March 2009    Volume 25, Number 3  

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



Dear Medicaid Provider,

Medical

Welcome to the March 2009 edition of the Medicaid Update. This month's publication features important policy and procedure guidelines to assist our diverse provider network including certified asthma and diabetes educators, dental providers, footwear providers, and ambulance providers. You will also find important information concerning the APG payment policy for reimbursement of ancillary services for laboratory and radiology procedures.

As always, we would like to thank you for being part of our provider network and for your efforts in delivering care to Medicaid beneficiaries.

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


In this issue....

Woman

POLICY AND BILLING GUIDANCE

APG payment policy for reimbursement of ancillary services
Medicaid coverage for mental health counseling provided by LCSW/LMSW
New APG rate codes for school based health clinics
Transportation Providers: April Release of Revised Transportation Request Form
Certified Asthma and Diabetes Educators
Dental services provided to beneficiaries with removable prosthetic replacements
Footwear providers must hold current certification to obtain reimbursement
Orderers of medical-surgical supplies now subject to post and clear
Provider Bulletins
Outpatient coding for Medicaid
OMIG lists disqualified individuals on Website
Coverage for fetal nuchal translucency measurement ultrasound

PHARMACY PROVIDERS

Q&A - Original serial number must be reported on the pharmacy claim for refill of Rx

NEWS FOR ALL PROVIDERS

Smoking Cessation Advertisement
eMedNY Provider Support
CSC offers Medicaid provider seminars
Provider Services


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

Call: 1-877-87FRAUD or (212 417-4570)

Your call will remain confidential.

You can also complete a Complaint Form online at:

www.omig.state.ny.us


Is Your E-mail Address Up To Date?

Please notify us immediately if your e-mail address changes so that we may continue to keep you apprised of current Medicaid policy guidelines and bulletins. It is the responsibility of each provider to alert Medicaid of any address or e-mail changes as soon as they occur. Please send your new information to medicaidupdate@health.state.ny.us. Thank you for your continued feedback.


APG Payment Policy: Reimbursement of Ancillary Laboratory and Radiology Services
Return to Table of Contents

Checklist

General Policy - Under the new APG payment methodology, Medicaid payment for laboratory and radiology services ordered by practitioners in hospital-based outpatient clinics or free standing diagnostic and treatment center (D&TC) clinics is made to the clinic.

When the hospital or D&TC patient receives the ancillary service from someone other than the clinic, the clinic is responsible for paying the individual or entity providing the ancillary service, even in the absence of a contractual relationship between the two parties.

The ancillary service provider may not bill Medicaid directly for lab or radiology services related to an APG reimbursed visit and should therefore bill the ordering clinic for the service provided to clinic patients. For example, when a practitioner in Clinic A orders a lab test or radiology service that the clinic is not able to provide and the patient goes to Provider B (separate hospital, lab or a radiology group) to receive the service, Clinic A will be responsible for billing eMedNY for the ancillary service and making arrangements to pay Provider B for the delivery of the service. Clinic providers may wish to develop or revisit existing contractual arrangements with laboratory and radiology providers to ensure the availability of ancillary services for their patients and to avoid payment issues upon the implementation of the new APG payment methodology.

Hospitals and D&TCs are responsible for advising outside lab and radiology service providers when the payment for the ancillary service is subject to APG reimbursement and the APG ancillary billing policy.

Hospital-Based Outpatient Clinics: The above laboratory and radiology billing policy is being phased in for hospital-based outpatient clinics.

Transitional billing policy for dates of service December 1, 2008 through June 30, 2009:

  • Ancillary services for clinic patients should be billed using the 1400 APG rate code.
  • Laboratory or radiology services which have historically been referred to an outside laboratory or radiology provider may continue to be billed directly to eMedNY by the ancillary service provider using the Medicaid fee schedule for this period. Medicaid will pay the laboratory or radiology services provider directly.
  • All ancillary services provided by the hospital should be reported on a clinic claim, even those that map to a "never pay APG" or an "if stand alone, do not pay APG"1 for correct coding purposes. This information will be used by the Department to update future base rates and weights.
  • For laboratory services provided by the hospital facility, the date of service reported on a claim should be the date of specimen collection. 2
  • For radiology procedures, the date of service reported on a claim should be the date the radiology service was actually provided. 2

1 See the APG provider manual for a description of "never pay" and "if stand alone do not pay" APGs: http://www.nyhealth.gov/health_care/medicaid/rates/apg/docs/apg_provider_manual

2 This does not apply to hospitals that were previously reimbursed under the PAC reimbursement methodology. PAC hospitals now paid under APGs should continue to report and bill for ancillary laboratory and radiology procedures using the date the patient was seen in the clinic (date of clinic visit) as the date of service for all ancillary procedures.

