September 2008  
Volume 24, Number 10  

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 Department of Health

Deborah Bachrach, Deputy Commissioner
Office of Health Insurance Programs


Dear Medicaid Provider,

Welcome to the September 2008 edition of the Medicaid Update. This newsletter is designed to bring you important information that can help support your practice, your patients and your community.

We believe you are an invaluable partner in ensuring our goal of providing access to high quality healthcare services. Please let us know how we can continue to keep this newsletter relevant to you.

We thank you for your support and active participation in these important programs and for working together to make a difference for our beneficiaries.


In this issue....

Policy and Billing Guidance

Clarification of services included in Prenatal Care Assistance Rate (PCAP)
Prescriber education program initiative soon underway
Moving forward to improve Child Health in New York State
Update on Mandatory Managed Care for SSI and SSI-Related Medicaid Enrollees
Attention: Providers and Submitters of Electronic Transactions
Billing Service Providers
Transportation Services: Information on NPI & Non-Emergency Transportation Prior Authorization
Transportation Providers: NPI & Transportation Claims


Provider Alert: Report National Drug Code (NDC) when billing on claims
EPIC Update
Palivizumab (Synagis®) Medicaid coverage for children
Tamper-Resistant Prescription Law Update
New Pharmacy Fill Edit
Pharmacies designated as 340B Entities
Family Health Plus Benefit
Prior Authorization will change for some drugs
Medicaid Preferred Drug List


Infant apnea monitor changes
Reimbursement for follow-up pap smears
Renew your Certification Statements annually!
Need help understanding why a claim was denied?
Sign up for electronic funds transfer today!
eMedNY Data Center is moving
Don't be Silent About Smoking
Provider Services

Message from the Editor

Medicaid Update newsletter will move to electronic distribution
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In an effort to distribute the Medicaid Update in a more efficient manner, reduce costs, and be more environmentally minded, beginning January 2009, the Office of Health Insurance Programs will no longer produce a printed version of the newsletter.

The Medicaid Update will ONLY be available electronically. This new delivery system will allow our providers to receive policy sensitive bulletins faster. The newsletter will be delivered monthly to your designated e-mail address in a Portable Document Format (PDF).

To receive the Medicaid Update electronically, please send your e-mail address with your provider ID# by Friday, October 31, 2008 to

Providers who are unsure about receiving an electronic-only version of the newsletter should bear in mind that the PDF newsletter can always be printed and read in hard copy.

Additionally, the current and archived newsletters are posted on the DOH Website at the following address

You will receive your final printed newsletter by mail in December 2008 as we transition from print newsletters to electronic distribution.

The Office of Health Insurance Programs anticipates that most providers will take advantage of this new delivery system, however, those who cannot may send a written request, along with your provider ID#, to the following address by Friday, October 31, 2008:

NYS Department of Health
Office of Health Insurance Programs
Attention: Kelli Kudlack
Corning Tower, Room 2029
Albany, New York 12237

Don't be left out...send us your e-mail address and provider # today!

Policy and Billing Updates

Clarification of services included in the Prenatal Care Assistance Rate (PCAP)
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PLEASE NOTE: This article includes important information regarding billing clarification for specific PCAP services. (For further details refer to the PCAP Policy and Billing Guidelines as referenced).

Initial Prenatal Evaluation Visit

Although the initial prenatal evaluation may be conducted in more than one encounter, only one initial prenatal evaluation visit using rate codes 3101 or 1601 can be billed per recipient per pregnancy. (Refer to page 7 of the PCAP Policy and Billing Guidelines).

Subsequent Prenatal Visits

Prenatal visits following the initial evaluation visit are to be billed as follow-up PCAP clinic visits using rate codes 3102 or 1602. These rate codes should not be billed as postpartum visits as described below. (Refer to page 8-9 of the PCAP Policy and Billing Guidelines)

Postpartum Visit

A postpartum visit is for the purpose of providing postpartum care for a period up to 60 days following delivery. Only one postpartum visit may be billed per recipient per pregnancy using rate codes 3102 or 1603. (Refer to page 13 of the PCAP Policy and Billing Guidelines).

Laboratory Services

Standard laboratory testing to determine the presence of health problems and concerns that may affect maternal and fetal health is included in the PCAP rate and should not be billed separately as fee-for-service procedures. (Refer to page 14 of the PCAP Policy and Billing Guidelines)

Ultrasound and Diagnostic Procedures

When ordering diagnostic services such as labs or ultrasounds, the PCAP provider must utilize a referral form that states that the provider should not bill Medicaid.

