April 2008  
Volume 24, Number 5  

New York State

Medicaid Update

The official newsletter of the New York Medicaid Program

David A. Paterson, 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



Information for All Providers

Correct Submission of Replacement Claims
Do not submit additional claim lines on replacement claims.

Paper Claim Submitters: Electronic Transmitter Identification Number Required
Obtain your ETIN today.

Computer Sciences Corporation Address Changes
New addresses effective March 29, 2008.

Payment Error Measurement Rate Program Update: Request for Medicaid Provider Documentation
Documentation may be requested as a part of this program.

Disclosure of Ownership and Control Information
Providers must send information to Medicaid.

Medicaid Presumptive Eligibility for Children
Providers may now encounter children without common forms of Medicaid identification.

Policy and Billing Guidance

Sterilization Consent Form Requirements
Proper completion of the Sterilization Consent Form.

Pharmacists: Prescription Serial Numbers and Compound Billing for Individual Ingredients
Information for billing compounded prescriptions.

Herpes Zoster Vaccine: Medicaid Reimbursement Policy When Medicare is the Primary Insurance
Medicare Part D covers Herpes Zoster Vaccine.

Claim Requirements for Physical and Occupational Therapies
Changes to Medicaid regulations for physical and occupational therapies.

New Rate Codes for Federally Qualified Health Centers
New rate codes effective June 1, 2008.

2008 Top 20 Diagnosis Related Group Table
The table to be used for discharges in calendar year 2008

Coming Soon: Easy Identification of 340B Priced Claims
Soon it will be easier to identify 340B drugs.

Preferred Drug Program Update
New drug categories added.

Reminder: Responsibility for Transportation Provider Reimbursement
OMRDD facilities and providers are responsible for non-emergency transportation.

Ambulance Providers: Obtaining Payment May Require a Medicaid Subrogation Notice
When it is appropriate to submit and what to include on a Medicaid Subrogation Notice.

Provider Services

The Medicaid Program is dedicated to assuring quality health care to the underprivileged of New York State.

We thank you who treat our enrollees with dignity and respect.

Caduceus


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

Correct Submission of Replacement Claims
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Replacement claims (also known as adjustment claims) change information on a previously paid claim. It is not permissible to add lines to a replacement claim that were not previously submitted on the original paid claim. Additional claim lines should be submitted as original claims.

Edit 02077, More Lines on Adjustment than Original, will deny replacement claims containing more lines than the original paid claim.

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


Attention:
Paper Claim Submitters

Electronic Transmitter Identification Number Required
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Soon, the Medicaid Program will require all providers to have an Electronic/Paper Transmitter Identification Number (ETIN) on file with Computer Sciences Corporation.

An ETIN application must be submitted as soon as possible to prevent an interruption of Medicaid payments. The ETIN Application and the Certification Statement required to obtain an ETIN can be found at:

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

No additional ETIN is necessary for those providers already submitting claims electronically (e.g., via ePACES).

Consider ePACES, an internet-based program that allows Medicaid providers to submit claims, eligibility requests (including Service Authorizations), claim status and electronic prior approval requests, and view the associated responses.

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


Computer Sciences Corporation Address Changes
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Please use the following chart when sending mail to Computer Sciences Corporation.
Address mail in the following format:

Computer Sciences Corporation

P.O. Box ______

Rensselaer, New York 12144-_____

P.O. Box ZIP Code Extension Description of Contents Form Types
46004600 Prior Approval and Prior Authorization Requests
  • EMEDNY-3614 (Dental)
  • EMEDNY-3615 (Drugs...Physician)
  • EMEDNY-2832 (Hearing Aid)
  • EMEDNY-1260 (Level of Care)
  • EMEDNY-3897 (Transportation)
  • EMEDNY-4106 (Group Transportation)
  • PA Additional Information
46014601Claims
  • EMEDNY-1500 (HCFA)
  • EMEDNY-0002 (Form A)
  • EMEDNY-0003 (Pharmacy)
46024602 Threshold Override ApplicationsEMEDNY-0001 (TOA)
46034603 Provider Enrollment Applications All Fee-For-Service and Rate-Based Enrollment Packets
46044604Edit ReviewProvider submitted documentation to adjudicate claims
4605 4605 Remittance Retrieval Requests from providers for copies of remittance statements
4606 4606 Additional Information Provider Enrollment Additional Information Form with attachments
4610 4610Provider MaintenanceProvider maintenance (update) forms and related correspondence
4614
New P.O. Box!
8614 Electronic Form Requests
  • Electronic Certifications
  • ETIN Applications
  • Security Packet A
  • Security Packet B
  • Electronic Remittance Request
  • Electronic Prior Approval Request
  • Remittance Sort Request
  • Pended Claim Recycle Request
  • Request to Disaffiliate/Delete an ETIN
4616
New P.O. Box!
8616 Electronic Funds TransferElectronic Funds Transfer Enrollment Forms