For dates of service on and after July 1, 2009:

  • All laboratory and radiology services, both those that are provided by the hospital facility as well as those that are referred to an outside laboratory or radiology provider, are the fiscal responsibility of the hospital outpatient clinic and should be included on the APG Medicaid claim. The hospital clinic must reimburse the laboratory or radiology provider directly. The laboratory/radiology provider may not bill Medicaid for these services.
  • All ancillary services should be reported on a clinic claim, even those that map to a "never pay APG" or an "if stand alone, do not pay APG" as the information will be used by the Department to update future base rates and weights.
  • Ancillary services for clinic patients should be billed using the 1400 APG rate code for hospital based outpatient clinics.

Doctor

For all lab services and radiology procedures (both those provided by the hospital as well as those referred to outside ancillary providers), the date of service reported on the claim should be the date of the medical visit/significant procedure, even if the laboratory or radiology procedure is performed prior or subsequent to the clinic visit. This applies to all hospitals including those previously reimbursed under the PAC reimbursement methodology.

Treatment Center (D&TC) Clinics

While the initial APG implementation date for D&TCs was March 1, 2009, D&TCs have been notified that the implementation date has been delayed pending federal CMS approval. Upon implementation of APG payment methodology for D&TCs (this date will be made available once federal approval is secured):

  • Ancillary services for clinic patients should be billed using the 1407 APG rate code for D&TC clinics. All laboratory and radiology services, both those that are provided by the D&TC as well as those that are referred to an outside laboratory or radiology provider, are the fiscal responsibility of the D&TC and should be included on the APG Medicaid claim. The D&TC must reimburse the laboratory or radiology provider directly. The laboratory/radiology provider may not bill Medicaid for these services.
  • For all lab services and radiology procedures (both those provided by the clinic as well as those referred to outside ancillary providers), the date of service reported on the claim should be the date of the medical visit/significant procedure, even if the laboratory or radiology procedure is performed prior or subsequent to the clinic visit.

Clinic Claim Submission for Laboratory and Radiology Procedures

Doctor

Hospital outpatient clinics and D&TCs should not report any ancillary services on their APG claim until the services are completed and test results have been reported to the ordering provider. Hospital-based outpatient clinics and D&TC clinics have two billing options for reporting ancillary services on their APG claim:

  • Submit the APG claim (medical visit/significant procedure with ancillaries) upon confirmation that all ancillary services have been provided to the patient. This method is preferred.
  • Submit the APG claim for the medical visit/significant procedure only. After confirmation that all ordered ancillary lab/radiology services have been provided to the patient, the clinic may submit a claim adjustment that reports the office visit/significant procedure and all completed ancillary tests. This method may be used if cash flow or other issues arise but is not the preferred billing method.

When Medicaid is Secondary Payor

When Medicare and other commercial insurance is involved and if the lab or radiology provider is required to bill Medicare or the commercial insurance directly, the ancillary provider should do so and then bill eMedNY for any balance due. The clinic should not report these ancillaries on their APG claim since they will not be paying the ancillary provider.

Please contact the Bureau of Policy Development and Coverage at (518) 473-2160 if you have additional questions concerning this information.

Further information regarding APGs and the grouper payment logic and policy manual is available for download at: http://www.nyhealth.gov/health_care/medicaid/rates/apg/index.htm


Medicaid coverage for mental health counseling provided by LCSW/LMSW in Article 28 certified clinics is delayed
Return to Table of Contents

Medicaid coverage for mental health counseling provided by Licensed Clinical Social Workers (LCSW) and Licensed Master Social Workers (LMSW) in Article 28 clinics was originally scheduled to be implemented on March 1, 2009, however, implementation has been delayed pending federal approval.

