New York State Medicaid Update - November 2019 Volume 35 - Number 11

In this issue …

New York State Medicaid National Diabetes Prevention Program

November was National Diabetes Awareness Month. Providers interested in helping Medicaid members stay healthy and prevent Type 2 diabetes can become a Medicaid National Diabetes Prevention Program (NDPP) service provider. Medicaid NDPP service providers assist Medicaid members to make lasting behavior changes through group-based training and individual support.

Steps to Become a Medicaid NDPP Service Provider:

  1. Achieve CDC Recognition
    Clinics, groups, individuals, and organizations looking to enroll in Medicaid as an NDPP Service provider must first comply with the standards and guidelines set forth by the Centers for Disease Control and Prevention (CDC) as outlined in the National Diabetes Prevention Recognition Program (DPRP), and obtain a valid, current CDC Pending, Preliminary, or Full NDPP recognition. Providers interested in becoming a CDC-recognized organization should apply online via the link listed below. The recognition process is handled by the CDC.
    CDC Resources:
  2. Apply to Become a Medicaid NDPP Service Provider
    Community Based Organizations (CBOs), clinics, Practitioner Group Practices, and Sole Practitioner Group Practices that have achieved CDC DPRP recognition are now able to enroll in NYS Medicaid as an NDPP service provider and be reimbursed for rendering NDPP services to Medicaid members. Once a Pending, Preliminary, or Full CDC recognition is obtained, providers can apply to become a Medicaid NDPP service provider. Applications based on provider type are available at:
  3. Provide Medicaid NDPP Services and Bill Medicaid
    In-person group-based sessions are offered and taught by trained Lifestyle Coaches using a CDC-approved curriculum to educate members on how to make long-lasting, sustainable lifestyle changes related to weight loss, increased physical activity, and healthy eating habits to prevent or delay the onset of Type 2 diabetes. Claims submitted to Medicaid will receive reimbursement of up to $551 when participants attend up to 22 group-based sessions over the course of one (1) year. Medicaid NDPP service providers will also be awarded a one-time $70 incentive payment for Medicaid members who achieve at least a five percent weight loss from their baseline over the course of the program. For more information and/or to enroll in NYS Medicaid as an NDPP service provider visit:

Questions and Additional Resources

Questions related to NYS Medicaid NDPP should be directed to: The NYS Medicaid NDPP Listserv provides information relative to Medicaid's coverage and reimbursement of the CDC's NDPP for Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) members and providers. Additional information relative to the upcoming 2020 NYS Medicaid NDPP symposia will also be communicated via the Listserv. Information on how to subscribe to the NDPP Listserv can be found at:

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The Medicaid Enrolled Provider Listing
(Formerly the Medicaid Fee-for-Service (FFS) Directory)

The Department of Health (DOH) recently changed and expanded the provider listing formerly known as the Medicaid Fee-for-Service (FFS) Directory. A description of and links to the new listing can be found at: As §5006 of the 21st Century Cures Act requires state Medicaid agencies to publish an FFS provider directory, the Bureau of Provider Enrollment continues to provide a list containing Medicaid FFS providers but has made the following enhancements to the data set including the following:

  • In order to accommodate the Managed Care Only (MCO) and Ordering, Prescribing, Referring, and Attending (OPRA) providers, the name of the data set has been changed from "Medicaid Fee-for-Service (FFS) Directory" to "Medicaid Enrolled Provider Listing."
  • The data set will be updated on a weekly basis.
  • The data elements "MMIS ID","MMIS NAME", and "UPDATED FILE DATE" have been renamed to "MEDICAID PROVIDER ID", "PROVIDER OR FACILITY NAME", "FILE DATE" respectively. Please refer to the document Medicaid Enrolled Provider Listing-Data Dictionary Change Log, Version 1.3 (found at the abovementioned web page after selecting "Show More") for further details.
  • The following new data elements have been added and are documented in the Change Log:
    • CITY
    • ZIP CODE

This enhanced data set will enable Medicaid and Children's Health Plus (CHP) Managed Care plans to confirm Medicaid FFS provider enrollment, a requirement under federal law. In addition, consumers with Medicaid FFS coverage will now be able to search for new providers by city or county.

