New York State Medicaid Update - May 2015 Volume 31 - Number 5
In this issue.....
- ALL PROVIDERS
- State Awards Contract for New York State Medicaid Transportation Management Initiative for Long Island
- The Independent Consumer Advocacy Network (ICAN)
- NY Medicaid EHR Incentive Program Update
- ICD-10 Reminder for Providers and Vendors
- Continued Medicaid Enrollment for Nursing Homes, Intermediate Care Facilities for the Developmentally Disabled, and Case Management Providers
- PHARMACY UDPATE
- Medicaid Pharmacy Prior Authorization Programs Update
- Origin Codes for New York State Fee-for-Service Medicaid Claims for Valid Prescriptions Dispensed When Not Written on Official New York State Prescription Forms
- New York Prescription Saver Program Eliminated Effective May 31, 2015
- OPRA Prescription Requirements for Unlicensed Residents, Interns and Foreign Physicians in Training
- New York State Medicaid Fee-for-Service Program Pharmacists as Immunizers Fact Sheet (Updated 5-14-15)
- New York State Medicaid Managed Care Pharmacy Benefit Information Website Update
- POLICY AND BILLING GUIDANCE
- Revised New York State Medicaid Requirements for Home Health Providers and Verification Organizations
- Medicaid Policy: Loss of Records Due to Unforeseen Event
- Reporting of the National Drug Code (NDC) is Required for all Physician Administered Drugs Billed to the Ambulatory Patient Group (APG) Fee Schedule
- PROVIDER DIRECTORY
State Awards Contract for New York State Medicaid Transportation Management Initiative for Long Island
The New York State Department of Health has announced the award of a contract to LogistiCare Solutions, LLC, to implement the State's Medicaid Transportation Management Initiative for Long Island. The award completes the Department's assumption of transportation management statewide, and builds on the successes of Medicaid transportation management in the rest of the State, including New York City. LogistiCare will begin managing Medicaid transportation services in the counties of Long Island, Nassau and Suffolk, in July 2015.
LogistiCare and the Department of Health will reach out to, and collaborate with, health care and transportation providers and county officials in implementing the transportation management roll out. Within a few months of implementation, the Department will transition Medicaid Managed Care enrollees to the fee for service transportation management. Notification regarding the effective date of the Medicaid Managed Care transition to Logisticare for Nassau and Suffolk Counties will be provided in a future Medicaid Update article.
This initiative represents the Department of Health's commitment to a more efficient model for Medicaid transportation management by centralizing specialized management expertise and improving resource coordination, resulting in a more seamless, cost efficient, and quality oriented delivery of transportation services to Medicaid enrollees. It also represents significant mandate relief for localities by shifting the responsibility for administering Medicaid transportation to a contractor, operating under the direction of the New York State Department of Health.
Other regions operating under a Medicaid transportation management contract with the New York State Department of Health are:
- The Hudson Valley Region, which covers 24 counties, managed by Medical Answering Services (MAS);
- The New York City Region, covering all 5 boroughs, managed by LogistiCare Solutions;
- Finger Lakes and Northern New York Regions, covering 24 counties, managed by MAS; and
- Western New York Region, covering 7 counties, managed by MAS.
The Department of Health has realized significant reductions in the cost of transportation when compared to the same months in the year prior to State management, improved service quality (including the ability to adjust to individual enrollee needs), and program accountability. This savings trend generally results from a decrease in the number of higher cost trips in favor of medically appropriate lower cost modes such as public transportation and other targeted efficiency efforts such as group rides.
Questions should be directed to the Medicaid Transportation Unit at (518) 473-2160.
The Independent Consumer Advocacy Network (ICAN)Serving Thousands of Older Adults and People with Disabilities in New York State
More than 3,200 older and vulnerable New Yorkers have already received free individual assistance and advocacy services since the start of the new program, Independent Consumer Advocacy Network (ICAN).
What does ICAN do?
