New York State Medicaid Update - February 2015 Volume 31 - Number 2
In this issue.....
- ALL PROVIDERS
- New York Medicaid EHR Incentive Program Update
- Payment Error Rate Measurement (PERM) Upcoming Request for Medicaid Provider Documentation
- Mandatory Compliance Program Obligations and Certification Requirement upon Revalidation of
Enrollment with the New York State Department of Health
- New York State of Health (NYSoH) ePACES Identifier
- The Medicaid Update Moves to Electronic Distribution
- PHARMACY UDPATE
- POLICY AND BILLING GUIDANCE
NY Medicaid EHR Incentive Program Update
The NY Medicaid Electronic Health Record (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 $645.3 million in incentive funds have been distributed within 16,504 payments to New York State Medicaid providers.
The NY Medicaid EHR Incentive Program Support Team takes great pride in offering providers free high quality program support and services. Don't take our word for it, call us at 1-877-646-5410 to speak with a program analyst for one-on-one support or navigate to the NY Medicaid EHR Incentive Program Website to view our online services. support or navigate to the to view our online services.
NY Medicaid EHR
Taking a closer look: NEW NY Medicaid EHR Incentive EP Program Deadlines.
Highlighted below are a number of deadlines coming fast in the NY Medicaid EHR Incentive Program. If you have any questions regarding the deadlines below please contact the NY Medicaid EHR Incentive Program Support Team at 1-877-646-5410.March 31, 2015 - Payment Year 2014 EP Attestation Deadline
Please be aware that EPs intending to attest for Payment Year 2014 must submit an attestation by March 31, firstname.lastname@example.org for program clarifications and details.
Payment Error Rate Measurement (PERM) Upcoming Request for Medicaid Provider Documentation
The Centers for Medicare & Medicaid Services (CMS), in partnership with the New York State Office of the Medicaid Inspector General (OMIG), will measure improper payments in the Medicaid and State Child Health Insurance programs under the Payment Error Rate Measurement (PERM) program. This will be the third time New York State will be participating. The State last participated in federal fiscal year (FY) 2011.
CMS, along with their contractor, and OMIG, have the authority to collect this information under sections 1902(a)(27) and 2107(b)(1) of the Social Security Act. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) statutes and regulations require the provision of such information upon request, and the information can be provided without patient consent.Documentation for a medical review of randomly selected claims will be requested by A+ Government Solutions, Inc., the CMS contractor. If claims you submitted are selected, the CMS contractor will request from you, in writing, documentation to substantiate claims paid in federal FY 2014 (October 1, 2013 - September 30, 2014). Your cooperation and a timely response are requested. Please submit the specific medical documents for the patient, as requested in the letter you receive from the CMS contractor, directly to the CMS contractor with a copy to OMIG at the following address:
Office of the Medicaid Inspector General
800 North Pearl Street
Albany, NY 12204
Attention: PERM Project Staff
Requests for documentation were originally scheduled to begin in March 2014. Due to a delay in the submission of the universes of paid claims, the requests will now start in March 2015. The sampled claims will be claims paid in federal FY 2014 (October 1, 2013 - September 30, 2014). All requests and receipts or non- receipt of documentation will be monitored for compliance. Failure to comply with the record requests will result in a determination of erroneous payment, and OMIG will pursue recovery of these amounts. Questions? Please contact PERM Project staff at (518) 486-7153 or (518) 402-7041.
Mandatory Compliance Program Obligations and Certification Requirement upon Revalidation of Enrollment with the New York State Department of Health
THIS IS AN ANNOUNCEMENT FROM THE NEW YORK STATE OFFICE OF THE MEDICAID INSPECTOR GENERAL (OMIG) FOR ALL PROVIDERS WHO ARE REQUIRED TO REVALIDATE THEIR MEDICAID ENROLLMENT WITH THE NEW YORK STATE DEPARTMENT OF HEALTH.
OMIG's Compliance Guidance 2015-01 Medicaid Providers Revalidating Enrollment with the New York State Department of Health - Mandatory Compliance Program Obligations and Certification Requirement upon Revalidation addresses the compliance program and certification obligations for Medicaid providers that are subject to the revalidation of enrollment process with the New York State Department of Health. Compliance Guidance 2015-01 is posted on OMIG's website, www.omig.ny.gov, and can be accessed at http://www.omig.ny.gov/images/stories/compliance_alerts/20150127_Compliance_Guidance_2015_01_final_1 _27_15.pdf.
Providers that are revalidating their Medicaid enrollment with the Department of Health must determine whether they are subject to New York's mandatory compliance program requirements found in New York State Social Services Law § 363-d (§ 363-d) and Title 18 of the New York Code of Rules and Regulations, Part 521 (Part 521). If they are subject to the mandatory compliance program requirements, Medicaid providers must implement an effective compliance program meeting those requirements.
Additionally, at the time Medicaid providers revalidate their enrollment, if they are subject to the mandatory compliance program requirements, the revalidating provider must certify on OMIG's website that their compliance program meets New York's statutory and regulatory requirements. Compliance Guidance 2015-01 provides guidance to revalidating providers on what must be submitted as part of their revalidating application.
If a revalidating provider is not certain if it is subject to the mandatory compliance program obligation, there is a link in the Compliance Guidance to a decision tree that can assist a provider with that decision.
Since the mandatory compliance program obligation went into effect on January 1, 2007, with the enactment of § 363-d and the accompanying regulations went into effect on July 1, 2009 with the adoption of Part 521, certain Medicaid providers have been required to have a compliance program and to certify that the compliance program meets the statutory and regulatory requirements. This certification obligation applies upon enrollment in the Medicaid program and in December each year.
There are a number of compliance related resources and forms available on OMIG's website's Compliance Tab that can be accessed at http://www.omig.ny.gov/compliance.
If you have any questions, please contact OMIG's Bureau of Compliance at (518) 408-0401 or by using the Bureau of Compliance's dedicated e-mail address at: email@example.com.
New York State of Health (NYSoH) ePACES Identifier
To assist providers in identifying NYSoH Medicaid recipients, an ePACES identifier has been activated. The identifier is displayed as H78 in the Office field.
Providers servicing NYSoH Medicaid consumers in need of Recipient Restriction changes, Exception coding to allow Medicaid payment for case management services, Exclusion coding, or who experience certain life changing events, can now identify NYSoH recipients and utilize our established points of contacts.NYSoH Restrictions
Individuals active in Recipient Restriction Program looking to change restricted providers:
|firstname.lastname@example.org||(518) 473-6397 voice||(518) 474-9062 fax|
Individuals in receipt of Comprehensive Medicaid Case Management Services including but not limited to Early Intervention. Submission of case management entry requests:
|email@example.com||(518) 473-6397 voice||(518) 474-9062 fax|
Individuals participating in Residential Rehabilitation Services for Youth (RRSY). Submission of admission/discharge notices:
|firstname.lastname@example.org||(518) 473-6397 voice||(518) 474-9062 fax|
Individuals in immediate need of certain services that are not available on NYSoH. Services include managed long term care, adults or children in need of waiver services, fee-for-service personal care, fee-for-service short term (up to 29 days) rehabilitation, all consumers (fee-for-service or managed care) in need of long term (permanent placement) in nursing home, ICF, congregate care facility, Special Needs Plans and Medicaid Advantage:
|email@example.com||(518) 473-6397 voice||(518) 474-9062 fax|
Questions may be referred to the Bureau of Medicaid Enrollment and Exchange Integration, Office of Health Insurance Programs at (518) 473-6397.
The Medicaid Update Moves to Electronic Distribution
Reminder: In an effort to reduce costs and be more environmentally minded, beginning April 1, 2015 the Office of Health Insurance Programs will no longer produce a printed version of the Medicaid Update.
The Medicaid Update will ONLY be available electronically. This delivery system allows 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).
If you do not presently receive the Medicaid Update electronically, please send your request to the following e-mail: MedicaidUpdate@health.ny.gov.
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: http://www.nyhealth.gov/health_care/medicaid/program/update/main.htm
New York State Medicaid Managed Care Pharmacy Benefit Information Website Update
*Note Name Change*
The NYSDOH Family Health Plus program officially ended. Due to that change we have updated the name of the website to remove Family Health Plus from the title.
The New York State Department of Health (NYSDOH), in partnership with the State University of New York at Stony Brook, continues to add new drug/drug categories to the New York State Medicaid Managed Care Pharmacy Benefit Information Website. The most recent update includes the addition of two new categories, Anticonvulsants-second generation and Hepatitis C Agents-Direct Acting Antivirals to the Therapeutic Classes, Other tab on the Drug Look-Up page. Patients and providers will quickly be able to view drug coverage in these therapeutic categories by specific Medicaid Managed Care plan(s) as shown below:
The Medicaid Managed Care Pharmacy Benefit Information website is available at: http://pbic.nysdoh.suny.edu
In addition you can link to the website from the following pages:
New York State Department of Health Medicaid Managed care Page:http://www.health.ny.gov/health_care/managed_care/
Click on Medicaid Managed Care Pharmacy Benefit Information Center
The eMedNY home page under "Featured Links" at:https://www.emedny.org/index.aspx
Click on New York State Medicaid Managed Care Pharmacy Benefit Information Center
Redesigning New York's Medicaid Program Page under supplemental information on specific MRT proposals:http://www.health.ny.gov/health_care/medicaid/redesign/
Click on MRT 11& MRT 15, Pharmacy Related Proposals, then click on Managed Care Plan Pharmacy Benefit Manager and Formulary Information.
