New York State Medicaid Update - August 2019 Volume 35 - Number 9

In this issue …

New York State Medicaid Fee-for-Service Program Pharmacists as Immunizers Fact Sheet

In accordance with New York State (NYS) Education Law, NYS Medicaid members can obtain the following vaccines when administered to patients 18 years of age and older: Zoster, pneumococcal, meningococcal, tetanus, diphtheria, and pertussis vaccines. For patients 2 years of age and older, influenza vaccines may be administered at a Medicaid enrolled pharmacy. The following conditions apply:

  • Only Medicaid-enrolled pharmacies, in accordance with NYS Education law, will receive reimbursement for immunization services and products. Services must be provided and documented in accordance to NYS Education laws and regulations, including the reporting of all immunizations administered to persons less than 19 years of age to either the State Department of Health using the New York State Immunization Information System (NYSIIS) or to the New York Citywide Immunization Registry (CIR). Additional information can be found at:
  • Pharmacies will only be able to bill for Medicaid non-dual-eligible enrollees. Dual-eligible enrollees will continue to access immunization services through Medicare.
  • Medicaid managed care (MMC) members will continue to access immunization services through their health plans. For Medicaid managed care Organization (MCO) billing guidance, please contact the MCO.
  • Reimbursement for these vaccines may be based on a patient-specific order or non-patient specific order. These orders must be kept on file at the pharmacy. The ordering prescriber's National Provider Identification (NPI) is required on the claim for the claim to be paid.
  • Vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) for individuals younger than 19 years of age are provided to Medicaid members, both fee-for-service (FFS) and MMC, free of charge by the Vaccines for Children (VFC) program.
    • Pharmacies wishing to administer VFC-available vaccines to Medicaid members younger than 19 years of age may enroll in the VFC program. Note: The VFC program is currently enrolling pharmacies to receive influenza vaccine only. Pharmacies immunizing patients 18 years of age with pneumococcal, meningococcal, tetanus, diphtheria and pertussis vaccines may not bill Medicaid for the costs of these vaccines. Patients 18 years of age who are enrolled in Medicaid are VFC-eligible and may receive these vaccines through a VFC healthcare practice or clinic.
    • NYS Medicaid should never be billed for the cost of any vaccine for persons younger than 19 years of age when it is available through the VFC Program. This applies to both FFS and MMC. Pharmacies that bill Medicaid for the cost of vaccines that are available through the VFC Program are subject to recovery of payment.
    • Pharmacies that are not enrolled in the VFC program may choose to provide vaccines for members younger than 19 years of age at no charge to the member or Medicaid program, and be reimbursed an administration fee of $17.85 by NYS Medicaid.
    • Additional information on the VFC Program, based on location, can be found at the following links:

Billing Instructions for FFS

Consistent with Medicaid immunization policy, pharmacies will bill the administration fee and, when applicable, acquisition cost of the vaccine using the appropriate procedure codes. Procedure codes can be found at:

Please note: National Drug Codes (NDCs) are not to be used for billing the vaccine product to Medicaid FFS. Reimbursement for the cost of the vaccine for individuals 19 years of age and older 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.”

Vaccine Claims Submitted via the NCPDP D.0 Format
NCPDP D.0. Claim Segment FieldValue
436-E1 (Product/Service ID Qualifier)Value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a procedure code
407-D7 (Product/Service ID)Enter an applicable procedure code listed in the tables below. Up to four claim lines can be submitted with one transaction.

NCPDP D.0 Companion guide can be found at:

Billing for Immunizations of Members 19 Years of Age and Older

For administration of multiple vaccines on the same date to members 19 years of age and older, procedure code "90471" should be used for administration of the first vaccine and "90472" for administration of any other vaccines administered on that day. One line should be billed for "90472" indicating the additional number of vaccines administered (insert quantity of 1 or 2).

Billing for Immunizations for Members 19 Years of Age and Younger

For VFC-eligible vaccines, whether enrolled in the VFC Program or not, the pharmacy would submit procedure code "90460" (administration of free vaccine) for administration of first or subsequent doses, then submit the appropriate vaccine procedure code(s) with a cost of $0.00. A system edit will ensure that when there is an incoming claim for the administrative fee (procedure code "90460") that there is also a claim in history for a VFC-eligible vaccine procedure code, reimbursed at $0.00. If no history claim is found, then the claim will be denied for the new edit 02291.

For National Council for Prescription Drug Programs (NCPDP) claims transactions that are denied for edit 02291, the corresponding Medicaid Eligibility Verification System (MEVS) Denial Reason code "738" will be returned "History Not Found for Administrative Vaccine Claim" and NCPDP Reject code "85" "Claim Not Processed."

The following procedure codes should be billed for select influenza for those 2 years of age and older; pneumococcal and meningococcal vaccines for those 18 years of age and older; and zoster for those 50 years of age and older:

Procedure CodeProcedure Description
90620Meningococcal recombinant protein and outer membrane vesicle vaccine, Serogroup B, two dose schedule, for intramuscular use
90621Meningococcal recombinant lipoprotein vaccine, Serogroup B, two or three dose schedule, for intramuscular use
90653Influenza virus vaccine (IIV), preservative free, for use in individuals 65 years of age and older, for intramuscular use
90656Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years of age and older, for intramuscular use
90658Influenza virus vaccine, split virus, for use in individuals 3 years of age and older, for intramuscular use
90661Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use
90662Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use
90670Pneumococcal conjugate vaccine, 13-valent, for intramuscular use
90672Influenza virus vaccine, quadrivalent, live, for intranasal use in individuals 2 years of age through 49 years of age
90673Influenza virus vaccine, trivalent, derived from recombinant DNA, preservative free, for intramuscular use for age 18 years of age and older
90674Influenza virus vaccine; quadrivalent, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use
90682Influenza virus vaccine, quadrivalent, (RIV4), derived from recombinant DNA, preservative and antibiotic free for intramuscular use
90686Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use
90688Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, with preservative, for intramuscular use
90714Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, for use in individuals seven years or older, for intramuscular use
90715Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), for use in individuals 7 years or older, for intramuscular use
90732Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years of age or older, for subcutaneous or intramuscular use
90733Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use, age 2 years of age and older
90734Meningococcal conjugate vaccine, Serogroups A, C, Y and W-135 (trivalent), for intramuscular use, age 11 through 55
90736Zoster (shingles) Vaccine, live, for subcutaneous injection, age 50 years and older
90750Zoster (shingles) Vaccine, age 50 years and older for intramuscular use
90756Influenza virus vaccine, quadrivalent, antibiotic free, for intramuscular use

The following procedure codes in the table below should be used for the actual administration of the vaccines listed above by a pharmacist:

Procedure CodeProcedure Description
90473Immunization administration of seasonal influenza intranasal vaccine for ages 19 years and older $8.57
90471Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) $13.23
90472Immunization administration (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
90460Immunization administration of free vaccine through VFC Program for ages 19 years and younger $17.85

Contact Information:

  • FFS billing questions should be directed to the eMedNY Call Center at (800) 343–9000.
  • MCO billing questions should be directed to the individual managed care plan. MCO information can be found at:

Additional Resources:

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New System Edit to be Implemented to Validate the Ingredient Cost for 340B Drugs

As previously communicated in the January 2018 and December 2018 Medicaid Update publications, 340B drug claims submitted to Medicaid via the National Council for Prescription Drug Programs (NCPDP) D.0 format are:

  • required to be properly identified as 340B for both fee-for-service (FFS) and Medicaid managed care (MMC) members; as well as
  • submitted at the 340B acquisition cost by invoice to the provider for FFS members, net any manufacturer discounts and/or other price reductions.
The following fields are required on Medicaid 340B drug claims submitted via NCPDP:
FieldMedicaid Primary ClaimMedicaid Secondary Claim (Primary: Medicare; Commercial)
420-DK, Submission Clarification Code (SCC)2020
423-DN, Basis of Cost Determination (BCD)*08No Requirements Specific to Medicaid
409-D9, Ingredient Cost Submitted*340B Acquisition CostNo Requirements Specific to Medicaid
426-DQ, Usual and Customary Cost (U&C) **Lowest Net Charge to Cash CustomersLowest Net Charge to Cash Customers

* MMC plans should be consulted on their requirements for this field.

**U&C is defined as the lowest price charged to the general public after all applicable discounts, including promotional discounts and discounted prices associated with loyalty programs.

Please Note: All 340B claims are subject to audit and investigation; in addition, claims improperly identified as 340B and/or claims with unsubstantiated Acquisition Cost may be considered fraudulent claims.

Effective September 12, 2019, for Medicaid FFS primary claims only, system editing will compare the ingredient cost submitted (NCPDP field 409-DK) with the 340B ceiling price for the product, as defined by Health Resources and Services Administration (HRSA). The 340B ceiling price refers to the maximum amount that a manufacturer can charge a covered entity for the purchase of a 340B covered outpatient drug.

The 340B ceiling price is statutorily defined as the Average Manufacturer Price (AMP) reduced by the rebate percentage, which is commonly referred to as the Unit Rebate Amount (URA). HRSA obtains the AMP and URA data from the Centers for Medicare and Medicaid Services (CMS) as part of quarterly reporting for the Medicaid Drug Rebate Program. This figure is then multiplied by the package size and case package size to produce a price that is used in the marketplace for purchasing covered outpatient drugs. For example, the AMP minus the URA indicates the cost of one pill.

Any pharmacy that submits a 340B drug claim, whenever the ingredient cost submitted is higher than the ceiling price, will be returned the Medicaid Eligibility Verification System (MEVS) Rx Denial code "708: "Exceeds NY Allowed Maximum" and the NCPDP Reject code "23: "M/I Ingredient Cost". The pharmacy would then have to resubmit the claim with the correct ingredient cost.

Contact Information:

  • FFS billing questions should be directed to the eMedNY Call Center at (800) 343–9000.
  • Policy questions regarding NYS Medicaid 340B should be directed to:
  • Billing questions regarding MMC plans should be directed to the enrollee's specific MCO.

Additional Resources:

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Pharmacy Dispensing of Drugs That Require Administration by a Practitioner

New York State (NYS) Medicaid recognizes the need for certain drugs requiring administration by a practitioner to be available to members by way of both the Medical Benefit and Pharmacy Benefit. Such practitioner-administered drugs are listed on the Medicaid Pharmacy List of Reimbursable Drugs ( and may be billed directly to the Medicaid Fee-for-Service (FFS) program by a pharmacy. The intent of this article is to provide guidance for proper dispensing and delivery of such drugs. Nothing in this policy is meant to suggest that all practitioner-administered drugs must be dispensed as a Pharmacy Benefit. The policy regarding practitioner-administered drug billing is addressed in the Physician Manual found at:

Practitioner-administered drugs dispensed as a Pharmacy Benefit must be delivered by the pharmacy directly to the site of administration. This is considered "white bagging" and is acceptable under the following guidelines:

  • Drugs should only be dispensed by the pharmacy directly to the patient when they are to be self-administered. The policy surrounding self-administered drug delivery can be found in the July 2019 Medicaid Update.
  • Prior to delivery of a practitioner-administered drug the dispensing pharmacy must confirm the delivery address, that the member still requires the drug, and that an appointment has been scheduled and confirmed for its administration. Automatic refills are not permitted. The policy surrounding refills can be found in the March 2018 Medicaid Update.
  • Delivery charges may not be billed to the member or NYS Medicaid.
  • The pharmacy is responsible for preparing and delivering the drug in accordance with administration guidelines in the package insert, as well as the replacement of improperly stored, lost, or stolen drugs until confirmed receipt by the authorized agent.
  • The pharmacy is required to obtain documentation of delivery by the receipt of a signature of an authorized agent at the site of administration.
  • All Medicaid claims for drugs that were not deliverable must be reversed within 60 days.
  • Once delivered and signed for, the site of administration is responsible for replacement of improperly stored, handled, lost, or stolen practitioner-administered drugs.

Practitioner-administered drugs dispensed directly to a patient by the pharmacy to bring to their practitioner’s office for administration is considered "brown bagging," and causes concern regarding proper storage or handling, which can affect the drug efficacy. Brown bagging is not acceptable under NYS Medicaid.

This policy refers to any drug being dispensed by a pharmacy for practitioner-administration to a Medicaid FFS member, including those billed as a secondary payment. Questions regarding a Medicaid Managed Care Plan policy on practitioner-administered drugs should be directed to the individual plan. Questions and/or clarification regarding information contained in this article should be directed to: or (518) 486-3209.

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Billing Changes for OPWDD ICF/IID Providers Effective July 1, 2019

On April 4, 2019 the New York State Office for People With Developmental Disabilities (OPWDD) notified providers operating Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) of new billing requirements effective July 1, 2019. These new requirements mandate inclusion of the National Provider Identifier (NPI) of the practitioner who completed the annual Level of Care Eligibility Determination (LCED) on each claim submission. This requirement was the result of findings by the Centers for Medicare and Medicaid Services (CMS) during a Payment Error Rate Measurement (PERM) review of the New York State Medicaid program. CMS determined that the signed annual LCED for individuals residing in an ICF/IID is the equivalent of a physician's order for service, therefore each claim must identify the NPI of the physician who completed/signed the LCED. The basis for this determination is Title 42 Code of Federal Regulations (CFR) §456.360.

Physician Medicaid Enrollment

Section 6401(a) of the Affordable Care Act (ACA) establishes requirements regarding provider Medicaid enrollment. Specifically, 42 CFR §455.410(b) requires providers reimbursed by the fee-for-service (FFS) Medicaid program be enrolled in state Medicaid programs if they “order” or “refer” services. Information on the Medicaid enrollment process for physicians can be found at:

Claim Submissions

As of July 1, 2019, the 837I claim submission for an agency's ICF/IID billings will be required to incorporate the NPI of the physician in the Attending Provider component of the claim form identified in the following segments: Loop: 2310A Segment NM109.

As referenced in the April 4, 2019 correspondence, effective for dates of service on or after July 1, 2019, provider failure to include this information on claims will result in disallowance.

While claim editing is currently not in place, OPWDD and the New York State Department of Health expect system edits to be in production in eMedNY on November 21, 2019. OPWDD is in the process of contacting specific providers of ICF/IIDs who are not complying with this requirement regarding corrective action.

Questions regarding these requirements should be sent to OPWDD at

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New York Medicaid EHR Incentive Program

Distribution to Eligible Professionals & Eligible Hospitals Since the Start of the Program in 2011*
Number of Payments:Distributed Funds:

*As of 8/12/2019

Through the New York (NY) Medicaid Electronic Health Record (EHR) Incentive Program eligible professionals (EPs) and eligible hospitals (EHs) in New York who adopt, implement, or upgrade certified EHR technology (CEHRT) and subsequently become meaningful users of CEHRT, can qualify for financial incentives. The Centers for Medicare and Medicaid Services (CMS) is dedicated to improving interoperability and patient access to health information. The NY Medicaid EHR Incentive Program is a part of the CMS Promoting Interoperability Program, but will continue to operate under the current name, NY Medicaid EHR Incentive Program.

Payment Year 2018 Meaningful Use Attestation Deadline

The Payment Year (PY) 2018 Meaningful Use attestation deadline is September 30, 2019. Providers are reminded to login to NY Medicaid EHR Incentive Program Administrative Support Service (MEIPASS) and begin their attestation. Providers can attest for PY 2018 in MEIPASS at the following link: Providers who have already submitted an attestation for 2018 will be contacted by the NY Medicaid Incentive Program Support Team with status updates. Questions or requests for assistance with the attestation process should be directed to

Meaningful Use Objective 0 — ONC Questions

EPs are required to attest to Objective 0 — ONC (Office of National Coordinator of Health Information Technology) Questions in which they must demonstrate that they have not restricted compatibility of the CEHRT through “information blocking.” Providers should work with their EHR vendor to ensure the technology is used correctly and is enabled to meet applicable standards and laws. Providers should also ensure that organizational policies and workflows are enabled and do not, in any way, restrict the CEHRT functionality.

The Objective 0 — ONC Questions were previously part of the NY Medicaid EHR Incentive Program attestation page, however, they are now instituted as Objective 0 in MEIPASS. This new objective includes a series of questions related to information blocking, which is broken down into two measures. There are no right or wrong answers to these questions; the only requirement is that they are answered as accurately and honestly as possible. Additional information can be found on the Prevention of Information Attestation Fact Sheet at :

Webinars and Q&A Sessions

A calendar with the date and times of upcoming webinars, as well as registration information, can be found at: Upcoming webinars include Security Risk Analysis, 2019 Public Health Reporting, EP Meaningful Use — Stage 3, and Patient Engagement for Eligible Professionals.

NY Medicaid EHR Incentive Program Tutorial Series

The NY Medicaid EHR Incentive Program has produced a series of tutorials to assist providers in preparation of the PY 2018 Meaningful Use Attestation and to aid in the event of a post-payment audit. Registration information for the PY2018 Meaningful Use Attestation Series and the Post-Payment Audit Education Series can be found at:

New York State (NYS) Regional Extension Centers (RECs)

NYS RECs offer free support to help providers achieve Meaningful Use of CEHRT. Support provided by NYS RECs includes, but is not limited to, the following: answers to questions regarding the program and requirements, assistance on selecting and using CEHRT, and help meeting program objectives. NYS RECs offer free assistance for all practices and providers located within New York.

For Providers Located: Inside the 5 boroughs of NYC Outside the 5 boroughs of NYC
Phone: 1-347-396-4888
New York eHealth Collaborative (NYeC)
Phone: 1-646-619-6400


The EHR Incentive Program has a dedicated support team ready to assist. Please contact the program at: 1-877-646-5410 (Option 2) or via email at:

Please Complete the New York Medicaid EHR Incentive Program Customer Satisfaction Survey

The NY Medicaid EHR Incentive Program values provider insight. The survey can be found at:

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Provider Training Schedule and Registration

Providers who are new to Medicaid billing, have billing questions, or are interested in learning more about ePACES, should consider registering for Medicaid training. Various types of training, which includes seminars and webinars, are available from eMedNY for providers and their billing staff. Training sessions are available at no cost to providers and include information on claim submission, Medicaid Eligibility Verification, and the eMedNY website.


Seminars are a valuable opportunity to meet personally with CSRA's eMedNY Regional Representatives. Seminars are in-person training sessions with groups of providers and billing staff conducted at locations throughout New York State. A list of upcoming seminars, listed by location, is available on the eMedNY website at:


Webinar training sessions are conducted online and offer providers the convenience of joining the meeting from their computer and telephone. Once registration is completed, providers will receive an email with instructions to join the online meeting at the appropriate time. No travel is required. Many sessions offer information and instruction about Medicaid's web-based billing and transaction program ePACES.

The electronic Provider Assisted Claim Entry System (ePACES) allows enrolled providers to submit the following types of transactions:

  • Claims
  • Eligibility Verifications
  • Claim Status Requests
  • Prior Approval/DVS Requests

Training dates, locations, and fast and easy registration are available on the eMedNY website at: The website is updated quarterly with new sessions. Regional Representatives from eMedNY look forward to assisting providers at upcoming training sessions. Questions related to webinar registration should be directed to the eMedNY Call Center at (800) 343–9000.

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Medicaid Eligibility Verification System (MEVS) and Dispensing Validation System (DVS) Provider Manual

The Medicaid Eligibility Verification System (MEVS) and Dispensing Validation System (DVS) enable providers to verify member eligibility prior to provision of services and obtain authorization for specific services covered under DVS. A member, also known as client or recipient, must present an official Common Benefit Identification Card (CBIC) to the provider when requesting services. The issuance of a CBIC does not constitute full authorization for provision of medical services and supplies. The member's eligibility must be verified through eMedNY to confirm the member's eligibility for services and supplies. A provider who does not verify eligibility prior to provision of services will risk the possibility of nonpayment for those services.

The verification process through eMedNY can be accessed using one of the following methods:

  • Telephone verification process: Audio Response Unit (ARU)
  • Other access methods:
  • Electronic Provider Assisted Claim Entry System (ePACES)
  • Central Processing Unit: CPU-to-CPU link
  • eMedNY eXchange
  • dial-up File Transfer Protocol (FTP)
  • File Transfer Service using Simple Object Access Protocol (SOAP)
  • CORE Web Services

Additional information regarding MEVS access methods is available for review at:

MEVS/DVS Provider Manual

The MEVS/DVS Provider Manual is a resourceful guide that will introduce providers to:

  • Information about Common Benefit Identification Cards (CBIC)/forms
  • Introduction to the (Telephone Audio Response Unit) Verification
  • Reference tables:
    • Eligibility Benefit Descriptions
    • Reject Reason CodesDecision Reason Codes
    • Exception Codes
    • County/District Codes
    • New York City Office Codes

The MEVS/DVS Provider Manual is conveniently located on the eMedNY website at: The MEVS/DVS Provider Manual is a valuable resource for interpreting the MEVS message providers encounter when checking eligibility.

For training on Medicaid eligibility or any other ePACES related functions, check out the eMedNY training page at: Provider questions on messages received should be directed to the eMedNY Call Center at(800) 343–9000.

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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

Donna Frescatore
Medicaid Director
Office of Health Insurance Programs