An ultrasound, non-stress test and/or biophysical profile performed during a prenatal follow-up visit, is part of the follow-up visit and may not be billed separately.

If a client has been referred to a non-PCAP provider for an ultrasound, non-stress test or biophysical profile, the PCAP provider is responsible for reimbursing the medical provider who performs these services.

Prenatal Vitamins and Iron Supplements

Prenatal vitamins and iron supplements are included in the PCAP rate. The recipient should not be given a fiscal order for these items to be filled at a pharmacy and billed fee-for-service. (Refer to page 14 the PCAP Policy and Billing Guidelines.).

Information concerning the PCAP program policy and billing guidelines can be found on the DOH Website at

Questions? Please contact the Bureau of Policy Development and Coverage at (518) 473-2160.

Policy and Billing Updates

Prescriber education program initiative soon underway
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The Prescriber Education program, a Medicaid pharmacy initiative in the State Fiscal Year 2008-2009 Health Budget, features a collaboration between the Department of Health and several academic institutions to "provide prescribers with an evidence-based, non-commercial source of the latest objective information about pharmaceuticals".

NYS Medicaid has formed a partnership with the State University of New York (SUNY) Medical and Pharmacy campuses, as well as the University of Massachusetts Medical System and Harvard Medical School.

The goal of the programs to optimize the quality of care for New York State Medicaid beneficiaries by providing clinicians with the most current information on best practices in pharmaceuticals and therapists.

There are two main components to the Prescriber Education program. The first component is the "core curriculum", which will be made accessible to Medicaid clinicians statewide via links from the Department of Health Website. The materials will be developed by Medicaid's academic partners.

Second is an on-site prescriber education component in clinics and physician offices. This will involve a combination of educational materials, phone conversations, and face-to-face visits by academic clinical pharmacists (PharmD's) from SUNY Medical and Pharmacy campuses, statewide.

The academic pharmacists will receive training through Dr. Jerry Avorn's program at Harvard Medical School. The trained staff will be initially deployed as a pilot from SUNY Upstate Medical University in Syracuse, where Dr. David Lehmann will be the program's medical director.

Beginning in October, academic clinical pharmacists from SUNY Upstate will be reaching out to Medicaid clinicians. The program will subsequently be introduced through the remaining SUNY campuses.

Moving forward to improve Child Health in New York State
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NYSIIS is the new New York State Immunization Information System, a free, web-based statewide system which maintains computerized immunization data of persons of all ages in a confidential and secure manner. Article 21, Title 6, of Public Health Law 2168, was signed into law in August 2006.

The law mandates that as of January 1, 2008, all immunizations administered to children less than 19 years of age must be entered in to NYSIIS. The system has now been fully implemented statewide. As of August 27, 2008, NYSIIS contains nearly 1.2 million patient records and 14.8 million immunizations.


Over 1,700 organizations are participating, representing 79% of the pediatric providers in the New York State who have been our primary focus during the first year of implementation.

Closer to Our Goal

With every passing day, we move closer to our Healthy People 2010 goal of having 95% of children less than 6 years old with two or more shots recorded in NYSIIS.

In under six months, we have already reached 31.4% which is doubled from our baseline. We anticipate continual increases as we move ahead.

NYSIIS Training

Additional classroom and webinar training sessions are scheduled to begin in mid-September. A detailed training schedule and registration information can be accessed at

Additional information can be obtained by calling (518) 473-2839 or on our website at the following links:

Update on Mandatory Managed Care for SSI and SSI-Related Medicaid Enrollees
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SS Card

New mandatory counties for SSI and SSI-related Medicaid enrollees

Mandatory enrollment of SSI and SSI related Medicaid enrollees, including those with serious mental illness, is being phased in geographically throughout the State.

Mandatory enrollment of SSI and SSI related individuals began in New York City in March 2007; and in Nassau, Onondaga, Oswego, Suffolk and Westchester counties in the fall of 2007; followed by Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Allegany and Rockland in the early spring of 2008; and Livingston, Monroe, Ontario, Seneca and Yates in the late spring of 2008.

Effective August 2008, mandatory enrollment of SSI and SSI-related Medicaid beneficiaries will be phased in the following counties:

  • Albany
  • Broome
  • Columbia
  • Greene
  • Herkimer
  • Oneida
  • Rensselaer
  • Saratoga
  • Cortland

How will SSI and SSI-related Medicaid enrollees enroll in managed care?

