New York State Medicaid Update - July 2012 Volume 28 - Number 8
In this issue…
- POLICY AND BILLING GUIDANCE
- PHARMACY UPDATES
- ALL PROVIDERS
Policy and Billing Guidance
Information for Medical Practitioners and Facilities
Transportation Management Initiative Continues in New York
The New York State Department of Health (NYSDOH) and its contractor, LogistiCare Solutions, have implemented non-emergency medical transportation management services for New York City Medicaid fee-for-service enrollees (i.e., those not in a managed care plan) who are receiving Medicaid covered services in Brooklyn and Queens.
All trips must be pre-arranged and confirmed by LogistiCare:
- Requests for routine services must be pre-arranged 72 hours (three days) in advance.
- Requests for urgent (same day or next day) care are arranged any time.
Key Transportation Telephone Numbers
|Medical Facility Services
|877-564-5925||Monday – Friday
7a.m. - 6 p.m.
|Providers may call to speak to one of our
specialists to request standing order or demand
response transport for an enrollee.
| Medical Facility Services
| 877-585-8758 (Brooklyn)
|24/7||Case managers or social workers fax the 2015
Medical Justification Form or the Standing Order
Request forms to this number.
|Hospital Discharge||877-564-5926||24/7||Hospital discharges are handled quickly and
|"Where's My Ride"||877-564-5923||24/7|| Call this number if there is a service issue or
complaint, or when the enrollee needs to be
| Reservation Number for
|877-564-5922||Monday – Friday
7a.m. - 6 p.m.
| This is the number a Medicaid fee-for-service
enrollee can call to request transportation.
Transportation Management Implementation Schedule for Rest of City
|Bronx||September 1, 2012|
|Manhattan||September 1, 2012|
|Staten Island||October 1, 2012|
|Managed Care Plan Enrollees
(other than long term care plans enrollees)
|January 1, 2013|
Can Enrollees Request Transportation to Medical Appointments?
New York City Medicaid enrollees may now request their own trips to and from their medical practice. This may relieve providers of the administrative task of arranging trips.
Prior to May 2012, providers were required to arrange a Medicaid enrollee's livery, ambulette and stretcher transport. Now, all that is required is the Medicaid Transportation Justification Request (Form 2015) to document the need for transportation via livery, ambulette or ambulance. This document is maintained by LogistiCare; when your patient requests a trip, we will confirm the necessary mode and assign your preferred transportation provider to the appointment.
If the documentation is not on file, LogistiCare will contact you directly and ask you to submit the Medicaid Transportation Justification Request.
This form, along with all other forms and policy material, is available online, at NYCMedicaidRide.net. The form can be saved electronically, and maintained as part of your electronic record. Questions for LogistiCare may be e-mailed to nyc@LogistiCare.com.
Questions regarding this article may be e-mailed to MedTrans@helath.state.ny.us, or via telephone at (518) 473-2160.
Written Orders Requirement for Preschool/School Supportive Health Services Program (SSHSP)
Pediatricians and other primary care providers serving children with disabilities may be asked to write orders for medical services provided through special education programs to students with Individualized Education Programs (IEPs) under the Preschool/School Supportive Health Services Program (SSHSP).
Preschool/School Supportive Health Services Program (SSHSP)
Section 1903(c) of the Social Security Act permits payment of certain Medicaid-covered services furnished to children with disabilities if those services are included in an Individualized Education Program (IEP). These services are provided as part of the special education programs in school districts, counties, and §4201 schools (schools for the blind and deaf). In New York State, Medicaid-covered services for students with an IEP under the SSHSP include:
- 1) Physical Therapy
- 2) Occupational Therapy
- 3) Speech Therapy
- 4) Psychological Evaluations
- 5) Psychological Counseling
- 6) Skilled Nursing
- 7) Medical Evaluations
- 8) Medical Specialist Evaluations
- 9) Audiological Evaluations
- 10) Special Transportation
Medicaid Managed Care and Fee-for-Service Medicaid
The services listed above, when received under the SSHSP, are carved-out of managed care and billed directly to Medicaid fee-for-service by the school, county, or §4201 school. This means that even if a child is enrolled in one of New York State's managed care plans, SSHSP services themselves are covered under fee-for-service Medicaid. However, whether the child is enrolled in a Medicaid managed plan or has fee-for-service Medicaid, the primary care provider may still be requested by the parent to supply a written order for service(s) that will be billed under SSHSP. In such instances, the written order would be completed as part of the usual and customary care being furnished to the child. The office or clinic visit is billable by the provider to the child's managed care plan or to Medicaid fee-for-service if the child is not enrolled in a plan. In some cases, the child's IEP includes a service that is not covered under the SSHSP, such as full time private duty nursing. Such services are the responsibility of the child’s managed care plan
Written Orders for SSHSP Services
Timely provision of written orders is important, as it establishes the medical necessity of the service being furnished to the student and facilitates the school districts, counties, and §4201 schools in accessing Medicaid funds to pay for IEP services.
The written order/referral must be in place prior to the provision of the service or the service is not Medicaid reimbursable. School districts, counties, and §4201 schools will not be reimbursed for the services they provide without this critical documentation.
For Medicaid policy questions, please contact the Office of Health Insurance Programs Policy Department at (518) 473-2160.
For Medicaid managed care, please contact the enrollee's health plan.
New York Medicaid Electronic Health Records Incentive Program Update
The Department is pleased to announce that as of July 13, 2012, the New York Medicaid Electronic Health Records (EHR) Incentive Program has now paid over $161 million in federal incentive funds to over 1,940 New York State hospitals and healthcare practitioners.
NYSDOH continues to review applications for Payment Year 2011 incentive payments that were submitted prior to the April 29, 2012 deadline, and applications for Payment Year 2012 are currently being accepted from providers who are new to the incentive program. Applications for providers' second incentive payment (including Meaningful Use Attestation) will be accepted starting in the fourth quarter of calendar year 2012.
If you have not yet registered for the New York Medicaid EHR Incentive program, we encourage you to visit the eMedNY.org website https://www.emedny.org/meipass/ or attend one of the informationalwebinars hosted by NYSDOH throughout the month of August.
|Wednesday, August 1||3:00-4:00PM||Eligible Professional Registration & Attestation|
|Thursday,August 2||12:00–1:00PM||MEIPASS Prerequisites|
|Tuesday,August 7||10:00–11:00AM||EP Support Documentation|
|Wednesday, August 8||3:00–4:00PM||Meaningful Use, Stage 1 (Eligible Professionals)|
|Wednesday, August 15||12:00–1:00PM||MEIPASS Prerequisites|
|Tuesday, August 21||10:00–11:00AM||Eligible Professional Registration & Attestation|
|Thursday, August 23||12:00–1:00PM||Meaningful Use, Stage 1 (Eligible Hospitals)|
|Tuesday, August 28||3:00–4:00PM||Meaningful Use, Stage 1 (Eligible Professionals)|
The webinar schedule is subject to change based on interest levels. To view the complete schedule or to register for one of the webinars, please view the webinar schedules posted on the eMedNY.org website at:
Current Month: https://www.emedny.org/meipass/webinar/Webinar.pdf
Mandatory Medicaid Managed Care Expanding To Wyoming County
Beginning in July 2012, managed care enrollment will be required for most Medicaid members residing in Wyoming County. Once a mandatory managed care program is implemented in a county, it is expected that the enrollment of all eligible Medicaid members will take up to twelve months to complete. Fidelis Care and Health Now health plans are currently available in Wyoming County.
Providers should check the Medicaid Eligibility Verification System (MEVS) prior to rendering services to determine Medicaid eligibility and the conditions of Medicaid coverage. Providers are strongly encouraged to check eligibility at each visit as eligibility and enrollment status may change at any time. If the Medicaid beneficiary is enrolled in a Medicaid managed care plan, the first coverage message will indicate "Eligible PCP".
MEVS responses no longer include scope of benefits information therefore providers will need to contact the health plan to determine what services the plan covers. Service Type codes will be used to identify carved-out services where possible. Medicaid will not reimburse a provider on a fee-for-service basis if a medical service is covered by the plan.
For more information on MEVS messages, please see the February 2011 Special Edition Medicaid Update at: http://www.health.ny.gov/health_care/medicaid/program/update/2011/feb11mu_special.pdf.
Providers may call the eMedNY Call Center at (800) 343-9000 with any Medicaid billing issues. Medicaid members may contact the New York Medicaid Choice at (800) 505-5678 or their local department of social services (LDSS) to learn more about managed care.
For additional information on managed care covered services and managed care plan types, please see the December 2010 Medicaid Update article entitled "Managed Care Covered Services" at: http://health.ny.gov/health_care/medicaid/program/update/2010/2010-12.htm.
NYSMPEP Drug Information Response Center Addresses Pharmacotherapy in Patients with Prediabetes
The New York State Medicaid Prescriber Education Program (NYSMPEP) is a collaboration between the New York State Department of Health (NYSDOH) and the State University of New York (SUNY), as approved by state legislation. This program was designed to provide prescribers with an evidence-based, non-commercial source of the latest objective information about pharmaceuticals. In conjunction, the Drug Information Response Center (DIRC) was developed to fulfill the mission of assisting clinicians in the delivery of health care to their Medicaid patients by providing timely, evidence-based information on pharmacotherapy to prescribers and serving as a resource for NYSMPEP academic educators in their outreach to prescribers. The following review was prepared by the DIRC in response to a request for information on the management of patients with prediabetes.