PHARMACY UPDATE FOR FIDA PLAN MEMBERS
Enrollment for FIDA (Fully Integrated Dual Advantage) Plans in Region 1 (Bronx, Kings, New York, Queens, Nassau and Richmond) Counties opened on January 1, 2015 for opt-in membership and passive enrollment will begin on April 1, 2015.
Below are some helpful resources for pharmacies assisting eligible dual Medicare-Medicaid members who recently enrolled in one of the FIDA plans. The resources include a sample FIDA Rx benefit card, information on the LINET program (Limited Income Newly Eligible Transition) Program, a list of the FIDA plans as well as the current counties they cover and a chart containing FIDA plan contact and billing information.
1 Sample FIDA Rx Benefit Card
See PDF Copy page 9
2 LINET Program Information
FIDA enrollees may encounter period of transition when their Part D FIDA coverage is not in effect and a new Part D Plan has not been chosen or assigned. In these circumstances, pharmacies should bill drug claims through the Medicare LINET Program. Additional information on the LINET Program is available at:
- 1) http://www.cms.gov/Medicare/Eligibility-and- Enrollment/LowIncSubMedicarePresCov/MedicareLimitedIncomeNET.html
- 2) https://www.humana.com/pharmacy/pharmacists/linet
- 3 List of all FIDA Plans(s) (PDF, 1pg)
- 4 FIDA Plan Contact & Billing Information (PDF, 1pg)
Questions regarding this article may be sent to: firstname.lastname@example.org.
POLICY AND BILLING GUIDANCE
Patient Centered Medical Home Statewide Program: Revised Policy and Incentive Payments
Effective April 1, 2015, New York State Medicaid is changing the reimbursement policy for providers working at practices that are recognized as a Patient Centered Medical Home (PCMH) by the National Committee for Quality Assurance (NCQA). The revised policy applies to both Medicaid Managed Care (MMC) and Fee-For- Service (FFS) and is consistent with the Medicaid Redesign Team (MRT) and State Health Innovation Plan's (SHIP) Triple Aim to improve quality of care, improve health, and reduce cost.
Earlier this year, NCQA's third set of PCMH standards was released. The 2014 standards "raise the bar" even higher than the 2011 standards, placing greater emphasis on care management, team-based care, and integrating behavioral and physical health care services, as well as setting additional standards for improving overall quality of care to patients.
The table below summarizes the MMC Per Member Per Month (PMPM) amounts and the FFS 'add-on' amounts for visits with qualified evaluation and management codes (see FFS billing details below) by provider type and recognition status as of April 1, 2015. All incentive payments for PCMH-recognized providers under NCQA's 2008 standards will be eliminated for both MMC and FFS.
Level 2 providers, who achieved their recognition under the NCQA 2011 standards, will have their incentive payments reduced to $2.00 PMPM and $6.75 and $7.75 per visit in FFS. Level 3 providers, who achieved their recognition under the NCQA 2011 standards, will have their incentive payments reduced to $4.00 PMPM and $14.50 and $12.50 per visit in FFS. Incentive payments for providers recognized as Level 2 PCMH under the new 2014 standards will be $6.00 PMPM and $20.50 and $23.25 per visit in FFS. Lastly, 2014 Level 3 incentive payments will be $8.00 PMPM and $29.00 and $25.25 per visit in FFS.
|NCQA Level 2
|NCQA Level 3
|MMC-PMPM||$2.00 / $6.00||$4.00 / $8.00|
|FFS Add-on Per Visit|
|Professional||$6.75 / $20.50||$14.50 / $29.00|
|Institutional||$7.75 / $23.25||$12.50 / $25.25|
*NCQA Level 1 payments for all standard years were discontinued on January 1, 2013. All payments for 2008- recognized providers will be eliminated effective April 1, 2015.
Fee-For-Service Billing Requirements:
Office-based practitioners will receive the medical home add-on payment amount when they meet the following criteria:
1) The billing provider within the servicing practitioner's practice must be designated as New York Medicaid Medical home (Level 2 or Level 3 under the 2011 or 2014 NCQA standards);
2) In a practitioner group practice the group National Provider Identifier (NPI) and the billing practitioner NPI must be designated as a New York Medicaid Medical Home (Level 2 or Level 3 under the 2011 or 2014 NCQA standards);
3) The claim must contain, and service provided must be consistent with, one of the following Evaluation and Management codes: 99201-99205, 99211-99215; or one of the following Preventive Medicine codes: 99381-99386, 99391-99396. The place of service code on the claim must be office (POS'11');
4) The claim must include the 9 digit zip-code of the designated practice's physical location.