Questions regarding the provider listing, maintaining provider enrollment files, or the revalidation process, should be directed to the eMedNY call center at (800) 343‑9000 , or via email at:

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Medicaid Fee-for-Service: Procedure Code Modifier 'ST' for Occupational, Physical, or Speech Therapy Services Provided to a Member with a Traumatic Brain Injury (TBI)

Certain Medicaid members are limited to 20 visits per fiscal year for occupational therapy, 40 visits per fiscal year for physical therapy, and 20 visits per fiscal year for speech therapy. Certain Medicaid members, settings, and circumstances are exempt from the visit limitations. These include:

  • Children from birth to 21 years of age (until their 21st birthday)
  • Individuals with a developmental disability (members with Restriction/Exemption (R/E) code 95)
  • Individuals with a traumatic brain injury (TBI) (members with R/E code 81, or having a TBI as defined in Public Health Law Article 27-cc*)
  • Individuals with both Medicare Part B and Medicaid coverage (dually eligible members) when Medicare Part B payment is approved for the therapy service
  • Rehabilitation services received as a hospital inpatient
  • Individuals receiving rehabilitation services in a nursing home in which they reside
  • Rehabilitation services provided by a certified home health agency (CHHA)

*TBI as defined in Public Health Law Article 27-cc: § 2741. "Traumatic brain injury" means an acquired injury to the brain caused by an external physical force resulting in total or partial disability or impairment and shall include but not be limited to damage to the central nervous system from anoxic/hypoxic episodes or damage to the central nervous system from allergic conditions, toxic substances, and other acute medical/clinical incidents. Such term shall include, but not be limited to, open and closed brain injuries that may result in mild, moderate or severe impairments in one or more areas, including cognition, language, memory, attention, reasoning, abstract thinking, judgment, problem-solving, sensory perceptual and motor abilities, psycho-social behavior, physical functions, information processing, and speech. Such term shall not include progressive dementias and other mentally impairing conditions, depression and psychiatric disorders in which there is no known or obvious central nervous system damage, neurological, metabolic and other medical conditions of chronic, congenital or degenerative nature or brain injuries induced by birth trauma.

The rehabilitation visit (occupational, physical, and speech therapy) limit for fee-for-service (FFS) members is enforced through prior authorization (PA), such that a PA number must be obtained for each non-exempt visit and included on the Medicaid FFS claim. Instructions for obtaining a PA through the Dispensing Validation System (DVS) for occupational, physical, and speech therapy in ePACES can be accessed online at: PA is not required for therapy visits that are exempt (per list above) from the visit limitation.

Effective September 26, 2019, eMedNY will accept procedure code modifier "ST" to identify occupational, physical, and speech therapy services provided to an FFS member with a TBI (who is not enrolled in the TBI waiver). Procedure code modifier "ST" may be reported with rehabilitation therapy procedure codes on Medicaid FFS claims without PA, to identify therapy services provided to members with TBIs who are not enrolled in the TBI waiver. In addition, the appropriate procedure code modifier "GO", "GP", and "GN" must be reported on FFS claims to identify the therapy type (occupational, physical, and speech, respectively). If procedure code modifier "ST" fails to be submitted with the rehabilitation therapy procedure codes on FFS claims for members with a TBI who are not enrolled in the TBI waiver, the claims may be denied due to eMedNY edit 00186 (required PA for procedure not found).

Questions and Additional Information:

  • Additional information may be found in the Rehabilitation Services Manual online at:
  • Questions regarding Medicaid Managed Care (MMC) reimbursement and/or billing requirements should be directed to the member's MMC plan.
  • Medicaid FFS coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP), Division of Program Development and Management at (518) 473‑2160.