A number of organizations have published guidelines with recommendations for the management of patients with prediabetes. The American Diabetes Association (ADA) defines prediabetes as a condition associated with fasting plasma glucose (FPG) levels of 100 to 125 mg/dL or 2-hour plasma glucose levels (after 75-g oral glucose tolerance test [OGTT]) of 140 to 199 mg/dL, or a glycosylated hemoglobin (A1C) of 5.7 to 6.4%.1 For individuals who meet any of these criteria, the ADA recommends referral to an ongoing support program promoting weight loss (≥7% ideally) and increased physical activity (≥150 min per week) and consideration of metformin therapy in patients with a body mass index (BMI) >35 kg/m2, age <60 years, and women with a history of gestational diabetes mellitus (GDM). Annual monitoring for diabetes development is recommended for all patients with prediabetes. Regarding drug therapy, the ADA specifies metformin as the only drug that should be considered. Other medications such as thiazolidinediones, alpha-glucosidase inhibitors, and incretin mimetics have been studied, but due to cost issues, side effects, and lack of data demonstrating consistent effects, these drugs are not recommended.¹,²
The American Association of Clinical Endocrinologists (AACE) defines prediabetes similarly, with the exception of A1C levels (5.5 to 6.4% as opposed to 5.7 to 6.4%) and an inclusion of metabolic syndrome as defined by the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III criteria as a prediabetes equivalent.³ Like the ADA, the AACE recommends annual monitoring for diabetes in these patients, in addition to addressing excessive weight and cardiovascular disease (CVD) risk factors. Weight loss of ≥7% is recommended, as is reduction in caloric intake (≥500 kcal/day) and regular exercise (≥30 min/day). Regarding drug therapy, the AACE suggests that metformin or perhaps thiazolidinediones be considered for younger patients at moderate to high risk of developing diabetes, those with additional CVD risk factors (e.g., hypertension, dyslipidemia, or polycystic ovarian syndrome), a family history of diabetes in a first-degree relative, and/or patients who are obese.
From a search of the literature, several studies have been conducted evaluating drug therapy for prevention of diabetes. In addition to those outlined in the ADA guidelines,(4-7); several meta-analyses have been published. Lily and Godwin sought to determine the efficacy of metformin in the prevention of diabetes,(8) in which they identified three randomized controlled trials for analysis.
Doses of metformin used in the studies varied from 250 mg twice daily, to 250 mg three times daily, and 850 mg twice daily. Lifestyle modifications in conjunction with metformin or placebo were evaluated in 1 study. Follow-up periods ranged from 12 months to 3 years. Overall, metformin therapy was found to result in a decreased risk of diabetes development (odds ratio [OR] 0.65, 95% confidence interval [CI] 0.55 to 0.78). Of note, in observing the results of the individual studies, not all demonstrated a significant reduction in the rate of diabetes development.
Hopper et al conducted a meta-analysis evaluating the effect of both pharmacologic and non-pharmacologic interventions in patients with prediabetes on incidence of all-cause and cardiovascular-related mortality.,(9) The investigators included trials involving a minimum of 100 patients with a follow-up time of ≥1 year. A total of 10 trials were included, with 23,152 patients, and a mean follow-up period of 3.75 years. Interestingly, the investigators determined that patients with non-pharmacologic interventions (e.g., dietary modifications and exercise) were superior to drug therapy in the prevention of diabetes with risk ratios of 0.52 (95% CI: 0.46 to 0.58) vs. 0.70 (95% CI: 0.58 to 0.85; p<0.05). No differences were observed between these groups in the incidence of all-cause mortality and cardiovascular death.
As described in the ADA and AACE guidelines, drug therapy is not strongly recommended for prevention of diabetes in all patients with prediabetes. Both organizations qualify those who may be better candidates, based on the results of the outlined studies. It appears that metformin may be most appropriate when considering initiation of drug therapy for prevention of diabetes. Of note, there is no one dosing recommendation for metformin that has been determined to be superior. All patients with prediabetes, however, should receive counseling on lifestyle modifications targeting weight loss and increased physical activity and be monitored at least annually for development of diabetes.
To contact a NYSMPEP academic educator in your area, please visit: http://nypep.nysdoh.suny.edu/contactus.
1. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(Suppl 1):S11-S63
2. Moutzouri E, Tsimihodimos V, Rizos E, Elisaf M. Prediabetes: to treat or not to treat? Eur J Pharmacol. 2011;672(1-3):9-19.
3. Handelsman Y, Mechanick JI, Blonde L, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract. 2011;17(Suppl 2):1-53.
4. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.
5. Chiasson JL, Josse RG, Gomis R, et al. Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomized trial. Lancet. 2002;359(9323):2072-2077.
6. DREAM (Diabetes REduction Assessment with ramipril and rosiglitazone Medication) Trial Investigators, Gerstein HC, Yusuf S, et al. Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomized controlled trial. Lancet. 2006;368(9541):1096-1105.
7. Ramachandran A, Snehalatha C, Mary S, et al. The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia. 2006;49(2):289-297.
8. Lily M, Godwin M. Treating prediabetes with metformin: systematic review and meta-analysis. Can Fam Physician. 2009;55(4):363-369.
9. Hopper I, Billah B, Skiba M, Krum H. Prevention of diabetes and reduction in major cardiovascular events in studies of subjects with prediabetes: meta-analysis of randomized controlled clinical trials. Eur J Cardiovasc Prev Rehabil. 2011;18(6):813-823.
OMH Residential Treatment Facility Prescription Drug Carve-Out
Effective September 1, 2012, reimbursement of prescription drugs for residents of the Office of Mental Health (OMH) Residential Treatment Facilities (RTF) will be covered as a Medicaid fee-for-service (FFS) benefit and billed directly to Medicaid by the dispensing pharmacy. There are currently 19 facilities statewide, with a total of 554 certified beds.
The change only affects prescription drugs. Physician administered drugs, commonly referred to as J-code drugs, and over-the-counter (OTC) drugs, medical supplies, immunization services (vaccines and their administration), nutritional supplies, sick room supplies, adult diapers, and durable medical equipment (DME) will not be carved out of the RTF rate and will remain the responsibility of the facility.
The NYS Medicaid FFS program only provides reimbursement for prescription drugs included on the NYS Medicaid Pharmacy List of Reimbursable Drugs, which can be found at: http://www.emedny.org/info/formfile.html.
Once this change takes effect, RTF providers will no longer purchase prescription drugs for the children and youth in their programs. Prescriptions must be written on the Official New York State Prescription Form (ONYSRx), with only one medication permitted per form. Prescriptions must then be dispensed and billed by a Medicaid enrolled pharmacy, using the child's individual Medicaid Client Identification Number (CIN). These children do not have Medicaid benefit cards; therefore, the OMH RTF will provide the CIN to the pharmacy.
Pharmacy Enrollment Information
Pharmacies that supply prescription drugs to OMH RTFs must be enrolled in the Medicaid program in order to submit claims for reimbursement. No other entity can function as a billing agent for a LTC pharmacy.
Enrollment information can be found at the following Web sites:
- Pharmacy Enrollment Packet:
- Additional information to be submitted by out-of-state pharmacies:
Prior Authorization Programs
The Medicaid program requires prior authorization for certain drugs through the Preferred Drug Program (PDP), Mandatory Generic Drug Program (MGDP), Clinical Drug Review Program (CDRP), and Brand When Less Than Generic Program (BLTG). The prescriber may need to obtain prior authorization for certain drugs. General information on prescription drug prior authorization can be found on the Magellan Medicaid Administration Web site available at: https://newyork.fhsc.com.
Note: If a prior authorization number has not been obtained by the prescriber and the pharmacist is unable to reach the prescriber, the pharmacist may obtain a prior authorization for up to a 72 hour emergency supply of a multi-source brand-name or non-preferred drug, subject to State laws and Medicaid restrictions. Once a 72 hour supply prior authorization number is given and a 72 hour supply is dispensed, the prescription is no longer valid for the remaining quantity and refills. The pharmacist is expected to follow-up with the prescriber to determine future needs.
Pharmacy Program information can be found on the Medicaid Pharmacy Program web page located at: http://www.health.ny.gov/health_care/medicaid/program/pharmacy.htm.
Information on the specific prior authorization programs as well as FQD/Step Therapy requirements can be found at the following websites:
- Preferred Drug Program
- Mandatory Generic Drug Program
- Clinical Drug Review Program
- Brand When Less Than Generic Program
- Step Therapy (ST) Program
- Frequency/Quantity/Duration (F/Q/D) Program
Additional information regarding the Medicaid prior authorization programs is available online at: https://newyork.fhsc.com/ or by calling (877) 309-9493. For pharmacy billing questions, please call (800) 343-9000.
FREQUENTLY ASKED QUESTIONS AND ANSWERS
Q1. What is included in the OMH RTF carve out?
A1. Only prescription drugs listed on Medicaid Pharmacy List of Reimbursable Drugs, which can be found at: http://www.emedny.org/info/formfile.html
Q2. How do I know which drugs on the Medicaid Pharmacy List of Reimbursable Drugs require a Prior Authorization (PA)?
A2. The Medicaid Pharmacy List contains a "PA CD" field. PA code of "0" indicates PA not required; PA code of "N" indicates PA required; and PA code of "G" indicates PA required/may be required.
Q3. Are emergency supplies of prescription drugs requiring PA permitted?
A3. Yes. If a prior authorization number has not been obtained by the prescriber and the pharmacist is unable to reach the prescriber, the pharmacist may obtain a prior authorization for up to a 72 hour emergency supply of a multi-source brand-name or non-preferred drug, subject to State laws and Medicaid restrictions. Once a 72 hour supply prior authorization number is given and a 72 hour supply is dispensed, the prescription is no longer valid for the remaining quantity and refills. The pharmacist is expected to follow-up with the prescriber to determine future needs. Additional information is available online at: https://newyork.fhsc.com/downloads/providers/NYRx_PA_emergency_supply_pharmacy_worksheet.docx
Q4. What is not included in the OMH RTF carve-out?
A4. Items not included are physician administered drugs (commonly referred to as J-code drugs), over the counter drugs, medical supplies, immunization services (vaccines and their administration), nutritional supplies, sick room supplies, adult diapers, and durable medical equipment (DME). These items remain the responsibility of the facility.
Q5. Are over the counter medications included in the carve-out?
A5. No, over the counter medications are not included in the carve-out and the cost of these items will remain in the RTF daily rate.
Q6. Are OTC drugs listed on the Preferred Drug List (PDL) also covered as a pharmacy benefit for OMH RTF?
A6. No. OTC drugs are not included in the OMH RTF carve-out. They will remain the responsibility of the OMH RTF.
Q7. Is a newly admitted resident eligible for an early fill on their drugs?
A7. Yes. When medically necessary, a pharmacist can override edit 01642 "Early Fill Overuse" denial at the point of sale, by using the following combination:
- National Council for Prescription Drug Programs (NCPDP) Reason for Service Code (439-E4) of 'N'(New Patient Processing);
- A valid Result of Service Code (441-E6), and
- Submission Clarification Code (420-DK) of '02'.
Q8. Will OMH RTF residents be responsible to pay their co-pays?
A8. No. Residents of an OMH RTF are exempt from Medicaid co-pays.
Q9. When using the client's Medicaid number to obtain prescription medications, what Medicaid sequence number should be placed on the pharmacy claim?
A9. A sequence number is not required on the pharmacy claim for these clients.
EPIC PROVIDER BULLETIN (PDF, 3KB, 3pg.)
New Training Schedule and Registration
- 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 training session. Computer Sciences Corporation (CSC) offers various types of educational opportunities to providers and their staff. Training sessions are available at no cost to providers and include information for claim submission, Medicaid Eligibility Verification, and the eMedNY Website.
Web Training Now Available
You can also register for a webinar in which training would be conducted online and you can join the meeting from your computer and telephone. After registration is completed, just log in at the announced time. No travel involved.
Many of the sessions planned for the upcoming months offer detailed instruction about Medicaid's free web-based program-ePACES which is the electronic Provider Assisted Claim Entry System that allows enrolled providers to submit the following type of transactions:
- 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 registration, locations, and dates are available on the eMedNY Website at: http://www.emedny.org/training/index.aspx
CSC Regional Representatives look forward to having you join them at upcoming meetings!
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.
- 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 www.omig.ny.gov.
- Provider Manuals/Companion Guides, Enrollment Information/Forms/Training Schedules: Please visit the eMedNY website at: www.emedny.org.
- Providers wishing to hear the current week's check/EFT amounts: Please call (866) 307-5549 (available Thursday PM for one week for the current week's amount)
- 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: http://www.emedny.org/training/index.aspx. For individual training requests, call (800) 343-9000 or e-mail: email@example.com.
- 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: https://www.emedny.org/info/ProviderEnrollment/allforms.aspx.
- Rate-Based/Institutional Providers: A change of address form is available at: https://www.emedny.org/info/ProviderEnrollment/allforms.aspx.
- Does your enrollment file need to be updated because you've experienced a change in ownership? Rate Base/Institutional and Fee-for-Service providers, please call (518) 474-3575, Option 4
- Do you have comments and/or suggestions regarding this publication?
- Please contact Kelli Kudlack at: firstname.lastname@example.org.