SSI and SSI-related beneficiaries in mandatory areas must choose a plan within 90 days of receiving a mailing that includes information about the Medicaid managed care program. Those who do not choose a health plan within the 90 day period will automatically be assigned to one.

Certain enrollees may be eligible for an exemption. Enrollees in New York City, Nassau, Suffolk and Westchester counties may call (800) 505-5678 to request an exemption. Beneficiaries in all other counties listed may call their local department of social services.

How will this change the way SSI and SSI-related enrollees obtain their Medicaid benefits?

Once enrolled in a health plan, SSI and SSI-related Medicaid individuals will keep his/her Medicaid benefits but get most of his/her health care from the health plan's network of providers, hospitals, physicians, and clinics.

SSI and SSI-related enrollees will continue to receive their Medicaid pharmacy benefits and most of their behavioral health benefits (mental health and substance abuse services) on a fee-for-service basis. Plan enrollees will receive a health plan identification card but will access carved out benefits, including behavioral health services using their regular Medicaid card.

What services are included in the managed care Benefit Package for SSI and SSI related Medicaid enrollees?

The benefit package for SSI enrollees is a "health only" package and includes:

  • All medically necessary physical health care, including primary care physician visits associated with a behavioral health diagnosis;
  • All laboratory services, emergency room visits and transportation, including those associated with behavioral health services or diagnoses;
  • Inpatient hospital admissions, including when the stay covers a combination of medical and behavioral health services but the DRG or rate code is not classified as behavioral health;
  • Drugs obtained and administered by a medical practitioner or facility, except for Risperdal Consta (J2794) which is reimbursed under Medicaid fee-for-service for all managed care enrollees; and
  • Chemical dependence detoxification services, including medically managed detoxification and medically supervised inpatient and outpatient withdrawal.

The benefit package for SSI and SSI-related enrollees does not include the following behavioral health services, which are billable directly to Medicaid fee for-service:

  • Mental health inpatient and outpatient services;
  • Mental health services certified by the New York State Office of Mental Health for individuals with serious mental illness;
  • Chemical dependence inpatient rehabilitation services; and,
  • All chemical dependence outpatient services, including methadone maintenance treatment programs.

Where can a provider get additional information about the managed care benefit package?

See the complete description of the Medicaid Managed Care benefit package and all services billable directly to Medicaid fee-for-service that SSI and SSI-related enrollees are entitled to at the following address

For questions regarding Medicaid managed care for the SSI and SSI-related population or a list of Medicaid rate and fee codes payable for Medicaid managed care SSI and SSI-related enrollees, providers may call (518) 473-0122.

Providers are urged to check eligibility at each visit, or at a minimum, on the first and tenth of every month to determine Medicaid eligibility and managed care enrollment status.

Identification of SSI or SSI-related Medicaid enrollees

Depending upon the method a provider uses to verify an enrollee's Medicaid eligibility, the following responses identify SSI or SSI-related enrollees:

  • MEVS will show an "S" in the category of assistance field.
  • On the VeriFone terminal, the category of assistance response will be returned after the anniversary date in the following format:
    MSG: COA=S
  • For telephone verifications, an SSI or SSI-related enrollee will be identified by "Category of Assistance S" after the anniversary month in the stated response.

For enrollees with any other category of assistance, it will not be returned via the terminal or telephone. This information is then followed by managed care plan eligibility and covered services if applicable.

Response Formats

Variable Eligibility and Claim Capture (5.1): Field 504 (message), position 21 will be "S" or space filled.

ePACES Response Details

Eligibility, Service Authorization, and DVS - the COA "S" will be displayed in the Medicaid Message section.

Providers/Submitters of Electronic Transactions
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Do you wish to test your electronic claims and other transactions before sending them to production? eMedNY offers end-to-end testing.

You can download the eMedNY Provider Testing User Guide, which contains all the information you need at the following Website address

If you have any questions, please contact the eMedNY Call Center at (800) 343-9000

Billing Service Providers
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Billing services and providers who utilize the services of a billing service need to be aware that CSC is enforcing a current policy regarding the release of provider information. The eMedNY Call Center cannot provide a billing service with providers' proprietary information such as Rate Codes, Category of Service, Specialty Codes, Locations Numbers, and Group Affiliations.

If a provider contracts with a billing service, it is expected that the provider will furnish the billing service with all the information that is required for the billing service to conduct business on provider's behalf.

The policy is in place to protect providers' information from being released to third parties who do not necessarily have a need for the providers' information.