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New York State Medicaid Fee-for-Service Policy and Billing Guidance for Onasemnogene Abeparvovec-xioi (ZOLGENSMA®)

New York State (NYS) Medicaid fee-for-service (FFS) will begin utilizing criteria to determine approval of onasemnogene abeparvovec-xioi (ZOLGENSMA®) for members who have a diagnosis of spinal muscular atrophy (SMA) when the member meets the criteria outlined in this policy. This FFS policy is effective December 1, 2019. ZOLGENSMA® is an adeno-associated vector-based gene therapy indicated for the treatment of pediatric patients less than two (2) years of age with a diagnosis of SMA with bi-allelic mutations in the survival motor neuron 1 (SMN1) gene. ZOLGENSMA® was approved by the U.S. Food and Drug Administration (FDA) for use on May 24, 2019.

NYS FFS Coverage Policy

In accordance with FDA indications, FFS will reimburse ZOLGENSMA® for one treatment per person for their lifetime when the following criteria are met:

  • The patient must have a confirmed diagnosis of SMA with bi-allelic mutations in the SMN1 gene;
  • The patient must have three (3) copies or less of the SMN2 gene;
  • The patient must be less than two (2) years of age;
  • For neonatal patients born prematurely, full-term corrected gestational age (40 weeks) must be reached
  • The patient must have a baseline anti-AAV9 antibody titer of ≤ 1:50 prior to administration; and
  • The patient must not have advanced disease (i.e., complete limb paralysis, permanent ventilation dependence)*.

*Permanent ventilator dependence is defined as requiring invasive ventilation (tracheostomy) or respiratory assistance for 16 or more hours per day (including noninvasive ventilator support) continuously for 14 or more days in the absence of an acute reversible event, excluding perioperative ventilation.

FFS Billing:

  • Payment for the drug's administration will be made through the outpatient Ambulatory Patient Groups (APG) payment when administered in a clinic setting or, if administered on an inpatient basis, the All Patient Refined Diagnosis Related Groups (APR-DRG) payment.
  • Facilities administering ZOLGENSMA® will be reimbursed for the cost of the drug using the ordered ambulatory fee schedule. The ordered ambulatory claim should be submitted on paper (using the eMedNY 150003 claim form) and should include the facility's actual acquisition cost by invoice. Documentation of medical necessity that includes the criteria listed above must accompany the claim. Ordered ambulatory billing guidelines can be found at:
  • The following documentation must be included with the claim:
    • Manufacturer's invoice showing the acquisition cost of the biologic, including all discounts, rebates or incentives;
    • Documentation of the medication administration; and
    • Documentation of the criteria listed under NYS FFS Coverage Policy.
  • HCPCS code "J3590" (unlisted biologic) should be used to bill for ZOLGENSMA® until a specific HCPCS code is assigned. The associated National Drug Code (NDC) must be included on the claim.
  • Actual reimbursement will be calculated based on the actual acquisition cost, per the submitted invoice. Providers should report actual acquisition cost in the allowed amount field. If the actual acquisition cost exceeds $99,999.99, this is the dollar amount providers should report on their claim. Reimbursement will be at the acquisition cost on the provider's invoice.
  • Missing or incomplete documentation submissions will result in denials of the claim and delay the processing claims payment.


Providers are reminded that any off-invoice discounts or rebates received from the manufacturer must be passed back to Medicaid. Additionally, consistent with any performance guarantee conveyed by the manufacturer of ZOLGENSMA® (e.g., drug manufacturer is paid only if the patient responds to therapy), Medicaid should not be billed if no payment has been made by the provider to the manufacturer. Storage and handling charges are included in the APR-DRG inpatient payment as well as the APG outpatient payment and will not be reimbursed separately.

Medicaid Managed Care (MMC) Billing

Providers participating in MMC should check with the individual health plans to determine their billing policies and how each MMC plan will apply this FFS policy.