File

Once federal approval is obtained, the Department intends to reimburse clinics retroactively for all dates of service beginning March 1, 2009. Mental health counseling provided by a psychiatrist or psychologist in an Article 28 clinic remains available to all eligible Medicaid enrollees.

Billing instructions for LCSW/LMSW

When implemented, Medicaid will reimburse for mental health counseling provided by LCSWs/LMSWs to children and adolescents under the age of 19 and pregnant women up to 60 days post-partum (based on the date of delivery or end of pregnancy).

Reimbursement requirements for LCSW/LMSW

  • A facility must have a psychiatry or psychology certification on its operating certificate;
  • Fee-for-service enrollees who are under age 19 are eligible for mental health services;
  • Fee-for-service pregnant women are eligible for mental health services. They must have a primary or secondary diagnosis of pregnancy (ICD-9 codes: 630-677, V22, V23, and V28). Mental health services are also available up to 60 days post-partum with a primary or secondary diagnosis of post-partum depression (ICD-9 codes 648.40 - 648.44).

New rate codes for Hospital Outpatient Department and Diagnostic and Treatment Center reimbursement for mental health counseling when provided by an LCSW/LMSW

4257 Individual Brief Counseling (psychotherapy which is insight oriented, behavior modifying and/or supportive, approximately 20-30 minutes face-to-face visit with the patient) $41
4258 Individual Comprehensive Counseling (psychotherapy which is insight oriented, behavior modifying and/or supportive, approximately 45-50 minutes face-to-face visit with patient) $62
4259Family Counseling (psychotherapy with or without patient)$70

New rate codes for School Based Health Center reimbursement for mental health counseling when provided by an LCSW/LMSW

3257 Individual Brief Counseling (psychotherapy which is insight oriented, behavior modifying and/or supportive, approximately 20-30 minutes face-to-face visit with the patient) $41
3258 Individual Comprehensive Counseling (insight oriented psychotherapy, behavior modifying and/or supportive, approximately 45-50 minutes face-to-face visit with patient) $62
3259 Family Counseling (psychotherapy with or without patient) $70

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


New Ambulatory Patient Group Rate Codes for School Based Health Clinics (SBHCs)
Return to Table of Contents

School Based Health Clinics Sponsored by Hospitals

Effective April 1, 2009, clinic rate codes 2888/2889 and APG grouper access rate code 1400, now used by hospital sponsored SBHCs, will be replaced with one APG grouper access rate code -1444 (note: APG grouper rate code 1400 must still be used by non-SBHC clinics). This new APG rate code should be used for both managed care and non-managed care Medicaid beneficiaries and is to be billed for both comprehensive as well as follow-up patient visits.

School Based Health Clinics Sponsored by Diagnostic and Treatment Centers

Effective upon the date of APG implementation for Diagnostic and Treatment Centers, rate codes 1627/1628 used by Diagnostic and Treatment Center sponsored SBHCs, will be replaced with one APG grouper access rate code 1447. This new APG rate code will be required for both managed care and non-managed care Medicaid beneficiaries and is to be billed for comprehensive as well as follow-up patient visits.

Note: The new APG grouper access rate codes (1444 and 1447) will be subject to Utilization Thresholds when applicable (see Utilization Threshold billing guidelines in the General Policy Section of the Clinic Provider Manual at: (http://www.emedny.org/ProviderManuals/AllProviders/index.html#genpolicy).

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


Nurse

New York City Providers Who Order Transportation Services
April Release of Revised Transportation Request Form
Return to Table of Contents

The pink, scannable Transportation Prior Approval Request Form (forms eMedNY 389701 and eMedNY 460101 ) will be replaced during April 2009 with a single updated version. This new version has the identifier eMedNY 389702, and contains a new field (Number of Days) which will be captured in the scan process.

