New York State Medicaid Update - October 2014 Volume 30 - Number 9

In this issue.....

Policy and Billing Guidance

Attention: Upstate Medical Providers and Transportation Vendors

Fee-for-Service Transportation Management Includes the Offices of Mental Health and People with Developmental Disabilities

Historically, the transportation of enrollees residing upstate whose Medicaid eligibility is with the New York State Office of Mental Health (OMH, county code 97) or Office for People With Developmental Disabilities (OPWDD, county code 98) has been handled in one of two ways:

1. When the cost of transportation is included in the rate paid to a Medicaid program (e.g., adult day health care, day habilitation, etc.), that program arranges transportation to and from that program;


2. When transportation is fee-for-service (FFS), prior authorization is generated by the OMH or OPWDD central office staff located in Albany.

For the majority of counties below, the Department of Health's contracted transportation managers arrange trips for all FFS enrollees, including OMH and OPWDD fiscal responsible enrollees. Effective January 1, 2015, the management of FFS transportation for OMH and OPWDD fiscal responsible enrollees residing in the following 7 counties will be undertaken by our upstate transportation manager, Medical Answering Services (MAS):

  • Allegany
  • Chautauqua
  • Genesee
  • Wyoming
  • Cattaraugus
  • Erie
  • Niagara

The Department of Health's contracted transportation managers currently arrange trips for all FFS enrollees, including OMH and OPWDD fiscal responsible enrollees for the following counties:

*Chemung*Fulton*Oneida*St. Lawrence*Tompkins

For dates of service on or after January 1, 2015, the ordering medical provider must seek authorization from MAS instead of central office staff of OMH or OPWDD. Staff in each agency's Albany-based central office will not process prior authorization requests with service dates on or after January 1, 2015. To secure approval prior to the trip, please call MAS at (855) 852-3289. Payment for trips performed without prior approval from MAS may be denied.

Ambulance vendors providing emergency transport to these enrollees must seek authorization from MAS for the correct reimbursement within 90 days of the date of service.

Information regarding Medicaid transportation, including required forms and a list of participating transportation vendors, is available online at:

The MAS field liaison is available to discuss the processes for requesting transportation authorization through MAS onsite at each facility. To request an onsite visit, please call MAS at the telephone number above.

Questions? Please contact the Medicaid Transportation Policy Unit at (518) 473-2160 or via e-mail to

Attention Enrollees Using Medicaid Transportation

Medicaid Enrollees Must Cancel Transportation Appointments when Transportation is Not Needed

What is a No-Show trip?

A No-Show trip occurs when a transportation vendor is scheduled to pick up a Medicaid enrollee, and waits a reasonable time for the enrollee (15 minutes), only to have the enrollee not appear for the service or indicate that he or she does not need the scheduled transportation on that day at that time.

During the trip attestation process, the vendor reports these scheduled trips as a "No-Show."

What can be done to prevent a No-Show?

Medicaid enrollees or their designated agents must call the transportation manager to cancel their transportation when it is known to them that they will not need the scheduled transportation (including standing order trips).

Additionally, if the appointment for which transportation is being cancelled is scheduled for the same day or next day, the Medicaid enrollees or their designated agent should also contact the transportation vendor directly to cancel the trip.

The transportation manager contact list by county can be accessed online at:

Department of Health No-Show Policy

First No-Show

Staff of the transportation manager shall contact the enrollee to determine the cause of the No-Show and discuss the cancellation policy, as well as provide a written communication documenting this outreach using a letter.

Second No-Show

If a second No-Show occurs within sixty (60) days from the first, the enrollee will receive a second letter of communication documenting the occurrence with a reminder of the cancellation policy. At this time, the enrollee will be informed that they MUST personally contact the transportation manager via telephone to discuss his/her future non-emergency transportation needs. Until the enrollee performs such outreach, no further transportation shall be scheduled.