- Answers questions about Medicare and Medicaid programs for people receiving long-term care;
- Gives enrollees advice about managed care options; and
- Helps enrollees resolve any issues with their plans or providers (including assistance with appeals and grievances).
Who does ICAN help?
- Anyone in a Medicaid Managed Care (MMC) plan who needs long term care services.
- Anyone applying for Medicaid long term care services and/or in need of help enrolling in a Managed Long Term Care (MLTC), MMC, or Fully Integrated Dual Advantage (FIDA) plan.
ICAN is funded through a multi-year grant from the New York State Department of Health and administered by the Community Service Society of New York, in consortium with several leading advocacy organizations.
NY Medicaid EHR Incentive Program Update
The NY Medicaid Electronic Health Record (EHR) Incentive Program provides financial incentives to eligible professionals 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 $671 million in incentive funds have been distributed within 17,775 payments to New York State Medicaid providers.
For more information, visit emedny.org/meipass
Taking a closer look: NY Medicaid EHR Incentive EP Program Updates
- June webinar dates on our Upcoming Event Calendar
- NEWFrequently Asked Questions about audit documentation and public health objectives
The Centers for Medicare and Medicaid Services (CMS) has released a proposed rule to modify meaningful use (MU) requirements for 2015 through 2017. The proposed modifications include a 90-day EHR reporting period for all providers in 2015 and 10 meaningful use objectives:
- Protect Electronic Health Information
- Clinical Decision Support
- Computerized Provider Order Entry (CPOE)
- Electronic Prescribing (eRx)
- Summary of Care
- Patient Specific Education
- Medication Reconciliation
- Patient Electronic Access (VDT)
- Secure Electronic Messaging
- Public Health and Clinical Data Registry (CDR) Reporting
To learn more about the proposed modifications, register for Stage 1 and Stage 2 webinars hosted by NY Medicaid EHR Incentive Program Support. The proposed rule is open for public comment until June 15, 2015. Comments may be submitted electronically at www.regulations.gov.
Questions? Contact firstname.lastname@example.org for program clarifications and details.
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.
Providers 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 rejected.
October 1, 2015 is only four months away. Transition to ICD-10 will take time and resources. If you are not yet preparing for transitioning to ICD-10, the time to start is now. Do not put your Medicaid payments at risk by delaying your compliance efforts.
Continued Medicaid Enrollment for Nursing Homes, Intermediate Care Facilities for the Developmentally Disabled, and Case Management Providers
Federal regulation 42 CFR, Part 455.414 requires New York State Medicaid providers to revalidate their enrollment every five years. Revalidation involves completion of the enrollment form for Nursing Homes, Intermediate Care Facilities and Case Management Providers.
You can save time and money by coordinating your New York State Medicaid revalidation with Medicare, another state's Medicaid program or CHIP Program. If you revalidate with New York within 12 months of your Medicare/state /CHIP enrollment, the New York application fee will be waived.
The Revalidation process for these providers has begun. Revalidation letters have been mailed to facilities and providers actively submitting claims to Medicaid. Find out more about Revalidation by clicking on the links below.
Click here for the Intermediate Care Facility Enrollment Form and Instructions
Clickhere for the Case Management Providers Enrollment Form and Instructions
Medicaid Pharmacy Prior Authorization Programs Update
On April 22, 2015, the New York State Medicaid Drug Utilization Review (DUR) Board recommended changes to the Medicaid pharmacy prior authorization programs. The Commissioner of Health has reviewed the recommendations of the Board and has approved changes to the Preferred Drug Program (PDP) within the fee-for-service (FFS) pharmacy program. Effective June 25, 2015, prior authorization (PA) requirements will change for some drugs in the following PDP classes:
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) - Prescription
- Angiotensin Converting Enzyme Inhibitors (ACEIs)
- Niacin Derivatives
- Triglyceride Lowering Agents
- Central Nervous System (CNS) Stimulants
- Multiple Sclerosis Agents
- Anti-Virals - Topical
- Steroids, Topical - High Potency
- Glucagon-like Peptide-1 (GLP-1) Agonists
- Anticoagulants - Oral
- Antibiotic/Steroids - Ophthalmic
- Urinary Tract Antispasmodics
- Anticholinergics/COPD Agents
- Beta2 Adrenergic Agents - Inhaled Long-Acting
For more detailed information on the above DURB recommendations, please refer to the meeting summary at: http://www.health.ny.gov/health_care/medicaid/program/dur/meetings/2015/04/summary_durb.pdf.
