DOH Medicaid Update February 1999 Vol.14, No.2

Office of Medicaid Management
DOH Medicaid Update
February 1999 Vol.14, No.2

State of New York
George E. Pataki, Governor

Department of Health
Antonia C. Novello, M.D., M.P.H., Dr. P.H.

Medicaid Update
is a monthly publication of the
New York State Department of Health,
Office of Medicaid Management,
14th Floor, Room 1466,
Corning Tower, Albany,
New York 12237

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Recently published Medicaid Update articles notified physicians that an appropriate CLIA certification must be on file with Medicaid to allow payment of claims for laboratory testing provided to their own patients. Medicaid is now enforcing the federal mandate to pay for only those tests covered by the physician's CLIA certificate. You may begin to experience denied claims for lab tests performed in your office if you failed to provide Medicaid with the necessary CLIA information.

The payment system has linked lab test procedure codes to the type of CLIA certification as follows:

CLIA Certificate of Compliance/Accreditation: Payment is available for all laboratory services procedure codes found in the current Physician MMIS Provider Manual.
CLIA Certificate - Physician Performed Microscopy Procedures (PPMP): Payment is available for the following laboratory procedure codes ONLY:
81002, 81015, 81025, 85013, 85018, 85651, 87082
CLIA Certificate of Waiver: Payment is available for the following procedure codes ONLY:
81000, 81002, 81025, 85013, 85018, 85651, 87082

If post-payment review reveals that the system paid inappropriately because you performed and billed for a test method OUTSIDE your CLIA approval, the payment may be disallowed.

NYCHHC et al. v. BANE
(Medicare Crossover Lawsuit)
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These instructions apply only to those providers who are named plaintiffs in the above-cited action.

This article will:

  • remind providers that the submission of edit corrections ended with the December 1998 purge run - except as noted in the following;
  • remind providers that the March 1999 purge cycle was the final error correction opportunity afforded to providers with previous Edit 162 and Edit 140 failures; and
  • remind providers that they may still submit documentation to permit adjudication of claims pended for Edits 127, 262 or 1281.


  1. The Department has previously informed you that the opportunity for submission of edit corrections of lawsuit claims ended with the last scheduled purge run for calendar year 1998.
  2. The Department has also previously informed you of a special process used as a final effort to resolve Edit 140 and Edit 162 claims. Providers who have had claims that had failed either Edit 140 or Edit 162, and after special processing had failed some other edit, had also been advised of the one additional opportunity to correct these edit failures. That opportunity ended with the March 1999 purge cycle.
  3. Providers may still continue to send in the required documentation to confirm Medicare data for any claim that pended for Edits 127, 262 or 1281, but only until May 11, 1999. The June 1999 purge cycle will be the final Medicare lawsuit claims processing cycle.

Providers responding to any of these three edits should send in a copy of the appropriate Provider Remittance Statement along with a copy of the applicable Explanation of Medicare Benefits [EOMB] to:

P.O. BOX 4105
ALBANY, NY 12204

PLEASE NOTE: Documentation that is submitted is required to be clipped together and properly highlighted, to permit accurate review. Failure to properly follow these instructions may result in non-payment if reviewers are unable to match documentation to specific claims.

For assistance, please call your CSC Healthcare Systems representative at:

Practitioner services: 1-800-522-5518 or [518] 447-9860
Institutional services: 1-800-522-1892 or [518] 447-9810
Professional services: 1-800-522-5535 or [518] 447-9830

EDITS 127, 262, 1281, and 1283

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Claims failing edit 127 (Medicare Paid Amount Reported Less Than Reasonable Amount), edit 262 (Medicare Paid, No Medicare On File), edit 1281 (Medicare Lawsuit Claim - Payment Amount Exceeds Upper Dollar Limit), and 1283 (Upper Dollar Limit Exceeded) will pend for review by Computer Sciences Corporation (CSC). Edit 262 and 1281 apply to Medicare Crossover Lawsuit claims only.

If you have claims pended for the above edits and you can provide documentation, i.e., Medicare Explanation of Medical Benefits (EOMB) to support that your billing was appropriate, please follow the procedures described below.

  1. On the Medicaid remittance statement, highlight the claim(s) pending for edit 127, 262, 1281, or 1283 that you would like CSC to review.
  2. On the Medicare EOMB, highlight the information corresponding to the claim(s) to be reviewed.
  3. Attach the Medicaid remittance statement and the Medicare EOMB together and mail them to the following address:

Computer Sciences Corporation
Attn.: Edit Review Panel
P.O. Box 4105
Albany, New York 12204

NOTE: It is essential that the documentation submitted is clipped together and properly highlighted. Documentation should be sent to the Edit Review Panel for these edits ONLY. Documentation sent for any other edits will be returned to the provider. Documentation that is incomplete or unusable will be returned to the provider.

CSC staff will review the documentation and adjudicate the claim(s) accordingly through the regular claim processing system. The adjudicated claims will appear on the provider remittance statement.

Providers making inquiries or requesting billing training by Regional Representatives should contact CSC by calling the appropriate number below. Please be prepared to supply your Medicaid Provider ID number.

Practitioner Services (800) 522-5518 (518) 447-9860
Institutional Services (800) 522-1892 (518) 447-9810
Professional Services (800) 522-5535 (518) 447-9830

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As of April 1,1999, orthodontic cases for Medicaid-eligible Westchester County recipients up to 21 years of age will require review and prior approval by the Albany Dental Prior Approval Unit of the New York State Department of Health. With the issuance of prior approval, any Medicaid enrolled, board qualified or certified Orthodontist participating in the Medicaid Program with specialty designator 801 or any clinical facility with specialty designator 912 will be able to provide care to Westchester County recipients eligible for Orthodontic benefits under the Program.

Medicaid approval will only be issued for cases presenting with severe handicapping malocclusions. The following procedure codes will now be subject to the prior approval process for Westchester County recipients only:

  • 08070 (Comprehensive orthodontic treatment of the transitional dentition)
  • 08080 (Comprehensive orthodontic treatment of the adolescent dentition)
  • 08090 (Comprehensive orthodontic treatment of the adult dentition - up to age 21)

Prior Approval request forms completed pursuant to instructions in the MMIS Dental Provider Manual, along with appropriate diagnostic aids and information (i.e., diagnostic radiographs AND intraoral photographs) should be sent to:

The Dental Prior Approval Unit
New York State Department of Health
Bureau of Medical Review and Payment
99 Washington Avenue, Suite 800
Albany, New York 12210

Orthodontists wishing to obtain the appropriate specialty designation should submit their requests to:

New York State Department of Health
Office of Medicaid Management
Provider Enrollment Unit
99 Washington Avenue, Suite 611
Albany, New York 12210-2806

Any questions regarding this new Medicaid prior approval requirement should be directed to the Dental Prior Approval Unit at (800) 342-3005.


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Effective for dates of service on and after January 1, 1999, use the following procedure code for billing:

90665 Lyme disease vaccine, adult dosage, for intramuscular use

Claims submitted using code 90665 for dates of service on and after January 1, 1999 may be submitted either electronically or on a paper claim form and no attachment is required. Insert your acquisition cost per dose plus a two dollar ($2.00) administration fee in the amount charged field of your claim form.

Reimbursement is available for vaccine administered in accordance with the FDA approval for this vaccine. If you have any questions about New York State Medicaid reimbursement, contact the New State Department of Health, Office of Medicaid Management at (518) 474-8161.

Selection of proper candidates to receive vaccine should proceed deliberately to define who really needs protection. This decision should be made by the physician, after a careful assessment of each patient's risk of exposure to infected tick habitat. Some of the factors to consider in this decision are the types of leisure and occupational outdoor activities, geographic location of residence and work, and potential travel to endemic areas.

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Physicians, dentists and other practitioners may be in individual practice or practice with others in a group. Each Medicaid claim (for individual or group practice) must identify the physician or other practitioner who actually provided the service.

When billing for any type of group practice (group of associates, or group employing other physicians or dentists), the group ID number (assigned by the Department of Health at the time of enrollment as a group) must be entered in the "Group Identification Number" field of the claim form, and the physician, dentist, or other practitioner who actually provided the service must be identified by entering his/her Medicaid ID number in the "Provider Identification Number" field of the claim form (on HCFA-1500, field 25A; on paper Form A, field 1; on Electronic Form A, record D1, positions 10-17). A physician, dentist, or other practitioner enrolled in Medicaid only as an individual provider must not use his/her individual provider ID number to bill Medicaid for services actually provided by another physician or dentist except for the two situations noted below:

  • When a physician is supervising a physician assistant or certified social worker (the physician assistant or the certified social worker must be identified in the "Service Provider" field (HCFA-1500, fields 22A [name] and 22C [Medicaid ID/license]; Electronic Form A, record D2, positions 58-65).
  • When a locum tenens agreement is in effect (see Physician MMIS Manual, Section 2.2.3 B, page 2-63 for instructions).

If you are a practitioner who is employing other practitioners, you should either be enrolled as a group, or bill using the Medicaid ID number of the practitioner who provides the service.

Audit staff have found numerous instances where groups are using only one member's Medicaid provider number to bill for services performed by other group members. This practice is incorrect. Improper billing distorts payment and service records maintained by the Department. Claims incorrectly submitted in the manner described may be considered "false" and constitute an unacceptable practice under Department regulations. Medicaid can accommodate payment to a group identification number, but the individual provider of care must be identified.

Also, please remember that immediate formal notification to the Bureau of Enrollment is necessary when:

  1. Group members are added.
  2. Group members are deleted.
  3. There is a change in ownership.
  4. There is a change of address or service location.

Notices of such changes should be sent to:

New York State Department of Health
Office of Medicaid Management
Provider Enrollment Unit
99 Washington Avenue, Suite 611
Albany, New York 12210-2806


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Prenatal Care Assistance Program (PCAP) Billing Procedures: This reminder is being issued to insure that all PCAPs are in full compliance with Article 28 billing policy.

All routine prenatal visits must be conducted in the Article 28 PCAP facility in order for a PCAP visit rate to be billed (including initial, re-visit and postpartum visit rates). This means that when a PCAP patient is referred by the PCAP to an off-site PCAP-affiliated provider, neither the PCAP nor the provider of service may bill Medicaid for that service.

In addition to the requirement for on-site Article 28 visits, clients must be seen by a physician, physician's assistant, nurse practitioner or licensed midwife in order for a PCAP visit to be billed.

The Bureau of Compliance & Audit may at any time examine this and other PCAP issues. If you have any questions about PCAP billing policy, regional staff will be available to answer them.

The Medicaid Update: Your Window Into The Medicaid Program

The State Department of Health welcomes your comments or suggestions regarding the Medicaid Update.

Please send suggestions to the editor, Timothy Perry-Coon:

NYS Department of Health
Office of Medicaid Management
Bureau of Program Guidance
99 Washington Ave., Suite 720
Albany, NY 12210
(e-mail )

The Medicaid Update, along with past issues of the Medicaid Update, can be accessed online at the New York State Department of Health web site: