DOH Medicaid Update October 2003 Vol.18, No.10

Office of Medicaid Management
DOH Medicaid Update
October 2003 Vol.18, No.10

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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We notified providers who bill electronically two months ago of the Department of Health's contingency plan to avoid disruption in claims processing and payment flow to providers who have not been able to fully achieve compliance with the Health Insurance Portability and Accountability Act (HIPAA) transaction standards by the October 16 deadline. Based on federal guidance issued in July, that contingency plan is now in effect. Trading partners - providers, vendors and clearinghouses - may, for a short transition period, continue to submit Medicaid proprietary (non-HIPAA-compliant) transactions while aggressively working toward full HIPAA compliance.

Until February 18, 2004:

  • Medicaid will continue to accept and process the current Medicaid proprietary formats (as well as HIPAA-compliant transactions).
    • Trading partners must continue to make every effort to migrate to HIPAA-compliant transaction submissions.
    • Trading partners will be expected to comply with Medicaid's open testing process outlined at
  • Providers may continue to use the current PACES (Provider Assisted Claim Entry System) or the Medicaid Eligibility Software, but are urged to convert to the HIPAA-compliant ePACES software, which is available free of charge. Information on ePACES may be found on the web site
  • TRANZ 330 POS devices will continue to be supported.
    • Providers who have not ordered their replacement device, the VeriFone 3750, should do so immediately (or switch to an alternate access method, such as ePACES).

After February 18, 2004:

  • All electronic transaction submissions must be HIPAA-compliant. Electronic claims submitted in a non-HIPAA-compliant format will be rejected.
  • TRANZ 330 devices will no longer be supported. The only POS devices that will be supported will be the VeriFone Omni 3750. For ordering information, please contact the Provider Services POS Inquiry Line at 800-343-9000 (Option 4), available Monday through Friday between 9:00 AM and 5:00 PM. Providers with Internet access can also obtain this information at under "What's New."
  • PACES and the Medicaid Eligibility Software will no longer be supported. Only ePACES will be supported.

This contingency plan is intended to enable the New York State Medicaid program to continue to process claims and pay to providers who have not been able to achieve full compliance, while aggressively continuing to work with them to become compliant through active outreach and testing.

Questions regarding HIPAA Medicaid compliance and this article may be directed to:

CSC's HIPAA Support Helpline at (866) 840-3445

Recipient Name Search and Check Amount Inquiry
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Sign Check

Do you have a patient who is on Medicaid, and you do not have their Medicaid identification number?

After submitting claims, do you wonder what your check amount will be?

Call (518) 472-1550 for the answers!


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Due to the tremendous response we have received from group providers advising us of the large volume of duplicate copies of the Medicaid Update the group receives each month, we have designed a way to eliminate the duplication.

Starting with this issue of the Medicaid Update, we will only send an Update to the group provider, not the individual members, unless the individual members are also actively billing from their own private practices.

The group provider should distribute pertinent articles in the Medicaid Update to their members.

We encourage group providers to receive the Medicaid Update electronically for ease of distribution. Individual members may also request to receive the Update directly from us electronically. The benefits are numerous:

  • You will receive the electronic version about three weeks earlier than the mailed hardcopy.
  • You will be able to disseminate internally via your own email system, and forward to staff, articles that are pertinent to your practice.
  • You will have the flexibility to copy, highlight and print articles as needed.

Just follow the steps below to let us know!

  1. Send an email to the Medicaid Update mailbox at:
  2. Provide the following information:
    • Name
    • Medicaid Provider Identification Number
    • Email address (or multiple addresses, if desired)
    • Whether or not you would like to continue to receive a hard copy

Thank you for the tremendous response and for providing us with the opportunity to identify ways to make the Medicaid Update more efficient. With your comments and suggestions, we are able to design and distribute a newsletter that is valuable to all.

(Other Medicaid providers can also receive the electronic version of the Medicaid Update-just follow the instructions above!)

Questions related to this article can be directed to the Bureau of Program Guidance at (518) 474-9219.


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Please make the following change to your MMIS Laboratory Services Provider Manual (Rev. 4/03), page 5-20:

The correct maximum fee for code 86336 Inhibin A is $6.50.

Questions may be referred to the Bureau of Medical Review and Payment at (518) 474-8161.


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Please make the following change to your MMIS Nursing Services Provider Manual (Rev. 9/03), page 4-1:

The correct procedure code number for RN services, up to 15 minutes is T1002.

Questions may be referred to the Bureau of Medical Review and Payment at (518) 474-8161.

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Private duty nursing providers may bill Medicaid retroactively to December 1, 2002 for the 3% increase for nursing services provided to children enrolled in the Care at Home (CAH) waiver programs.

Independent providers, and licensed home care services agencies that have submitted an attestation, are eligible for the 3% add-on to the county approved fee. Providers should contact their patient's county of fiscal responsibility for the new fees.

To bill Medicaid retroactively for nursing services provided to a child enrolled in the CAH waiver program, you must submit a claim adjustment to CSC, the Medicaid fiscal agent. For information on how to adjust previously paid claims, please contact Provider Relations at CSC, at (800) 522-5518.

For dates of service prior to September 1, 2003, claims must be adjusted using CAH procedure codes: LPN - W9049 and RN - W9050.

When submitting an adjusted claim for dates of services on or after September 1, 2003, the following new CAH procedure codes and modifiers must be used: LPN - S9124U1 (replaces W9049), RN - S9123U1 (replaces W9050). Note: The modifier "U1" must be added to the new nursing procedure codes (S9124, S9123) in order to bill for CAH!

Please note the correct modifier to use when billing for CAH waiver services is "U1", not "UI" as stated in the September Medicaid Update.

Questions may be referred to the Medicaid Bureau of Maternal and Child Health at (518) 486-6562.


Frequently Asked Questions
Medicaid Coverage of
Oral Enteral Formulas

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  • Q:   How do I use the telephone prior authorization system for enteral formulas?
    • A:   Complete the revised Prescriber Worksheet on the next page and call the toll free Enteral Formula Prior Authorization Line at (866) 211-1736.
  • Q:  I'm prescribing an oral formula. How can I obtain an authorization?
    • A:   If a patient has an inborn metabolic disease or is an infant with severe food allergies or gastroesophogeal reflux disease not responding to added rice formula, answer YES to Question 9. (Medicaid coverage of oral formulas for other conditions is available only when you verify that necessary nutrients from food cannot be absorbed or metabolized by answering YES to Question 12, Question 13 or Question 14 and you answer YES to Question 15. By doing so, you are stating that there is objective medical evidence in the medical record supporting the need for enteral nutrition including: an established diagnostic condition, the pathological process causing malnutrition, and that nutritional depletion is imminent and can be forestalled by use of a specific formula).
  • Q:  My patient qualified for enteral formula according to the Medicaid criteria but now there is no current documentation in the medical record that the patient has tried alternatives, had recent weight loss or no growth, or has no condition that prevents consumption of normal food. Is the formula covered now?
    • A:   If the patient's medical condition has changed and there is no current medical need for it, the enteral formula is not covered by Medicaid.


  • Pharmacy provider billing: (800) 343-9000
  • DME provider billing: (800) 522-5535
  • Policy questions, coverage criteria, HCPCS codes: (518) 474-8161
  • Obtaining prior approval forms for medically necessary enterals that cannot be authorized through the telephone system: (800) 522-5518
  • Completing prior approval forms for medically necessary enterals that cannot be authorized through the telephone system: (800) 342-3005



NYS Medicaid Program Enteral Formula Prior Authorization Prescriber Worksheet

The NYS Medicaid Program Enteral Formula Prior Authorization Prescriber Worksheet is available only as a portable document format (PDF) file. Requests for the NYS Medicaid Program Enteral Formula Prior Authorization Prescriber Worksheet in an alternate format should be made by sending an e-mail note to:

When Mother Is Enrolled In Medicaid Managed Care Or Family Health Plus
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Newborns born to women receiving Medical Assistance on the date of birth are automatically eligible for Medicaid for one year. If the mother is enrolled in a Medicaid Managed Care plan, the newborn will be enrolled in the same plan from the date of birth. Women who are in receipt of Family Health Plus (FHP) at the time they give birth are treated in the same manner as women in receipt of Medicaid for purposes of hospital reporting and the infant's Medicaid eligibility. If the mother's FHPlus plan also participates in Medicaid Managed Care, the newborn will be automatically enrolled in that Medicaid Managed Care plan. If the mother's FHP plan does not participate in Medicaid Managed Care, the mother will be asked to select a Medicaid Managed Care plan for the unborn child if she resides in a mandatory county. If the mother resides in a voluntary county and her plan does not participate in Medicaid Managed Care, the automated newborn enrollment process will put the infant in fee-for-service Medicaid and she may choose a Medicaid Managed Care plan or Medicaid fee-for-service for the newborn thereafter. If she resides in a mandatory county, the mother in FHPlus may subsequently transfer the newborn to another health plan if other children in the household are in a different health plan. The only exceptions to the automatic enrollment of a newborn into the same Managed Care plan as the mother are when the newborn under six months weighs less than 1200 grams (2 lbs. 10 ounces), or is determined eligible for the SSI related category, or the mother is enrolled in certain special needs or partial capitation plans. The child may subsequently be disenrolled to fee-for-service Medicaid, or be transferred to another health plan at the mother's request, if residing in a voluntary county.