Article 28 Clinics - Outpatient Departments, Diagnostic and Treatment Centers, and Federally Qualified Health Centers:
The medical home designation will be associated with each clinic on a site-specific basis. Clinics will receive the medical home add-on when they fulfill the following requirements:
1) The billing clinic (site-specific) must be designated as a medical home (Level 2 or Level 3 under the 2011 or 2014 NCQA standards);
2) Claims must contain, and the service provided must be consistent with, one of the following Evaluation and Management codes 99201-99205, 99211-99215; or one of the following Preventive Medicine codes 99381-99386, 99391-99396;
3) The submitted rate code must be one of the following 1400, 1407, 1422, 1425, 1432, 1435, 1444, 1447, 1450, 1453, 1480, 2887, 2888, 2889, 2940-2942, 2945, 2985, 2987, 4012, 4013; and
4) The claim must include the 9 digit zip-code of the designated practice's physical location.
In the event that both a practitioner working in a clinic (who submits a professional claim) and the clinic have a medical home designation, only the clinic will receive the enhanced payment.
New York Medicaid providers participating in the Adirondack Medical Home Demonstration Project are not eligible for enhanced payment through the Statewide Patient-Centered Medical Home Program.
For more information on how to achieve NCQA PCMH recognition, providers may contact NCQA at (888) 275-7585 or visit the NCQA website at www.ncqa.org.
MMC PCMH questions may be directed to the Division of Health Plan Contracting and Oversight at 518-474-5050, or the eMedNY Call Center at (800) 343-9000 or email@example.com regarding Medicaid FFS questions.
For more information on claim eligibility please contact eMedNY at (800) 343-9000.
ICD-10 Reminder for Providers and Vendors
- The eMedNY Provider Testing Environment (PTE) is available for end-to-end testing of Medicaid claims with ICD-10 diagnosis codes (procedure codes for inpatient hospitals). The PTE mirrors the eMedNY production environment, in both content and functionality. Submitters and providers can be assured that successful testing through the PTE will minimize potential issues with submission of their production files come October 1, 2015. All Medicaid partners are urged to test at their earliest convenience.
- The https://www.emedny.org/icd/index.aspx website provides an extensive amount of eMedNY related ICD-10 information including FAQs and eMedNY end-to-end testing. The area should be visited regularly to ensure submitters have the most up to date ICD-10 information.
- Provider and vendors are encouraged to regularly access the federal CMS ICD-10 website www.cms.gov/Medicare/Coding/ICD10/index.html for the most comprehensive and detailed compilation of ICD-10 resources including Intro Guide to ICD-10, ICD-10 and Clinical Documentation, ICD-10 Official Coding Guidelines, General Equivalence Mappings (GEMs), and many other documents focusing on all aspects of ICD-10 implementation.
- Medicaid providers are reminded that they are ultimately responsible for ensuring that the data submitted to New York Medicaid by them, or a third party on their behalf, is correct and compliant with mandated standards and regulations. As such it is of utmost importance that providers take a proactive role and work diligently with their staff, clearinghouse, billing service or software vendor to ensure their practice will be able to successfully submit ICD-10 compliant transactions for services rendered on or after October 1, 2015.
- Effective October 1, 2015 New York Medicaid will only accept, recognize and process ICD-10 codes for services rendered on or after October 1, 2015. ICD-9 codes will only be accepted for services rendered prior to October 1, 2015. Transactions which contain ICD-9 codes, with a date of service of October 1, 2015 or after will be denied.
Office of the Medicaid Inspector General:
For suspected fraud complaints/allegations, call 1-877-87FRAUD, (877) 873-7283, or visit www.omig.ny.gov.
Provider Manuals/Companion Guides, Enrollment Information/Forms/Training Schedules:
Please visit the eMedNY website at: www.emedny.org.
Providers wishing to 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.
To sign up for a provider seminar in your area, please enroll online at: http://www.emedny.org/training/index.aspx. For individual training requests,
call (800) 343-9000 or e-mail: firstname.lastname@example.org.
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: http://www.health.ny.gov/health_care/medicaid/program/prescriber_education/presc-educationproghttp://nypep.nysdoh.suny.edu/home
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 www.emedny.org/info/ProviderEnrollment/index.aspx 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.