Third No-Show

If a third No-Show occurs within ninety (90) days of the telephone conversation between the transportation manager and the enrollee, the enrollee shall receive a third letter documenting the occurrence, and a statement that the enrollee must schedule and pay for his/her own transportation in the future, and the methodology and parameters for reimbursement.

All enrollee No-Show correspondence is documented and maintained by the transportation manager in the enrollee's file.

For additional questions on this policy, contact the Transportation Policy Unit at (518) 473-2160 or at

NYS Medicaid Now Covers Non-invasive Prenatal Testing for Trisomy 21, 18 and 13

Prenatal Testing

Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) will begin covering non-invasive prenatal trisomy screening using cell-free fetal DNA for high-risk singleton pregnancies effective November 1, 2014 and January 1, 2015 respectively when one or more of the following criteria is met:

  • Either parent has a family history of an aneuploidy in a 1st* or 2nd** degree relative;
  • The pregnant woman is of advanced maternal age (defined by the American College of Obstetricians and Gynecologists as 35 years or older at the time of delivery);
  • Standard serum screening or fetal ultrasonographic findings indicate an increased risk of an aneuploidy;
  • Parent(s) have a history of a previous pregnancy with a trisomy; and/or
  • Either parent is known to have a Robertsonian translocation.

*1st degree relatives: Parents, children, siblings
**2nd degree relatives: Grandparents, aunts and uncles, nieces and nephews, and grandchildren

General Background

Fetal chromosomal abnormalities affect approximately 1 in 150 live births annually. Aneuploidies, an abnormal number of chromosomes, are the most prevalent. Trisomy is a type of chromosomal abnormality in which there are three copies of a given chromosome instead of two. The most common types of chromosomal abnormalities in fetuses are trisomy 21 (Down syndrome), 18 (Edwards syndrome) and 13 (Patau syndrome). Down syndrome is a condition associated with intellectual disability, a characteristic facial appearance and poor muscle tone in infancy. Edwards syndrome results in slow growth before birth, low birth weight and physical abnormalities (e.g., heart defects). Patau syndrome presents with severe intellectual disability and physical abnormalities in several parts of the body. In all of these cases, the risk of having a child with the chromosomal abnormality increases with the mother's age.

In recent years, non-invasive sequencing-based testing has become available. These tests identify cell- free fetal DNA present in the maternal blood. This DNA can be mapped or analyzed to determine whether fetal chromosomal abnormalities are present.


  • Follow-up genetic counseling should be provided to those who test positive for a fetal chromosomal abnormality.
  • Prenatal testing of a fetus by amniocentesis or chorionic villus sampling should be offered in the following circumstances:
    • Following a positive or high risk score in a non-invasive prenatal trisomy screening test; or,
    • Following an inconclusive result in a high-risk pregnancy.
  • Diagnostic testing (e.g., cytogenetic analysis or molecular genetic testing) for suspected aneuploidies continues to be covered if medically necessary.
  • Cell-free fetal DNA testing should not be offered to women with multiple gestations or low-risk pregnancies because it has not been sufficiently evaluated in these groups.
  • Micro-deletion testing in conjunction with non-invasive trisomy testing is not reimbursable.
  • Consistent with existing policy, NYS Regulations at 18 NYCRR Section 505.7(g)(4) require that providers order tests individually. No payment will be made for tests ordered as groupings or combinations of tests. For more information on this and additional regulations pertaining to laboratory services, please visit the following link:

Questions regarding Medicaid FFS policy should be directed to the Division of Program Development and Management at (518) 473-2160. Questions regarding MMC reimbursement and/or documentation requirements should be directed to the enrollee's MMC plan.

Medicaid Coverage Discontinued for Topical Oxygen Wound Therapy (TOWT)

Policy Coverage Decision

Effective December 1, 2014, New York State Medicaid fee-for-service (FFS) and effective January 1, 2015, Medicaid Managed Care (MMC) will no longer cover TOWT.

This coverage determination is based on the current available medical evidence of TOWT usage outcomes. Published studies to date do not provide sufficient evidence that TOWT enhances the rate of healing of chronic wounds.

Medicaid FFS and MMC will continue to cover treatment for patients currently undergoing TOWT until their full course of treatment is complete.

HCPCS codes associated with TOWT:

A4575Topical oxygen chamber, disposable
E1390Oxygen concentrator, single delivery port
E0446*Topical oxygen delivery system, not otherwise specified, includes all supplies & accessories

*This code is not in use by Medicaid FFS, but may be in use by one or more of the MMC Plans.

Questions regarding Medicaid FFS policy should be directed to the Division of Program Development and Management at (518) 473-2160.

Questions related to MMC should be directed to the enrollee"s MMC Plans.


Medicaid Pharmacy Program Prior Authorization (PA) Update

Effective October 16, 2014, the fee-for-service (FFS) pharmacy program will implement the following parameters associated with the treatment of Hepatitis C Virus (HCV). The clinical criteria and/or point of service editing below is the result of recommendations made by the Drug Utilization Review Board (DURB) at the September 18, 2014 meeting. Other recommendations made by the DURB at the September meeting will be implemented at a future date.

Hepatitis C Virus - clinical criteria addressing:

1. FDA labeling and compendia supported use

  • Verification of diagnosis, genotype, dosing and duration, etc.

2. Prescriber experience and training

  • Prescribed by hepatologist, gastroenterologist, infectious disease specialist, transplant physician or health care practitioner experienced and trained in the treatment of HCV or a healthcare practitioner under the direct supervision of a listed specialist.


  • Clinical experience is defined as the management at least 20 patients with HCV infection and treatment of 10 HCV patients in the last 12 months and at least 10 HCV- related CME credits in the last 12 months.


  • Management and treatment of HCV infection in partnership (defined as consultation, preceptorship, or via telemedicine) with an experienced HCV provider who meets the above criteria.

3. Patient readiness and adherence

  • Evaluation by using scales or assessment tools readily available to healthcare practitioners at: or to determine a patient's readiness to initiate HCV treatment, specifically drug and alcohol abuse potential.

4. Disease Prognosis and Severity

  • Evidence of Stage 3 or 4 hepatic fibrosis including one of the following: Liver biopsy confirming a METAVIR score F3 or F4 OR Transient elastography Fibroscan(®) score greater than or equal to 9.5 kPa; OR FibroSure(®) score of greater than or equal to 0.58; OR APRI score greater than 1.5; OR Radiological imaging consistent with cirrhosis (e.g. evidence of portal hypertension).


  • Evidence of extra-hepatic manifestation of HCV, such as type 2 or 3 essential mixed cryoglobulinemia with end- organ manifestations (e.g. vasculitis), or kidney disease (e.g. proteinuria, nephrotic syndrome or membranoproliferative glomerulonephritis). Documentation of the presence of extra-hepatic manifestations based on lab results or imaging results (e.g. CBC, erythrocyte sedimentation rate (ESR)/ C-reactive protein (CRP), urinalysis, BUN/ creatinine and angiography) must be submitted.

Liver Transplant
HIV-1 co-infection
HBV co-infection
Other coexistent liver disease (e.g. nonalcoholic steatohepatitis)
Type 2 diabetes mellitus (insulin resistant)
Porphyria cutanea tarda
Debilitating fatigue impacting quality of life
(e.g., secondary to extra-hepatic manifestations and/or liver disease)

Below is a link to our prior authorization fax form and Hepatitis C specific worksheets:

To obtain a PA, prescribers must contact the clinical call center at 1-877-309-9493. The clinical call center is available 24 hours per day, 7 days per week with pharmacy technicians and pharmacists who will work with you, or your agent, to quickly obtain a PA.

