New York State Medicaid Update - July 2016 Volume 32 - Number 7

In this issue …

Breastfeeding Grand Rounds: Building a Continuum of Care to Support Exclusive Breastfeeding in New York State

Breastfeeding Grand Rounds (BFGR) is a free, annual webcast sponsored by the University at Albany School of Public Health in partnership with the New York State Department of Health. The program draws upon the expertise and experiences of health professionals working in the breastfeeding field, to increase the viewer’s knowledge and enhance breastfeeding practices. BFGR 2016 will focus on the importance of consistent education and infant feeding messages throughout motherhood, from preconception to postpartum, to help mothers achieve their breastfeeding goals.

Breastfeeding is a public health issue, not a lifestyle choice. The risks associated with breastfeeding attrition are well documented. Children and mothers who do not breastfeed are at increased risk of infections and chronic diseases. Despite the high percentage of breastfeeding initiation in New York, only a small percentage of mothers breastfeed exclusively for six months, as recommended by The American Academy of Pediatrics, The American College of Obstetricians and Gynecologists, The World Health Organization and many other leaders in child and maternal health.

The viewing audience for this webcast, which is intended for healthcare professionals and paraprofessionals, will learn about three major strategies underway in New York State to change health care practices and increase breastfeeding duration and rates of exclusive breastfeeding. The panelists will share strategies, challenges, and best practices to inspire the viewer to adopt the lessons and strategies to enhance breastfeeding education, care and support services.

“Breastfeeding Grand Rounds: Building a Continuum of Care to Support Exclusive Breastfeeding in New York State” will air on August 4, 2016 from 8:30 AM – 10:30 AM. For more information please visit

New York Medicaid EHR Incentive Program Update

The New York 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 $783 million in incentive funds have been distributed within 24,253 payments to New York State Medicaid providers.


Million Paid

Are you eligible? For more information, visit

NEW Certified Health IT Product List

The Office of the National Coordinator has launched a new Certified Health IT Product List (CHPL) at All currently certified 2014 Edition products along with new 2015 Edition products are listed on the new CHPL site. Providers must have a complete, certified EHR system in order to participate in the EHR Incentive Program.


Did you know that 2016 is the last year for eligible professionals to begin participation? Sign up for our live webinars to learn about the NY Medicaid EHR Incentive Program. Dates are available on our Upcoming Event Calendar.

MEIPASS Availability

As of July 1, 2016 NY Medicaid EHR Incentive Program Administrative Support Service (MEIPASS) was closed due to important maintenance being performed on the system. It is anticipated that MEIPASS will reopen in early fourth quarter of calendar year 2016. Announcements will be made via LISTSERV and the program website. Program support will continue to be available by phone at 877-646-5410.

Questions? Contact for program clarifications and details.

Payment Policy for Global Surgery Periods: Reminder

The purpose of this article is to remind providers of fee-for-service Medicaid payment rules for global surgery periods, also known as follow-up days or post-operative periods. New York State Medicaid follows Medicare rules on billing and payment during global surgery periods. Medicare’s March 2015 guidance on global surgery periods is available on the Centers for Medicare and Medicaid Services website. Global surgery edits have been developed and are being phased in.

Global surgery includes all necessary services normally furnished by a surgeon before, during, and after a procedure. New York State Medicaid payment for the surgical procedure includes the pre-operative, intra-operative, and post-operative services normally performed by the practitioner. Global surgery days, or follow-up days (f/u days), are identified on each practitioner's fee schedule. For procedures with 10 and 90-day follow-up periods, all routine services related to the surgery are included in payment for the procedure. There may be instances when evaluation and management services, unrelated to the original procedure, may occur during the post-operative period. In these instances, providers may select the appropriate modifier to include on the claim; however, this should not be routine practice.

Minor procedures and endoscopies may not have a follow-up period (indicated by a "0" in the f/u days column on the practitioner fee schedule). When the evaluation and management service that leads to the decision to provide the minor procedure occurs on the same day as the procedure, providers should bill Medicaid only for the procedure. There may be instances when the patient's condition requires a significant, separately identifiable evaluation and management service, above and beyond the usual care. In these instances, providers may select the appropriate modifier to include on the claim; however, this should not be routine practice.