Hospital Responsibilities

Hospitals must report live births to women in receipt of Medicaid/FHPlus to the State Department of Health, or its designee, within five (5) business days of the birth. Hospitals may face a financial penalty of up to $3,500 per occurrence for each birth it fails to report within the established five-day timeframe. Hospitals also must notify each mother, in writing upon discharge, that her newborn is deemed to be enrolled in the Medicaid program and that she may access care, services, and supplies available under the Medicaid program for her baby, provided that she was in receipt of Medicaid or FHPlus at the time of the birth. Infants born to women enrolled in FHPlus are also entitled to one year of "automatic" Medicaid eligibility. Since July 1, 2000, births have been reported by hospitals through an Electronic Birth Certificate process.

Current State regulations require hospitals and all approved Medicaid providers to conduct a Medicaid eligibility verification (eMedNY) clearance on each presenting Medicaid recipient to determine Medicaid eligibility status and medical coverage. Under this policy, hospitals must also determine the newborn's Managed Care status by checking the mother's status on eMedNY. The hospital must check:

  • Medicaid eligibility status;
  • Medical coverage - Eligible PCP or FHPlus and an Insurance Code indicate enrollment in Managed Care or FHPlus plan and the specific Managed Care or FHP provider; and
  • Benefit coverage codes to determine whether the recipient has 'inpatient hospital' (letter 'A') and other relevant coverage included in the Managed Care benefit package.

It is possible that a pregnant managed care enrollee may present herself at an out-of-network hospital and need to be admitted for delivery. In this case, that hospital must notify the Managed Care plan promptly and bill the Managed Care plan for the newborn's and mother's inpatient costs associated with the birth. Managed Care plans will reimburse the hospital at the Medicaid rate or at another rate if agreed to between the Managed Care plan and the hospital. The hospital should not bill the Medicaid Management Information System (MMIS). If a hospital bills MMIS and is paid, the State will recover the erroneous payment. The Managed Care plan may not deny inpatient hospital costs if billing or notification is not timely except as otherwise provided by contractual agreement between the plan and the hospital.

Providers must continue to determine whether the newborn and/or mother is enrolled in a Managed Care plan. If either is enrolled and the service to be provided is a covered service by the Managed Care plan, the provider should contact the plan before rendering service, except in an emergency.

Note: HIV Special Needs Plans (SNPs) are managed care plans specifically for Medicaid recipients with HIV or AIDS. The policy for enrollment of infants whose mothers are HIV SNP enrollees is generally the same as for other Medicaid Managed Care plans. If the newborn's mother is enrolled in an HIV SNP at the time of his/her birth (and the child is not in an excluded category as described above), the newborn will be enrolled in the plan of the mother, effective the first day of the child's month of birth. The child may subsequently be disenrolled to fee-for-service Medicaid at the mother's request if residing in a voluntary county. If residing in a mandatory county, the child may be transferred to another plan at the mother's request.

Questions regarding Medicaid Managed Care may be referred to the Office of Managed Care at (518) 486-9015.
Questions regarding FHP or Medicaid eligibility for newborns may be referred to the toll-free Newborn Helpline at (877) 463-7680.

Diabetes is a major public health problem and is becoming more prevalent in all age groups. Nationwide there are approximately 16 million people who have diabetes, of which approximately 90% have Type 2 diabetes. In New York State, approximately 800,000 people are estimated to have diagnosed diabetes, 84% of which are over the age of 45. It is estimated that an additional 500,000 people with Type 2 diabetes remain undiagnosed.

Improving the health of New Yorkers is essential for the future of our State. In an effort to promote quality health outcomes, the chart on the following page was developed to summarize services that are covered by the New York State Medicaid program in accordance with the 2003 Clinical Practice Recommendations of the American Diabetes Association.

The Medicaid program encourages clinicians to assess their patients for diabetes risk factors and provide or refer their patients for services in accordance with the American Diabetes Association clinical practice recommendations.

Source: NYS Department of Health, Diabetes Control and Prevention Program, "Diabetes Surveillance in New York State, 2001."

The NYS Medicaid Program reimburses for medically necessary care, services, and supplies for the diagnosis and treatment of diabetes. For more information, please contact the Bureau of Program Guidance at (518) 474-9219.

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2003 Clinical Practice Recommendations
ADA Standard ADA Frequency Medicaid Covered
Physician/Clinic Visit
  • Weight monitoring
  • Blood pressure monitoring (Adult - < 130/80)
  • Patient education including self-management & dietary counseling
  • Pharmacological management
  • Physical Therapy/Exercise management
Each regular
diabetes visit*
Key Laboratory Tests
  • Glycated hemoglobin - HbA1C - <7%
  • Preprandial plasma glucose - 90 - 130 mg/dl
  • Peak postprandial plasma glucose - < 180 mg/dl
  • Lipid profile - Adult Goal - LDL < 100mg/dl, HDL > 40 mg/dl in men, HDL > 50 mg/dl in women, Trigylcerides < 150 mg/dl,
  • Urinalysis for protein
  • Microalbumin measurement

As needed*
As needed*


Comprehensive Foot ExamAnnually*Yes, when performed by primary care provider, or by a podiatrist for children <21 years of age or adults over age 64, or for Medicare crossover patients.
Dilated Eye Exam by Ophthalmologist/OptometristAnnuallyYes, the patient record must document medical necessity, if done more frequently than once every two years.
Self-Monitoring of Blood Glucose & KetonesAt least dailyYes
Insulin Regimens At least dailyYes, all insulin products (prescription & OTC) are covered.
Coverage of Oral Medications, including adjunctive medications: oral hypoglycemic agents, glucagon, antihypertensives, lipid-lowering agents, aspirin therapy, & other endocrine drugsAt least dailyYes, all oral diabetic agents, adjuvant agents and injectible glucagon are covered.
Smoking Cessation Pharmacologic Coverage As neededYes, all forms covered for two courses of therapy a year.
Annual Influenza VaccineAnnuallyYes
Diabetes Supplies
Diabetes daily care items:
  • Needles
  • Syringes
  • Insulin cartridge delivery system
  • Spring powered device for lancet
  • Lancets
  • Alcohol and alcohol wipes
  • Insulin Pumps**
  • Infusion sets for insulin pump, needle,
    and non-needle type**
  • Syringe with needle for external insulin pump**
Diabetes diagnostic agents:
  • Home blood glucose monitor
  • Blood glucose monitor with special features
    (i.e. voice synthesizer, automatic times, etc.)**
  • Urine reagent strips
  • Blood glucose test or reagent strips
  • Replacement battery for use with home glucose monitor
  • Blood glucose monitor calibrator solution/chips***
As prescribedYes

* More frequently based on medical necessity, ** Medicaid Prior Approval required, *** Medicaid DVS required

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Man and Report

This month's patient educational tools features an article on "Important Vaccination for People with Diabetes."

The Medicaid program encourages practitioners to copy and distribute the following information to their patients and to share them with their colleagues.




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If you have diabetes, it is very important to keep up to date on your vaccinations, also called immunizations. Vaccines can prevent illnesses that can be very serious for people with diabetes.

Influenza Vaccine

Influenza (often called the flu) can be a serious illness. Influenza is caused by a virus that spreads from one person to the nose or throat of others. Signs of the flu may include sudden high fever, chills, body aches, runny nose, cough and headache.

An annual flu shot is recommended for people with diabetes. The best time to get a flu shot is between October and mid-November, before the flu season begins.


Pneumococcal Vaccine

Pneumococcal disease is a major source of illness and death. It can lead to serious infections of the lungs (pneumonia), the blood (bacteremia), and the covering of the brain (meningitis). Pneumococcal polysaccharide vaccine (often called PPV) can help prevent the disease.

PPV can be given at the same time as the flu vaccine, or at any other time of the year. Usually one dose of PPV is all that is needed. Ask your health care practitioner whether you might need a second vaccine.

Other Types of Vaccinations

Be sure to check with your health care practitioner to see if you need any other vaccinations or booster shots, such as:

  • Measles/Mumps/Rubella vaccine
  • Varicella (chicken pox) vaccine
  • Tetanus/Diphtheria (Td) Toxoid
  • Hepatitis A and B vaccines
  • Polio vaccine

Source: Center for Disease Control and Prevention, "Take Charge of Your Diabetes", 3rd edition, 2002, ppgs. 69-72.
Prepared by the NYSDOH, Office of Medicaid Management, Bureau of Program Guidance

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On April 30, 2003 the Medicaid program implemented a temporary change in policy to allow fax fiscal orders for OTC products.

Effective immediately, the Medicaid Program will continue the policy listed below on a permanent basis.



To support the use of over-the-counter (OTC) products when medically indicated, the Medicaid program will allow fax fiscal orders for OTC products. The requirements have been aligned with policies related to the allowable use of a fax for prescription products for ease of administration.
Fax fiscal orders for OTC products must meet the following requirements:

  • Receipt of the hard copy fiscal order by the pharmacy within thirty (30) business days only if there are refills for the OTC product.
  • Fax orders must originate from an unblocked fax number (that is, the source fax number is clearly visible on the fax that is received).
  • The fax fiscal order must include the physician stamp and signature.
  • Each page of a fax fiscal order may include only one (1) product. Lists of products are not acceptable as faxed fiscal orders.

This change is being implemented to assist and support the use of cost-effective OTC products, when appropriate.

Please note: This policy applies only to fax orders, and not telephone orders, for OTC products. Department regulations prohibit telephone orders for OTC products.

Please direct any questions to the Pharmacy Policy and Operations Unit at (518) 486-3209 or

Many Medicaid recipients who live in the community will qualify for the services of the program described below.
Please hand this sheet to your patients, or refer your patients to the program


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The New York State Office of Temporary and Disability Assistance's Food Stamp Nutrition Education Program, is called Eat Smart New York (ESNY).

Eat Smart

ESNY provides services for hard to reach populations such as:

  • the drug addicted,
  • the mentally and physically handicapped,
  • the geographically isolated,
  • senior citizens, and
  • underprivileged children.

ESNY's nutrition education services are free to those who financially qualify!

Classes are held at area cooperative extensions, in individual homes or on-site agencies such as senior centers or head start locations.

Client referrals may come from a variety of sources including, medical practitioners, local social services districts, and self-referral. Contact your local cooperative extension to make a referral for ESNY nutrition services!

Our Goal

To improve the nutrition-related skills of Food Stamp recipients, specifically those skills related to selecting, purchasing and preparing a low-cost nutritional diet for themselves and their family.

Program Objectives

Improved self-sufficiency of Food Stamp recipients
Increased variety in food choices
Decreased reliance on emergency food resources
Improved food preparation skills
Increased skills in food budgeting and meal planning
Improved knowledge of safe food practices
Improved diet for entire family
Nutrition facts label reading
Increased consumption of fruits and vegetables
Choosing foods that are nutrient dense
Supermarket shopping solutions to help select
the most nutritious food options

ESNY's nutrition educators may not provide medical nutrition therapy, but they can assist clients to achieve a healthy lifestyle by teaching them to choose foods that are nutrient dense and will help protect against disease. Through nutrition education, individuals learn to eat more nutritiously and to practice portion control with true serving sizes. Nutrition educators can increase the client's awareness of what foods are lacking or are in excess in their diets. They can also assist clients in following a diet prescribed by their medical practitioner.

Nutrition education can result in healthier bodies, improved mental attitude, lower cholesterol, lower blood sugars, etc. There are a myriad of advantages to be reaped from learning to purchase, prepare and consume nutritious foods!

To locate one of the 56 ESNY projects that are in your area, you may go to the FSNEP website at:

Or you may contact, Ms. Sandy Borrelli, NYS FSNEP coordinator, at (518) 473-0401 Or email


Fraud impacts all taxpayers.

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Do you suspect that a recipient or a provider has engaged in fraudulent activities?

Please call:


Your call will remain confidential.



Providers! Are You Changing Your
Correspondence Address or Pay to Address?
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If you change your address, it is your responsibility to notify the Medicaid Program in writing. Keeping your file current will ensure you receive all updates and announcements.

Your request should include your

  • provider name;
  • provider identification number;
  • category of service;
  • new address;
  • new telephone number; and,
  • provider's signature.

Signature stamps, photocopies, etc. are not acceptable.

Indicate if this new address is to include changes to both the correspondence address and pay to address and mail to:

Bureau of Enrollment
Office of Medicaid Management
New York State Department of Health
150 Broadway, Suite 6E
Albany, New York 12204-2736

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: