In this issue …

Medicaid Fee-For-Service Implementing Edits to Limit Initial Opioid Prescribing to a Seven Day Supply

Effective August 24th, 2017, the Medicaid fee-for-service (FFS) program will be implementing a seven (7) day supply limit on initial opioid prescribing for acute pain. This is consistent with Public Health Law § 3331(5), as amended in 2016, which prohibits a practitioner from prescribing more than a 7-day supply of an opioid medication for acute pain. More information on this legislation can be found in articles in the July 2016 and June 2017 issues of the Medicaid Update. This is a change from the current editing, implemented on December 5, 2013, which set the limit to a fifteen (15) day supply on initial opioid prescriptions.

Prior authorization (PA) will be required for claims that do not meet the above criteria. To obtain a PA, please contact the 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 a PA.

The most up-to-date information on the Medicaid FFS Pharmacy Prior Authorization (PA) Programs and a full listing of drugs subject to the Medicaid FFS Pharmacy Programs can be found at: and

Medicaid enrolled prescribers can also initiate PA requests using a web-based application. PAXpress® is a web based pharmacy PA request/response application accessible through

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New York State Medicaid Coverage of Digital Breast Tomosynthesis Three-dimensional Mammography

The New York State Medicaid Program is committed to ensuring that Medicaid members have ready access to breast cancer screening. Digital breast tomosynthesis (DBT), 3-D mammography, has shown to be beneficial when combined with digital mammography in screening for breast cancer. Women should be made aware of the potential benefits and harms of screening, as well their own risk for breast cancer, and decide, with a health care provider, when and how to be screened for breast cancer.

New York State Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) will provide coverage for screening digital breast tomosynthesis (CPT code: 77063) beginning September 1, 2017 and November 1, 2017 respectively. Since this is an add-on code, payment will be made only when furnished in conjunction with a 2-D digital mammography.


DBT is a modification of digital mammography. Tomosynthesis is a 3-D imaging technique that involves acquiring images of a stationary compressed breast at multiple angles during a short scan. The individual images are projections through the breast at different angles and are then reconstructed into a series of thin, high-resolution slices that can be displayed in a variety of formats. While the breast is positioned and compressed similarly to a standard mammogram, images are captured through a number of different x-ray source angles. Objects at different heights in the breast project differently for each angle. The data is then reconstructed to generate images that enhance objects from a given height by appropriate shifting of the projections relative to one another.

Practitioners and hospitals are responsible for ensuring that the codes (and modifiers when applicable) submitted for reimbursement accurately reflect the diagnosis and procedure(s) that were reported. Reviews may be conducted as appropriate, pursuant to 18 NYCRR 504.8, on adjudicated claims. Medical records must be maintained by providers for a period of not less than six years from the date of payment.

Policy questions regarding Medicaid fee-for-service may be directed to the Office of Health Insurance Programs (OHIP), Division of Program Development and Management at (518) 473–2160 . Questions regarding Medicaid fee-for-service billing or claims should be directed to the eMedNY Call Center at 1-800-343-9000. Questions regarding Medicaid Managed Care (MMC) billing and reimbursement should be directed to the enrollee's MMC Plan.

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Reminder: Medicaid Billing for Prescription Drugs when Prescribed by Unlicensed Residents, Interns and Foreign Physicians in Training

The purpose of this article is to provide a reminder regarding NYS Medicaid's billing requirement for drugs when prescribed by unlicensed residents, interns and foreign physicians in training only.

  • NYS Medicaid accepts 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 licensed 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.
  • Effective January 2014, NYS fee-for-service Medicaid implemented claims editing that enforced the Ordering/Prescribing/Referring/Attending (OPRA) requirements for healthcare professionals, practice managers, facility administrators, and servicing/billing providers.
  • Because NYS Medicaid's provider enrollment system can only accept licensed providers, pharmacy claims for services ordered by unlicensed residents, interns and foreign physicians in training programs reject when initially submitted for payment.

The urgent/emergency override continues to be available to pharmacies to enable payment for prescription drug claims when prescribed by unlicensed residents, interns and foreign physicians in training only.

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 can provide the medication and receive reimbursement by resubmitting the claim using the following emergency override procedure:

  1. In the Reason for Service Code Field (439-E4) also known as the Drug Utilization Conflict Field – enter "PN" (Prescriber Consultation)
  2. 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).
  3. 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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Consumer Directed Personal Assistance Program - Fiscal Intermediary Authorization

The enacted 2017-18 New York State Budget created a new Authorization process for all entities operating as Fiscal Intermediaries (FIs) for the Consumer Directed Personal Assistance Program (CDPAP). The new Authorization process will be required for both FIs that contract with Local Departments of Social Services and those that contract with Managed Care Organizations.