Please note that PA requirements are not dependent on the date a prescription is written. New prescriptions and refills on existing prescriptions require PA even if the prescription was written before the date the drug was determined to require PA.
The following is a link to the most up-to-date information on the Medicaid FFS Pharmacy PA programs. This document contains a full listing of drugs subject to PDP, Clinical Drug Review Program (CDRP), DUR Program, Brand Less than Generic program (BLTG), Dose Optimization Program and the Mandatory Generic Drug Program (MGDP): https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf.
To obtain a PA, please call the prior authorization 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 PA.
Medicaid enrolled prescribers with an active e-PACES account can initiate PA requests through the web-based application PAXpress(®). The website for PAXpress is https://paxpress.nypa.hidinc.com/.
Origin Codes for New York State Fee-for-Service Medicaid Claims for Valid Prescriptions Dispensed When Not Written on Official NYS Prescription Forms
New York State allows e-prescribing, as well as written prescriptions when issued on an Official New York State Prescription form. Both formats must conform to all State Education Rules and Public Health Law requirements. When submitting claims for prescriptions written on an Official New York State Prescription form, the serialized number from the Official Prescription MUST be used.
In specific situations, State Education Law allows the dispensing of prescription drugs and/or supplies when not written on Official New York State Prescription Forms.
The table below lists some of the specific situations along with the applicable NYS Medicaid required codes to be entered in NCPDP field 454-EK in lieu of the Prescription Serial Number:
|99999999||Oral prescriptions and products dispensed pursuant to a non-patient specific order*|
|DDDDDDDD||Prescriptions dispensed as Medically Necessary during a Declared State of Emergency (excluding controlled substances)|
|EEEEEEEE||Prescriptions submitted electronically (computer to computer)**|
|NNNNNNNN||Prescriptions for nursing home patients (excluding controlled substances) in
accordance with written procedures approved by the medical or other
authorized board of the facility.
|SSSSSSSS||Fiscal orders for supplies|
|TTTTTTTT||Transfer prescriptions (traditional, intra-chain, file buys)***|
|ZZZZZZZZ|| Prescriptions written by out-of-state prescribers or by prescribers within a
federal institution (e.g., US Department of Veterans Affairs) or Indian
* Products dispensed pursuant to a non-patient specific order may include, but are not limited to, emergency contraceptives (e.g., Plan B.)
** Electronically submitted prescriptions that do not transmit properly or default to a facsimile must conform to the requirements of the New York State Education Law at: http://www.op.nysed.gov/prof/pharm/pharmelectrans.htm.
*** Transfers are not allowed for controlled substances in New York State.
Prescriptions received by the pharmacy as a facsimile must be an original hard copy on the Official New York State Prescription Form that is manually signed by the prescriber, and that serial number must be used. Prescriptions for controlled substances that are submitted electronically but fail transmission MAY NOT default to facsimile.
For questions on this billing requirement, providers may contact the eMedNY Call Center at (800) 343-9000.
New York Prescription Saver Program Eliminated Effective May 31, 2015
The New York State budget for fiscal year 2015-2016 which was approved on April 1, 2015, eliminated the New York Prescription Saver Program (NYPS) as of June 1, 2015.
- Effective immediately, new applications for both members and providers will no longer be accepted.
- A message about the program elimination is posted on the NYPS website.
- The NYPS website on-line application process has been disabled.
- Existing members may continue utilizing the program until May 31, 2015.
- All claims transactions will receive the following message: On 5/31/15 NYPS claims processing ends. Reversals end 6/30/15.
- Members should reach out to the New York State Office for the Aging local Health Insurance Information Counseling and Assistance Program (HIICAP) counselor to inquire what other discount programs may be available to them.
If you have questions, please contact the NYPS Provider Helpline at 1-800-785-4922.
OPRA Prescription Requirements for Unlicensed Residents, Interns and Foreign Physicians in Training
In December 2013, New York State (NYS) Medicaid issued a Special Edition (Vol.29, No.13) of the Medicaid Update to provide enrollment requirements and guidance for all Ordering, Prescribing, Referring, and Attending (OPRA) servicing/billing providers.
The purpose of this article is to provide a reminder regarding OPRA prescription requirements for unlicensed residents, interns and foreign physicians in training.
- NYS Medicaid recognizes prescriptions written by providers legally authorized to prescribe per NY Education Law, Article 131, Section 6526, and 10 NYCRR 80.75(e). This includes unlicensed residents, interns and foreign physicians in training programs, under the supervision of a NY State Medicaid enrolled physician.
- In accordance with NY Education Law, NYS Medicaid does NOT require the name and signature of the supervising physician to be included on the prescription. However, in order to enable billing by the dispensing pharmacy, prescriptions written by unlicensed residents must include the NPI of the supervising/attending physician who is enrolled in Medicaid (see option 2 below regarding billing requirements).
- NYS Medicaid only enrolls licensed providers. As a result, unlicensed residents, interns or foreign physicians in training programs are not eligible for enrollment as NYS Medicaid providers.
- Effective January 2014, NYS fee-for-service Medicaid implemented claims editing that enforced the OPRA requirement for healthcare professionals, practice managers, facility administrators, and servicing/billing providers. Therefore, pharmacy claims for services ordered by unlicensed residents, interns and foreign physicians in training programs reject when initially submitted for payment. The following two (2) options continue to be available to pharmacies, to enable payment:
1. Resubmit the claim, using the National Provider Identifier (NPI) of the enrolled NYS Medicaid provider (the intern or resident's supervising physician).
2. In the event the NPI number of the supervising physician cannot be obtained or the pharmacy's billing system is limited to submitting only one prescriber NPI number, then use the urgent/emergency override option (outlined below).
Directions for Urgent/Emergency Override:
If you have a prescription written by an unlicensed resident, intern or foreign physician in a training program you will receive a reject code of "56" via NCPDP transaction stating the provider has a non-matched Prescriber ID listed in NCPDP field number 511 -FB.
In the case of claims for items prescribed by unlicensed residents, interns or foreign physicians in training programs, pharmacies are allowed to provide the medication and receive reimbursement by resubmitting the claim using the following emergency override procedure:
- In the Reason for Service Code Field (439-E4) also known as the Drug Utilization Conflict Field - enter "PN" (Prescriber Consultation)
- In the Result of Service Code Field (441 -E6) - enter one of the following applicable values (1 A, 1 B, 1 C, 1 D, 1 E, 1 F, 1 G, 1 H, 1 J, 1K, 2A, 2B, 3A, 3B, 3C, 3D, 3E, 3F, 3G, 3H, 3J, 3K, 3M, 3N, or 4A)
- In the Submission Clarification Code Field (420-DK) also known as the Drug Prescription Override Field - enter "02" (Other Override)
Contact the eMedNY Call Center at (800) 343-9000 for questions regarding this billing requirement.
New York State Medicaid Fee-for-Service Program Pharmacists as Immunizers Fact Sheet (Updated 5-14-15)
Administration of select vaccines by qualified pharmacists employed by, or under contract with, Medicaid enrolled pharmacies is reimbursable under NYS Medicaid.
NY Education Law Sections 6527, 6801, 6909, and regulation 8 NYCRR Section 63.9 permits licensed pharmacists who obtain additional certification to administer the following vaccines: Influenza, pneumococcal and meningococcal vaccines when administered to patients 18 or older pursuant to a patient-specific or non- patient specific order; and Zoster vaccines when administered to patients 50 or older pursuant to a patient- specific order.
The following conditions apply:
- Only Medicaid enrolled pharmacies that employ or contract with NYS certified pharmacists to administer vaccines will receive reimbursement for immunization services and products. Pharmacy interns cannot administer immunizations in New York State.
- Services must be provided and documented in accordance to NYS Department of Education laws and regulations. Visit http://www.op.nysed.gov/prof/pharm/pharmimmunizations.htm for additional information.
- Pharmacies will only be able to bill for Medicaid fee-for-service non-dual enrollees. Medicaid managed care enrollees will continue to access immunization services through their health plans. Dual eligible enrollees will continue to access immunization services through Medicare.
- Reimbursement for influenza, pneumococcal and meningococcal vaccines will be based on a patient specific order or non-patient specific order. Reimbursement for zoster (shingles) vaccine is based on a patient specific order. These orders must be kept on file at the pharmacy. The ordering prescriber's NPI is required on the claim for the claim to be paid.
- Consistent with Medicaid immunization policy, for administration of vaccines ages 19 and over, pharmacies will bill the administration and acquisition cost of the vaccine using the appropriate procedure codes listed below. Please note that NDCs are not to be used for billing the vaccine product. Reimbursement for the product will be made at no more than the actual acquisition cost to the pharmacy. No dispensing fee or enrollee co-payment applies. Pharmacies will bill with a quantity of "1" and a day supply of "1".
- Billing Instructions for 19 years of age and older: Providers must submit via NCPDP D.0, in the Claim Segment field 436-E1 (Product/Service ID Qualifier), a value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a Procedure code. Lastly, in field 407-D7 (Product/Service ID), enter the Procedure code. Providers may submit up to 4 claim lines with one transaction. For example, providers may submit one claim line with the Procedure code 90656 (Influenza Virus Vaccine), and another claim line for Procedure code 90471 (Immunization Administration through 19 years of age and older). For administration (ages 19 and older) of multiple vaccines on the same date, code 90471 should be used for the first vaccine and 90472 for ANY other vaccines administered on that day. One line will be billed for 90472 indicating the additional number of vaccines administered (insert 1 or 2).
- Vaccines for individuals under the age of 19 are provided free of charge by the Vaccines for Children (VFC) program. Medicaid WILL NOT reimburse providers for vaccines for individuals under the age of 19 when available through the VFC program. For reimbursement purposes, the administration of the components of a combination vaccine will continue to be considered as one vaccine administration.
- Providers have an obligation to participate in VFC if they want to offer vaccinations to patients less than 19 years of age. Although pharmacies are not required to join the VFC program when limiting their vaccine administrations to beneficiaries 19 and older, please remember that during times of flu season, the Governor often issues an executive order allowing pharmacies to immunize patients less than 19 years of age. Vaccine administration for the VFC population is at an enhanced reimbursement fee of $17.85. By not enrolling in the VFC program, these pharmacies will not be able to administer to this population.
- VFC Billing Instructions though 18 years of age: Providers must submit via NCPDP D.0, in the Claim Segment field 436-E1 (Product/Service ID Qualifier), a value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a Procedure Code. Lastly, in field 407-D7 (Product/Service ID), enter the Procedure Code. Providers may submit up to 4 claim lines with one transaction. For example, providers may submit one claim line with the Procedure Code 90656 (Influenza Virus Vaccine), and another claim line for Procedure Code 90460 (VFC Immunization Administration through 18 years of age). For administration (through 18 years of age) of multiple VFC vaccines on the same date, code 90460 should be used for each vaccine administered.