  • FFS policy and billing questions may be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management at (518) 473‑2160.
  • MMC reimbursement, billing, and/or documentation questions should be directed to the enrollee's MMC plan.
  • FFS claim questions should be directed to the eMedNY call center at (800) 343‑9000.

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Claims Processing for Independent Practitioner Services for Individuals with Developmental Disabilities (IPSIDD)

On September 26, 2019, updated payment logic for Independent Practitioner Services for Individuals with Developmental Disabilities (IPSIDD) was implemented in eMedNY. This update allows claims to be paid up to the IPSIDD Medicaid fee schedule when the Medicare fee schedule is lower for claims first submitted and adjudicated by Medicare and then submitted/crossed over to Medicaid. Prior to this update, claim submissions first processed and paid by Medicare were subject to existing practitioner service reimbursement rules that pay only the Medicare Part B coinsurance when the Medicaid rate is higher. This payment logic update was the result of authorization in State Plan Amendment (SPA) 18-0040 and aligns with payment maximization rules in place for Article 16 clinics.

SPA 18-0040 was effective June 1, 2018. In order to accommodate the update retroactively, the Office for People with Developmental Disabilities (OPWDD) and the Department of Health (DOH) submitted a special input of prior paid claims back to this authorization date. The special input recalculated service dates billed on and after June 1, 2018 under the updated payment logic. The special input was processed in cycle 2202 and the corresponding remittance statement for this cycle identifies the claim adjustments with edit reason code "01999" (claim has been special input by NYS FA).

Questions regarding this process should be emailed to OPWDD at: General questions about professional claim submissions should be directed to the eMedNY call center at (800) 343‑9000.

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Medicaid Pharmacy Prior Authorization Programs Update

On September 19, 2019, the New York State (NYS) Medicaid Drug Utilization Review (DUR) Board recommended changes to the Medicaid pharmacy prior authorization (PA) programs. Effective November 21, 2019, the fee-for-service (FFS) pharmacy program implemented the following changes.

Opioid Utilization as it Relates to the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act

Prior Authorization (PA): all requests for an opioid ≥ 90 morphine milligram equivalents (MMEs) per day for use in opioid-naïve patients will require a PA.

Antipsychotic Utilization in Children as Related to the SUPPORT Act

  • Educational letters will be sent to providers who prescribe antipsychotic medications for patients less than 21 years of age to inform of the need for metabolic monitoring when on an antipsychotic.
  • PA will be required for patients less than 21 years of age who are taking ≥ 2 different oral antipsychotics for more than 90 days (letters to be sent to those prescribers who may be impacted by this initiative).

Opioid and Antipsychotic Concurrent Utilization as Related to the SUPPORT Act

Educational letters will be sent to prescribers highlighting the SUPPORT Act requirements addressing the concurrent use of antipsychotic and opioid medications, and the importance of mental health treatment and coordination of care.

Leukotriene Modifiers used in the Treatment of Asthma

Educational letters will be sent to prescribers regarding leukotriene modifier use relative to current asthma treatment guidelines.

Additional Information:

To obtain a PA, providers may contact the clinical call center at (877) 309‑9493. The clinical call center is available 24 hours per day, seven days per week and staffed with pharmacy technicians and pharmacists available to assist providers in quickly obtaining a PA. Medicaid-enrolled prescribers can also initiate PA requests using a web-based application. PAXpress® is a web-based pharmacy PA request/response application accessible via a new button labeled "PAXpress" located on the webpage under the MEIPASS button. Additional relevant information can also be found at the following links:;; and

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Prescription Contraceptive Drugs for Family Planning

Amendments were made to Title 18 New York Codes, Rules, and Regulations (NYCRR) §505.3(d) and (e) to allow for a written order of prescription contraceptives for family planning purposes to be filled twelve (12) times within one year.