Specifically, Section 1 of Part E of Chapter 57 of the Laws of 2017 amended the New York State Social Services Law (SSL) by adding two new subdivisions, 4-a and 4-b, to §365-f. The purpose of these changes is to improve oversight of the program and the FIs that play a vital role in the CDPAP and to better align SSL §365-f with the CDPAP regulations under Title 18 NYCRR §505.28.

The two new subdivisions:

  • Better define what an FI is, and what such entities are and are not responsible for;
  • Create a new Authorization process which will be required for all FIs;
  • Grant the Department the authority to revoke, suspend, limit or annul an FI's Authorization in the event the FI is found to be out of compliance; and
  • Provide FIs with the option to challenge determinations under this new subdivision via a proceeding under Article 78 of the New York Civil Practice Law and Rules.

SSL 365-f(4-a) outlines the activities in which an FI should not be engaged, such as recruiting and hiring personal assistants. This reflects the CDPAP regulations under Title 18 NYCRR §505.28, and should be followed regardless of the above-mentioned legislation. It has never been appropriate for an FI to participate in such activities.

These new provisions are effective April 1, 2017. It should be noted that legislation has been passed by the Senate and Assembly that would delay the effective date of these provisions until January 1, 2018. Further, the bill would give those entities operating as an FI prior to April 1, 2017 one year (until January 1, 2019) to become Authorized by the Department. This bill has yet to be delivered to the Governor for action. The Department will provide an update if this bill is signed into law, outlining how that would impact implementation of the new Authorization process.

In the meantime, the Department will continue to move forward with the creation of the new FI Authorization process. Once a timeline for implementation is complete, more detailed information will be communicated via targeted email distributions, postings on the Medicaid Redesign Team (MRT) webpage and the monthly Medicaid Update. Questions or comments regarding the FI Authorization process can be sent to:

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Home Health Care Medicare Maximization Services Settlement Agreement for Pending Medicare Appeals

The Office of the Medicaid Inspector General (OMIG) has experienced significant delays in receiving Medicare coverage determinations for home health appeals filed with the federal Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council (Council). These appeals are submitted under a contract between OMIG and the University of Massachusetts Medical School (UMass) to maximize Medicare reimbursement for dual-eligible Medicare/Medicaid recipients and ensure Medicaid remains payor of last resort.

To help reduce the current backlog of home health appeals pending at OMHA and the Council, OMIG is working collaboratively with the Centers for Medicare and Medicaid Services (CMS) under a Settlement Conference Facilitation (SCF) pilot. The SCF has resulted in CMS and OMIG reaching an agreement that will produce settlement payments to home health providers that have appeals pending at OMHA and Council. The original pending appeals included in this agreement will be formally dismissed by Medicare, and settlement payments will commence directly to home health providers from the Medicare Administrative Contractor in September 2017. Due to the fact that all providers have been compensated in-full via the Medicaid payment, any Medicare payments received through this process are required to be returned to the state.

Notification letters will be issued by UMass to all home health providers that receive a Medicare payment as a result of this settlement. These letters will include detailed information, including instructions on remitting the settlement payment to OMIG. If you have any questions concerning the above information, you may contact the UMass Medicare Appeals Team at 1-866-626-7594.

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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 (EPs) 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 $818 million in incentive funds have been distributed within 26,108 payments to New York State Medicaid providers.


Million Paid

Are you eligible? For more information, visit:

Last Chance to Participate

The deadline to attest to 2016 Meaningful Use for the New York State Medicaid EHR Program is September 15, 2017. Incentive payments for EPs are disbursed over the course of six participation years. EPs may receive up to $21,250 for the first participation year and $8,500 for each remaining participation year. Though incentive payments continue until 2021, the 2016 payment year is the last opportunity for new EPs to begin participation.

2016 MU Deadline: September 15, 2017
Last Chance to Join the Meaningful Use Program
Total Incentives: $63,750

To participate in the EHR Incentive Program, you must have a certified EHR system (, be enrolled as a fee-for-service New York Medicaid provider, and be registered with the Centers for Medicare and Medicaid Services.

Incentive payments continue until 2021, but new EPs must be registered and able to report 2016 EHR measures by September 15, 2017.

writing iconPrerequisites

computer icon Next Steps


The NY Medicaid EHR Incentive Program website 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. Tutorials are being added frequently. Visit the Tutorials page to access these videos here:


The NY Medicaid EHR Incentive Program has several instructor-led webinars available on a variety of topics to assist in the meaningful use attestation process. Webinars are offered at different times, including 7am, to accommodate many schedules. Visit the Webinar Calendar page to register for a session here:

phone icon Contact us at 877-646-5410 option 2 or
Questions? We have a dedicated support team that will guide you through the registration and attestation process.

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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