The following procedure codes should be billed for pharmacist administration of select influenza, pneumococcal and meningococcal vaccines for age 18 and over, and zoster for age 50 and over:
|Procedure Code||Procedure Description|
|90620||Meningococcal recombinant protein and outer membrane vesicle
vaccine, Serogroup B, 2 dose schedule, for intramuscular use
|90621||Meningococcal recombinant lipoprotein vaccine, Serogroup B, 2 or 3 dose schedule, for intramuscular use|
|90656||Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years of age and above, for intramuscular use|
|90658||Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use|
|90661||Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use|
|90670||Pneumococcal conjugate vaccine, 13-valent, for intramuscular use|
|90672||Influenza virus vaccine, quadrivalent, live, for intranasal use in individuals 2 years of age through 49|
|90673||Influenza virus vaccine, trivalent, derived from recombinant DNA, preservative free, for intramuscular use for 18 years through 49 years for use in patients with an egg allergy. (The use in patients over the age of 50 is currently pending FDA approval, so eMedNY would indicate a maximum age of 49.|
|90686||Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use|
|90688||Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, with preservative, for intramuscular use|
|90732||Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years of age or older, for subcutaneous or intramuscular use|
|90733||Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use, age 2 years of age and older|
|90734||Meningococcal conjugate vaccine, Serogroups A,C,Y and W-135 (trivalent), for intramuscular use, age 11 through 55|
|90736||Zoster (shingles) Vaccine, live, for subcutaneous injection, age 50 and older|
|90460||Immunization administration through 18 years of Age via Any Route of Administration with Counseling; First or Only Component of Each Vaccine or Toxoid Administered (to be used by VFC enrolled pharmacies when administering vaccines obtained from VFC Program) $17.85|
|90471||Immunization administration ages 19 and older (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) $13.23|
|90472||Immunization administration ages 19 and older (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure) $13.23|
|90473||Immunization administration ages 19 and older of seasonal influenza intranasal vaccine $8.57|
NOTE: The maximum fees for vaccine drugs are adjusted periodically by the State to reflect the estimated acquisition cost. Insert acquisition cost per dose in amount charged field on claim form.
For VFC enrollment information, go to:
Questions regarding Medicaid reimbursement of immunizations may be directed to the Medicaid Pharmacy Program at 518 486-3209 or PPNO@health.ny.gov
Additional information on influenza can be found at NYS Department of Health's website at http://www.health.ny.gov/diseases/communicable/influenza/
CDC vaccine and immunization information can be found at http://www.cdc.gov/vaccines/
New York State Medicaid Managed Care Pharmacy Benefit Information Website Update
The New York State Department of Health in partnership with the State University of New York at Stony Brook continue to add new drug/drug categories to the New York State Medicaid Managed Care Pharmacy Benefit Information Website. The most recent update that occurred in April 2015, includes the addition of two new categories, Smoking Cessation and Drugs to Treat Chemical Dependence 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.
Policy and Billing Guidance
Revised New York State Medicaid Requirements for Home Health Providers and Verification Organizations
In accordance with Chapter 59 of the Laws of 2011, as amended in 2014, certain providers of home health services that exceed $15 million in Medicaid fee-for-service and/or Medicaid managed care reimbursements are required to utilize a Verification Organization (VO) to perform a pre-claim review. The VO must verify the home health services within a claim or encounter collected from Electronic Visit Verification (EVV) prior to submission of the claim or encounter to the Department of Health (DOH) or to a managed care provider.
The Office of the Medicaid Inspector General (OMIG) has identified the participating providers that are required to utilize a VO. Those providers required to participate will be notified by the OMIG by certified letter. Only providers that receive notification from OMIG are required to have their services verified by a VO. If you have any questions regarding your status under the amended law please contact OMIG at (518) 402-1470.
Providers requiring a VO must select their VO from the OMIG and DOH joint list of approved VOs, which can be found on the OMIG's website at http://omig.ny.gov under the Resources tab. Follow the Verification Organizations link. Please note that the VO you select does not have to be the same vendor you utilize for your EVV services.
Additional information and resources related to the law can be found on the OMIG's website at http://omig.ny.gov under the Resources tab. Follow the Home Health Requirements and/or Questions and Answers links.