Payment Error Measurement Rate
(PERM) Program Update

Request for Medicaid Provider Documentation
Return to Table of Contents

Requests and subsequent receipt/non-receipt of documentation will be tracked.

Failure to provide requested records will result in a determination of erroneous payment, and the OMIG will pursue recovery.

The Centers for Medicare & Medicaid Services (CMS), in partnership with the New York State Office of the Medicaid Inspector General (OMIG), is measuring improper payments in the Medicaid and State Child Health Insurance programs under the Payment Error Rate Measurement (PERM) program.

CMS, their contractor, and the OMIG have the authority to collect this information under sections 1902(a)(27) and 2107(b)(1) of the Social Security Act. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) statutes and regulations require the provision of such information upon request, and the information can be provided without patient consent.

Documentation for medical review of randomly selected claims will be requested by Livanta LLC, the CMS contractor. If claims you submitted are selected, the CMS contractor will request from you, in writing, documentation to substantiate claims paid in federal fiscal year 2008 (October 1, 2007 - September 30, 2008) . Your cooperation and a timely response are requested. Submit the specific medical documents for the patient, as requested in the letter you receive from the CMS contractor, directly to the CMS contractor with a copy to the OMIG.

Requests for documentation will begin in May 2008.

Questions? Please contact PERM Project staff at (518) 486-7153 or (518) 408-0533.


Do you suspect that an Medicaid enrollee or a provider has engaged in fraudulent activities?
Return to Table of Contents

Please call:

1-877-87FRAUD

Your call will remain confidential.

Or complete a Complaint Form available at:

www.omig.state.ny.us


Disclosure of Ownership and Control Information
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Application forms for Fee-for-Service providers are available at http://www.emedny.org/info/ProviderEnrollment/index.html. Providers must download a separate application for each submission.

Rate-Based/Institutional providers should complete and submit a new Disclosure of Ownership document to the Medicaid Program. To obtain a copy of this document, please call the Rate-Based Provider Unit at (518) 474-8161, or email rbu@health.state.ny.us. Based upon the State's review of the document, the provider may also be required to complete a new enrollment form.

Enrollment, including the use of a Medicaid provider identification number, is not assignable or transferable to another owner without completion and approval of appropriate paperwork. Providers and fiscal agents (known as disclosing entities) must report any change in ownership or control within 15 days of the change by filing an amended application form which includes the ownership and disclosure form. Failure to comply with the submission of ownership and control changes can result in the termination of your provider number and/or monetary penalties.

Medicaid regulations at 18 NYCRR §502.2 define ownership or control interest as a person or corporation that:

  • has an ownership interest totaling five percent or more in a disclosing entity;
  • has an indirect ownership interest equal to five percent or more in a disclosing entity;
  • has a combination of direct and indirect ownership interests equal to five percent or more in a disclosing entity;
  • owns an interest of five percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least five percent of the value of the property or assets of the disclosing entity;
  • is an officer or director of a disclosing entity that is organized as a corporation; or
  • is a partner in a disclosing entity that is organized as a partnership.

Each provider and fiscal agent must disclose the following information:

  • the name and address of each person with an ownership or control interest in the disclosing entity or in any subcontractor in which the disclosing entity has direct or indirect ownership of five percent or more or who is a managing employee in the disclosing entity;
  • whether any of the persons named is related to another as spouse, parent, child or sibling; and
  • the name of any other disclosing entity in which a person with an ownership or control interest in the disclosing entity also has an ownership or control interest.

Questions? Please contact Enrollment staff at (800) 342-3005, Option #4.


Medicaid Presumptive Eligibility for Children
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Children younger than age 19 may now become presumptively eligible for Medicaid if assessed by a State-designated Qualified Entity (QE).

Presumptive eligibility is determined by QEs through a screening. Children who appear eligible based on the screening may receive all Medicaid covered care and services, until a full Medicaid eligibility determination is made by their local department of social services.

Medicaid providers may encounter children determined presumptively eligible, but who are not in possession of a Benefit Identification Card or a Medicaid Client Identification Number (CIN). These children will have a letter, from the QE, indicating they are presumptively eligible for Medicaid and are therefore entitled to Medicaid coverage.

The QE that screened the child will be given a CIN once an ongoing Medicaid determination has been made. The CIN will be used for billing during the presumptive period. Providers may obtain this CIN from the QE.

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


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 to: medicaidupdate@health.state.ny.us


Policy and Billing Guidance.......

Sterilization Consent Form Requirements
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Attention

  • Surgeons
  • Anesthesiologists
  • Hospitals
  • Article 28 Clinics

When procedures are performed for the primary purpose of rendering an individual incapable of reproducing, the patient must have been informed of the risks and benefits of sterilization and have signed and received a copy of the Sterilization Consent Form (LDSS-3134 or LDSS-3134s).

The completed and signed Sterilization Consent Form must be attached to the claim form and submitted with all surgeon, anesthesiologist and facility claims for sterilizations. Hospitals and Article 28 clinics submitting claims electronically must maintain a copy of the completed Sterilization Consent Form in their files.

The sterilization consent form is available in both English and Spanish at:

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

When completing the Sterilization Consent Form:

  • Be certain that the form is completed so it can be easily read. An illegible or altered form is unacceptable (and will cause a paper claim to deny).
  • Ensure that the form is signed and dated by the individual to be sterilized and the physician who performed the procedure.
  • Complete each required field in order to ensure payment.
  • Include the full name of the surgery or procedure in terms that are understandable to the patient. Abbreviations or acronyms are unacceptable in the "Consent to Sterilization" section (left side) of the Consent Form.

Claims without a properly completed Sterilization Consent Form will not be processed for payment. In conformance with the 2006 New York State Surgical and Invasive Procedure Protocol, claims signed by the patient on or after June 1, 2008 with an abbreviation or acronym used for the procedure name will be denied. The New York State Surgical and Invasive Procedure Protocol is available online at:

http://www.health.state.ny.us/professionals/protocols_and_guidelines/surgical_and_invasive_procedure/docs/protocol.pdf

Refer to the Billing Section of your Provider Manual for additional completion instructions.

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


Attention
Pharmacists

Prescription Serial Numbers and Compound Billing for Individual Ingredients
Return to Table of Contents

When billing for compounded prescriptions using the individual NDC code:

Pills

  • Each ingredient must have a unique prescription number.
  • Initial ingredient should be identified using the prescription serial number from the official New York State prescription form. Note: Compounds containing controlled substances must treat the controlled substance in greatest quantity as the initial ingredient.
  • Subsequent ingredients should be identified by using CCCCCCCC in lieu of the prescription serial number.

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


Herpes Zoster Vaccine:
Medicaid Reimbursement Policy When Medicare is the Primary Insurance
Return to Table of Contents

Effective January 1, 2008, administration of Herpes Zoster vaccine (Zostavax) to a dual-eligible enrollee (i.e., a patient with both Medicare and Medicaid), is covered by Medicare Part D, not Medicare Part B, and cannot be billed to Medicaid for reimbursement.

For more information about other preventive vaccines covered by Medicare Part D, the provider should contact the patient's Medicare Part D prescription plan.

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


Information for You and Your Patients...
Return to Table of Contents

Smokers Quitline
(866) 697-8487

Managed Care Complaints
(800) 206-8125


Claim Requirements for Physical and Occupational Therapies
Return to Table of Contents

This is an update to the October 2007 Medicaid Update article titled "Requirements for Billing a Clinic Threshold Visit Claim Involving Physical Therapy"

Medicaid regulations now allow occupational therapy assistants and physical therapist assistants to qualify as professionals that can provide rehabilitative services to Medicaid enrollees. The full text of the regulation is available at the Department's website: www.nyhealth.gov/regulations/nycrr/title_18/ (search Title 18, and type in 505.11).

Physical Therapy

Physical therapy services may be billed when:

  • The physical therapist or physical therapist assistant is licensed or certified, respectively, and currently registered with the New York State Education Department.
  • There is appropriate supervision, meeting requirements identified by the State Education Department, of the physical therapist assistant by the physical therapist.
  • Physical therapy services are provided on a one-to-one basis with the patient and the physical therapist or physical therapist assistant.
  • The patient encounter must last for a minimum of 15 minutes as designated by the procedure code being billed.

A clinic threshold visit may be billed when the patient is seen by a physical therapist or physical therapist assistant when the conditions above are met.

Private practicing physical therapists can bill Medicaid fee-for-service for the rehabilitative therapy services provided by physical therapist assistants when the conditions above are met.

Occupational Therapy

Occupational therapy services may be billed when:

  • The occupational therapist or occupational therapy assistant is licensed or certified, respectively, and currently registered with the New York State Education Department.
  • There is appropriate supervision, meeting requirements identified by the State Education Department, of the occupational therapy assistant by the occupational therapist.
  • Occupational therapy services are provided on a one-to-one basis with the patient and the occupational therapist or occupational therapy assistant.
  • The patient encounter must last for a minimum of 15 minutes as designated by the procedure being billed.

A clinic threshold visit may be billed when the patient is seen by an occupational therapist or occupational therapy assistant when the aforementioned conditions are met.

Private practicing occupational therapists can bill Medicaid fee-for-service for the rehabilitative therapy services provided by occupational therapy assistants when the aforementioned conditions are met.

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


New Rate Codes for Federally Qualified Health Centers
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Federally Qualified Health Centers (FQHCs) will receive a notification letter regarding the addition of three new rate codes and their respective reimbursement amounts for clinic services provided by freestanding and hospital-based clinics that are FQHCs (including FQHC "look-alikes" and rural health clinics).

Effective for dates of service on or after June 1, 2008, the new FQHC rate codes are as follows:

Rate CodeService
4011 FQHC Group Psychotherapy*
4012 FQHC Off-Site Visit*
4013 FQHC Individual Threshold Visit

* Group psychotherapy and off-site visits are only reimbursable to FQHC clinics.

Providers may not bill any combination of the 4011, 4012, 4013 rate codes for the same Medicaid enrollee on the same date of service.

Questions concerning FQHC payment policy should be directed to
the Bureau of Primary and Acute Care Reimbursement at (518) 474-3267.


The February 2008 Medicaid Update contained an article entitled "Clarification of Commercial Insurance Billing Requirement". The article contained billing guidance regarding Medicaid payment in situations where the provider contracts or does not contract with a commercial insurance payer.

The Medicaid billing guidance contained in the article applies to Articles 16, 28, 31, and 32 clinics and practitioners (including Durable Medical Equipment providers).

For questions regarding appropriate billing procedures, please call Robert Pozniak at (518) 257-4511.

For questions regarding Third Party policy issues, please call (518) 474-9193.


Attention
Hospitals Billing
Diagnosis Related Groups

2008 Top 20
Diagnosis Related Groups (DRGs)
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The table below shows the Top 20 Diagnosis Related Groups (DRGs) which impact Medicaid payments to New York State hospitals. This table will be used for discharges which occur in calendar year 2008. When payment for one of these DRGs is indicated, the remittance statement will list rate code 2996 rather than 2946.

Providers can access the Service Intensity Weight (SIW) table for New York State hospitals at:

www.health.state.ny.us/facilities/hospital/drg/drgs.htm

DRG #DIAGNOSIS RELATED GROUP NAME
88Chronic Obstructive Pulmonary Disease
89Simple Pneumonia & Pleurisy Age 17 W Cc
127Heart Failure & Shock
143Chest Pain
183Esophagitis, Gastroent & Misc Digest Disord Age17 W/O Cc
209Maj Joint & Limb Reattachment Procedure Of Low Ext, Exc Hip, Exc For Comp
359 Uterine & Adnexa Proc For Ca In Situ & Nonmalig W/O Cc
370Cesarean Section W CC
371Cesarean Section W/O CC
372Vaginal Delivery W Complicating Diagnoses
373Vaginal Delivery W/O Complicating Diagnoses
494Laparoscopic CholecystectomyW/O Cde W/O Cc
627Neonate, Bwt 2499g, W/O Signif Or Proc, W Major Prob
628Neonate, Bwt 2499g, W/O Signif Or Proc, W Minor Prob
629Neonate, Bwt 2499g, W/O Sign Or Proc, W Norm Newb Diag
775Bronchitis & Asthma Age ‹18 W/O Cc
814Nonbacterial Gastroenteritis & Abdominal Pain Age ›17 W/O Cc
854Percutaneous Cardiovascular Procedure W Drug-Eluting Stent W/O Ami
883Laparoscopic Appendectomy
886Other Antepartum Diagnoses W/O O.R. Procedure

Note: The table for calendar years 2007 and 2008 is the same.

Questions? Please call the Pre-payment Review Group, Rate Based Provider Bureau at (800) 342-3005.


Attention
Hospitals & Pharmacies
Designated as 340B Entities

Coming Soon: Easy Identification of 340B Priced Claims
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Providers will be notified when the following options are available:

When using these options the 340B price must be billed to Medicaid.

It is not necessary to enter the NDC code or NDC units on ordered ambulatory (837 I) 340B claims.

Pharmacy Providers

A pharmacy will have the ability to identify when it is billing Medicaid for a 340B drug by entering a value of 09 in field 423-DN, basis of cost determination, using NCPDP version J.1.

Ordered Ambulatory Providers

Hospitals and clinics will have the ability to identify when they are billing Medicaid for a 340B drug by entering a value of UD when using the product service qualifier-loop 2400, SV2 segment, data element SV202-3 through SV202-6 on the 837I electronic format.

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


Question

Do You Have a Question About the Medicaid Program?

  

Please write to:

Medicaid@health.state.ny.us

 

Your question will be answered as soon as possible.


Preferred Drug Program Update
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Pills

Prescriptions written on or after April 15, 2008, for nonpreferred drugs in the following drug categories, will require prior authorization:

  • Growth Hormones
  • Erythropoiesis Stimulating Agents
  • Progestins (for Cachexia)
  • Carbamazepine Derivatives
  • Ophthalmic Non-Steroidal Anti-Inflammatory Drugs
  • Ophthalmic Alpha-2 Adrenergic Agonists.

The current Preferred Drug List may be found on the following sites:

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 prior authorization worksheet/fax form can be found at:

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

For Preferred Drug Program questions, call (877) 309-9493.

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

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

 

The New York State Medicaid Preferred Drug List

is available at the following website:

https://newyork.fhsc.com/


Office of Mental Retardation and Developmental Disabilities Certified:

  • Day Treatment;
  • Day Habilitation and Residential Providers;
  • Intermediate Care Facilities;
  • Supervised Community Residences and
  • Supervised and Supportive Individualized Residential Alternatives

Transportation providers may not separately bill Medicaid for transportation as described in this article.

Responsibility for Transportation Provider Reimbursement
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Office of Mental Retardation and Developmental Disabilities (OMRDD) Day Treatment and Day Habilitation agencies must provide or pay for transportation to and from their programs using their day program reimbursement.

OMRDD certified Intermediate Care Facilities (ICF/DDs), Supervised Community Residences, and Supervised and Supportive Individualized Residential Alternatives must provide or pay for all resident transportation to medical and clinical appointments, at no additional cost to the Medicaid Program.

Ambulance service should not be used for routine transportation to medical or clinical visits, or to and from day programs. Emergency 911 ambulance service, or ambulance discharge from a hospital, may be billed separately to Medicaid on a fee-for-service basis.

Questions? Please contact Karla Smith of OMRDD at (518) 402-4333 or by email at karla.smith@omr.state.ny.us


Attention
Ambulance Providers

Obtaining Payment May Require a Medicaid Subrogation Notice
Return to Table of Contents

When a Medicaid enrollee has commercial insurance in which the ambulance company is not a participating provider, and active Medicaid coverage, the ambulance company can send a "Medicaid Subrogation Notice" to the commercial insurance company advising them to pay the ambulance provider as an agent of the Department of Health. The Medicaid Subrogation Notice can be obtained from the local department of social services.

Note: providers not participating in Medicare can not bill Medicare regardless of the New York State Subrogation Laws.

Questions? Please call the Third Party Policy Unit at (518) 474-9193 or
the Transportation Policy Unit at (518) 474-5187.


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/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 (518) 473-3782

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.

Comments and Suggestions Regarding This Publication?
Please contact the editor, Kelli Kudlach, 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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