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


National Provider Identifier (NPI) & Non-Emergency Transportation Prior Authorization
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Non-emergency transportation services must be requested by a practitioner. Often, if the request is made on behalf of a facility (e.g., a dialysis clinic) or medical program (e.g., adult day health care), the facility's or program's 8-digit Medicaid identification number is used as the ordering provider on the prior authorization.

Effective immediately, only an individual practitioner's NPI will be accepted as an orderer. The practice of allowing a facility or program to use the facility's or program's identification number (or NPI) requesting transportation on behalf of a practitioner is no longer permitted.

There will be a transition period through December 1, 2008 to allow practitioners time to comply with this requirement. It is imperative that prior authorization requests come into compliance as soon as possible.

The list of approved orderers of non-emergency transportation includes:

  • physicians, including all specialists; residents; physician assistants; nurse practitioners; dentists;
  • optometrists; speech, physical, and occupational therapists; nurse midwives; psychologists;
  • podiatrists; respiratory therapists; and audiologists.

New York City Prior Authorization Request Forms

The practitioner identified as the service requestor, or an authorized designee, can sign the Request Form.

Existing Prior Authorizations

Previously approved prior authorizations do not need to be changed. Effective immediately, new prior authorizations must adhere to this change in policy.

Questions about transportation policy can be directed to the Transportation Policy Unit at (518) 474-5187, or via e-mail at or the Transportation Policy Manual on-line at


National Provider Identifier (NPI) & Transportation Claims
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Clarification: Should Transportation Providers be concerned about NPI?


Ambulette, livery, and taxi providers themselves do not qualify for an NPI. However, for ambulette and NYC livery claims, an ordering practitioner must be identified. Ordering practitioners will have a NPI which must be reflected on transportation claims.

The ordering practitioner's NPI will be provided on the non-emergency prior authorization roster as the Referring/Ordering provider number.

Ambulance Providers (Category of Service 0601)

Ambulance providers will have a NPI and may use EITHER their NPI or 8-digit Medicaid identification number on their non-emergency transportation claim, although only the 8-digit number will appear on the prior authorization roster. When an ambulance provider submits a claim for an emergency transport, their NPI must be used. Questions regarding claims can be directed to the eMedNY Call Center at (800) 343-9000.

Questions about transportation policy can be directed to the Transportation Policy Unit at (518) 474-5187 or via e-mail at


Physicians, Nurse Practitioners, Licensed Midwives, and Ordered Ambulatory Providers
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The 2005 Federal Deficit Reduction Act (DRA) requires providers to report the National Drug Code (NDC) when billing for physician administered drugs on Medicaid claims in addition to existing reporting requirements (i.e. Healthcare Common Procedure Coding System - HCPCS).

Electronic claims require a valid 11-digit NDC number for payment. NDCs are not required on claims submitted for 340B drugs billed at their acquisition cost. The NDC is maintained by the Food and Drug Administration and contains identifying information for the labeler/manufacturer and drug product. Medicaid is required to use this information to maximize federal drug rebates.

NDC Reporting

The NDC can be found on the drug invoice and/or product package. The Health Insurance Portability and Accountability Act standard code set for a NDC is 11-digits, in a 5-4-2 configuration. The first five digits represent the labeler/manufacturer, the next four digits represent the drug and strength and the last two represent the package size. Therefore, when submitting a NDC to the department, a leading zero may be needed to be added. When the NDC is listed in a ten digit configuration, where the zero is added depends upon the configuration of the NDC.

Examples of the NDC and leading zero placements follow:

NDC # Configuration
Leading Zero Placement for
5-4-2 Configuration


For your information a listing of the drug labelers/vendors currently participating in the Medicaid program is available at:

New York's Prescription Program For Seniors
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Beginning October 1, 2008, prescribers must obtain a prior authorization for brand name drugs when an A-rated generic is available and EPIC is the primary payer. To initiate a prior authorization, the prescriber must contact the EPIC prior authorization voice interactive call line at (800) 256-8082.

A prior authorization will not be required for the following exemptions
Clozaril® Coumadin® Dilantin® Gengraf® Lanoxin® Levoxyl® Neoral® Sandimmune® Synthroid® Tegretol® Unithroid™ Zarontin®

Pharmacies can request a prior authorization to dispense a 3-day emergency supply if needed, by calling the EPIC prior authorization call line at (800) 256-8082.