The new form will be sent to current users. If your printer is configured to print pertinent information on this transportation request form, you will need to reconfigure your output specifications to conform to the new spacing. While the Medicaid Program will continue to accept both the old and revised versions of the forms until June 30, 2009, providers should begin using the new form as soon as possible. After June 30, only the new version will be accepted for processing. Revised instructions for completion of this form, as well as regulations regarding the request for Medicaid-funded transportation services, are included in the Prior Authorization Guidelines Manual, online at http://www.emedny.org/ProviderManuals/Transportation/index.html

Any questions regarding transportation policy can be referred to the Transportation Policy Unit at (518) 408-4825 or via e-mail to medtrans@health.state.ny.us

Requests for a supply of this new form can be made by calling the eMedNY Call Center at (800) 343-9000.


Enrollment Update

Certified Asthma and Diabetes Educators
Return to Table of Contents

On January 1, 2009, New York State Medicaid began covering asthma and diabetes self-management services (ASMT and DSMT), when provided by a New York State licensed, registered or certified health care professional, who is also certified as an educator by the National Asthma Educator Certification Board (CAE) or the National Certification Board for Diabetes Educators (CDE).

It is the responsibility of hospital outpatient departments and diagnostic and treatment centers to notify Medicaid that they employ certified diabetes and asthma educators.

To notify Medicaid of their staffs' certification, clinics should complete the applicable forms found at the links below:

http://www.emedny.org/info/ProviderEnrollment/Provider%20Maintenance%20Forms/Clinic%20Certification%20of%20Staff%20Certified%20as%20Asthma%20Educators.pdf

http://www.emedny.org/info/ProviderEnrollment/Provider%20Maintenance%20Forms/Clinic%20Certification%20of%20Staff%20Certified%20as%20Diabetes%20Educators.pdf

File

Please send completed forms to:

Office of Health Insurance Programs
Division of Provider Relations & Utilization Management
Rate Based Provider Bureau
Suite 6E, 150 Broadway
Albany, New York 12204-2736

Upon receipt of the required forms, facilities will be notified of their eligibility to bill for diabetes and/or asthma education services provided by their certified staff.

If you have questions regarding the completion of these forms, please contact the Rate Based Provider Bureau at (800) 342-3005, Option 4 or (518) 474-3575, Option 4.

For currently enrolled fee-for-service providers who are also a CAE or CDE, an expedited enrollment process is available. It is only necessary to submit the CAE or CDE Employment Certification and Enrollment Questionnaire forms located at http://www.emedny.org/info/ProviderEnrollment/index.html

Please send the forms along with your certification to:
Computer Sciences Corporation
P.O. Box 4610
Rensselaer, New York 12144

Questions regarding individual CAE/CDE enrollment? Please contact the Fee-for-Service Provider Enrollment Bureau at (518) 402-7032.


Dental Providers

Dental services provided to beneficiaries with removable prosthetic replacements
Return to Table of Contents

Dental

  • Cleaning of removable prosthesis (either full or partial) or soft tissue not directly related to natural teeth is not a covered service. Prophylaxis and/or scaling and root planning is only payable when performed on natural dentition or abutments for fixed prosthesis.
  • New York State Medicaid does not provide for "immediate" prosthesis (either full dentures or partial dentures). It is expected that tissues will be allowed to heal for a minimum of four (4) to six (6) weeks prior to taking the final impression(s).
  • Claims are not to be submitted until the denture(s), either full and/or partial, are completed and delivered to the beneficiary. The "date of service" used on the claim is the date that the denture(s) are delivered. If the prosthesis cannot be delivered or the beneficiary has lost eligibility following the date of the "decisive appointment," claims should be submitted following the guidelines for "Interrupted Treatment" in the MMIS Dental Provider Manual or in the June 2008 Medicaid Update.
  • Medicaid payment is considered payment in-full. Except for beneficiaries with a "spend down," beneficiaries cannot be charged beyond the Medicaid fee. Deposits, down-payments or advance payments are not allowed.
  • Radiographs (X-rays) are not routinely required to obtain prior approval for dentures for an edentulous patient. The guidelines published by the ADA and the U.S. Department of Health and Human Services on the use of X-rays should be followed:

    For new adult edentulous patients: "the panel recommends that an individualized radiographic examination, based on clinical signs and symptoms be performed."

