May 2010    Volume 26, Number 7 

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 DOH

Donna J. Frescatore, Medicaid Director & Deputy Commissioner
Office of Health Insurance Programs



 

Doctors and Nurses

In this issue....

Asthma Self-Management Training (ASMT) Available

POLICY AND BILLING GUIDANCE

Affiliated Practitioner NPIs Must Be Registered with eMedNY
Educating Providers and Patients About Safe Injection Practices
Statewide Patient Centered Medical Home Program Receives Approval For Office-Based Practitioners
TRANSPORTATION PROVIDERS: Trip Documentation Required
DENTAL PROVIDERS: Electronic Submission of Attachments with Dental Prior Approval Requests
Medicaid Billing Instructions for Office of Mental Health Licensed Outpatient Programs
Durable Medical Equipment Address Updates
AMBULANCE PROVIDERS: Acceptable Claim Modifiers
Licensed Midwives as First Assistant at Cesarean Section Deliveries
Providers May Bill Medicaid Fee-For-Service for Family Planning & Reproductive. Health Services Provided to Enrollees of Fidelis Care New York

PHARMACY UDATES

New York State Medicaid and Family Health Plus Providers
Medicaid Preferred Drug Program Change in Provider Notification
Requirement for Pharmacies to Enter Dispensing Pharmacist NPI on Claims Delayed
Automatic Refills Update
New Edit Code Implemented
Prescribers of Injectable Prescriptions and Ancillary Supplies

ALL PROVIDERS

Smoking Cessation Awareness
Provider Directory


Asthma Self-Management Training (ASMT) Services for Medicaid Beneficiaries
a web series presented by the
Certified Asthma Educator Subcommittee of the Asthma Partnership of New York
Return to Table of Contents

As of January 1, 2009 New York Medicaid provides coverage of asthma selfmanagement training (ASMT) services for Medicaid beneficiaries diagnosed with asthma. ASMT services are to be provided by a NYS licensed, registered, or certified health care professional, who is certified as an asthma educator (AE-C) by the National Asthma Educator Certification Board.

  • Who can order ASMT services?
  • Who can provide ASMT services?
  • Who can bill for ASMT services?
  • What is the process to bill for ASMT services?
  • How can patient access to ASMT services be enhanced?

Register for a session in this upcoming Web series for more information. Questions? Please contact (518) 486-6065.

Presenters

Donna Haskin, RN, BSN
Director, Program and Quality Initiatives,
Office of HealthInsurance Programs
New York State Department of Health

Pat Waniewski, RN, MS
Director, Bureau of Community Chronic Disease Prevention
New York State Department of Health

Anne Little, MPH, AE-C
Coalition Director, Asthma Coalition of Long Island Co-Chair,
Certified Asthma Educator Subcommittee

Jane E. Corrarino, RN, MS
CPHN IV, Suffolk County Department of Health Services Co-Chair,
Certified Asthma Educator Subcommittee

Session and Registration Information

Registration is required to participate (see links below).

June 10, 2010 (8:00 am - 9:00 am) https://nysdoh.webex.com/nysdoh/k2/j.php?ED=137167672&UID=1131619652&FM=1

June 10, 2010 (12:00 pm - 1:00pm) https://nysdoh.webex.com/nysdoh/k2/j.php?ED=137169077&UID=1131626517&FM=1

June 14, 2010 (5:00 pm - 6:00pm) https://nysdoh.webex.com/nysdoh/k2/j.php?ED=137169417&UID=1131628467&FM=1


Keyboard

IMPORTANT NOTICE TO HOSPITALS AND CLINICS:
Affiliated Practitioner NPIs Must Be Registered with eMedNY
Return to Table of Contents

Effective June 3, 2010, New York State Medicaid will deny claims if the attending provider's National Provider Identifier (NPI) is not affiliated with the facility. These claims will result in denial code Edit 02067- Attending Provider Not Linked to Billing Provider, which will be reported in the 835 Supplemental File and paper remittances. The HIPAA X12 denial code will be defined as 208/N55. Hospitals and clinics that have not yet registered the NPI of all their affiliated practitioners with Medicaid must do so prior to June 3, 2010.

New York State Medicaid provides two methods for registering NPIs:

On the Web at: https://npi.emedny.org/Facility/, or via batch by following the instructions on the NYHIPAADESK tab, click on NPI and then Facilities Practitioner's NPI Reporting (Batch Instructions).

Facilities that have a large number of practitioners are encouraged to maintain a "roster" of all their attending providers NPIs. As updates are made to the roster, please forward them to New York State Medicaid using the batch Facilities method (above).