Effective October 1, 2008, if a drug is denied by Part D because it is not on the formulary or it requires prior authorization, the pharmacist needs to contact the prescriber before billing EPIC to determine if an alternative drug covered by the Part D plan can be substituted:

  • If the prescriber changes the drug to one on the Part D plan formulary, the new drug should be billed to Part D as primary and EPIC as secondary.
  • If the prescriber does not agree to change the drug, the claim denied by Part D should be submitted to EPIC with a Submission Clarification Code of 7 (prescriber determined medically necessary) to certify that the prescriber was consulted.
  • If the prescriber could not be reached, the claim denied by Part D can be submitted to EPIC with a Submission Clarification Code of 99 (other) to certify an attempt was made to contact the prescriber. The prescriber should be consulted before the next refill.

EPIC will also begin to submit appeals to Part D plans on behalf of enrollees for drugs not covered by the primary payer. EPIC will contact the prescriber to obtain the clinical information needed to request a formulary exception or prior authorization.

Palivizumab (Synagis®) Medicaid Coverage For Children At Risk For Respiratory Syncytial Virus Infections
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Palivizumab is an intramuscular injection used as prophylaxis for respiratory syncytial virus (RSV). It is used in certain high-risk infants and children with histories of prematurity, chronic lung disease (CLD), or congenital heart disease. RSV is a leading cause of bronchiolitis and pneumonia in infants. Palivizumab should be administered in five monthly doses throughout the RSV season, typically beginning in November.


The following are guidelines for identifying infants and children who should be considered for RSV prophylaxis, adapted from the evidence based recommendations for the prevention of RSV with palivizumab in children less than two years of age published by the American Academy of Pediatrics:

  • Infants and children less than 24 months of age with CLD of prematurity who have required medical therapy for CLD within the past six months before the anticipated start of the RSV season;
  • Neonates born at greater than 28 weeks and less than 32 weeks gestation with or without CLD who are less than six months of age at the start of the RSV season;
  • Neonates born at 28 weeks gestation or less with or without CLD and who are less than 12 months of age at the start of the RSV season;
  • Neonates born between 32 and 35 weeks gestation with or without CLD less than six months of age at the start of the RSV season only if two or more additional risk factors are present including: school-age siblings, child-care attendance, exposure to air pollutants, or congenital abnormalities;
  • Children 24 months of age or younger with hemodynamically significant cyanotic and acyanotic congenital heart disease.
  • Palivizumab should not be used for the treatment of RSV disease.

Practitioner Billing

When billing the cost and administration of palivizumab, physicians and nurse practitioners should:

  • Use code 90749 (unlisted vaccine/toxoid), and include a copy of the invoice attached to the claim.
  • Describe the product name and total dose administered on the claim form.
  • Insert the acquisition cost plus a two-dollar ($2.00) administration fee in the "amount charged" field.

For more information on practitioner billing, see the Physician Provider Manual, Procedure Code and Fee Schedule, Procedure Codes Drugs, page 7, version 2008-1 (5/15/2008), at the following Website address

Pharmacy Billing

Pharmacy providers should enter the palivizumab NDC number, for the product dispensed, into the on-line billing system as they would for any prescription pharmaceutical.

For further information on Medicaid coverage guidelines of palivizumab, please contact the following:

For physician providers: (518) 473-2160
For pharmacy providers: (518) 486-3209
For billing questions: (800) 343-9000


  1. American Academy of Pediatrics, Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and Management of Bronchiolitis. Pediatrics. 2006;118:1774-1793
  2. McEvoy, G.K. (Ed.). (2008). American Hospital Formulary Service Drug Information. (pp. 779-782). Bethesda, MD: American Society of Health System Pharmacists
  3. Meissner H.C., et al. Prevention of RSV Infection in High Risk Infants: Consensus Opinion on the Role of Immunoprophylaxis with Palivizumab, a Humanized Respiratory Syncytial Virus Monoclonal Antibody for Prevention of Respiratory Syncytial Virus Infection in High Risk Infants.
    Pediatric Infectious Disease Journal. 1999; 18 (3):223-231.
  4. Synagis® (palivizumab) prescribing information. Medimmune, Inc., Rev. Date Feb. 28, 2007.
  5. United States Pharmacopeia-Drug Information. (2007). Vol. 1. Drug Information for the Healthcare Professional (27th ed., pp. 2256-2258). Greenwood Village, CO: Thomson Micromedex

Tamper-Resistant Prescription Law
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Federal law, effective October 1, 2008, requires that written outpatient Medicaid prescriptions (as well as fiscal orders for non-prescription drugs and insulin) must contain all three tamper-resistant characteristics as defined by the federal Centers for Medicare and Medicaid Services (CMS).

