacceptable practice under 18 NYCRR Section 515 which subjects both the pharmacy and the prescriber to administrative sanctions.

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


Do You Have a Question About the Medicaid Program?

Question

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Please write to: medicaid@health.state.ny.us.

Your question will be forwarded to the appropriate policy liaison for response and will be answered as soon as possible.


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

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

ACLOVATE 0.05% OINTMENTLITHOBID 300 MG TABLET SA
BIAXIN XL 500 MG TABLET SAMETROGEL-VAGINAL 0.75% GEL
CORTEF 20 MG TABLETQUESTRAN LIGHT PACKET
CUTIVATE 0.05% CREAMROXICODONE 15 MG TABLET
CUTIVATE 0.005% OINTMENTTEMOVATE 0.05% CREAM, SOLUTION, GEL
CYTOTEC 100 MCG, 200 MCG TABLETTESSALON 200 MG CAPSULE
DESFERAL 500 MG VIALTIAZAC 420 MG CAPSULE SA
ESTRACE 1 MG, 2 MG TABLETZOFRAN 2 MG/ML VIAL

Prescriptions for the brand name drugs listed above written prior to December 1, 2007, but filled on or after December 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.

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.

To review the list of Medicaid preferred drugs, please go to:

http://newyork.fhsc.com or http://nyhealth.gov

or to receive a copy of the Medicaid Preferred Drug List, please call:

(877) 309-9493.

For Medicaid pharmacy billing questions, please call:
(800) 343-9000.

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


Group Providers

What You Should Know About Internal Revenue Service 1099 Forms
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Group practices that wish to have their Medicaid claims payment issued to the Group must enter the Group Provider Medicaid Identification Number on their claims. Funds for checks issued to Groups 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 form can not be returned to Computer Sciences Corporation as the 1099 form 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 payments 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. Therefore any claims paid in 2007 to an individual practitioner MMIS ID that should have been paid to the group ID, MUST be voided and rebilled in 2007 to affect a change to the 1099 issued for 2007.

Questions about claim submissions? Please call the eMedNY Call Center at:

(800) 343-9000.


Private Duty Nursing Providers

Fee Increase for Medically Fragile Children
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Based on legislative authority, Medicaid is paying an enhanced fee to eligible independent and agency Private Duty Nursing (PDN) providers for services provided to consumers under the age of 21. The enhanced fee is a 30 percent add-on to payable claims to enrolled PDN providers, who have submitted appropriate attestation to have Specialty 579 added to their enrollment files.

Nurse

The intent of the legislation is that the entire 30 percent add-on, net of any fixed costs is to be paid to the nurses directly providing the service to the patient. Examples of fixed costs include the nursing agency (employer) share of Social Security, tax withholdings and other pro rata premiums such that after payment of such fixed costs, the nursing agency provider neither gains nor loses as a result of the 30 percent add-on.

Payment of the enhanced fee began in August 2007 with dates of service retroactive to January 1, 2007.

Nursing agency providers should review their payment records and ensure any add-on monies received are paid to their nurses in accordance with the above clarification.

Questions? Please contact the Pre-Payment Review Group at:

(800) 342-3005 Option 1.


Private Duty Nursing Providers

Prior Approval Submission Deadline for Care At Home Waiver Enrollees
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As noted in the March 2007 Medicaid Update, private duty nursing services (PDN) provided to children enrolled in the Care at Home (CAH) Waiver program are now subject to prior approval review.

Transition to this process began April 1, 2007 and ran through August 1, 2007. Most providers have submitted and obtained prior approval during this transition timeframe. However, some CAH Waiver cases exist where the providers have not yet submitted an initial prior approval request. To ensure continuity of care, all providers must submit an initial prior approval request no later than December 1, 2007.

Effective for dates of service on and after January 1, 2008:

  • The 'U1' modifier (CAH prior approval bypass) will be discontinued.
  • Claims submitted with the 'U1' modifier will be denied.
  • Prior approval will be required for all PDN codes.
  • Claims submitted without a valid prior approval number will be denied.

Instructions for completing and submitting the prior approval request form (EMEDNY-361501) can be found in the Private Duty Nursing Provider Manual. The Provider Manual and prior approval request forms can be ordered by calling CSC at (800) 343-9000.

