New York State Medicaid Update - January 2012 Volume 28 - Number 1

In this issue…

Policy and Billing Guidance

New Federal Rules Require Enrollment Revalidation for All Providers

New federal rules and regulations require that all enrolled providers revalidate their enrollment at least every five years. Revalidation will include attestation of credentials as well as the agreement to abide by the rules and regulations of the Medicaid program. Certain provider types will be required to pay a fee for revalidation.

A revalidation process will be initiated by the Department in the fall of 2012. Revalidation will be rolled out by provider type. Correspondence will be sent to providers, advising them of their need to revalidate their enrollment. Providers will then have 150 days from receipt of the notice to complete the process. Failure to comply with the revalidation and attestation within the timeframe will result in provider disenrollment.

In the coming months, additional information regarding the revalidation schedule and instructions will be posted on Please contact the eMedNY Call Center at (800) 343-9000 with any questions.

Not for Profit Providers Enrolled in the Medicaid Program Must Comply with Rules Regarding Compensation and Administrative Expenses

Governor Cuomo's Executive Order No: 38, directs the Department to promulgate regulations, and take any other actions within the agency's authority to prevent taxpayer dollars from being diverted to pay for excessive salaries and compensation at not-for-profit entities that receive taxpayer support from the State of New York.

The Department considers compensation, bonuses and incentives paid by a provider and its costs of administration that exceed a level that is reasonable to be a factor having a direct bearing on the provider's ability to furnish high-quality medical care, services, or supplies to Medicaid recipients, and to be fiscally responsible to the Medicaid program.

The Department may deny or terminate enrollment as a provider in the Medicaid program if it is determined that executive compensation, bonuses, incentives and costs of administration exceed reasonable levels.

Medicaid Transportation Management - New York City

The Medicaid Redesign Team (MRT) is committed to minimizing the barriers to accessing needed transportation, improving the quality of transportation services, ensuring consistent application of Medicaid rules and reducing costs. The MRT's investment in this initiative will result in the nation's largest Medicaid non-emergency transportation management program.

The Department is pleased to announce that LogistiCare Solutions was awarded a contract to manage the transportation needs of New York City enrollees. LogistiCare is one of the nation's leaders in non-emergency transportation management, and will work with medical facilities and practitioners to ease the burden of arranging necessary transportation.

For those Medicaid enrollees not covered by a managed care plan, orders for transportation will be phased in by borough throughout 2012. Medical facilities or practitioners who request transportation will contact LogistiCare to schedule transportation according to the seasonal timeline below (exact dates will be communicated in a future publication):

Practitioner/Facility Location and Implementation Date

  • Brooklyn (Spring)
  • Queens (Late Spring)
  • Manhattan (Summer)
  • Bronx (Summer)
  • Staten Island (Fall)

Additionally, on January 1, 2013, LogistiCare will assume the management of transportation of enrollees covered by a managed care plan, resulting in a single process for medical practitioners and enrollees requesting transportation.

LogistiCare will meet with facilities and practitioners prior to the implementation date of each borough. LogistiCare also offers webinars regarding new processes at convenient times for your participation, and will e-mail written guidelines on specific topics. If you would like information regarding upcoming webinars, or would like to arrange a meeting with LogistiCare staff to coordinate your current processes with LogistiCare's system, please send an e-mail indicating your interest, along with your name, address, facility name and national provider identification number (NPI), and telephone number via e-mail to:

Transportation Providers

Enrolled Medicaid transportation providers will continue to participate, and will be used for those facilities and practitioners who request their service. Further, reimbursement of rendered transports will continue to be made via eMedNY at the Department of Health established fees. Please contact LogistiCare via e-mail at: to set an appointment for LogistiCare staff to visit your place of business and discuss the new transportation management process. Questions regarding this article and general questions regarding Medicaid transportation policy can be sent via e-mail to:

Electronic Health Record Incentive Payments Begin

The New York Medicaid Electronic Health Record Incentive Program has begun distributing payments to providers who have registered and attested for adoption, implementation and upgrade (AIU) to certified electronic health record (EHR) technology. This federally funded program is intended to speed the transition of medical practice from paper-based processes to interoperable electronic systems, providing clinical benefits as well as reducing the overall cost of health care.