Below is a link to the most up-to-date information on the Medicaid FFS Pharmacy Prior Authorization (PA) Programs. This document contains a full listing of drugs subject to the Medicaid FFS Pharmacy Programs:

For more detailed information on the DURB meeting, please visit:

Medicaid FFS coverage guidelines for tests related to the treatment of Hepatitis C Virus are as follows:

HCV FibroSURE (CPT 0001M), a six biochemical marker index blood test, is covered by NYS Medicaid when used to determine medical necessity for use of drug therapies to treat hepatitis C. The test results are used to develop an algorithm to measure fibrosis stage and necroinflammatory activity in the liver. To be eligible for FibroSURE testing, recipients must be at least 18 years of age and not have any of the following contraindications: Gilbert disease, acute hemolysis, and acute viral hepatitis, drug induced hepatitis, genetic liver disease, autoimmune hepatitis, and/or extra hepatic cholestasis.

FibroScan, ultrasound based elastography, is covered by NYS Medicaid when used to determine medical necessity for use of drug therapies to treat hepatitis C. The test is used to detect and monitor hepatic fibrosis in persons with a diagnosis of hepatitis C. FibroScan is not covered for recipients under 18 years of age. Additionally, please note that testing should not be performed within six months following a liver biopsy. Practitioners who are providing FibroScan in their private office should bill the unlisted CPT code 91299 on paper, by report. If FibroScan is provided to a clinic patient, the practitioner should bill procedure code 91299 with a -26 modifier and the facility should bill 91299 for the technical component with a -TC modifier. Both the practitioner and clinic should bill on paper, by report.

Questions regarding Medicaid FFS policy on testing guidelines should be directed to the Division of Program Development and Management at (518) 473-2160.

For information regarding how Medicaid Managed Care plans will handle specific Hepatitis C Virus treatment coverage criteria and testing, contact plans directly at:


NY Medicaid Electronic Health Records (EHR)Incentive Program Update

The NY Medicaid EHR Incentive Program provides financial incentives to eligible practitioners and hospitals to promote the transition to EHRs. Providers who practice using EHRs are in the forefront of improving quality, reducing costs and addressing health disparities. Since December 2011, over $612.1 million in incentive funds have been distributed within 15,435 payments to New York State Medicaid providers.

Taking a closer look: CMS Certified EHR Technology (CEHRT) Flexibility Final Rule

The Centers for Medicare and Medicaid Services (CMS) has released a CMS CEHRT Flexibility Final Rule to allow eligible professionals (EPs) or eligible hospitals (EHs) more flexibility in how they use CEHRT to meet meaningful use for an EHR Incentive Program reporting period. The Flexibility Rule is only for Payment Year 2014 and applies to EPs and EHs that are unable to fully implement 2014 Edition CEHRT due to delays in 2014 Edition CEHRT availability. Below are several scenarios allowed by the Flexibility Rule:

Providers using 2011 Edition CEHRT or a combination of 2011/2014 Edition CEHRT scheduled to attest to 2014 Meaningful Use Stage 1 objectives in Payment Year 2014

In this scenario, EPs or EHs are able to attest to 2011 or 2013 Meaningful Use Stage 1 requirements using 2011 Edition CEHRT or a combination of 2011/2014 Edition CEHRTs in place of attesting to 2014 Meaningful Use Stage 1. All EPs and EHs are required to use 2014 Edition CEHRT in 2015.

Providers using 2011 Edition CEHRT or a combination of 2011/2014 Edition CEHRT scheduled to attest to 2014 Meaningful Use Stage 2 objectives in Payment Year 2014.

In this scenario, EPs or EHs are able to attest to 2011 or 2013 Meaningful Use Stage 1 requirements using 2011 Edition CEHRT or a combination of 2011/2014 Edition CEHRTs in place of attesting to Meaningful Use Stage 2. All EPs and EHs are required to use 2014 Edition CEHRT in 2015.

CMS CEHRT Flexibility Final Rule

For assistance and further details, the NY Medicaid EHR Incentive Program support service highly recommends that you review the CMS CEHRT Flexibility Final Rule. The rule also finalizes the extension of Meaningful Use Stage 2 through 2016 for certain providers and announces the Stage 3 timeline, which will begin in 2017 for providers who first became meaningful EHR users in 2011 or 2012.