Questions related to Care At Home I and II policy and procedures should be directed to the Bureau of Maternal and Child Health at:
(518) 486-6562.

Questions related to Care At Home III, IV and VI policy and procedures should be directed to Office of Mental Retardation and Developmental Disabilities Care At Home Waiver Unit at:
(518) 463-6562.

Questions related to PDN billing, ordering, and completing prior approval forms should be directed to Computer Sciences Corporation at:
(800) 343-9000.

Questions related to PDN prior approval should be directed to the Department of Health's Pre-Payment Review Group at:
(800) 342-3005 option 1.


Physicians Billing for Critical Care

Clarification on Reporting Critical Care Procedure Codes 99291 and 99292
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This is a follow up to the June 2007 Medicaid Update article on billing for critical care services with additional information related to claims submission for these codes:

  • 99291: Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
  • 99292: each additional 30 minutes (listed separately, in addition to code 99291 for primary service). NOTE: Report Required.

Please note the revision for code 99291 to "first 30-74 minutes" as published in Current Procedural Terminology (CPT) and on page 44 of the Medicaid Physician Fee Schedule.

Also note the following guidelines:

  • Critical care of less than 30 minutes total duration on a given date or services for a patient who is not critically ill but happens to be in a critical care unit should be reported with the appropriate Evaluation and Management code;
  • Add-on code 99292 for critical care services in excess of 74 minutes requires submission of paper claims with appropriate medical record documentation attached (see below);
  • Add-on code, 99292 must be billed with primary code 99291 on the same claim form and should never be reported as a stand-alone code. Additionally, multiple units of code 99292 must be combined onto one claim line.

Attachment of Supporting Medical Documentation

Claims for procedure code 99292 require manual review for medical necessity and pricing by the Department of Health (DOH). If upon review of the attachments, illegible or invalid information is found, or medical documentation is missing, the claim will be denied.

For proper billing:

  • Date(s) and begin and end times of the critical care services must be documented and must match the claim date(s) of service.
  • Time spent performing separately reportable procedures or services should not be included in the time reported as critical care time.
  • Legible signatures of the attending practitioner are required.
  • Stamped signatures are recommended on supporting documentation, but only in addition to the written signature.
  • Clinical information must be legible and support billing critical care services.
  • Clarifications of chart notes are acceptable, but not revisions.
  • Underlining or circling pertinent information is acceptable but highlighting is not--highlighting obscures the image on the scanned documentation.
  • Each page of documentation requires patient identification to match the claim form and the documentation must identify the billing provider.

For questions regarding claims billed for critical care, please call:

(800) 342-3005, option #3 for "Medical Pended Claims".


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.


Providers Who Receive Electronic Remittances

Electronic Remittances May Not Always Equal the Total Weekly Paid Amount
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Providers who have chosen to receive electronic remittance information automatically receive the status of claims submitted electronically in the 835/820 electronic remittance format.

State-submitted adjustments/voids are transactions submitted by New York State or one of its contractors, such as Island Peer Review Organization (IPRO) and Public Consulting Group (PCG), and are based on audit findings.

The status of submitted paper claims and state-submitted adjustments/voids, however, is reported on a paper remittance unless the provider requests these to be delivered on the 835/820.

If Computer Sciences Corporation (CSC) issues a paper remittance in addition to an electronic remittance, there is a separate check associated with each remittance statement.

Reporting Paper Claims and State-Submitted Adjustments and Voids on an Electronic Remittance

To have these types of transactions reported on the electronic remittance, providers must designate the Electronic Transmitter Identification Number (ETIN) for the remittance to which they wish to have these transactions delivered.

To communicate this information, providers need to submit an Electronic Remittance Request Form located online at: http://www.emedny.org/info/ProviderEnrollment/index.html

When completing the form, place an X in the appropriate box related to item number 4, which indicates that claims submitted on paper claim forms and adjustments/voids submitted by the State can be reported on the electronic remittance (835 or 820) and that no paper remittance will be issued. Complete the rest of the form and submit it to:

Computer Sciences Corporation

Attn: Provider Enrollment Support

1 CSC Way

Rensselaer, New York 12144

FAX: (518) 257-4632.