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

EDUCATING PROVIDERS & PATIENTS ABOUT SAFE INJECTION PRACTICES
The New York State Department of Health (NYSDOH) has partnered with the Centers for Disease Control and Prevention (CDC) and the Safe Injection Practices Coalition (SIPC) to pilot a campaign to promote greater awareness of basic infection control procedures when healthcare providers administer any type of injection. Please take a moment to complete the survey available for viewing at: http://chws.albany.edu/injectionsafety. Don't delay! Fill out this important survey today!

Statewide Patient Centered Medical Home Program Receives Approval For Office-Based Practitioners, FQHCs, and D&TCs
Return to Table of Contents

doctor

Incentive payments to office-based physicians' and registered nurse practitioners' practices, Federally Qualified Health Centers (FQHCs), and Diagnostic and Treatment Centers (D&TCs) recognized by New York State Medicaid and the National Committee for Quality Assurance (NCQA) as Physician Practice Connections-Patient Centered Medical Homes (PPC®-PCMH™), will commence for visits performed on or after July 1, 2010.

NCQA will provide a monthly list of PPC®-PCMH™ recognized providers to New York Medicaid for use in claims processing. PPC®-PCMH™ incentive payments for Article 28 hospital outpatient departments (OPDs) are pending CMS approval. Providers will be notified in a later edition of the Medicaid Update when approval is finalized.

To ensure receipt of incentive payments, recognized providers must make certain that NCQA has the 4-digit extension of the zip code (zip+4) for each practice site certified by NCQA as a patient centered medical home. Also, in an individual provider's practice, the individual practitioner's billing National Provider Identifier (NPI) must be on file with NCQA. Office-based practitioners that are part of a group practice must also have their group practice NPI (practice site NPI) on file with NCQA. Article 28 facilities must have their billing NPI (practice site NPI) on file with NCQA. Failure to provide a practice site NPI (practitioner group NPI or clinic NPI) and the zip+4 of each recognized service location, will jeopardize incentive payments by New York Medicaid. Practitioner groups and clinics can e-mail their practice site NPI (Medicaid billing NPI#) and their zip+4 information to NCQA at: ppc-pcmh@ncqa.org.

For recognized providers to receive fee-for-service incentive payments from New York State Medicaid, the following conditions are required:

Office-Based Practitioners:

  • Claims must include one of the following evaluation and management codes: 99201- 99205, 99211- 99215 or preventive medicine codes: 99381-99386, 99391-99396;
  • The place of service coded on the claim must be office (11);
  • In an individual provider's practice, the individual practitioner's billing NPI must be included on the claim; and
  • In a group practice, both the group NPI and the billing practitioner's NPI must be included on the claim.

Article 28 Clinics (OPDs, D&TCs and FQHCs):

  • Claims must include one of the following evaluation and management codes: 99201- 99205 or 99211- 99215 or preventive medicine codes: 99381-99386, 99391-99396;
  • In a clinic, the billing clinic's NPI must be included on the claim;
  • For both office-based practitioners and Article 28 clinics, it is critical that the claim include the zip+4 for the NCQA recognized location.

Notes:

  • Practices with Registered Nurse Practitioners (RNPs), including Article 28 facilities and office-based practitioners, must include the RNPs on their NCQA PPC®-PCMH™ application. This will allow Medicaid to properly process Patient Centered Medical Home incentive payments for primary care nurse practitioner services.
  • In the event that both a practitioner working in a clinic (who submits a professional claim) and the clinic have a medical home designation, only the clinic will receive the enhanced payment.
  • New York State Medicaid providers participating in the Adirondack Medical Home Demonstration Project are not eligible for incentive payments through the Statewide Patient Centered Medical Home Program.

For recognized providers to receive incentive payments for Medicaid and Family Health Plus managed care enrollees the following applies:

  • Providers must be designated as the enrollee's primary care provider.
  • Office-based practitioners and Article 28 clinics will receive incentive payments for Medicaid and Family Health Plus managed care enrollees directly from the managed care plan. Providers with questions regarding the frequency or basis of payment to be received from their health plans should contact the plans directly.
  • The State will make available to health plans a monthly file from NCQA with updated provider recognition data to enable plans to identify which of their contracted providers are eligible to receive the enhanced payment.
  • Upon implementation, providers will be eligible to receive payment from health plans the first month in which the provider is listed on the monthly file of NCQA recognized providers posted on the HPN. There is no requirement to modify contracts between health plans and providers related to Medical Home.
  • To ensure receipt of incentive payments from health plans, providers must make certain that NCQA has the 4-digit extension of the zip code (zip+4) for each practice site certified by NCQA as a patient centered medical home.
  • The State will make payments to Medicaid Managed Care plans for the sole purpose of the health plan making enhanced payments to contracted office-based physicians/practices and Article 28 clinics that meet New York's medical home standards and provide primary care services to persons enrolled in Medicaid Managed Care and Family Health Plus.
  • Payment from the State to Managed care plans will be made on a Per Member Per Month (PMPM) basis depending upon a providers NCQA recognition level equal to $2.00 (level 1), $4.00 (level 2), or $6.00 (level 3) for each enrollee whose designated primary care physician and/or nurse practitioner has received recognition as a Physician Practice Connections-Patient Centered Medical Home (PPC-PCMH).
  • Medical Home payments to health plans are a pass-thru to providers therefore prompt payment requirements do not apply to the distribution of Medical Home funds.

Questions/Information:

For additional information on how to achieve NCQA certification as a NCQA PPC®-PCMH™ provider, please contact the NCQA Customer Support Center at (888) 275-7585, or visit the NCQA Website at: www.ncqa.org. Since New York State Medicaid is recognized as a sponsoring organization, providers will receive a 20 percent discount from NCQA toward the cost of the PPC®-PCMH™application. For additional information please review the December 2009 Special Edition of the Medicaid Update, available online at: http://nyhealth.gov/health_care/medicaid/program/update/2009/2009-12spec.htm. or contact the Division of Financial Planning and Policy at (518) 473-2160. Please contact the Bureau of Managed Care Finance at (518) 474-5050 with any questions regarding health plan medical home payments for network providers.

Required NCQA Disclaimer:

The Physician Practice Connections-Patient Centered Medical Home (PPC®-PCMH™) Recognition Program is developed, owned, and managed by the National Committee for Quality Assurance (NCQA). To learn more about the PPC®-PCMH™ Recognition Program, refer to the program's Website at http://www.ncqa.org/tabid/631/Default.aspx. NCQA is not involved in any determination of clinician incentive payments under the NY State Medicaid Medical Home Program.


TRANSPORTATION PROVIDERS: Trip Documentation Required
Return to Table of Contents


Transportation providers will only be reimbursed when acceptable records verifying a trip's occurrence are complete and available to auditors upon request.

Ambulance Providers: Ambulance providers are responsible for completing the Pre-Hospital Care Report, which is a complete record of the ambulance trip and satisfies Medicaid's trip documentation requirements.

Ambulette, Taxi, Livery, and Group Ride Providers: For each leg of the trip, trip verification should be completed at the time of the trip and must include, at a minimum:

  • The Medicaid beneficiary's name and Medicaid identification number;
  • Both the origination of the trip and time of pickup;
  • Both the destination of the trip and time of drop off;
  • The vehicle license plate number; and
  • The full printed name of the driver providing the transportation.

Although the driver's signature is not required at this time, it is advised that providers include an attestation in the trip documentation that states "I provided the indicated transportation services," and request the driver's signature.

Providers are urged to maintain a record with all information listed above in case of a Medicaid audit. If any of the information above is lacking, illegible, or false, a claim will be denied.

The following items are considered unacceptable documentation of a trip:

  • A driver or vehicle manifest, or dispatch sheet;
  • An issuance of a prior authorization by the authorizing agent with subsequent checkmarks on a prior authorization roster;
  • An attendance log from the day program.

Questions? E-mail the Medicaid Transportation Policy Unit at medtrans@health.state.ny.us.


DENTAL PROVIDERS: Electronic Submission of Attachments with Dental Prior Approval Requests
Return to Table of Contents

dental

Effective June 24, 2010, dental providers may submit documents stored in a digitized format (x-rays, treatment plans, charting, photographs, etc.) as electronic attachments to dental prior approval requests when submitted through ePACES. This enhanced feature is currently only available through ePACES.

The following file formats will be supported: JPEG; TIF; PNG; and GIF.

For those using ePACES, a new menu option; "PA Attachment", will be created on the ePACES menu list. When clicking this menu option it will bring up a new "PA Attachment" Web page where attachments can be added. The necessary update to ePACES will be made automatically.

To enroll in ePACES, providers will need the following:

  • Computer with internet access;
  • Valid e-mail address;
  • National Provider Identifier (NPI); and
  • Electronic Transmitter Identification Number (ETIN).

To enroll in ePACES, please contact the eMedNY Call Center at (800) 343-9000.