For questions related to Medicaid fee-for-service policy, please contact the Office of Health Insurance Programs, Division of Program Development and Management at (518) 473–2160 . Billing questions for individuals enrolled in Medicaid managed care plans should be directed to the individual enrollee’s Medicaid managed care plan.

Change to Medicaid Reimbursement of Medicare Part C Copayment and Coinsurance Liabilities

Effective April 1, 2016, an amendment to New York State Social Services Law* changes Medicaid reimbursement of Medicare Part C (Medicare Advantage or Medicare managed care) copayment and/or co-insurance liabilities for services provided to dually eligible Medicaid members. Dually eligible members are those individuals having both Medicare and Medicaid coverage.

Presently the Medicaid program pays the full copayment or coinsurance amounts for Medicare Part C claims. Retroactively to April 1, 2016, Medicaid will reimburse at the rate of eighty-five percent (85%) of the Medicare Part C copayment or coinsurance amount.

The Department is in the process of making the necessary eMedNY System changes to enable the implementation of the new payment policy. Implementation will be applied retroactively pending system support. Paid claims will then be adjusted automatically to reflect the new cost-sharing limits.

This change will affect institutional claims and professional claims when submitting claims for Medicaid reimbursement of a Medicare Part C copayment or coinsurance. This change will also apply to pharmacy items when submitted as a professional claim.

There is no change to the current reimbursement methodology of Medicare Part C copayment/coinsurance amounts for ambulance providers and psychologists. Medicaid will continue to reimburse these providers the full Medicare Part C copayment/coinsurance amounts.

Note: A provider of a Medicare Part C benefit cannot seek to recover any copayment, or coinsurance amount from Medicare/Medicaid dually eligible individuals. The provider is required to accept the Medicare Part C health plan payment and any Medicaid payment as payment in full for the service. The member may not be billed for any Medicare Part C copayment/coinsurance amount that is not reimbursed by Medicaid.

Providers will be notified prior to claim adjustments being made by a future Medicaid Update article.

Questions? Please contact the Office of Health Insurance Programs, Division of Program Development and Management at (518) 473–2160.

* A new subparagraph (iv) was added to paragraph (d) of subdivision 1 of Section 367-a of the Social Services Law.

New Legislation Enacted to Limit Initial Opioid Prescribing to a Seven Day Supply for Acute Pain

To further reduce overprescribing of opioid medications, effective July 22, 2016, initial opioid prescribing for acute pain is limited to a seven (7) day supply per New York State Public Health Law Section 3331, 5. (b), (c). A practitioner may not initially prescribe more than a 7-day supply of an opioid medication for acute pain. Acute pain is defined as pain, whether resulting from disease, accidental or intentional trauma, or other cause, that the practitioner reasonably expects to last only a short period of time. This rule shall not include prescribing for chronic pain, pain being treated as a part of cancer care, hospice or other end-of-life care, or pain being treated as part of palliative care practices. Upon any subsequent consultations for the same pain, the practitioner may issue, in accordance with existing rules and regulations, any appropriate renewal, refill, or new prescription for an opioid.

The Department of Health will communicate a date in the near future when this will be systematically enforced by the Medicaid Fee-for-Service Program. The following procedure is being put in place until such time that the Department is able to implement an automated solution to exempt copayments for such subsequent opioid prescriptions.

If a prescriber initiates a subsequent prescription for the same pain medication within 30 days of the initial 7-day supply, and the pharmacist is notified and/or confirms this upon reviewing the patient’s prescription history or utilizing ProDUR editing, the following may be used to exempt the copayment for the subsequent prescription.

Although pharmacists should continue to use all of the tools at their disposal when dispensing opioid prescriptions, pharmacists are not required to verify with the prescriber whether an opioid prescription written for greater than a 7-day supply is in accordance with the above-referenced statutory requirements. Pharmacists may continue to dispense opioids as prescribed, consistent with current laws, regulations, and Medicaid policies.