Since December 2011, over$32 million in incentive payments have been disbursed to Medicaid providers.

Change in Bariatric Surgery Policy

Effective February 4, 2012, any hospital in New York State that meets the Center for Medicare and Medicaid Services' (CMS) minimum facility standards and is designated either by the American College of Surgeons and/or the American Society for Metabolic and Bariatric Surgery as a Medicare Approved Facility for Bariatric Surgery, will be reimbursed for bariatric surgical services for Medicaid fee-for-service and managed care recipients.

Currently, only certain New York City hospitals designated by the NYS Department of Health (NYSDOH) may be reimbursed for bariatric surgical services to Medicaid fee-for-service recipients. As of February 4, 2012, fee-for-service Medicaid recipients in New York City may seek bariatric surgical services at any CMS Approved Facility for Bariatric Surgery, and any CMS approved facility may be reimbursed for such services for fee-for-service recipients. Current policy remains unchanged for managed care recipients: any CMS Approved Facility may be reimbursed for bariatric surgical services for managed care recipients.

As of January 2012, the following New York State hospitals have this CMS designation:

  • Adirondack Medical Center (Saranac Lake)
  • Albany Medical Center (Albany)
  • Arnot Ogden Medical Center (Elmira)
  • Bassett Medical Center (Cooperstown)
  • Bellevue Hospital (Manhattan)
  • Bon Secours Community Hospital (Port Jervis)
  • Brookdale University Hospital / Medical Center (Brooklyn)
  • Ellis Hospital (Schenectady)
  • Faxton-St. Lukes Healthcare (Utica)
  • Good Samaritan Hospital (Suffern)
  • Good Samaritan Hospital Medical Center (West Islip)
  • Harlem Hospital Center (Manhattan)
  • Highland Hospital (Rochester)
  • Jacobi Medical Center (Bronx)
  • John T. Mather Memorial Hospital (Port Jefferson)
  • Kaleida Health, Buffalo General (Buffalo)
  • Lawrence Hospital Center (Bronxville)
  • Lenox Hill Hospital (Manhattan)
  • Lutheran Medical Center (Brooklyn)
  • Maimonides Medical Center (Brooklyn)
  • Mercy Medical Center (Rockville Centre)
  • Montefiore Medical Center (Bronx)
  • Mount Sinai School of Medicine (Manhattan)
  • Nassau University Medical Center (East Meadow)
  • New York Methodist Hospital (Brooklyn)
  • New York-Presbyterian Hospital/Columbia University Medical Center (Manhattan)
  • New York-Presbyterian Hospital/Weill Cornell Medical Center (Manhattan)
  • North Shore University Hospital at Manhasset (Manhasset)
  • NYU Langone Medical Center (Manhattan)
  • Orange Regional Medical Center (Middletown)
  • Peconic Bay Medical Center (Riverhead)
  • Rochester General Hospital (Rochester)
  • Sisters of Charity Hospital (Buffalo)
  • Sound Shore Medical Center of Westchester (New Rochelle)
  • South Nassau Communities Hospital (Oceanside)
  • Southampton Hospital (Southampton)
  • St. Catherine of Siena Medical Center (Smithtown)
  • St. Joseph's Hospital Health Center (Syracuse)
  • St. Luke's/Roosevelt (Manhattan)
  • Staten Island University Hospital (Staten Island)
  • SUNY Upstate Medical University (Syracuse)
  • Syosset Hospital (Syosset)
  • Westchester Medical Center (Valhalla)
  • Winthrop University Hospital (Mineola)

This list of designated hospitals is updated routinely and should be checked prior to scheduling bariatric surgery for any Medicaid recipient. Please see:

Any questions regarding this policy should be directed to Michael Lindsey at (518) 486-9012.

Payment Error Rate Measurement Program - Medical Review of Sampled Claims

This is a follow-up to the PERM Project articles previously published in the September 2010 and July 2011 Medicaid Updates.

The New York State Medicaid Program is included in the current cycle of the Payment Error Rate Measurement (PERM) Program, implemented by the Centers for Medicare & Medicaid Services (CMS) to measure improper payments in areas of significant public expenditures.

CMS is utilizing A+ Government Solutions to review the provider's service documentation for a random sample of Medicaid fee-for-service payments made between October 1, 2010 and September 30, 2011. This Medical Review will examine the supporting medical record or other required documentation to determine if the service complied with applicable Medicaid rules and whether the provider received the correct Medicaid payment.

Sampled providers will be contacted by A+ Government Solutions to provide the documentation necessary to substantiate the paid claim.Additionally, the NYS Office of the Medicaid Inspector General (OMIG) will request a copy of this documentation to confirm all required items have been submitted. Please submit the specific medical documents for the patient, as requested in the letters, to the CMS contractor and to the OMIG (addresses for both will be provided in the requests for documentation).

If you are contacted, your cooperation and timely response is requested, as receipt of the documentation is essential to the success of the program.

Further information on the PERM Program is available on the CMS provider Website at:

Questions? Please contact the Payment Error Rate Measurement project staff via e-mail at: or by phone at (518) 402-0066 or (518) 408-0660.

Pharmacy Updates

The New York State Medicaid Prescriber Education Program: Focus on Diabetes

The New York State Medicaid Prescriber Education Program (NYSMPEP) is continuing to provide prescribers with a source of unbiased, evidence-based, non commercial pharmacotherapy information. Currently, NYSMPEP is actively involved in diabetes education.

The NYSMPEP's white paper on diabetes, entitled, "Treating Type 2 Diabetes Mellitus: a New York State Medicaid Clinical Guidance Document," provides prescribers with a broad overview of the diagnosis and screening for this widespread disease and a brief discussion about its complications. Its primary focus is on disease state management, including lifestyle interventions. The white paper offers prescribers a suggested treatment algorithm, based on current ADA recommendations and other published literature, and an in-depth discussion on the various classes of anti-diabetic agents available.

The NYSMPEP's key messages for the diabetes white paper are:

  • Metformin should be used as a first-line medication in almost every patient with type 2 diabetes.
  • DPP-4 inhibitors and GLP-1 agonists should not be used first line in patients with type 2 diabetes because metformin, sulfonylureas and insulin are more efficacious.
  • HbA1c goals should be individualized for each patient with type 2 diabetes: less than 7 percent for most patients and less than 8 percent for specific high-risk subgroups.
  • Patients with type 2 diabetes should have an HbA1c test every three to six months.

Each of these key messages is addressed in detail during one-on-one educational sessions between NYSMPEP academic educators and prescribers. Diabetes resources are available online and include: the diabetes white paper, slide sets focusing on each key message, a variety of diabetes related tables and charts, and one-page documents on "New Diabetes Medications" and "Insulin Basics," which were developed in response to feedback received during academic educator sessions. Please visit the NYSMPEP Website at: for additional information or to schedule a visit with an academic educator in your area.

Dispense Brand Name Drugs When Less Expensive

This program is cost containment initiative which promotes the use of certain multi-source brand name drugs when the cost of the brand name drug is less expensive than the generic equivalent. Medicaid continually evaluates the program and makes changes to the drugs included in this initiative.

In the future, additions and deletions to this program will be posted 10 days in advance of the change at:

Please keep in mind that drugs removed from this program may be subject to prior authorization requirements of other pharmacy programs; again promoting the use of the most cost-effective product.

All Providers

Training Schedule and Registration

With the implementation of changes for HIPAA-compliant electronic submissions, including ePACES, CSC Regional Representatives have scheduled educational sessions to demonstrate the new ePACES screens and functionality, as well as other training sessions for new providers, specific provider types, Managed Care and the Medicaid Eligibility Verification System.

ePACESis the electronic Provider Assisted Claim Entry System which allows enrolled providers to submit the following type of transactions:

  • Claims
  • Eligibility Verifications
  • Claim Status Requests
  • Prior Approval/DVS Requests

Physician, Nurse Practitioner, DME and Private Duty Nursing claims can even be submitted 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:

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

If you are unable to access the Internet to register or have questions about registration, please contact the eMedNY Call Center at (800) 343-9000.