    For recall adult edentulous patients: "the panel recommends that no radiographic examination be performed without evidence of disease."
  • All treatment notes, X-rays, laboratory prescriptions and laboratory invoices should be made part of the patient's treatment record to be made available upon request in support of any treatment provided.

Questions? Please contact the Division of Provider Relations and Utilization Management, Dental Bureau at (800) 342-3005, option 2.


Footwear Providers

Footwear providers must hold current certification to obtain Medicaid reimbursement
Return to Table of Contents

As required in regulation Title 18 NYCRR 505.5 (b) (ii), New York State Medicaid will reimburse providers for prescription footwear only if they hold a current certification from one of the following:

  • The Board for Certification in Pedorthics
  • The Board for Orthotist Certification
  • The American Board for Certification in Orthotics and Prosthetics

Effective April 1, 2009, DME providers must complete the following form and submit proper documentation as stated above to receive reimbursement for prescription footwear. Providers who fail to submit the form and documentation will not be reimbursed for prescription footwear for dates of service on or after April 1, 2009. If you have any questions about this requirement, please contact the Division of Provider Relations and Utilization Management at (800) 342-3005, option 1. Questions about the form? Contact the eMedNY CallCenter at (800) 343-9000.

 

NEW YORK STATE MEDICAID PROGRAM PRESCRIPTION FOOTWEAR CERTIFICATION

Provider Name: ________________________________________________________________________________

Medicaid Provider Identification Number: ________________________________________________________

National Provider Identifier (NPI): _______________________________________________________________

I have attached a copy of my current certification by one of the following:

  • The American Board for Certification in Orthotics and Prosthetics
  • The Board for Certification in Pedorthics
  • The Board for Orthotist Certification

Owner's Signature: _____________________________________________________ Date:__________

The owner must sign and date this form. Signature stamps, photocopies, etc., are not acceptable.

Please submit this application and supporting documents and mail to:

Computer Sciences Corporation
P. O. Box 4610
Rensselaer, New York 12144

NOTE: When your certification expires, please submit a copy of your current certification to the address above.


File

Orderers of medical-surgical supplies now subject to post & clear
Return to Table of Contents

Providers who order medical care, services or supplies, may be designated by the Department as "posting" providers. Posting of the order establishes a record that the care, services or supplies have been ordered by a qualified provider. It also enables the Department to verify that the order has been legitimately requested prior to paying a provider who submits a claim for furnishing the supplies.

Effective June 1, 2009, designated posting providers will be required to "Post" all of their orders for medical-surgical supplies and drugs by entering the number of orders (original plus the number of refills) via the Automated Response Unit (ARU), VeriFone terminal or ePACES. DME and Pharmacy providers will be required to "Clear" the number of items ordered on the date of service before filling an order.

Posting and Clearing providers should be aware of the following:

  • A separate service authorization (SA) clear transaction will be required for supplies;
  • Requests processed through the enteral formula telephone authorization line will now require an SA;
  • All services billed via 837P and paper will require an enabling SA;
  • Fiscal orders for supplies will need to post the original plus the number of refills. Units for supply posts and SAs will be based upon the total fills of the order. For each order with refill(s), the units posted shall be 1 (the original) plus number of refills. (1 script with 3 refills would be posted as "4").

Additional Posting Information: Prescriptions for Family Health Plus enrollees are subject to all Medicaid program requirements. Providers designated as Posters are required to "Post" all of their orders for covered pharmacy benefits (including enteral formulae, hearing aid batteries, and diabetic supplies) for their patients covered by Family Health Plus prior to the filling of the prescription.