For guidance regarding a pharmacist's ability to add/change information on a controlled substance prescription, see 10 NYCRR 80.67 and 80.69 or

Additional information on opioids and this legislation can be found at the Bureau of Narcotic Enforcement website at: or by contacting the Bureau of Narcotic Enforcement at 1-866-811-7957.

For billing questions please contact the eMedNY Call Center at 1-800-343-9000.

Questions specific to Medicaid Fee-For-Service policy can be directed to or by calling 518-486-3209.

Matching Origin Codes to Correct Prescription Serial Number Within Medicaid Fee-For-Service (FFS)

Reminder: The appropriate serial number is required when billing NY State Medicaid FFS. It has been noticed that many pharmacies are billing with incorrect information; there has been and continue to be audits on these fields submitted by pharmacies. Please utilize the following chart to make the serial number determination:

1ONYSRxWritten - Prescriptions prescribed in NY will be on Official New York Prescription forms with a designated serial number to use.
1ZZZZZZZZWritten - Prescriptions prescribed from out-of-state providers or by prescribers within a federal institution (e.g., US Department of Veterans Affairs) or Indian Reservation.
299999999Telephone - Prescriptions obtained via oral instructions or interactive voice response using a telephone.
3EEEEEEEEElectronic - Prescriptions obtained via SCRIPT or HL7 standard transactions, or electronically within closed systems.*
4ONYSRxFacsimile – ONYSRx Prescriptions obtained via fax machine transmission.
4NNNNNNNNFacsimile - Prescriptions obtained via fax machine transmission for nursing home patients (excluding controlled substances) in accordance with written procedures approved by the medical or other authorized board of the facility.
5TTTTTTTTPharmacy - this value is used to cover any situation where a new Rx number needs to be created from an existing valid prescription such as traditional transfers, intra-chain transfers, file buys, software upgrades/migration, and any reason necessary to give it a new number.**
599999999Pharmacy - this value is appropriate for "Pharmacy dispensing" when applicable such as non-patient specific orders, BTC (behind the counter), Plan B, established protocols, etc.
5DDDDDDDDPharmacy - this value is used to cover prescriptions dispensed as Medically Necessary during a Declared State of Emergency (excluding controlled substances).

*Electronically transmitted prescriptions that fail and come to the pharmacy as a facsimile are invalid. Reference:

** Remember to use original date prescribed as "written date" when processing prescription transfers. Transfers are not allowed for controlled substances in New York State.

For questions on this billing requirement, providers may contact the eMedNY Call Center at (800) 343–9000.

Medicaid Fee-For-Service (FFS) Reimbursement of Medicare Part B Pharmacy Claims: Notification of Automatic Adjustments of Previously Paid Claims

As a result of a change in reimbursement methodology for pharmacy claims for Medicare/Medicaid dually eligible individuals, previously paid claims for the dates of service July 1, 2015 through April 20, 2016 that were not billed in accordance with the mandated changes are being adjusted automatically to reflect the new cost sharing limits. Please see page 21 of the April 2016 Medicaid Update for specific details.

The affected claims have been reprocessed in cycle 2030, check date 07/18/16, release date 08/03/16.

The 835 Remittance Advice for the adjustments will return Claim Adjustment Reason Code "A1" - (Claim/ Service Denied), Remittance Remark Code "N421" -(Claim Payment was the result of a Payer's Retroactive Adjustment Due to a Review Organization Decision), Claim Adjustment Group Code- "OA" - (Other Adjustments), Healthcare Claim Status Code- "46"-(Internal Audit Review).

Please contact the eMedNY Call Center at(800) 343–9000 for questions regarding this billing requirement.

Provider Directory

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.

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: and

Need to change your address? Does your enrollment file need to be updated because you have 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.

Comments and Suggestions Regarding This Publication?
Please contact the editor, Amy Siegfried, at