Reminder: CMS Discretionary Enforcement Period for 5010 Compliance Ends March 31, 2012

Medicaid providers who are still submitting electronic transactions in the HIPAA Version 4010 format are urged to complete their system transition to Version 5010 as soon as possible. The CMS discretionary enforcement period for Version 5010 compliance ends on March 31, 2012. Providers who fail to comply by this deadline will be putting their Medicaid payments at risk. As stated in a previous communication, New York Medicaid will continue to operate a dual system for inbound transactions through the March 31 date. However, in keeping with the federal Version 5010 compliance guidelines, effective April 1, 2012, Medicaid will begin to accept and process only Version 5010 inbound transactions.

Do not delay your Version 5010 transition efforts. If you are experiencing difficulties the Department and CSC have educational and technical resources available to assist you. Extensive information on all Medicaid changes for Version 5010 is included at under "eMedNYHIPAASupport" and in the February 2011 5010 Special Edition Medicaid Update. In addition, CSC Call Center and EDI technical support staffs are available to assist you with your 5010 transition questions and issues. Please contact them at (800) 343-9000.

Issuance of IRS Form 1099

Computer Sciences Corporation, the eMedNY contractor for the New York State Department of Health (NYSDOH), issues IRS (Internal Revenue Service) Form 1099 to providers at the beginning of each year for the previous year's Medicaid payments. The 1099s are issued with the individual provider's social security number or for businesses, with the Federal Employer Identification Number (FEIN) registered with NY Medicaid.

As with previous years, please note that the IRS 1099 amount is notbased on the date of the checks; rather,it is based on the date the checks were released to providers.

Due to the two-week check lag between the date of the check and the date the check is issued, the IRS 1099 amount will not correspond to the sum of all checks issued for your provider identification number during the calendar year. The IRS 1099 amount is based on check release date.

The IRS 1099 that will be issued for the year 2011 will include the following:

  • Check dated 12/20/10 (Cycle 1739) released on 01/05/2011 through,
  • Check dated 12/12/11 (Cycle 1790) released 12/28/11.

Additionally, each year, CSC receives calls from individual providers who are issued 1099s for funds the practitioner is unaware of. This happens because in order for group practice providers to direct Medicaid payments to a group NPI and corresponding IRS 1099 for the group, group practices must submit the group NPI in the appropriate field on the claim (paper or electronic). Claims that do not have the group NPI entered will cause payment to go to the individual provider and his/her IRS 1099. Regardless of who deposits the funds, the 1099 will be issued to the individual provider when the funds had been paid to the individual provider's NPI.

Also note that 1099s are not issued to providers whose yearly payments are less than $600.00.

IRS 1099s for the year 2011 will be mailed no later than January 31, 2012.

Any questions should be directed to the eMedNY Call Center at (800) 343-9000.

Provider Directory

  • Office of the Medicaid Inspector General: For general inquiries or provider self-disclosures, please call (518) 473-3782. For suspected fraud complaints/allegations, call 1-877-87FRAUD (1-877-873-7283), or visit
  • Provider Manuals/Companion Guides, Enrollment Information/Forms/Training Schedules: Please visit the eMedNY website at:
  • Do you have questions about billing and performing MEVS transactions? Please call the eMedNY Call Center at (800) 343-9000.
  • Provider Training: To sign up for a provider seminar in your area, please enroll online at: For individual training requests, call (800) 343-9000 or e-mail:
  • Enrollee Eligibility: Call the Touchtone Telephone Verification System at (800) 997-1111.
  • Address Change? Address changes should be directed to the eMedNY Call Center at (800) 343-9000.
  • Fee-for-Service Providers: A change of address form is available at:
  • Rate-Based/Institutional Providers: A change of address form is available at:
  • 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.
  • Do you have comments and/or suggestions regarding this publication?
  • Please contact Kelli Kudlack at: