New York State Medicaid Update - May 2017 Volume 33 - Number 5

In this issue …

Coverage of Outpatient Clotting Factor for Managed Care Enrollees

Effective July 1, 2017, outpatient clotting factor products and associated services will be included in the Medicaid Managed Care (MMC) benefit package. This change applies to all MMC plans, including mainstream Medicaid Managed Care Plans (MMCP), HIV Special Needs Plans (HIV SNP) and Health and Recovery Plans (HARP).

Prior to the July 1, 2017 transition date, clotting factor products for plan enrollees were provided through Medicaid–enrolled pharmacies and clinics in all non–inpatient settings, including in the home, and were billed to Medicaid Fee–for–Service (FFS). Clotting factor products administered during an inpatient stay prior to the transition date were covered by the enrollee´s managed care plan.

After the transition date, plans will be responsible for providing and coordinating the coverage of all FDA–approved human plasma–derived clotting factors and recombinant clotting factors. There shall be no interruption in the provision of medically necessary clotting factor products and services because of this transition.

Responsibilities of Providers of Clotting Factor Products and Services

Providers of clotting factor products and services are responsible for coordinating with plans to develop an individualized care plan and patient–specific care management. Providers will submit claims to Plans for clotting factor products and associated services provided to Plan enrollees per the Plans´ billing guidelines.

Clotting factor guidelines and additional information can be found at the MRT 8401 link provided:

For questions regarding Medicaid Managed Care (MMC), providers should contact the enrollee´s MMC plan directly for implementation details.

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Medicaid Managed Care Encounter Reimbursement Process for Capitation Payments Recovered in Audit

The New York State Department of Health (NYSDOH) and the Office of the Medicaid Inspector General (OMIG) are responsible for the administration and oversight of the Medicaid program. In recent years, several situations of duplicate or overlapping Medicaid payments made on behalf of Medicaid Managed Care enrollees have been identified during audits. OMIG and NYSDOH have worked jointly to arrive at a process to address this issue that ensures the integrity of the Medicaid program while not placing an undue burden on the Managed Care Plans (Plans) and network providers.

The process established for reimbursing Plans for incurred costs following the issuance of a Final Audit Report where duplicate or overlapping payments are recovered is described below.

During the audit process, OMIG will identify and recover all inappropriately paid capitation payments, including those months with encounters, consistent with state laws, regulations and the Medicaid Managed Care Model Contract (Contract). The Plan may subsequently receive reimbursement for costs following the issuance of the Final Audit Report, and after the Plan has repaid all identified overpayments. When these conditions are met, NYSDOH will reimburse the Plan for costs incurred during the recovered capitation month. The reimbursement will be based on encounters which the Plan has successfully submitted to NYSDOH. Encounters not eligible for reimbursement include administratively denied encounters and encounters for which the Plan has already been reimbursed for the cost of services. The scenarios approved by the Centers for Medicare and Medicaid Services (CMS) where Plans may be reimbursed for services provided are outlined in the charts on the following pages.

This process will only be used for specified duplicate Medicaid payment scenarios and will be applied to audits that are currently open with dates of service after January 1, 2010, and future audits. Plans receiving retroactive disenrollment notifications from Local Departments of Social Services (LDSS) for the following disenrollment codes should refrain from voiding claims when there is encounter data present until these claims appear in an OMIG audit: code 3 (permanent resident nursing home); code 4 (foster care); code 5 (long–term acute care hospital); or code 13 (multiple client identification number – different plans). Where a Final Audit Report has been issued, this process will not be applied.

NYSDOH reimbursement procedure for costs incurred is as follows:

  • On a semi–annual basis, NYSDOH will receive Plan audit recovery information from OMIG. This information will be reviewed and matched to Plan–submitted and accepted header level encounter data, with a minimum six (6) months of runout from the applicable recovery period.
  • Upon completion of the data matching process, NYSDOH will share results with Plans to review for a period of 30 days prior to payment effectuation. In instances where a Plan may have discrepancies with NYSDOH calculated "lump sum" reimbursement amount, NYSDOH will develop a process to review the expenditure analysis with Plans. Plans will not be allowed to amend or submit encounter data which would alter the results of services provided. Note: encounter reimbursement audits post Encounter Intake System (EIS) implementation will take place after a validation of the data is complete.
  • Once the 30–day review period has expired, NYSDOH will initiate Plan specific reimbursements, based on a calculated summary of Plan encounter expenditures incurred. Payments will then be processed in subsequent Plan cycle remittance checks. Plans will be notified of the pending reimbursement amounts and supporting detail via a Plan specific remittance statement generated by NYSDOH.

Questions regarding enrollment or eligibility should be directed to NYSDOH at Questions or issues related to the OMIG audit process should be directed to OMIG at Questions or issues regarding NYSDOH reimbursement process should be directed to NYSDOH at

NYS Department of Health/NYS Office of Medicaid Inspector General Capitation Recovery Scenarios for Medicaid Managed Care (MMC) and Managed Long Term Care (MLTC) Will Reimburse Plan for Encounters

The recovery scenarios listed below describe scenarios whereby the capitation payment is recovered. In these scenarios, where the Managed Care Organization (MCO) provided a service and incurred cost during the period, the MCO would be reimbursed through a process developed by NYSDOH and OMIG. The Plan will only be reimbursed for encounters that were successfully submitted and appear in the Medicaid Data Warehouse (MDW).

Eligibility Recovery ScenarioNYSDOH/OMIG ActionPlan Encounter Reimbursement
Enrollee in Foster Care, not Eligible for Medicaid Managed Care (MMC) Capitation Payment Recovery Reimburse the plan for the cost of services provided/drugs dispensed during overlap period.
Enrollee has Permanent Residency in an Institution, Not Eligible for Managed Care (MMC)* Capitation Payment Recovery Reimburse the plan for the cost of services provided/drugs dispensed during overlap period.
Retroactive Enrollment into Managed Care (MMC, MLTC) Capitation Payment Recovery Reimburse the plan for the cost of services provided/drugs dispensed during overlap period.
Multiple CIN/Different Plans (MMC, MLTC) Capitation Payment Recovery from the Plan with Fewer Encounters Reimburse the plan with fewer encounters for the cost of services provided/drugs dispensed during the overlap period.
Multiple CIN/FFS (MMC, MLTC) Capitation Payment Recovery if there are fee–for–service (FFS) payments during the payment month and/or it is determined the enrollee was ineligible for Managed Care. Reimburse the plan for the cost of services provided/drugs dispensed during overlap period.

*Nursing home services became part of the Medicaid Managed Care benefit package on the following dates: 2/1/2015 in NYC; 4/1/15 in Nassau, Suffolk, and Westchester County, and 7/1/15 Rest of State.

NYS Department of Health/NYS Office of the Medicaid Inspector General Capitation Recovery Scenarios Will Not Reimburse Plan for Encounters

The recovery scenarios listed below are examples of instances where the capitation payment would be recovered and there would be no reimbursable encounters. The Plan should work with the OMIG auditor assigned to a particular project to ensure they have a complete understanding of the process for each audit.

Eligibility Recovery Scenario NYSDOH/OMIG Action Plan Encounter Reimbursement
Enrollee Deceased Capitation Payment Recovery Plan is entitled to the capitation payment for the month of death, but no encounter reimbursement for months following the month of death.
Enrollee Incarcerated Capitation Payment Recovery Plan is entitled to the capitation payment for the months the enrollee was incarcerated and released; any encounters during months where the individual was incarcerated for the entire payment month would not be reimbursed.
Third Party Coverage from Same Plan´s Commercial Product Capitation Payment Recovery No encounter reimbursement. The Plan´s commercial product is responsible for enrollee´s care, and the Plan should pursue payment for any encounters from their commercial product.
Moved out of state Capitation Payment Recovery No encounter reimbursement. Encounters would indicate enrollee was likely in the state for the month in question. The presence of encounters would render the capitation payment paid appropriate.
Multiple CIN/Same Plan Capitation Payment Recovery No encounter reimbursement, as the Plan is responsible for the enrollee´s care.
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Attention Managed Care Network Providers: Medicaid Provider Enrollment Requirement

Section 5005(b)(2) of the 21st Century Cures Act amended Section 1932(d) of the Social Security Act (SSA) and requires that effective January 1, 2018, all Medicaid Managed Care and Children´s Health Insurance Program providers must enroll with state Medicaid programs. The SSA requires that the enrollment include providing identifying information including name, specialty, date of birth, social security number, National Provider Identifier (NPI), federal taxpayer identification number, and the state license or certification number.

For example, if a physician currently participates in a network with a Medicaid managed care plan that provides services to, or orders, prescribes, or certifies eligibility for services for, individuals who are eligible for medical assistance, the physician must enroll with New York State Medicaid.

Common Enrollment Questions:

  • To check on your enrollment status, please call CSRA at 1–800–343–9000. Practitioners may also check the Enrolled Practitioners Search function at:
  • If you are already enrolled as a Medicaid fee–for–service (FFS) provider and are listed as active, you will not have to enroll again.
  • If at one time you were a FFS provider, and your enrollment has lapsed (no longer actively enrolled), you may be able to keep your original Provider Identification Number (PID), also known as MMIS ID, by reinstating.
  • Practitioners who do not wish to enroll as a Medicaid FFS billing provider may enroll as a non–billing, Ordering/Prescribing/Referring/Attending (OPRA) provider.
  • Enrollment in Medicaid FFS does not require providers to accept Medicaid FFS patients.

If you are not actively enrolled, please go to: and navigate to your provider type. Print the Instructions and the Enrollment form. At this website, you will also find a Provider Enrollment Guide, a How Do I Do It? Resource Guide, FAQs, and all forms related to enrollment in New York State Medicaid.

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Medicaid Coverage Discontinued for Topical Oxygen Wound Therapy (TOWT)

This article updates the November 2014 Medicaid Update article titled, "Topical Oxygen Wound Therapy (TOWT) Continues to be Covered Until Further Notice." Effective July 1, 2017, the New York State Medicaid program will no longer cover topical oxygen wound therapy (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 will continue to cover treatment for Medicaid fee–for–service (FFS) and Medicaid Managed Care (MMC) patients currently undergoing TOWT until their full course of treatment is complete.

HCPCS codes associated with TOWT are as follows:

  • A4575 – Topical oxygen chamber, disposable
  • E1390 – Oxygen concentrator, single delivery port
  • E0446* – Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories

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

For Medicaid FFS enrollees currently undergoing TOWT, code A4575 will now require prior approval for all instances in order to monitor completion of treatment. When all Medicaid FFS members have completed their current course of TOWT, the codes listed above will no longer be active in eMedNY.

Questions regarding Medicaid FFS should be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management at (518) 473–2160. Questions regarding Prior Approval should directed to the OHIP Bureau of Medical Review at (800) 342–3005. Questions regarding MMC reimbursement and/or documentation requirements should be directed to the enrollee´s MMC plan.

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Reminder: Free Online Opioid Prescriber Training Program Available Which Meets the Mandatory Prescriber Opioid Education Requirements in New York State

Prescribers licensed under Title Eight of the Education Law in New York to treat people and who have a Drug Enforcement Administration (DEA) registration to prescribe controlled substances, as well as medical residents who prescribe controlled substances under a facility DEA registration number, must complete at least three (3) hours of course work or training in pain management, palliative care and addiction. The course work or training must be completed by July 1, 2017, and once every three (3) years thereafter, pursuant to Public Health Law (PHL) §3309–a(3).

The course work or training may be live or online and must include the following eight (8) topics:

  1. New York State and federal requirements for prescribing controlled substances;
  2. Pain management;
  3. Appropriate prescribing;
  4. Managing acute pain;
  5. Palliative medicine;
  6. Prevention, screening and signs of addiction;
  7. Responses to abuse and addiction; and
  8. End–of–life care.

Specific guidance from the Bureau of Narcotic Enforcement related to the Mandatory Prescriber Opioid Education can be found at: Practitioners must notify the New York State Department of Health (NYSDOH) that they have completed the educational requirement by attesting through their Health Commerce Account. Information on how to do this is now available on the Bureau of Narcotic Enforcement website at:

Pursuant to the new requirements, development of an online Opioid Prescriber Training Program was established collaboratively with the State University of New York (SUNY) at Buffalo School of Pharmacy and Pharmaceutical Sciences and NYSDOH. The online program was developed through cooperative agreement number 5 U16 CE002614–03 with the Centers for Disease Control and Prevention (CDC) and NYSDOH. The content does not necessarily represent the official views of the CDC. The Opioid Prescriber Training Program is available at no charge to prescribers and is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education (CME) for practitioners. The program will cover all eight (8) topics required per legislation.

Prescribers must create an account to register for the Training Program and to receive a CME accreditation certificate. The online Opioid Prescriber Training Program is located on the SUNY Buffalo School of Pharmacy & Pharmaceutical Sciences Website at:

In addition to the online Opioid Prescriber Training Program, the New York State Medicaid Provider Education Program (NYSMPEP) provides on–site educational sessions for practitioners serving Medicaid members, as well as educational information resources. NYSMPEP was established with the goal to promote better health outcomes for all NYS Medicaid members by engaging practitioners with information on evidence based, unbiased pharmacotherapy. The NYSMPEP is a partnership between NYSDOH and the SUNY. Academic educators hold Doctorate of Pharmacy (PharmD) degrees and are trained to provide educational sessions to prescribers throughout New York. An educational session with a PharmD educator consists of either one–on–one sessions, small group sessions, or large group settings, such as a grand rounds platform. More information regarding the NYSMPEP and available resources is located at:

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NY Medicaid EHR Incentive Program Update

The NY Medicaid Electronic Health Records (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 $786 million in incentive funds have been distributed within 24,796 payments to New York State Medicaid providers.


Million Paid

Are you eligible? For more information, visit

MEIPASS Open for Meaningful Use

The NY Medicaid EHR Incentive Program Administrative Support Service (MEIPASS) is now open and is accepting attestations for 2015 and 2016 meaningful use (MU). The final deadlines have been extended and are listed below.

  • 2015 MU deadline: 6/30/17
  • 2016 MU deadline: 9/15/17


The New York Medicaid EHR Incentive Program website ( now has recorded video tutorials available for on–demand assistance. The interactive tutorials are instructor–led with step–by–step guidance to assist with completing your MU attestation. Visit the tutorials page here:, to access these videos.


The NY Medicaid EHR Incentive Program has several instructor–led webinars available on a variety of topics to assist in the MU attestation process. Webinars are offered at different times, including 7 am, to accommodate many schedules. Use the links below to register:

Preparing to Attest

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.

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Reminder: OPRA Prescription Requirements for Unlicensed Residents, Interns and Foreign Physicians in Training

As of March 25, 2011, Federal Rules and Regulations required that all ordering and referring physicians or other professionals providing services to Medicaid enrollees be enrolled as participating providers. In December 2013, the New York State Department of Health (NYSDOH) issued a Special Edition 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 only:

  • New York State (NYS) Medicaid recognizes prescriptions written by providers legally authorized to prescribe per NY Education Law, Article 131, Section 6526, and Title 10 NYCRR Section 80.75(e). This includes unlicensed residents, interns and foreign physicians in training programs, under the supervision of a NYS 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 for unlicensed residents, interns and foreign physicians in training only:
    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 National Council for Prescription Drug Programs (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 can 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 (1A, 1B, 1C, 1D, 1E, 1F, 1G, 1H, 1J, 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)

Please note that the above override should NOT be used for a licensed prescriber who has not yet enrolled in NYS Medicaid. In the event of a prescription being sent by a non–enrolled licensed prescriber, the prescriber should be encouraged to enroll in the NYS Medicaid Program. Information regarding how to enroll can be found at:

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

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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

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