CMS has confirmed that the official New York State prescription form meets all federal tamper-resistant requirements.

To comply with the tamper-resistant requirements by October 1, 2008, prescribers in facilities using NYS serialized facility labels provided by the Bureau of Narcotic Enforcement must follow the instructions below for all noncontrolled substances (controlled substance prescriptions must be issued on the Official NYS prescription form).

  • Use Official New York State prescription forms, or
  • Use serialized facility labels affixed to the facility's own prescription form that includes one of the additional tamper resistant features: The quantity prescribed is preceded and followed by computer-generated asterisks, e.g., "Quantity ***50***", "Dispense ***50***."

For questions regarding Medicaid tamper-resistant requirements, please contact the Bureau of Pharmacy Policy and Operations at (518) 486-3209.

Effective October 1, 2008

New Pharmacy Early Fill Edit
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Effective October 1, 2008, a new pharmacy early fill edit will be implemented that will deny drug claims when less than 75% of the previously dispensed amount, based on the previously dispensed supply, has been used. The eMedNY claim denial message will indicate the reason for denial and specify the date that is the earliest the claim will be accepted for payment.

The determination of an early fill will be applied to all claims for the same drug product and strength, regardless of prescribing provider, billing provider, or prescription number.

When medically necessary, pharmacists will be able to override denials at point of service by using a combination of the Reason for Service Code, Result of Service Code and the Submission Clarification Code as follows:

Field Description Action
Reason for Service Code
Field 439-E4
Result of Service Code
Field 441-E6
Appropriate Result
of Service Code
Submission Clarification Code
Field 420-DK
"03" Vacation Supply
"04" Lost Prescription

Pharmacists should use Code "03" when the early fill is for vacation or travel purposes. Code "04" should be used when an early fill is needed because the enrollee's medication has been lost, damaged/destroyed, or stolen.

Please note that pharmacists are responsible for ensuring that early fills involving controlled substances, including the pharmacist override provision, are compliant with all controlled substance law, regulation and policy.

Do you have questions regarding this new edit? Please call the eMedNY Call Center at (800) 343-9000.


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In the future, pharmacy providers billing Medicaid at 340B prices will be able to identify their drug claims as a 340B priced claim as follows:

Pharmacy Providers: A pharmacy will have the ability to identify when they are billing Medicaid for a 340B drug by using the NCPDP version 5.1 field 423-DN, basis of cost determination. By entering a value of 09 in this field, a pharmacy can designate when they are billing for a 340B drug. When using the 340B option, actual acquisition cost must be billed to Medicaid. This option will be available in the future; we will notify providers in advance of the implementation. Please contact your software vendor regarding this new requirement.

Questions?Contact the Bureau of Pharmacy Policy and Operations at (518) 486-3209.

Effective October 1, 2008

Family Health Plus Pharmacy Benefit
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The pharmacy benefit for Family Health Plus managed care enrollees will be "carved out" of the managed care plan benefit package and will be administered by the Medicaid fee-for-service program, effective October 1, 2008. Family Health Plus enrollees will be issued a Medicaid Benefit Identification Card to obtain their pharmacy benefit.

If enrollees are already using a Medicaid Benefit Identification Card to obtain other benefits, they can use the same Benefit Identification Card to access their pharmacy benefits on or after October 1, 2008.

If they currently use a Family Health Plus managed care identification card to access their pharmacy benefits, they must continue to do so until October 1, 2008.


  • Prescription drugs
  • Insulin and diabetic supplies currently covered as a pharmacy benefit by Medicaid (e.g., insulin syringes, blood glucose test strips, lancets, alcohol swabs)
  • Smoking cessation agents, including OTC products
  • Select over-the-counter medications covered on the Medicaid Preferred Drug List (Prilosec OTC, loratadine, Zyrtec)
  • Hearing aid batteries
  • Enteral formulae

PLEASE NOTE: Prescriptions for Family Health Plus enrollees will be subject to all Medicaid program requirements. Providers may need to obtain prior authorization from Medicaid for certain prescription drugs through the following initiatives: the Clinical Drug Review Program (CDRP), the Preferred Drug Program (PDP), the Mandatory Generic Drug Program (MGDP). Information on these programs is available at or through the Clinical Call Center at (877) 309-9493. Enteral formulae prior authorization forms can be obtained at, or by calling (866) 211-1736.

