---

---

Information for All Providers

Duplicate Claims Denials
Note to providers regarding the most common reason for claims denials.

eMedNY Website Highlight: What's New
Where to find a list of new or changed online documents.

Medicare Coinsurance Update
Notifies providers when Medicaid will pay the full Medicare coinsurance amount.

Reminder: Seminar Schedule and Registration
Find out how to sign up for a billing seminar!

Your Provider Manual is Online
Be sure that you're up to date!

Reminder: Access to the Medicaid Eligibility Verification System via ePACES
Sign up for ePACES.

Policy and Billing Guidance

Attention Prescribers: Enteral Formula Prior Authorization
Information provided during the prior authorization process is subject to confirmation.

Attention Prescribers: Be Prepared When Requesting Prior Authorization for Non-Preferred Drugs.
This article details information that the prescriber must provide at the time a request for prior authorization is made.

Attention Dentists and Hearing Aid Providers: Dispensing Validation Systems Coming Soon
Describes new systems to be implemented in 2008.

Reminder: Coverage of Medical Supplies and Over-the-Counter Drugs by the Office of Mental Retardation and Developmental Disabilities
A new policy went into effect January 1, 2008.

General Information

Medicare Part D Update: Cost Sharing Clarification
Clarification of information contained in the January 2008 Medicaid Update.

Medicaid Eligibility Renewal Changes
Certain enrollees are able to provide income and address information any time following initial application.

Provider Services

---

Information for All Providers...........

On average, 240,000 claims are denied each week for a single reason:

Duplicate Claim in History
(Edit Reason Code 00705).

This edit means that the service claimed had been previously billed and paid by Medicaid.

Providers Utilizing a Billing Service or Clearinghouse

Providers who utilize a billing service or clearinghouse that charges a fee per transaction may incur unnecessary costs when a duplicative claim is submitted.

Work closely with these entities to ensure their claim submission systems comply with Medicaid billing requirements. A large number of pended or denied claims could signify billing deficiencies and should be addressed with the billing service or clearinghouse.

Providers Who Bill Directly

Providers who bill Medicaid directly are encouraged to monitor their billing system to ensure claims are completed correctly and their status is properly tracked to avoid duplicate billing.

If you are experiencing billing difficulties, please call the eMedNY Call Center at (800) 343-9000.

---

At http://www.emedny.org/new/index.html, you can find a chronological list of new or changed document postings. Each posting is dated and a description is provided to alert providers of information that may be of particular interest. Posted documents have a clickable link to easily bring the reader to the current version.

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

---

As an update to previous articles, there are two additional circumstances when the full Medicare coinsurance amount will be paid:

1. When no Medicaid fee is listed in the applicable Fee Schedule for a procedure code;
   
   or
   
   
2. If the procedure code is not active for Medicaid-only billing.

Two special claims reprocessing runs have been completed to calculate the appropriate Medicare coinsurance amount to be paid by Medicaid for dates of service on and after April 1, 2005 in accordance with the above circumstances.

Claims were reprocessed based on the procedure codes and modifiers submitted to Medicaid. Providers must bill Medicaid with the same procedure codes and modifiers billed to Medicare to obtain the correct coinsurance payment, either full coinsurance or 20% of coinsurance.

If provider reporting was changed from the Medicare claim to the Medicaid claim, providers must file an adjusted claim; reporting the same procedure and modifier as billed to Medicare.

Additional Information

For additional information regarding reimbursement of Medicare coinsurance, please refer to the online index of Medicaid Update articles at:

http://www.health.state.ny.us/health_care/medicaid/program/update/medup-index.htm

For billing questions, call the eMedNY Call Center at (800) 343-9000.

---

---

To find and register for the eMedNY Training Seminar appropriate for your provider category and location, go to:

http://www.emedny.org/training/index.aspx

---

 

Click on the link to your Provider Manual at http://www.emedny.org/ProviderManuals/index.html and you will find 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 theeMedNY Call Center at the number below to request a paper copy:
(800) 343-9000.

---

Providers who do not verify eligibility and conditions of coverage before rendering services to Medicaid enrollees run the risk of non-payment of claims.

Find out how to sign up for ePACES by calling the eMedNY Call Center at (800) 343-9000.

---

Policy and Billing Guidance...........

Prescribers must initiate a prior authorization for enteral formula by calling the number below and answering questions on the automated voice interactive system:

(866) 211-1736.

The information provided may be used to validate appropriate coverage and payment on a post-payment basis.

The prescriber and/or dispenser will be held accountable if inaccurate information is provided. Examples of inaccurate information include, but are not limited to:

• Answering "YES" to tube feeding when the enrollee is taking the formula by mouth;
• Reporting inaccurate enrollee age, weight or height;
• Requesting daily caloric supplementation that is not supported by the enrollee's medical record or covered by Medicaid; or
• Allowing or encouraging an enteral dispensing provider to initiate the prior authorization.

Enteral Formula Guidance for Prescribers

The Prescriber Worksheet is located at:

http://www.emedny.org/ProviderManuals/Physician/communications.html

The Coverage Criteria is located in the DME Provider Manual at:

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

The Coding Classification List and Dispenser Worksheet are located at:

http://www.emedny.org/ProviderManuals/DME/communications.html

Questions? Call the Pre-Payment Review Group at (800) 342-3005, Option # 1.

---

Prior authorization requests for non-preferred drugs in the Preferred Drug Program are processed through the pharmacy prior authorization clinical call center.