For more information, please visit the helpful links below:

*CMS Flexibility Final Rule Press Release
*CMS CEHRT Flexibility Final Rule
*CMS Meaningful Use Stage 2 Final Rule

Have Questions? Contact for program clarifications and details


eMedNY ICD-10 Provider Testing Environment is Open

Providers and vendors are again reminded that the eMedNY Provider Testing Environment (PTE) is available for submitters to begin testing Medicaid claims with ICD-10 diagnosis codes and inpatient hospital claims that utilize ICD-10 procedure codes. All New York Medicaid submitters are urged to expedite their transition from ICD-9 to ICD-10 coding and take advantage of the ICD-10 end-to-end testing provided via the PTE. Please read the information below as it will assist you with your testing efforts.

Date of Service Requirement

When submitting test claims with ICD-10 codes submitters must use a date of service of July 1, 2014 or any date of service up to the date of the test submission. Future dates are not allowed. Submitters who may be testing claims with ICD-9 codes must use a date of service prior to July 1, 2014.

What is PTE?

The eMedNY PTE is designed to enable NYS Medicaid trading partners to test batch and real-time EDI (Electronic Data Interchange) transactions using the same validation, adjudication logic and methods as the eMedNY production environment. Test transactions submitted to the eMedNY PTE undergo processes that verify and report on data structure and content to the same degree of stringency as live transactions sent to the eMedNY production environment, and receive, in most cases, the same system responses at each step.

For similar inquiries, the response in the PTE may not be identical to the response in the production environment. For example, edits involving duplicate and near-duplicate claims, or prior authorization submissions, are not applied in PTE, so as to allow for iterative testing. Also no claim, or authorization, requests are pended in PTE.

Test Indicator

Since existing access methods are being used for PTE access, it is critical that the test indicator is valued in the inbound/outbound transactions.

For ASC X12 transactions: "Test Indicator" in ISA15 is set to "T"

For NCPDP Batch 1.2/D.0 transactions: File Type (702-MC) field in the NCPDP Batch Header is set to "T"

Important Note: If the appropriate indicator for a transaction is not set to Test, the transactions will be processed through the production environment.

New Medicaid Training Schedule and Registration

  • Do you have billing questions?
  • Are you new to Medicaid billing?
  • Would you like to learn more about ePACES?
  • Do you have questions on filling out forms such as Electronic Funds Transfer Authorization and Electronic Remittance Request?

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, Electronic Transmitter Identification Number Recertification Requirements- Electronic Remittance Advice/PDF Remit, Electronic Funds Transfer Completion, and eMedNY Website Review.

Web Training 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:

  • Claims (Dental, Professional, Institutional)
  • Eligibility Verifications
  • Claim Status Requests
  • Prior Approval/DVS Requests

Physician, Nurse Practitioner, Durable Medical Equipment 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 and dates are available on the eMedNY Website at:

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 suspected fraud complaints/allegations, call 1-877-87FRAUD, (877) 873-7283, or visit

Provider Manuals/Companion Guides, Enrollment Information/Forms/Training Schedules:
Please visit the eMedNY website at:

Providers wishing to listen to 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: For individual training requests,
call (800) 343-9000 or e-mail:

Enrollee Eligibility:
Call the Touchtone Telephone Verification System at (800) 997-1111.

Medicaid Prescriber Education Program:
For current information on best practices in pharmacotherapy, please visit the following websites:

Need to change your address? Does your enrollment file need to be updated because you've experienced a change in ownership? Do you want to enroll another NPI? Did you receive a letter advising you to revalidate your enrollment?
Visit and choose the link appropriate for you (e.g., physician, nursing home, dental group, etc.)

Medicaid Electronic Health Record Incentive Program questions?
Contact the New York Medicaid EHR Call Center at (877) 646-5410 for assistance.