Medicaid Policy Loss of Records Due to Unforeseen Event
This article supercedes the December 2012 Medicaid Update article
Federal law and State regulations require all Medicaid providers to maintain records necessary to fully disclose the extent of services, care, and supplies provided to Medicaid enrollees. This is stated in Title 18 of the New York Codes Rules and Regulations at Section 504.3:
By enrolling the provider agrees:
- (a) To prepare and maintain contemporaneous records demonstrating its right to receive payment under the Medicaid program and to keep for a period of six years from the date the care, services or supplies were furnished, all records necessary to disclose the nature and extent of services furnished and all information regarding claims for payment submitted by, or on behalf of, the provider and to furnish such records and information, upon request.
Other record-keeping requirements for providers can be found in the Provider Policy Manuals located online at:
Providers whose records are unexpectedly damaged, lost, or destroyed are required to notify, immediately upon discovery of the loss, the Self-Disclosure Unit of the New York State Office of the Medicaid Inspector General (OMIG).
This self-reporting notification must include: specific details of the event causing the loss, destruction or damage to records, the type of required records lost, destructed or damaged, the date/s of service of the records, documents/photographs substantiating damaged records and any efforts made to remediate/mitigate the damaged records. Other evidence of loss, e.g., police reports, must accompany the self-reporting notification.
To submit a self-disclosure or request assistance in preparing a submission, you may contact the Self-Disclosure Unit via electronic mail or the postal service:
The Office of the Medicaid Inspector General
Attention: Self-Disclosure Unit
800 North Pearl Street
Albany, NY 12204
Electronic mail: SelfDisclosures@omig.ny.gov
Providers must also notify any other State or local regulatory agency of their loss, damage or destruction as required by those regulatory agencies.
PLEASE NOTE that in the event of an audit for the time period in which the loss, destruction, or damage occurred, OMIG will evaluate, on a case-by-case basis, whether there are mitigating circumstances for missing or damaged documents.
Reporting of the National Drug Code (NDC) is Required for all Physican Administered Drugs Billed to the Ambulatory Patient Group (APG) Fee ScheduleEnforcement Begins July 1, 2015
Beginning July 1, 2015, the eMedNY billing system will begin enforcing the payment policy that requires providers to report the NDC for the APG fee schedule drugs listed below (see page 36 of the APG Provider Manual). If one of the following physician administered drugs billed under APGs does not include an NDC the line will not pay. However, drugs obtained at the 340B price, indicated by the UD modifier, do not require the NDC for the line to pay.
|HCPCS Code||HCPCS Code Description||HCPS Code||HCPCS Code Description||HCPCS Code||HCPCS Code Description|
|J0129||Abatacept Injection||J1459||Inj IVIG privigen 500 mg||J3489||Injection, zoledronic acid|
|J0178||Aflibercept Injection||J1561||Gamunex-C/Gammaked||J9000||Doxorubicin HCL Injection|
|J0475||Baclofen 10 MG Injection||J1568||Octagam Injection||J9041||Bortezcmib Injection|
|J0490||Belimumab Injection||J1569||Gammagard liquid Injection||J9047||Injection, carfilzomib|
|J0583||Bivalirudin||J1572||Flebogamma Injection||J9179||Eribulin mesylate injection|
|J0592||Buprenorphine hydrochloride||J1745||Infliximab injection||J9201||Gemcitabine hcl injection|
|J0638||Canakinumab injection||J2315||Inj, Naltrexone, Depot Form,1mg||J9306||Injection, pertuzumab|
|J0894||Decitabine injection||J2323||Natalizumab injection||J9315||Romidepsin injection|
|J1050||Medroxyprogesterone acetate||J2353||Octreotide injection, depot||Q2049||Imported lipodox inj|
|J1453||Fosaprepitant injection||J2997||Alteplase recombinant||S4993||Contraceptive pills for bc|
- Note, all APG fee schedule drugs (excluding J0592) also require providers to code the number of units and acquisition cost in order for the claim line to pay.
Questions regarding Medicaid FFS policy should be directed to the Division of Program Development and Management at (518) 473-2160. Billing procedure questions should be directed to 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 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: email@example.com.
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.