Drug co-payments for Family Health Plus enrollees will not change. Co-payments will remain at $6.00 for brand name drugs, $3.00 for generic drugs, $1.00 for diabetic supplies, hearing aid batteries and enteral formulae, and $0.50 for covered over-the-counter drugs. For more information, refer to the April 2006 Medicaid Update, Family Health Plus Co-payment Information."

With the exception of controlled substances, prescriptions must be filled within 60 days and are valid for 6 months from original prescription date with up to five refills.

Drugs administered in the physician's office (J-Code drugs) remain in the managed care benefit package and should continue to be billed to the enrollee's Family Health Plus managed care plan.

Questions? Contact Medicaid Pharmacy Policy & Operations staff at (518) 486-3209.

Effective September 25, 2008

Prior Authorization will change for some drugs
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The New York State Medicaid Pharmacy and Therapeutics (P&T) Committee recently reviewed 11 drug classes currently subject to the Preferred Drug Program (PDP). Effective September 25, 2008, prior authorization requirements will change for some drugs in the following two drug classes:

  • Anti-Emetics
  • Urinary Tract Antispasmodics

In addition to these changes, the PDP is also expanding to include two new drug classes. Prescriptions written on or after September 25, 2008 for non-preferred drugs in the following drug categories will require prior authorization:

  • Anticoagulants - Injectable
  • Niacin Derivatives

To obtain prior authorization for non-preferred drugs, please call the Call Center at (877) 309-9493 and follow the appropriate prompts.

Following is the most up-to-date Preferred Drug List (PDL), with a full listing of preferred and non-preferred drugs for each of the drug classes currently subject to the PDP. Additional information, such as a "Quicklist"of only preferred drugs and updated prior authorization forms, is available at each of the following Websites: or or

New York State Medicaid Preferred Drug List

Remember! Preferred drugs do not require prior authorization!

For clinical concerns or preferred drug program questions, contact (877) 309-9493.

For billing questions, contact (800) 343-9000.

For Medicaid pharmacy policy and operations questions, call (518) 486 -3209.

Infant Apnea monitor changes
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Effective for dates of service on and after September 1, 2008, vendors will have to obtain an electronic Dispensing Validation System (DVS) prior authorization number before providing an apnea monitor to infants under 1 (one) year of age.

A DVS request is submitted in "real time", which means that the status of the request will be available by the end of your DVS session.

DVS checks service limits on the procedure code requested, including frequency, units and age. If service limits are not exceeded, an immediate authorization number is returned. If service limits are exceeded, a prior approval must be requested.

The vendor must report the prior authorization number on the claim. An apnea monitor DVS authorization will be granted for an approved period of service of 30 days, and can be cancelled by the provider within 90 days of the authorization date.

In the ordering provider identification field on prior authorizations and claims, the actual provider identification number of the qualified ordering provider must be entered.

Board certified pulmonologists or board eligible pulmonologists are qualified to order apnea monitors. No facility or center provider identification numbers will be allowed in the ordering provider field. The ordering and dispensing provider's 10-digit NPI number must be reported on the DVS request and the claim. All other requirements, coverage and policies relating to apnea monitors remain in effect. Prior approval is still required for beneficiaries over 1 (one) year of age.

For additional information and assistance in obtaining a DVS through e-PACES and the POS terminal or to obtain eMedNY Prior Approval Request Form 361401 (paper form) for DVS overrides, contact Computer Sciences Corporation (CSC) at (800) 343-9000. For information regarding general Medicaid coverage of apnea monitors or a specific prior approval submission, call the Medical Prior Approval Bureau at (800) 342-3005, Option # 1.

Reimbursement for follow-up pap smears
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Effective immediately, reimbursement will be available for follow-up pap smears provided to Family Planning Benefit Program enrollees only when the enrollee has had a previous abnormal pap smear. This enhanced program coverage provides continuity of care and referral for medical intervention if necessary.

  • If the primary reason for the followup visit is for the follow-up pap smear and a family planning visit is secondary, the primary ICD-9 diagnosis code must indicate an abnormal pap smear with the appropriate CPT code for the laboratory test. The secondary ICD-9 diagnosis code must be in the V25 series with the appropriate evaluation and management follow-up visit.
  • If the primary reason for the followup visit is for family planning and the follow-up pap smear is secondary, the primary ICD-9 diagnosis code must be in the V25 series with the appropriate evaluation and management follow-up visit code. The secondary ICD-9 diagnosis code must indicate an abnormal pap smear with the appropriate CPT code for the laboratory test.
  • These billing requirements apply to both clinic as well as practitioner claims.

If you have any questions, please contact the Bureau of Policy Development and Coverage at (518) 473-2160.

Certification Statements must be renewed annually!
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The Certification Statement for providers billing Medicaid is required in order to submit electronic and paper claims. Providers utilizing multiple Electronic/Paper Transmitter Identification Numbers (ETIN) for billing must submit a certification for each ETIN. The Certification Statement must be renewed on an annual basis. Failure to renew will result in the inability to submit claims and receive payments from New York Medicaid.

For your convenience, Computer Sciences Corporation (CSC) will send two certification renewal notices, each with a pre-printed certification form. The first notice is sent 45 days prior to the expiration of your current certification. If your renewed certification is not received within 30 days of the expiration, a second notice will be sent. It is only necessary to return one of these renewed certifications.

The renewal forms are pre-printed with the ETIN, certification date, provider name and provider ID. Please sign and notarize one of the forms and return it to the address provided. Please do not alter the pre-printed information.

Please call the eMedNY Call Center at (800) 343-9000 to inquire if your certification has been updated.

Do you need help understanding why a claim was denied?
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  • Did you know that the eMedNY Website has a section to help submitters interpret the edits or reason codes for which claims may be denied?

If you need assistance understanding the denial reasons on an electronic remittance (835) or a paper remittance, the EDIT ERROR KNOWLEDGEBASE (EEKB) offers likely reasons why a claim failed for a specific edit and suggests possible resolutions to the error.

If you receive your remittance electronically, you can use the EEKB to view information by either the edit number supplied on your electronic supplemental file or by the reason code supplied on your 835. If you receive your remittance on paper, then the edit numbers are listed on the last page(s) of your remittance statement.

The EEKB can also assist with interpreting errors received on an electronic claim status response (277) transaction. To access the EEKB go to and select NYHIPAADESK. From the menu on the left select ERROR KNOWLEDGEBASE.

Questions about claim denials or how to access and use the EEKB should be directed to the eMedNY Call Center at (800) 343-9000.

Sign up for electronic funds transfer today!
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Thousands of Medicaid providers have already signed up for Electronic Funds Transfer (EFT), and are enjoying the convenience that this service offers.


  • EFT allows Medicaid funds to be electronically transferred to your bank account of choice (checking or savings)
  • EFT eliminates mail time as funds are transferred at the same time the paper check is mailed. Providers who have chosen to receive paper remittances and who sign up for EFT will still be mailed the same paper remittance statements
  • Providers who sign up for EFT still have the associated paper remittance mailed according to the same schedule along with a statement about the amount of the EFT transfer
  • Providers' banking institutions have funds available within 48 hours or less.

If you would like to enroll in EFT, please complete the EFT Provider Enrollment form which can be accessed at in the Featured Links section, then click on Provider Enrollment Forms. Prior to completing the form, carefully read the instruction sheet, which can be found at the above Website.

If you do not have internet access, you can still sign up for EFT! Just contact the Call Center at (800) 343-9000 for instructions. After sending the EFT PROVIDER ENROLLMENT FORM to CSC, please allow four to six weeks for processing. During this period, you should review your bank statement and look for an EFT transaction in the amount of $0.01, which CSC will submit as a test. Your first real EFT transaction will take place approximately 10 days later.

Questions? Please contact CSC Provider Enrollment Support at (800) 343-9000.

eMedNY Data Center is moving
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The eMedNY Data Center will soon be moving to a new facility. Due to the magnitude of this move and to maintain minimal down time of system availability, careful planning is underway to execute the move based on a phased approach.

Each phase will take place during the weekends/off-hours from mid-September through mid-November.

Any event that may impact availability of services to a segment of users will be communicated in advance to allow any contingency planning. We expect this move to the new facility be completed by the end of 2008.

Keep posted to our Website,, for updates on the progress of the move, and for notices of potential impact.

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

No Smoking


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Missing Issues?
The Medicaid Update, indexed by subject area, can be accessed online at:

Hard copies can be obtained upon request by e-mailing:

Office of the Medicaid Inspector General: (518) 473-3782

Questions about an Article?
Each article contains a contact number for further information, questions or comments.

Questions about billing and performing EMEVS 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:

For individual training requests, call (800) 343-9000 or email:

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:

Rate-Based/Institutional Providers
A change of address form is available at:

Comments and Suggestions Regarding This Publication?
Please contact the editor, Kelli Kudlack, at:

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.