Call (877) 309-9493, select option "1"
and speak with a call center representative to obtain prior authorization.

The following information must be provided for a prior authorization to be issued:

• Prescriber's Medicaid ID number or license number;
• Enrollee's Medicaid ID number; and
• The name of the non-preferred drug.

If you prescribe a preferred drug, no prior authorization is required.

Prescribers will be asked the following questions:

• Has the patient experienced a treatment failure with the preferred drug?
• Has the patient experienced an adverse drug reaction with a preferred drug?
• Is there a documented history of successful therapeutic control with a non-preferred drug and transition to a preferred drug is medically contraindicated?
• Non-preferred drugs on the PDL that are followed by a "CC" (clinical criteria), will require an additional question pertinent to that drug.

---

Later this year, the Dispensing Validation Systems (DVS) will be implemented for certain hearing aid and dental procedure codes.

What will DVS do?

Once implemented, authorization to provide services (e.g., replacement of full dentures after the four year frequency limit has passed), can be obtained through DVS without submitting a prior approval request.

How will DVS be accessed?

Providers will be required to access the system by one of the following methods:

• a Medicaid Eligibility Verification System (MEVS) terminal, or,
• ePACES or similar, compatible software.

If you do not have ePACES or MEVS access, please call Computer Sciences Corporation at (800) 343-9000 to make arrangements to prepare for the implementation of DVS.

Additional information about the implementation date and DVS procedures will be included in future Medicaid Update articles.

Questions? Please call the Pre-Payment Review Group (800) 342-3005.

---

---

For purchases made on or after January 1, 2008, each:

• Intermediate Care Facility for the Developmentally Disabled (ICF/DD);
• Supervised Individualized Residential Alternative (IRA);
• Supervised Community Residence (CR); and
• Specialty Hospital

certified by the Office of Mental Retardation and Developmental Disabilities, is responsible for the costs of:

• medical gloves;
• underpads and diapers; and
• over-the-counter drugs (except insulin).

Questions? Please contact Jack Anderton of OMRDD at (518) 402-4339, or via email to
john.anderton@omr.state.ny.us

---

Do you want to receive your copy of the Medicaid Update up to 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!

---

General Information...........

In 2008, cost sharing for full benefit dual eligibles (those with both Medicaid and Medicare) is $1.05 for generic and $3.10 for brand name drugs, unless the enrollee is institutionalized. Institutionalized enrollees are not subject to Medicare Part D co-pays.

What if it appears a full dual eligible beneficiary is being charged an incorrect deductible or high co-payment?

The Centers for Medicare and Medicaid Services (CMS) requires Medicare Part D plans to rely on best available evidence to determine that the enrollee is a dual eligible (Medicare/Medicaid) or has been determined eligible for the Low Income Subsidy (LIS) by the Social Security Administration. CMS considers it best practice for the Part D plans to work with pharmacies to resolve these issues at the point of sale when enrollees present the pharmacist with appropriate evidence of low income subsidy status.

The Medicare Part D Best Available Evidence Policy is available at:

http://www.cms.hhs.gov/PrescriptionDrugCovContra/Downloads/BAEGuidance_06.27.07.pdf

Acceptable Proof of Medicaid Eligibility

Plan sponsors must obtain documentation to support a change to the enrollee's LIS status. To establish a person's Medicaid status, the plan must obtain one or more of the following documents confirming Medicaid eligibility:

• A report of contact including the date a verification call was made to the State Medicaid Agency and the name, title and telephone number of the State representative who verified the Medicaid status during the discrepant period; or
• A copy of State-issued documentation or a screen print from the State's Medicaid system that confirms active Medicaid status during the discrepant period.

Acceptable Proof of Change in Level of Care

To establish that an enrollee is institutionalized and qualifies for a zero cost-sharing level, the plan will require one or more of the following:

• A remittance from the facility showing Medicaid payment for a full calendar month for that individual during the discrepant period; or
• A copy of a state document that confirms Medicaid payment to the facility for a full calendar month on behalf of the enrollee.

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

---

Effective January 1, 2008, Medicaid enrollees in the following categories are allowed to attest, at renewal or any time after initial application, to the amount of their income and to their residence, even if their address has changed since their last eligibility determination:

image

• community Medicaid enrollees not seeking coverage of long-term care services;
• enrollees exempt from a resource test;
• all Family Health Plus (FHPlus) enrollees; and
• enrollees of:
  • the Medicare Savings Program (MSP);
  • the Family Planning Benefit Program (FPBP);
  • Medicaid Buy-In Program for Working Persons with Disabilities (MBI-WPD); and
  • the Medicaid Cancer Treatment Program (Breast, Cervical, Colorectal and Prostate).

Documentation of income and residence at initial application is required. Local social services districts are required to verify the accuracy of the income information provided by comparing it to information to which they have access; e.g., computer matches or information obtained by another department within the agency.

A periodic sample of enrollees will be required to provide documentation of income and residence at renewal. This provision will be refined at a later date.

Questions? Please call the Bureau of Medicaid and Family Health Plus Enrollment at (518) 474-8887.

---

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/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: http://www.omig.state.ny.us

Questions about an Article?
Each article contains a contact number for further information, questions or comments.

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

Provider Training
To sign up for a provider seminar in your area, please enroll online at:

http://www.emedny.org/training/index.aspx

For individual training requests, call (800) 343-9000 or email:

emednyproviderrelations@csc.com

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 Providers
A change of address form is available at:

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

Rate-Based/Institutional Providers
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.