Durable Medical Equipment Address Updates
Return to Table of Contents

hands

New York Medicaid policy requires that each newly enrolled Durable Medical Equipment (DME) provider be a fully operational walk-in business that is open to the general public, and is staffed with trained personnel capable of providing the proper fitting, demonstration, and service of the supplies available to Medicaid beneficiaries.

Additionally, the DME provider must:

  • conduct business prior to being enrolled in Medicaid;
  • have a storefront with a sign indicating the business is open to the public (a storefront has been required for DME enrollment since 1999);
  • operate during normal business hours; and
  • clearly display items provided, and allow for handicapped access to the store.

Effective January 1, 2011, enrolled DME providers that relocate their service address must ensure that the new address is a fully operational walk-in store that is open to the general public and meets all criteria listed above. Any DME provider that changes its service address after January 1, 2011, and does not meet the criteria listed above will be considered non-compliant and will be terminated from New York State Medicaid.

Questions? Please contact the Office of the Medicaid Inspector General's Enrollment and Reinstatement Unit at (518) 408-0851.


Medicaid Billing Instructions for Office of Mental Health Licensed Outpatient Programs
Return to Table of Contents

Medicaid billing instructions for services provided under the Office of Mental Health (OMH) licensed outpatient programs are as follows:

  • Only the licensed program is eligible to seek and receive Medicaid and/or Medicare reimbursement for the services provided under the auspice of the licensed program;
  • Physicians or other licensed clinicians, regardless of how they are engaged by the OMH licensed program, may not seek separate Medicaid and/or Medicare reimbursement for services provided by the OMH licensed outpatient program;
  • Only the OMH licensed program can bill Medicaid for the services rendered under the program's OMH approved staffing plan. NOTE: This clarification applies ONLY to mental health services provided by programs pursuant to Parts 587 and 588 of the Mental Hygiene Law. OMH licensed clinics will soon become subject to program and reimbursement standards which will be established in a new regulatory section, Part 599 (not yet issued). Medicaid billing instructions (FAQs) for these new regulations will be available after the new regulations are issued.

Questions? Please contact the Office of Mental Health Financial Planning at (518) 474-6911.


AMBULANCE PROVIDERS: Acceptable Claim Modifiers
Return to Table of Contents

The following is an updated list of acceptable modifiers. Bolded modifiers were recently added to accommodate claims with Medicare coverage.

Origination/DestinationModifier
DIAG THERA SITE NOT P OR H ORIG/RES,DOM,CUST FACIL DE
DIAG THERA SITE NOT P OR H ORIG/HOSP BASE DIALYSIS DG
DIAG THERA SITE NOT P OR H ORIG/HOSPITAL DH
DIAG THERA SITE NOT P OR H ORIG/TRANS BETW AMB MOD DI
DIAG THERA SITE NOT P OR H ORIG/NON-HOSP DIALYSIS DJ
DIAG THERA SITE NOT P OR H ORIGIN CODES/SNF DN
DIAG THERA SITE NOT P OR H ORIGIN CDS/PHYS OFFICE DP
DIAG THERA SITE NOT P OR H ORIGIN CDS/RESIDENCE DR
DIAG THERA SITE NOT P OR H ORIG/DEST INTERM STOP DX
RES, DOM, CUST FAC(NOT 1819)/DIAG THERA NOT P OR H ED
RES, DOM, CUST FAC(NOT 1819)/HOSP BASE DIALYSIS EG
RES, DOM, CUST FACILTY(NOT 1819)/HOSPITAL EH
RES, DOM, CUST FAC /SITE TRANS BETWEEN AMBUL MODES EI
RES, DOM, CUST FAC(NOT 1819)/ NON-HOSP DIALYSIS EJ
RES, DOM, CUST FAC(NOT 1819)/ SNF 1819 FACILITY EN
RES, DOM, CUST FAC(NOT 1819)/ RESIDENCE ER
RES, DOM, CUST FAC(NOT 1819)/DEST CD INTERM STOP EX
HOSP DIALYSIS FAC/ORIG DIAG THER SITE NOT P OR H GD
HOSP DIALYSIS FAC/RES, DOM, CUST FAC (NOT 1819) GE
HOSP DIALYSIS FACILITY (HOSP RELATED)/ HOSPITAL GH
HOSP DIALYSIS FAC/SITE OR TRANS BETW AMBUL MODES GI
MULTIPLE PATIENT TRANSPORT GM
HOSP DIALYSIS FAC(HOSP RELATED)/SNF (1819 FAC) GN
HOSP DIALYSIS FAC(HOSP RELATED)/PHYSICIANS OFFICE GP
HOSP DIALYSIS FAC(HOSP RELATED)/RESIDENCE GR
HOSP DIALYSIS FAC(HOSP RELATED)/DEST INTERM STOP GX
HOSP/DIAG THERA SITE NOT P OR H USED AS ORIGIN CDS HD
HOSP/RES, DOM, CUST FACILITY OTHER THAN 1819 FAC HE
HOSPITAL/HOSP DIALYSIS FACILITY(HOSP OR HOSP RELAT) HG
HOSPITAL/HOSPITAL HH
HOSPITAL/SITE OF TRANS BETW MODES OF AMBUL TRANSP HI
HOSPITAL/NON-HOSPITAL BASED DIALYSIS FACILITY HJ
HOSPITAL/SKILLED NURSING FACILITY SNF (1819 FAC) HN
HOSPITAL/PHYSICIAN'S OFFICE HP
HOSPITAL/RESIDENCE HR
HOSPITAL/DEST CD INTERM STOP AT PHYS OFC TO HOSP HX
SITE OF TRAN BETW MODE OF AMB/DIAG THER NOT P OR H ID
SITE OF TRANS BETW MODE OF AMB/HOSP BASED DIALYSIS IG
SITE OF TRANS BETWEEN MODES OF AMBULANCE/HOSPITAL IH
SITE OF TRANS BETW MODES OF AMB/NON-HOSP DIALYSIS IJ
SITE OF TRANS BETW MODES OF AMB/SNF (1819 FACILITY) IN
SITE OF TRANS BETW MODES OF AMB TRANS/PHYS OFFICE IP
SITE OF TRANS BETW MODES OF AMB/DEST INTERM STOP IX
NON-HOSP DIALYSIS FAC/DIAG THERA ORIGIN NOT P OR H JD
NON-HOSP DIALYSIS FAC/RES, DOM, CUS FAC (NOT 1819) JE
NON-HOSPITAL BASED DIALYSIS FACILITY/HOSPITAL JH
NON-HOSP DIALYSIS FAC/SITE OF TRANS BETW MODES AMB JI
NON-HOSP BASED DIALYSIS FAC/SNF (1819 FACILITY) JN
NON-HOSPITAL BASED DIALYSIS FACILITY/PHYSICIAN OFC JP
NON-HOSPITAL BASED DIALYSIS FACILITY/RESIDENCE JR
NON-HOSP DIALYSIS FAC/DEST CD INTERM STOP AT PHYS JX
SNF (1819 FACILITY)/DIAG THERA ORIGIN(NOT P OR H) ND
SNF (1819 FACILITY)/HOSP BASED DIALYSIS(HOSP RELAT NG
SNF (1819 FACILITY)/HOSPITAL NH
SNF (1819 FACILITY)/TRANS BETWEEN MODES OF AMBUL NI
SNF (1819 FACILITY)/NON-HOSP BASED DIALYSIS FACIL NJ
SNF (1819 FACILITY)/SNF (1819 FACILITY) NN
SNF (1819 FACILITY)/PHYSICIAN'S OFFICE NP
SNF (1819 FACILITY)/RESIDENCE NR
SNF (1819 FACILITY)/DEST CD INTERM STOP PHYS OFFIC NX
PHYS OFFICE/DIAG THERA SITE ORIGIN CDS NOT P OR H PD
PHYS OFFICE/RES, DOM, CUS FACILITY(NOT 1819 FACIL) PE
PHYS OFFICE/HOSP BASED DIALYSIS FACILITY PG
PHYSICIAN'S OFFICE/HOSPITAL PH
PHYS OFC/SITE OF TRANS BETWE MODES OF AMBUL TRANSP PI
PHYS OFFICE/NON-HOSPITAL BASED DIALYSIS FACILITY PJ
PHYSICIAN'S OFFICE/SNF (1819 FACILITY) PN
PHYSICIAN'S OFFICE/RESIDENCE PR
PATIENT PRONOUNCED DEAD AFTER AMBULANCE CALLED QL
AMBULANCE SERVICES UNDER ARRANGEMENT BY A HOSPITAL QM
AMBULANCE SERVICES FURNISHED DIRECTLY BY A HOSPITAL QN
RESIDENCE/DIAG THERA SITE ORIGIN CDS NOT P OR H RD
RESIDENCE/HOSPITAL BASED DIALYSIS FACILITY RG
RESIDENCE/HOSPITAL RH
RESIDENCE/SITE OF TRANS BETWE MODES OF AMBUL TRANS RI
RESIDENCE/NON-HOSPITAL BASED DIALYSIS FACILITY RJ
RESIDENCE/SKILLED NURSINC FACILITY (SNF)(1819 FAC) RN
RESIDENCE/PHYSICIAN'S OFFICE RP
RESIDENCE/DEST CD INTERM STOP AT PHYS OFF TO HOSP RX
SCENE OF ACCIDENT ACUTE/DIAG THER ORIG NOT P OR H SD
SCENE OF ACCIDENT ACUTE EVENT/HOSP BASED DIALYSIS SG
SCENE OF ACCIDENT ACUTE EVENT/HOSPITAL SH
SCENE OF ACCIDENT ACUTE/TRANS BETW MODES AMBUL TRA SI
SCENE OF ACCIDENT OR ACUTE/NON-HOSP BASED DIALYSIS SJ
SCENE OF ACCIDENT OR ACUTE EVENT/SNF (1819 FAC) SN
SCENE OF ACCIDENT OR ACUTE EVENT/PHYSICIAN'S OFFIC SP
DEST CD INTERM STOP AT PHYS OFC ON WAY TO HOSP SX

Billing questions? Please contact the eMedNY Call Center at (800) 343-9000. Policy questions? Please contact the Medicaid Transportation Unit at (518) 474-5187 or e-mail MedTrans@health.state.ny.us.


Pregnancy

Licensed Midwives as First Assistant at Cesarean Section Deliveries
Return to Table of Contents

Effective April 1, 2010, New York Medicaid will reimburse for First Assistant services performed by licensed midwives at cesarean section deliveries. The role of the First Assistant at surgery is to practice under the direction of the surgeon/obstetrician; to collaborate with the surgical team; and to actively assist in completing the surgical procedure safely and expeditiously. The First Assistant must possess the necessary knowledge, skills, and judgment specific to the clinical practice area.

Consistent with Medicaid policy for all other recognized practitioners performing First Assistant services, reimbursement will be made to the surgeon/obstetrician at 120% of the Medicaid fee schedule amount. The claim for these services must be made by the physician using the "AS" modifier.

Policy questions? Please contact the Division of Financial Planning and Policy at (518) 473-2160.

Billing questions? Please contact the eMedNY Call Center at (800) 343-9000.






Medicaid Managed Care & Family Health Plus (FHPlus) Enrollees of NYS Catholic Health Plan (d/b/a Fidelis Care New York)
Return to Table of Contents

Providers May Bill Medicaid Fee-For-Service for Family Planning & Reproductive Health Services Provided to Enrollees of Fidelis Care New York. This applies only to Medicaid Managed Care & Family Health Plus (FHPlus) enrollees of NYS Catholic Health Plan (d/b/a Fidelis Care New York) (plan code SP).

To be reimbursed by Medicaid for family planning and reproductive health services provided to Medicaid managed care and FHPlus enrollees in Fidelis Care New York, providers must participate in Medicaid and be qualified to provide family planning and reproductive health services, or related laboratory services. Providers should bill eMedNY directly by submitting either an electronic or paper claim indicating family planning or reproductive health services. Reimbursement will be made at the Medicaid rates.

Family Health Plus Enrollees

How can providers identify Fidelis Care New York FHPlus enrollees? Providers will receive the following eligibility messages for clients with Family Health Plus Coverage:

  • ARU Message: "Family Health Plus," "Insurance Coverage Code "SP".
  • OMNI 3750/Vx570 Message: "Other or Additional Payer" for Elig-Ben Info, "FAMILY HEALTH PLUS" for Plan, and "SP" for Plan CD.
  • ePACES Message: "Other or Additional Payer" for Eligibility Information, "FAMILY HEALTH PLUS" for Plan Name, and "SP" for Carrier Code.
  • NCPDP (Family Planning Drug or Supply) Message: 017 - Family Health Plus Services Only, and "SP" for Plan CD.
  • NCPDP (Not a Family Planning Drug or Supply) Message: 017 - Family Health Plus Services Only, and "SP" for Plan CD.
  • PC - Host and Batch Message: "R" and "SP".

How do providers submit claims for family planning and reproductive health services provided to FHPlus enrollees in Fidelis? Providers should use the beneficiary's Client Identification Number (CIN) located on the health plan identification card to bill eMedNY (providers should also use the beneficiary's CIN to verify coverage and plan enrollment through eMedNY at each visit). For some FHPlus members, a provider may need to enter a sequence number when the claim is entered on the same day the service is rendered. The sequence number will not appear on the health plan card.

If you receive one of the error messages below, request the beneficiary CBIC, or "BENEFIT CARD" which will confirm the sequence number. If the beneficiary does not have the CBIC card, the provider should contact the local department of social services or HRA (NYC) for assistance.

Error Messages:

  • ARU Message: Invalid Sequence Number.
  • OMNI 3750/Vx570 Message: ePACES - Invalid/Missing Subscriber/Insured ID.
  • NCPDP Message: 063 Invalid Sequence Number and 08 M/I Person Code.
  • PC - Host, Batch Message: 72 Invalid/Missing Subscriber/Insured ID.

Please refer to the provider manuals and HIPAA837 Companion Guides at: http://www.emedny.org, for details on the codes and fields to identify these services.

Medicaid Managed Care Enrollees

How can providers identify Fidelis Care New York Medicaid Managed Care enrollees? At each visit, providers should use the beneficiary's CIN to verify coverage and plan enrollment through eMedNY. Providers will receive the following eligibility messages for clients with Medicaid Managed Care Coverage:

  • ARU Message: "Eligible PCP," Insurance Coverage Code SP, and Scope of Benefits.
  • OMNI 3750/Vx570 Message: "Managed Care Coordinator" for Elig/Ben Info, "NYS Catholic Health Plan Inc." for Plan, "SP" for Plan CD and Scope of Benefits.
  • ePACES Message: "MC Coordinator" for Eligibility Information, "NYS Catholic Health Plan Inc." for Medicaid Managed Care and "SP" and Scope of Benefits for Carrier Code.
  • NCPDP Message: "006" (Eligible PCP), "SP" for Plan CD, and Scope of Benefits.
  • PC - Host and Batch Message: "MC", "SP" and Scope of Benefits.

For details on the codes and fields identifying these services, please refer to the online provider manuals at: http://www.emedny.org/ProviderManuals/index.html.

To register as a provider with New York Medicaid, please visit: http://www.emedny.org/info/ProviderEnrollment/index.html.

Pharmacists can access the list of Medicaid reimbursable drugs at: http://www.eMedNY.org/info/formfile.html.

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


New York State Medicaid and Family Health Plus Providers
Return to Table of Contents

Allergies

Allergy season has arrived! Please note the drugs listed below are preferred in their drug class and DO NOT require prior authorization.

Intranasal Antihistamines

  • Astelin
  • Astepro

Ophthalmic Antihistamines

  • Pataday
  • Patanol

Second Generation Antihistamines

  • OTC cetirizine
  • OTC cetirizine-D
  • OTC loratadine
  • OTC loratadine-D

Intranasal Corticosteroids

  • Fluticasone,
  • Nasonex

Inhaled Corticosteroids

  • Advair Diskus,
  • Advair HFA
  • Asmanex,
  • Azmacort
  • Flovent Diskus
  • Flovent HFA
  • QVAR
  • Symbicort

Inhaled Short Acting Beta-2 Adrenergic Agents

  • Albuterol
  • Maxair Autohaler
  • Proventil HFA
  • Ventolin HFA

The Medicaid Preferred Drug Program (PDP) promotes the use of less expensive, equally effective prescription drugs when medically appropriate. For a complete listing of preferred agents in all therapeutic classes managed within the Preferred Drug Program, please refer to the NYS Medicaid Quicklist available online at: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDLquicklist.pdf.

Additional information is available online at: https://newyork.fhsc.com and www.nyhealth.gov.


PRESCRIBERS AND PHARMACY PROVIDERS:
Medicaid Preferred Drug Program Change in Provider Notification
Return to Table of Contents

Effective immediately, in accordance with the Office of Taxpayer Accountability fiscal reform initiatives, all updates to the Medicaid Preferred Drug Program (PDP) and Clinical Drug Review Program (CDRP) will be communicated to providers via the Medicaid Update. Information on the PDP and CDRP, including a downloadable version of the most current Preferred Drug List (PDL), is available online at: https://newyork.fhsc.com.

Providers may sign up to receive direct e-mail notifications of changes to the PDP and CDRP at: https://newyork.fhsc.com/providers/notify.asp. To receive a faxed copy of the most current PDL, please contact the prior authorization clinical call center at (877) 309-9493. For clinical concerns or Preferred Drug Program questions, please call (877) 309-9493.

For pharmacy billing questions, please call (800) 343-9000. For Medicaid pharmacy policy questions, please call (518) 486-3209.


NATIONAL PROVIDER IDENTIFIER (NPI) UPDATE:
Requirement for Pharmacies to Enter Dispensing Pharmacist NPI on Claims Delayed
Return to Table of Contents

Pharmacies are required to enter the Dispensing Pharmacist's National Provider Identifier (NPI) on the NCPDP claim in field 444-E9 Provider ID, with an '05' in field 465-EY Provider ID Qualifier. To allow pharmacies time to implement this change and to ensure access to necessary medications for beneficiaries, the OMIG will defer the enforcement of this requirement until further notice. The OMIG will continue to monitor all NCPDP claims for Dispensing Pharmacist's NPI. Pharmacists who do not possess an NPI can apply for one at: www.cms.hhs.gov/NationalProvIdentStand/.

For pharmacy billing questions, please call (800) 343-9000. For Medicaid pharmacy policy questions, please call (518) 486-3209.


PRESCRIBERS AND PHARMACY PROVIDERS: Automatic Refills Update
Return to Table of Contents

Automatic refill programs offered by pharmacies are NOT an option for Medicaid beneficiaries. Automatic refilling of prescriptions/orders for prescription drugs, over-the-counter products, medical surgical supplies, and enteral products are NOT allowed under New York State Medicaid. The following are allowed:

REQUESTS FOR A REFILL: A Medicaid beneficiary or designated caregiver must contact the pharmacy for each refill.

PROVIDER INQUIRY: A provider may initiate contact with a Medicaid beneficiary to determine if a refill is necessary. Documentation of the need for each refill shall be maintained in the patient record. The documentation must include the date and time of contact, the Medicaid beneficiary or designated caregiver's name, and the name of the pharmacy staff member who contacted the beneficiary or caregiver. The documentation must be available for audit purposes. Reminder: Compliance with HIPAA privacy guidelines is mandatory.

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


PRESCRIBERS AND PHARMACY PROVIDERS: New Edit Code Implemented
Return to Table of Contents

Effective May 27, 2010, Medicaid implemented Edit 00528 "Missing or Invalid Quantity Dispensed." This edit will ensure that prescription drugs are reimbursed according to appropriate packaging and unit of use quantities. This edit will deny claims when the dispensed quantity submitted does not correspond with a drug package size, or unit of use decimal quantity.

For example, a claim for one ASMANEX TWISTHALER 220 MCG, 120 doses, would be submitted with a quantity of 0.240 grams. If a pharmacy submits a claim that doesn't correspond with the drug package size (or a multiple of the package size), it will be denied and the error message will read "Missing or Invalid Quantity Dispensed". The pharmacy must correct the claim to represent the appropriate quantity that corresponds to the number of units and the drug package size being dispensed.

Billing Questions? Please contact the eMedNY Call Center at (800) 343-9000. Medicaid pharmacy policy and operations questions, contact (518) 486-3209.


PRESCRIBERS AND PHARMACY PROVIDERS: Prescribers of Injectable Prescriptions and Ancillary Supplies
Return to Table of Contents

Recent pharmacy audits have revealed that some providers are using homecare referral forms and pre-printed manufacturer forms for injectable orders. The majority of these forms were found to be non-compliant with prescription regulations as stated in 18 NYCRR Section 505.3, Section 6810 of NYS Education Law, and 10 NYCRR Part 910. As a result, several pharmacies were cited for unprofessional conduct as defined in Regents Rules 29.7. All prescriptions/fiscal orders for injectable drugs must meet Medicaid prescription requirements, as well as State and Federal requirements.

This includes but is not limited to: patient name, date ordered, prescriber imprinted name, and signature of prescriber. Injectable orders may not be refilled unless there are authorized refills noted on the prescription document. No more than five refills are permitted, and no order may be refilled more than 180 days after the date of issuance. Please note: Ancillary drugs/medical supplies used in injectable administration (i.e., epinephrine, syringes/needles, alcohol swabs, etc.) require a prescription/fiscal order to support claims billed to Medicaid. Each prescription/fiscal order should have a unique prescription number. It is not acceptable to create "supply kits" to be billed under one NDC number. Multiple drugs cannot be on the same prescription unless administered in a nursing home.

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

Pharmacy Policy Questions? Please contact Medicaid Pharmacy and Policy Operations at (518) 486-3209

Office of the Medicaid Inspector General: http://www.omig.state.ny.us or call (518) 473-3782 with general inquiries or 1-877-87FRAUD with suspected fraud complaints or allegations.


No Smoking

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


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

Please 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


Info

Provider Directory
Return to Table of Contents

Office of the Medicaid Inspector General:
http://www.omig.state.ny.us or call (518) 473-3782 with general inquiries or 1-877-87FRAUD with suspected fraud complaints or allegations.
This contact information can also be used for Provider Self-Disclosures.

Questions about billing and performing MEVS 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

Does your enrollment file need to be updated because you've experienced a change in ownership?
Fee-for-Service Providers please call (518) 402-7032
Rate-Based/Institutional Providers please call (518) 474-3575

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.