Effective November 21, 2019, system enhancements were implemented to enable prescription contraceptives for family planning purposes to be filled up to twelve (12) times within one year after the date of issuance, provided the prescription is for a one-month supply. Additionally, the system can accommodate dispensing up to a 12-month supply at once within a year.

Questions regarding this amendment should be sent to:

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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 11/04/2019

Through the 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.

2019 Attestations

MEIPASS is not currently accepting attestations for 2019 meaningful use. Announcements will be made when MEIPASS is ready to accept 2019 attestations. To receive important announcements providers may sign up for the program LISTSERV at:

MEIPASS Attestation Walkthrough

The MEIPASS Attestation Walkthrough (PDF) is now available on the NY Medicaid EHR Incentive Program website that provides an overview of Payment Year (PY) 2019 MEIPASS Updates. More information on PY 2019 MEIPASS Updates can be found at:

Security Risk Analysis (SRA)

Effective PY 2019, an EP must indicate in MEIPASS who completed the Security Risk Analysis (SRA) and their relationship to the EP. Providers should refer to the following options when selecting the relationship to the EP:

  • Self is described as the person completing the SRA
  • Independent Third-Party Consultant is described as an individual employed by an entity outside of the EP's practice
  • Other is described as an individual who is not the EP or an independent third-party consultant. For example, an individual with the internal information technology (IT) department or "IT staff"

Certified EHR Technology (CEHRT) Requirements

As a reminder, all providers must meet the following requirements in order to be eligible for an EHR incentive payment. Effective 2019, providers must enter numerator and denominator data in MEIPASS.

  • Do a combined 50 percent or more of member encounters occur at locations equipped with certified EHR technology during the EHR Reporting Period?
    • Numerator: The number of encounters in the denominator at locations with CEHRT during the EHR Reporting Period.
    • Denominator: The number of encounters at all locations during the EHR Reporting Period (including locations without CEHRT).
  • Do at least 80 percent of unique members have stored data within the provider's certified EHR technology during the EHR reporting period?
    • Numerator: The number of unique members in the denominator seen during the EHR Reporting Period, with stored data within the EHR System, for all provider locations with CEHRT.
    • Denominator: The number of unique members seen during the EHR Reporting Period, for all provider locations with CEHRT.

Additional guidance on this topic is available in section "FAQ EP12" on the Frequently Asked Questions (FAQ) page of the NY Medicaid EHR Incentive Program web site at: or in "Tutorial Three" of the "Post-Payment Audit Education Series" available to view at:

Webinars and Q&A Sessions

Upcoming NY Medicaid EHR Incentive Program webinars include:

  • Security Risk Analysis
  • 2019 Public Health Reporting
  • EP Meaningful Use – Stage 3
  • Patient Engagement for Eligible Professionals
  • Health Information Exchange.

A calendar with the date and times of these webinars, as well as registration information, can be found at:

NY Medicaid EHR Incentive Program Tutorial Series

The NY Medicaid EHR Incentive Program has produced a series of tutorials to assist providers on a variety of topics. These tutorial series include:

  • PY2018 Meaningful Use Attestation Series
  • Post-Payment Audit Education Series
  • MURPH Audit Report Card
  • Eligible Professional MURPH Registration Video Guide
  • Eligible Hospital MURPH Registration Video Guide

Additional information on the available tutorials 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 five boroughs of NYC Outside the five boroughs of NYC
Phone: (347) 396‑4888
New York eHealth Collaborative (NYeC)
Phone: (646) 619‑6400


The EHR Incentive Program has a dedicated support team ready to assist. Please contact the program at: (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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ePACES Administrator Functions and Security

When a provider first establishes an account within the Electronic Provider Assisted Claim Entry System (ePACES), the individual who completed the account setup is granted special authority and is designated as the ePACES account "Administrator." The ePACES Administrator is responsible for creating user identification (ID) and granting appropriate access for all individuals within the provider's office who will be performing ePACES transactions. Please note: Additional information on adding/editing users can be found under the "User Admin" link on the left-hand side of the account holders dashboard screen. The login page for ePACES can be found at:

It is imperative that individuals with ePACES access not share their user ID information with others. New York State (NYS) Medicaid and the Health Insurance Portability Accountability Act (HIPAA) require that each individual has a unique user ID. When additional members of a provider's office require access to ePACES, they must be assigned the appropriate individual level of access by the ePACES Administrator.

NYS Medicaid encourages providers to have more than one Administrator. The original ePACES Administrator has the authority to assign additional Administrators. This practice allows efficiency should an Administrator be out of the office or become disaffiliated with the organization. Please note: As soon as Administrators or users become disaffiliated with a provider organization, their ePACES account password must be changed. Once the password is changed, the Administrator must then inactivate that User account following the 120-day ePACES data retention requirement.

ePACES account holders who are currently sharing account information and/or do not know the identity of their ePACES account Administrator should call the eMedNY Call Center for assistance at (800) 343‑9000.

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VFC Provider Vaccine Storage Unit Compliance

Effective January 1, 2020, all providers enrolled in the New York State Vaccines for Children Program (VFC) are required to use stand-alone storage units for VFC inventory. Stand-alone units are self-contained storage units dedicated to a single temperature range and are considered the best type of storage unit for maintaining the temperatures necessary to keep vaccines viable.

The use of combination household-style refrigerator/freezer units that share a single compressor is no longer acceptable. Stand-alone storage unit purchasing guidance can be found at:

Questions regarding this policy should be directed to the Vaccines for Children Program at (800) 543‑7468.

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Reminder: Medicare Card Replacement Initiative

The Centers for Medicare and Medicaid Services (CMS) has replaced all Medicare Social Security-based member identifiers, also known as the Health Insurance Claim Number (HICN), with a new Medicare Beneficiary Identifier (MBI). Effective January 1, 2020, in alignment with the CMS Medicare Card Replacement Initiative, eMedNY will only return the MBI on eligibility responses for any dates of service. This applies to eligibility transactions from all sources: the Audio Response Unit (ARU), the X12/005010X279 271 Eligibility Benefit Response, and ePACES (Electronic Provider Assisted Claim Entry System). Additional information, including links to the Medicare Card Replacement Initiative on the CMS website, can be found under the "New Medicare Cards" section of the eMedNY homepage at:

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eMedNY Offers Medicaid Provider Training

Providers who are new to Medicaid billing, have billing questions, or who are interested in learning more about the electronic Provider Assisted Claim Entry System (ePACES) should consider registering for Medicaid training. eMedNY offers various types of training to providers and their billing staff. Training sessions are available at no cost to providers and cover information including claim submission, Medicaid Eligibility Verification, and the eMedNY website.


Seminars are a valuable opportunity to meet with the CSRA eMedNY Regional Representatives across the State. Seminars are in-person training sessions with groups of providers and billing staff conducted at locations throughout New York State. A schedule of seminars by location can be found on the eMedNY website at:

Webinar Training

Webinar training opportunities are also available. Webinar training sessions are conducted online such that providers join the meeting from their site location via a computer and telephone. Once registered, providers receive an email with instructions on how to log in then join the webinar at the appropriate time. No travel is necessary.

Many webinars offer detailed instruction on Medicaid's free web-based program ePACES which allows enrolled providers to submit the following types of transactions:

  • claims;
  • eligibility verifications;
  • claim status requests; and/or
  • prior approval/DVS requests.

Physicians, nurse practitioners and private duty nurses can submit claims in "real-time" via ePACES. Submitting claims in real-time ensures that the claim is processed within seconds then providers can obtain the status of a real-time claim, including the paid amount, without waiting for the remittance advice.

Training dates, locations, and fast/easy registration information are available on the eMedNY website at: The website is updated quarterly with new sessions. The eMedNY Regional Representatives are eager to meet with and provide guidance to providers at upcoming training sessions. Providers who are unable to access the internet to register, or who have questions about registration, should contact 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