New York State Medicaid Update - December 2016 Volume 32 - Number 12

In this issue …

Attention Pharmacists and Prescribers: Emergency Services Only Coverage

Effective December 22, 2016, the New York State Department of Health (Department) will implement editing changes around the Submission Clarification Code (SCC) used to override denied claims for drugs not covered for members whose Medicaid benefit is "Emergency Services Only". Claims submitted for drugs not covered will be denied with the response message "NDC not covered" when utilizing a SCC not authorized by the Department.

  • Medicaid fee-for-service (FFS) coverage is available for a limited list of drugs for beneficiaries of "Emergency Services Only" coverage, category of eligibility (COE) 07.
  • Coverage criteria based on federal regulations [42 CFR 440.255(c)], and a list of covered medications for Emergency Services Only can be found at:
  • Medications not on the list will reject with the response message "NDC not covered".
  • Any and all exception/override requests for drugs systematically denied must be submitted via a letter of medical necessity by the prescriber and formally approved by the Department. These requests include Health Insurance Portability and Accountability Act Protected Health Information (HIPAA PHI) and should be encrypted when sent by email.
  • Pharmacies should not attempt to override these rejections prior to obtaining Department approval. All non-approved overrides are subject to recovery of payment.


  • Pharmacies with current written Department authorization have been contacted; however, if your Emergency Medicaid patient has been previously reviewed and medication(s) were authorized by the Department in writing, and your pharmacy has not been contacted, please call 518-486-3209 for further instruction.
  • Claims that have been previously paid without the Department's authorization are subject to audit and recovery.
  • For non-covered medications – pharmacies and prescribers may seek alternate funding through patient assistance programs or discount card programs available to the general public.

Reminder from the Office of the Medicaid Inspector General (OMIG) Regarding the Managed Care Annual Program Integrity Report

This is a reminder to all Managed Care Organizations subject to the requirements of the March 1, 2014 Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan Model Contract that the 2016 Annual Program Integrity Report (Report) must be submitted between January 1, 2017 and January 31, 2017.

The Report will only be accepted electronically and must be submitted securely. Additional information, as well as a link to submit reports will be posted on OMIG's website under the 'Resources' tab on the homepage.

The Report form is on OMIG's website at:

Reporting Instructions may be accessed at:

Additional guidance can be found at:

Questions regarding the report may be directed to

New Legislation Regarding Emergency 5-Day Supply of Drugs used to Treat Substance Use Disorders in Medicaid Fee-for-Service (FFS) & Medicaid Managed Care

Effective January 1, 2017, Insurance Law section 3216 paragraph 31-a, requires insurance carriers to provide at least 5 days' coverage for emergencies, without prior authorization, for medications used to treat substance use disorders. This includes medication associated with the management of opioid withdrawal and/or stabilization as well as medication used for opioid overdose reversal. Additionally, no additional copayment or coinsurance shall be imposed on an insured who received an emergency supply of medication and then received up to a thirty-day supply of the same medication in the same thirty day period in which the emergency supply of medication was dispensed.

Medicaid Fee-for-Service (FFS)

A pharmacist can initiate an emergency 5-day supply of a non-preferred medication for the treatment of a substance use disorder by calling the clinical call center at 1-877-309-9493. The clinical call center is available 24 hours per day, 7 days per week.

To obtain FFS preferred medication listings and criteria see the following website, Medicaid FFS Preferred Drug List and Pharmacy Prior Authorization Programs at:

If a prescriber initiates a subsequent prescription for the same medication for the treatment of a substance use disorder within 30 days of the initial 5-day emergency 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:

This process will be utilized the Department is able to systematically address the exemptions of copayment(s) on eligible subsequent prescription(s) within the 30 day period.

Medicaid Managed Care

Managed Care plans will develop and communicate their own processes/procedures to comply with this law.

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 $783 million in incentive funds have been distributed within 24,287 payments to New York State Medicaid providers.


Million Paid

Are you eligible? For more information, visit

Did You Know?

2016 is the last year that eligible professionals (EPs) may begin participation in the NY Medicaid EHR Incentive Program. An EP may receive up to $63,750 over the course of six years for the adoption and meaningful use of certified EHR technology. All adoption or meaningful use activities for payment year 2016 must be completed within the 2016 calendar year.

MEIPASS Availability

The NY Medicaid EHR Incentive Program Administrative Support Service (MEIPASS) is currently closed due to important maintenance being performed on the system for meaningful use attestations for payment year 2015 and beyond. Program support will continue to be available by phone at 877-646-5410.

We thank you for your patience. Launch of the new MEIPASS system has been delayed due to issues found during testing. We want to make sure that the system operates smoothly for the provider community and for our team at the Department of Health. Please sign up for our LISTSERV to receive notification about when we will be accepting attestations again.

Preparing to Attest

Visit to register for the program.

Verify your system is complete and certified at on the Certified Health IT Product List.

Utilize NY Medicaid EHR Incentive Program support services:

  • Numerator Request: EPs may request a summary of their Medicaid claims as guidance for calculating Medicaid patient volume.
  • Pre-validation: Individual and group EPs who have already determined their Medicaid patient volume may submit data to NY Medicaid prior to attesting.

Questions? Contact NY Medicaid EHR Incentive Program Support at

Need Assistance?

In addition to the NY Medicaid EHR Incentive Program Support Team, who can be reached via phone at 877-646-5410 or via email at, there are two Regional Extension Centers (RECs) available to assist you.

EPs in New York City can contact NYC REACH at 347-396-4888 or

EPs outside of New York City can contact NYeC at 646-619-6400 or

Questions? Contact for program clarifications and details.