For providers who only submit electronic claims and who do not submit paper claim forms, to have State submitted adjustments/voids reported on your electronic remittance, follow the procedures outlined above.

Questions about electronic remittance options should be directed to the eMedNY Call Center at:

(800) 343-9000.


ATTENTION
Physicians, Nurse Practitioners; Licensed Midwives; and Article 28 Hospital-Based and Freestanding Clinics

National Drug Code Required on Medicaid Claims
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The federal Deficit Reduction Act (DRA) of 2005 (at Section 6002) added provisions requiring ambulatory care providers to collect and submit National Drug Code (NDC) numbers on Medicaid claims.

Effective for dates of service on or after January 1, 2008 this provision will require all claims for physician-administered drugs to include the 11-digit NDC (which identifies the drug and manufacturer).

This article previously appeared in the June 2007 Medicaid Update and has been updated to advise providers of new information.

To ensure federal funding for drugs under the Medicaid Program, the New York State Medicaid Program will be collecting rebates based on the information provided on these claims.

Following implementation, claims for physician-administered drugs without valid 11-digit NDC numbers will be rejected.

Drugs subject to this provision include drugs commonly administered and billed in the ambulatory setting (e.g., chemotherapeutics, immune globulins, etc.).

Information on claim format 837 will be provided in the December 2007 Medicaid Update.

Questions? Please call Medicaid Pharmacy Policy and Operations staff at (518) 486-3209.


Did you know

Educational materials have been developed for Medicaid enrollees to help them understand how the Preferred Drug Program may impact their pharmacy coverage.

Brochures are available in English and Spanish.

Prescribers and pharmacists can request a supply by calling:

(518) 951-2040.


Pharmacists

Preferred Drug Program News
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Call Center messaging is updated for every implementation of prior authorization requirements. Please be sure to listen for new information. Once you have heard the new messaging, you can bypass it during subsequent calls by following these steps:

Pills

Call the pharmacy prior authorization call center at (877) 309-9493. Select Option 2 for Pharmacist and then chose one of the following:

  • To validate a prior authorization ending with a 'W', press 1.
    • Press 1 to bypass messaging and begin entering the prior authorization number.
  • To validate a prior authorization that does not end with a 'W", press 2.
    • Press 1 and then 6 to bypass messaging and begin entering the prior authorization number.
  • For information or technical assistance with a prior authorization press 3

Option 9 provides a pharmacy prior authorization program overview and is periodically changed to include specific information to assist providers when requirements change.

Providers can request e-mail notification when there are changes made to the Preferred Drug List (PDL). Requests should be sent to:

NYPDPNotices@firsthealth.com

The most current PDL can be found at: http://newyork.fhsc.com or http://nyhealth.com

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

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

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


General Information.....

Influenza (Flu) Fact Sheets
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Fact sheets (in English and Spanish) regarding the flu can be printed or downloaded online at:

http://www.nyhealth.gov/diseases/communicable/

If you'd like to obtain a stock of flu fact sheets for your patients, please copy or remove this page from the Medicaid Update. Then, complete the following information and fax it to:

(518) 473-5884:

Form NameQuantity (Limit 100)
Influenza (Flu) Fact Sheet - English 
Influenza (Flu) Fact Sheet - Spanish 
Mailing Address
       
       
       
       
       

Comments or suggestions regarding Communicable Disease fact sheets should be sent to:

Regional Epidemiology Program

Bureau of Communicable Disease Control

New York State Department of Health

Empire State Plaza, 651 Corning Tower

Albany, New York 12237-0627

 

Telephone: (518) 473-4439

Fax: (518) 408-1745

influenza@health.state.ny.us


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.health.state.ny.us/health_care/medicaid/program/update/main.htm
Hard copies can be obtained upon request by emailing: medicaidupdate@health.state.ny.us

Office of the Medicaid Inspector General Contact Information
(518) 473-3782 or www.omig.state.ny.us

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

Enrollee Eligibility
Call the Touchtone Telephone Verification System at any of the numbers below:
(800) 997-1111    (800) 225-3040       (800) 394-1234.

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

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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