HELPFUL LINKS:

List of Ordering Providers Designated as Posters: http://www.omig.state.ny.us

List of Medical-Surgical Supplies - Pharmacy Provider Manual, OTC and Supply Codes, Sections 4.2 - 4.4:
http://www.emedny.org/ProviderManuals/index.html

MEVS Provider Manual: http://www.emedny.org/ProviderManuals/AllProviders/supplemental.html#MEVSPM

ePACES: http://www.emedny.org/HIPAA/SupportDocs/ePACES.html

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


Provider Bulletins
Return to Table of Contents

Ambulance Providers

Proper coding of Medicare crossover claims

Some ambulance providers have inappropriately billed Medicaid for Medicare Part B crossover amounts under the A0999 - UNLISTED AMBULANCE SERVICE procedure, when Medicare has approved payment of different procedure codes. When submitting an ambulance claim to Medicaid, the same codes paid by Medicare should be billed to Medicaid. Billing questions? Please contact the eMedNY Call Center at (800) 343-9000. Policy questions? Call Medicaid Transportation Staff at (518) 408-4825, or e-mail MedTrans@health.state.ny.us

Notice to Hospitals

Submission of DRG claims for Medicaid beneficiaries who become eligible during the inpatient stay

A recent enhancement to eMedNY now allows DRG claims to be submitted and paid electronically. Hospitals should bill these claims through eMedNY for the inlier period. Although the claim will be pended for manual review, the pro-rated DRG payment will be made electronically. All other editing applicable to DRG claims will be applied. If the stay qualifies for day-outlier reimbursement, the hospital should submit a separate claim using rate code 2956. Questions? Contact the Rate Based Provider Bureau at (800) 342-3005, option 4.

FFS Enrollment Update

Fee-for-service providers

Effective February 1, 2009, fee-for-service providers (practitioners, DME, laboratories, pharmacies, etc.) will no longer be required to submit their NPI confirmation letter with their enrollment applications. The Department of Health will continue to verify the NPI number using the National Plan and Provider Enumeration System (NPPES) Website at https://nppes.cms.hhs.gov/NPPES/Welcome.do. For all applicable FFS providers, the NPI number is a requirement on the enrollment application. Questions regarding FFS enrollment? Please contact the eMedNY Call Center at (800) 343-9000.

DME, Hearing Aid, Audiology & Vision Care

New RB Modifier to replace RP Modifier effective April 1

Due to the discontinuation of the HCPCS Modifier - RP (Replacement & Repair (DMEPOS), Medicaid will no longer accept Modifier - RP for dates of service after 3/31/2009. Effective for dates of service on or after 4/1/2009, Modifier - RB (Replacement of a part of DME furnished as part of a repair) will be the valid modifier to use when billing for a replacement part. Questions? Contact the Division of Provider Relations and Utilization Management at (800) 342-3005.

NYS Medicaid and Family Health Plus Prescribers

All prior authorization requests require National Provider Identifier (NPI)

Please be aware that all requests for prior authorization require the use of your 10-digit National Provider Identifier (NPI).

  • The NPI of a facility or hospital cannot be substituted for your NPI.
  • Providing a facility NPI in place of your own NPI will result in a rejected prior authorization at the pharmacy.
  • If rejected, an additional call to the clinical call center will be necessary to obtain a valid prior authorization.

Additional NPI information can be accessed at the following Websites: http://www.cms.hhs.gov/NationalProvIdentStand or http://www.emedny.org/hipaa/NPI/index.html.


Files

Outpatient coding for Medicaid
Return to Table of Contents

All providers billing Medicaid for the provision of hospital based and freestanding outpatient services, including behavioral health services, are responsible for submitting claims data that is complete and accurate. This means that ICD-9 diagnosis and HCPCS/CPT-4 procedure coding submitted on claims must be inclusive of all services relating to the visit and must be accurate in accordance with the most recent coding updates.

Also, charges at the line level must be present and reflective of reasonable charges for the services provided. This is required regardless of the reimbursement methodology (e.g. APG, Medicaid Fee Schedule, etc.) through which the claim is being adjudicated. The Department is now testing new coding edits to ensure that all procedure codes submitted on a claim are valid. Claims with invalid coding will be denied. Procedures to ensure the accuracy and reasonableness of line level charges for all outpatient Medicaid claims will be implemented in the near future.

This action is part of an ongoing effort to ensure accuracy and completeness of Medicaid claims data. It will also ensure that the most complete data available when the Department prepares its Upper Payment Limit (UPL) calculations for the Centers for Medicare and Medicaid Services (CMS). The UPL is a critical test and incomplete or inaccurate data in the UPL calculation could jeopardize federal funding. Specifics regarding the new claims edits will be shared with providers and their associations prior to implementation. Questions? Please contact the Bureau of HCRA Operations and Financial Analysis at (518) 473-8822.