NYS Medicaid Change in 340B Claim Identification Effective 04/01/2017

Federal law (42 USC 256b(a)(5)(A)(i)) prohibits duplicate discounts, such that drug manufacturers are not required to provide a discounted 340B price and a Medicaid drug rebate for the same drug. To prevent duplicate discounts from taking place, NYS Medicaid has been using claim level identifiers and the Health Resources and Services Administration's (HRSA) Medicaid Exclusion File, which provides information on 340B providers who are prescribing 340B drugs for Medicaid members.

Mandated use of claim level identifiers has been in effect for many years for medical claims (J-code drugs), and became effective on July 23, 2015 for National Council for Prescription Drug Programs (NCPDP) claims, as noted in the article titled "NYS Medicaid Fee-for-Service NCPDP D.0 Billing Changes for 340B Drug Claims" in the July 2015 Medicaid Update.

Effective April 1, 2017, the NYS Department of Health (Department) intends to change the way that it identifies 340B drugs for exclusion from rebates, by relying solely on the mandated 340B claim level identifiers. This decision is due to the questionable accuracy of the HRSA Medicaid Exclusion File, as well as discrepancies in reported Medicaid ID numbers & National Provider Identifiers (NPIs), all of which impact the State's ability to accurately identify when 340b drugs are dispensed for Medicaid members.

The table below summarizes the claim level reporting requirements:

Claim TypeFieldFee-For-Service (FFS)Managed Care (MCO)
NCPDP420-DK, Submission Clarification Code (SCC)2020
NCPDP423-DN, Basis of Cost Determination (BCD)08*none

* All Fee-For-Service (FFS) 340B claims must be submitted at acquisition cost, by invoice, inclusive of all discounts. Please note that a FFS NCPDP claim with a 20 SCC should have a corresponding 08 BCD.

340B claims submitted with a date of service on or after April 1, 2017 will only be excluded from the drug rebate invoicing process if submitted with the above-listed, NYS mandated 340B claim level identifiers. It is the responsibility of the 340B Covered Entity and their contracted pharmacies to correctly report claims filled with 340B stock for 340B-eligible patients to ensure rebates are not collected for these drugs. If a rebate is received by the Department for a drug obtained via the 340B program due to incorrect claim level identifiers, the 340B-covered entity will be responsible to reimburse the manufacturer the 340B discount.

Please note that the above NYS Medicaid billing process change does not negate the Covered Entity's responsibility for providing the Health Resources and Services Administration (HRSA) with any required information in relation to its determination on whether to use 340B drugs for Medicaid patients.

Billing questions regarding the FFS program should be directed to the eMedNY Call Center at(800) 343–9000 .

Billing questions regarding Managed Care plans should be directed to the plans.

FAQs on HRSA's 340B program, as well as information on how to ask additional questions, can be found on the HRSA website at:

Information on HRSA requirements when Covered Entities use 340B drugs for Medicaid patients can be found at the following site:

NYS Medicaid 340B policy questions can be sent to

Ordering/Prescribing/Referring (OPR) Providers Must Revalidate for Claims to be Paid

Federal regulation requires State Medicaid agencies to revalidate the enrollment of all providers every five years. For many providers Medicaid payment is contingent on the ordering/prescribing/referring (OPR) provider also revalidating their enrollment in Medicaid. OPR providers who do not comply with the revalidation requirement will be terminated from the Medicaid Program.

The NYS Department of Health has determined that many providers are at risk for not being paid for their services because the OPR provider has not complied with the revalidation requirement. Because this has the potential to result in significant non-payable claims for you/your facility, we urge you to reach out and encourage your OPR providers to revalidate their enrollment. Please remember to confirm that your OPR provider is enrolled before rendering service

The Claim Adjustment Reason Code for non-enrolled OPR provider on your 835 remittance will be:

B7 - This Provider was Not Certified/Eligible to be Paid For this Procedure/Service on this Date of Service.

If performing a claim status look for Claim Status Code 91 with Entity Code 1P.

The required revalidation form and instructions are available at The completed form must be mailed, with all required documentation and fee (if required), to the address provided on page 2 of the form. Questions should be addressed to the eMedNY Call Center at 800-343-9000, Option 2.

Public Health Emergency Response Network Pharmacy Program (PHERN PP)

A message from the New York City Department of Health and Mental Hygiene to community pharmacists in New York City.

As a community pharmacist, you are among the most accessible and trusted healthcare professionals in your community. We at the New York City Department of Health and Mental Hygiene (NYC DOHMH) recognize that you serve a critical role not only providing medications but also important health information to residents of your communities on a daily basis.

NYC DOHMH is very interested in working with community pharmacists to support them in preparing for and recovering from disasters and other emergencies. However, we currently have no mechanism to communicate effectively with the more than 2,000 independent community pharmacies in NYC.

To address this gap, NYC DOHMH created the Public Health Emergency Response Network Pharmacy Program (PHERN PP), a simple application that allows NYC pharmacies to quickly and easily "register" and provide pharmacy contact and other service information. This information will assist us in engaging in a productive, reciprocal exchange of information that is essential for effective emergency preparedness and response, and will enable us to better support you and your important work ensuring the health and well-being of all New Yorkers.

The registration process is simple and should only take five minutes. Go to and scroll down to select the PHERN Pharmacy Program. Questions about the program can be directed to Eric Medina, PHERN PP Coordinator, at

Thank you for supporting this important emergency preparedness initiative in NYC!

The Medicaid Update is a monthly publication of the New York State Department of Health.

Andrew M. Cuomo
State of New York

Howard A. Zucker, M.D., J.D.
New York State Department of Health

Jason A. Helgerson
Medicaid Director
Office of Health Insurance Programs