Globe

OMIG lists disqualified individuals and entities on Website
Return to Table of Contents

On January 12, 2009, the Office of the Medicaid Inspector General (OMIG) released a revised provider database and assumed the responsibility for updating and posting the list of excluded, restricted and terminated individuals or entities.

Before the provider database revision, the OMIG furnished this information monthly to the Department of Health and CSC for posting on the DOH and eMedNY Websites. This new approach enables OMIG to make nightly data updates to the list, and include more information about the individual/provider (e.g., the type of action taken, such as "termination" and "exclusion"). In the previous format, only terminations were listed; the new format includes the category of sanction and provides details about the regulation that supports the action. Additionally, the new format allows the user to search by name, provider number or license number. Users can also download formatted or tab delimited lists (suitable for downloading into spreadsheets) with this system. This information is a helpful tool for providers seeking to verify the status of prospective employees. Using the list will assist providers in avoiding claim denials and will help OMIG and the Department of Health ensure that claims for medical care, services and/or supplies are ordered or prescribed by individuals permitted to do so under the Medicaid program.

Any claims submitted for medical care or prescribed by providers appearing on this list may be denied, and the enrolled provider dispensing prescriptions, filling orders or providing services may be held responsible for repayment of any Medicaid payments made under these circumstances.

To verify information, please visit http://www.omig.state.ny.us and click on the "disqualified individuals" button on the left side of the home page.


Coverage for fetal nuchal translucency measurement ultrasound screening test approved
Return to Table of Contents

Ultrasound

Effective for dates of service on or after January 1, 2009, Medicaid will cover the following two CPT codes for Fetal Nuchal Translucency Measurement Ultrasound screening for Trisomy 21 (Down Syndrome) and certain other chromosomal abnormalities and birth defects:

CPT CODE 76813

Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation.

CPT CODE 76814

Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation (use in conjunction with 76813).

The American College of Obstetricians and Gynecologists (ACOG) recommends that ultrasounds be performed in a setting with demonstrated ultrasound credentialing and ongoing quality monitoring. ACOG clinical practice guidelines also recommend that the clinic offer counseling to pregnant women regarding the risk of giving birth to a child with Down Syndrome, chromosomal abnormalities, and/or birth defects.

ACOG clinical practice guidelines regarding screening for fetal chromosomal abnormalities are available via the National Guideline Clearinghouse Website at: www.guideline.gov/summary/summary.aspx?doc_id=10921&nbr=5701&ss=6&xl=999

REMINDER: Medicaid currently covers first and second trimester screening tests for Trisomy 21 (Down Syndrome) and certain other chromosomal abnormalities and birth defects under the following CPT codes:

Please Note:

For additional information regarding laboratory and radiology ancillary services when provided to clinic patients, please refer to this month's cover article - APG payment policy for reimbursement of ancillary services (laboratory services and radiology procedures.

Fees associated with procedures referenced in this article are available on-line at: http://www.eMedNY.org

First Trimester Screening:

CPT 84702 Gonadotropin, chorionic (hCG); quantitative

CPT 84163 Pregnancy-associated plasma protein-A (PAPP-A)

Second Trimester Screening:

CPT 82105 Alpha-fetoprotein

CPT 82677 Estriol

CPT 84702 Gonadotropin, chorionic (hCG); quantitative

CPT 86336 Inhibin A

Other Tests/Confirmatory Tests:

CPT 59000 Amniocentesis; diagnostic

CPT 76946 Ultrasonic guidance for amniocentesis

CPT 88267 Chromosome analysis, amniotic fluid or chorionic villus

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


Prescriptions With Official Serial Numbers: Medicaid Billing Requirements

Pills

Original serial number must be reported on the pharmacy claim for refill of Rx initially paid by other third-party payor
Return to Table of Contents

Q: Is the NYS serial number required on the Medicaid claim for a refill of a hard copy or fax prescription that was previously (initially) paid by another third party payor that did not require submission of the serial number?

Pills

A: Yes. Medicaid claims for refills of hard copy or fax prescriptions previously paid by another third party must include the NYS serial number. If the pharmacy's computer records do not contain the serial number from the original prescription, the serial number must be retrieved from the original or scanned hard copy prescription and submitted when billing Medicaid. For such refills, pharmacists are not allowed to use any of the serial number override codes in place of the actual serial number.

Questions may be directed to the Bureau of Pharmacy Policy and Operations at (518) 486-3209.


Clipboard

Pharmacy Providers
Return to Table of Contents

Effective June 1, 2009, designated posting providers must "Post" all of their orders for prescriptions, fiscal orders and medical-surgical supplies by entering the number of orders (original plus the number of refills) via the Automated Response Unit (ARU), VeriFone terminal or via ePACES. Pharmacy providers will be required to "Clear" the number of items ordered on the date of service before filling an order.

When a claim hits edit 00746 "No Service Authorization on File" this results because the original prescription or the refills have not been posted by the posting prescriber.

Did you know that you can identify Posting providers on the eMedNY Website? http://www.emedny.org/info/posting.html

If you have any questions, please contact the eMedNY Call Center at (800) 343-9000.


Smoking Cessation
Return to Table of Contents

No Smoking

By providing counseling, pharmacotherapy, and referrals, you can double your patients' chances of successfully quitting.
For more information, visit http://www.talktoyourpatients.org or call the NY State Smokers' Quitline at 1-866-NY-QUITS (1-866-697-8487).


eMedNY Provider Support
Return to Table of Contents

eMedNY offers a variety of support options for providers who may be experiencing problems or that need assistance with submission of transactions and/or resolving outstanding billing issues. Support is available for New York State Medicaid providers in the following areas:

eMedny

  • Provider Enrollment
  • Billing
  • Eligibility Verification
  • Prior Approval Requests
  • The Electronic Provider Assisted Claim Entry System (ePACES)
  • Electronic Responses/Remittance and Claim Denial Interpretation

eMedNY Call Center

The eMedNY Call Center can be reached by telephone at (800) 343-9000.

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 Time (excluding holidays).

For provider inquiries pertaining to eligibility, service authorizations, DVS, and pharmacy claims:
Monday through Friday: 7:00 a.m. - 10:00 p.m., Eastern Time (excluding holidays)
Weekends and Holidays: 8:30 a.m. - 5:30 p.m., Eastern Time.

The Call Center can refer a help desk ticket for technical inquiries about electronic file rejections and electronic HIPAA formatting of files to CSC's Tier II. A CSC representative from Tier II will respond to the request and contact the provider.

CSC Regional Representatives

Computer Sciences Corporation has regional representatives who can assist providers with individual training requests. CSC regional representatives also offer seminars throughout the State every month. Please register on-line at http://www.emedny.org, and click on Training. Requests for individual training can be made through the Call Center number above or via e-mail at: eMedNYProviderRelations@csc.com.

eMedNY.org Website

The eMedNY Website offers information on all aspects of the eMedNY claims processing system including, provider self-help documents, provider manuals, billing instructions and links to associated Websites. In addition, eMedNY offers a self help section with numerous documents to assist providers. We welcome your inquiries and thank you for your continued participation in the New York Medicaid Program.


Paper

CSC offers Medicaid provider seminars
Return to Table of Contents

  • 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, you should 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 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

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 paid amount without waiting for the remittance advice.

Fast and easy seminar registration, locations, and dates are available on the eMedNY Website at: http://www.emedny.org/training/index.aspx

Please review the seminar descriptions carefully to identify the seminar appropriate for your training requirements. Registration confirmation will instantly be sent to your e-mail address.

If you are unable to access the Internet to register, you may also request a list of seminars and registration information to be faxed to you through CSC-s Fax on Demand at (800) 370-5809. Please request document 1001 for April - June seminar dates.

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

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


Paper

PROVIDER SERVICES
Return to Table of Contents

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 eMedNY Call Center 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 the eMedNY Call Center 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, Kelli Kudlack, 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.

Please Note

Some documents on this page are saved in the Portable Document Format (PDF). If it's not already on your computer, you'll need to download the latest free version of Adobe Reader.