New York State Medicaid Update - June 2020 Volume 36 - Number 11

In this issue …

Medicaid Pharmacy List of Reimbursable Drugs

A list of Medicaid reimbursable drugs may be found on the eMedNY website. Only prescription and non-prescription drugs which appear on the list are reimbursable under the Medicaid Pharmacy Program. The Pharmacy Formulary File is found under the "Information" tab on the homepage of the eMedNY website ( The list or reimbursable drugs may be searched and sorted by National Drug Code (NDC), Description, Drug Type, Labeler, Cost, Prior Authorization (PA) Code, or Over the Counter (OTC) Indicator. The list of Medicaid reimbursable drugs may be viewed and downloaded as a portable document format (PDF) file by selecting the "View/Download PDF of Reimbursable Drugs" link on the file page or directly at:

Attention Prescribers:

  • The Medicaid Pharmacy List of Reimbursable drugs includes only those drugs covered under the Pharmacy benefit and is not inclusive of all covered practitioner administered drugs. Information regarding Medicaid fee-for-service covered "Practitioner Administered Drugs" can be found in the Provider Manuals at: within the "Procedure Code and Fee Schedule" sections for Drugs, and in "Provider Communications".
  • For coverage information regarding Practitioner Administered Drugs for managed care enrollees, please refer to the managed care plan's medical benefit of policies and procedures.
  • Questions should be directed to the eMedNY Call Center at (800) 343‑9000.

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Medicaid Pharmacy Prior Authorization Programs Update

On February 13, 2020, the New York State Medicaid Drug Utilization Review (DUR) Board recommended changes to the Medicaid pharmacy prior authorization programs. Effective May 14, 2020, the fee-for-service (FFS) pharmacy program implemented the following parameters:

  • Management of Non-Acute Pain: All new requests for an opioid for non-acute pain (pain requiring > 7 days of therapy) greater than or equal to 90 morphine milligram equivalents (MMEs) per day will require a PA. Patients established on greater than or equal to 90 MMEs, or with a cancer or sickle cell diagnosis, or who are in hospice care will not require PA.
  • Eosinophilic Asthma (EA): PA will be required for patients with no history of corticosteroid utilization and no concurrent corticosteroid use, who are prescribed medications for the treatment of EA.
  • Second Generation Oral Antipsychotics (SGA): PA will be required for patients prescribed a dose above the maximum daily dose (MDD) approved by the FDA in the package labeling. Patients established on higher MDD will not require PA.

Additional Information and Resources:

To obtain a PA, please 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 through a new button "PAXpress" located on under the MEIPASS button. Additional relevant information can also be found at the following links:,, or

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Attention Prescribers and Pharmacies: Clarification of Medicaid Coverage for Over the Counter (OTC) Drugs

Medicaid covers over the counter (OTC) drugs for members that obtain fiscal orders that meet Medicaid criteria. These OTC drugs include select medications in the following categories: analgesic and antipyretic, antacid, anti-diarrheal, antihistamine, anti-vertigo, artificial tears and ocular/oral lubricants, chronic renal disease, cough and cold, dermatological, family planning, fecal softener and laxative, hematinic, insulin, pediculicide, smoking cessation agents, and vitamins/minerals.

All categories are represented on the Medicaid Formulary, however, not every item made by every manufacturer is covered. Furthermore, not all formulations and/or package sizes are covered. Quantities may also be limited based on acute/episodic vs. chronic/maintenance uses. The following are some examples and helpful information for prescribing and dispensing OTC items for Medicaid members:


Many drugs have multiple types of formulations, such as gel and ointment. The list will have the form available for coverage.


  • Ibuprofen tablets are covered, but capsules are not.
  • Hydrocortisone cream is covered but not when it contains aloe.

Packaging and Quantity

OTC drugs are generally covered in packaging and package sizes that are most cost effective. While prescribers may not know the package size that is covered, the dispensing pharmacist may choose the package size available that most closely resembles the fiscal order. This may mean that there are slight differences in the quantities actually dispensed.


  • Polyethylene glycol 3350 is covered in bottles, but not coverable in dose packets.
  • A prescriber writes a fiscal order for anti-diarrheal tablets for a quantity of 30 tablets, while the pharmacist has access to package sizes of 18 and 24. The order could be appropriately dispensed as 24 tablets in the prepackaged box or 30 tablets from a stock bottle. Alternatively, if the prescriber wrote for calcium 500mg tablets quantity 60, it would be inappropriate for the pharmacist to dispense the entire 500 tablet stock bottle but a package size of 100 is permissible.


Maintenance OTC medications are ones that members take on a regular basis for chronic needs. Medicaid encourages prescribing maintenance OTC medications in appropriate quantities to reduce trips to the pharmacy and to encourage compliance. Most maintenance medications are available to members up to a 90-day supply.


  • Medication such as daily low dose aspirin for cardioprotection
  • Medicaition such as daily insulin for diabetes.

Acute Use

Acute use OTC medications should be prescribed in the quantity and day supply to treat the one episode of the acute event. Excessive quantities, those that exceed the amount generally needed to treat one episode of the acute event, and refills will not be covered for OTC drugs that are generally prescribed for acute use.

Example: Medications such as pseudoephedrine that is prescribed for a cold.

Additional Information and Resources:

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Billing Guidance for Reporting Newborn Birth Weights

The New York State (NYS) Department of Health reminds hospitals to accurately report newborn birth weights on inpatient claims. Pursuant to the inpatient billing procedures for All Patient Refined Diagnostic Related Groups (APR DRGs) documented in the eMedNY New York State UB-04 Billing Guidelines - Inpatient Hospital document, claims for newborns must accurately contain the newborn's birth weight in grams. The birth weight is reported using Value Code "54" in the "Value Information" segment. To ensure proper payment when billing Medicaid fee-for-service (FFS), providers should follow the billing guidelines detailed in the eMedNY New York State UB-04 Billing Guidelines - Inpatient Hospital document (, Rule 3 – Newborns) which can be found at:


  • 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.
  • Medicaid managed care (MMC) reimbursement, billing, and/or documentation requirement 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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Billing Guidance for Reporting Alternate Level of Care

The New York State (NYS) Department of Health (the Department) reminds hospitals to accurately report the alternate level of care (ALC) status of a patient when billing Medicaid to ensure appropriate payment. This article reiterates ALC billing guidance to NYS Medicaid providers to ensure that the correct billing procedures are followed.

New York Codes, Rules, and Regulations (NYCRR) Title 10, §86-1.15(h) defines ALC services as: "those services provided by a hospital to a patient for whom it has been determined that inpatient hospital services are not medically necessary, but that post-hospital extended care services are medically necessary, consistent with utilization review standards, and are being provided by the hospital and are not otherwise available." Hospitals must properly report occurrence span code "75" with the date span the member was in ALC on the acute care claim. eMedNY Inpatient Billing Guideline §2.3.3 requires that ALC claims be split-billed. Split-billing is the "submission of multiple date range claims that when compiled represent the period from Admit to Discharge." Hospitals should not bill for acute levels of care for days while patients are in an ALC setting.

For more information regarding inpatient billing please see the New York State UB-04 Billing Guidelines – Inpatient Hospital document at:

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Guidance on Submitting Fee-for-Service Dental Claims That Involve Teledentistry and Telephonic Services for Date(s) of Service During the COVID-19 State of Emergency

Teledentistry and telephonic services fall under the umbrella of Telehealth. Dental claims involving teledentistry and dental telephonic codes can only be considered if the claim submission meets specific requirements.

Telehealth is defined as the use of electronic information and communication technologies to deliver health care to patients at a distance. Medicaid covered services provided via telehealth include assessment, diagnosis, consultation, treatment, education, care management and/or self-management of a Medicaid member. While New York State (NYS) is in the State of Emergency, this definition is expanded to include telephone conversations. Therefore, during the State of Emergency, telehealth includes telephonic, telemedicine, store and forward, and remote patient monitoring. Telemedicine includes teledentistry. Telemedicine/teledentistry is the term used in this guidance to denote two-way audiovisual communication to deliver clinical health care services to a patient at an originating site by a telehealth provider located at a distant site.

Originating Site

The originating site is where the patient member is located at the time health care services are delivered by means of telehealth. Originating sites during the State of Emergency can be anywhere the patient member is located including the member's home. There are no limits on originating sites during the State of Emergency.

There is one procedure code applicable to the originating site – "Q3014" (see below). There may not be a billable originating site (e.g. if a patient initiates an audiovisual connection with the dentist from their residence).

"Q3014" - Telehealth Originating Site facility fee.

Dentists enrolled in the NYS Medicaid Program who initiate the service at the originating site may use procedure code "Q3014". The following criteria apply:

  • "Q3014" reimburses at $27.76.
  • "Q3014" must be entered on line #1 of the claim.
  • "Q3014" may be entered as the only code on the claim.
  • If other treatment is performed these services can be entered on subsequent claim lines.
  • Must use Place of Service (POS) code – "02" for the originating site.

Distant Site

The distant site is the site where the telehealth provider is located while delivering health care services by means of telehealth. During the State of Emergency any site within the fifty United States or United States' territories is eligible to be a distant site for delivery and payment purposes, including Federally Qualified Health Centers (FQHC) and the provider's home, for all patients including patients dually eligible for Medicaid and Medicare. The POS code – "02" must be used for the distant site. There are two procedure codes, "D9995" and "D9996", applicable for use by the dentist at the distant site.

"D9995" - Teledentistry – synchronous; real time encounter claim submission. The following criteria apply:

  • "D9995" reimburses at $0.00.
  • "D9995" must not be reported as a stand-alone procedure.
  • "D9995" must be entered on line #1 of the claim.
  • All services rendered must be reported on subsequent claim lines.
  • Services rendered should be appropriate for telehealth (teledentistry) and within the provider's scope of practice.
  • Approvable services listed on subsequent lines reimburse at the fee listed on the NYS Medicaid Fee Schedule as per policy.
  • Claims may pend for manual review.
Example 1 - Dental Claim Submitted Correctly:
  • "D9995" would be entered on claim line #1.
  • There may be a fee listed for "D9995"; Medicaid will reimburse at $0.00.
  • "D0140" is entered on claim line #2.
  • There would be a fee of $14.00 or more entered for "D0140"; Medicaid will reimburse at the usual Medicaid fee of $14.00.
  • This claim will reimburse a total of $14.00.
Example 2 - Dental Claim Submitted Incorrectly:
  • "D9995" entered on claim line #1.
  • There may be a fee entered for "D9995"; Medicaid will reimburse at $0.00.
  • No additional procedure codes listed on subsequent lines.
  • This claim will reimburse at $0.00.
  • Claims for "D9995" submitted as a stand-alone procedure may be denied by DOH to alert providers of this error.
Example 3 - Dental Claim Submitted Incorrectly:
  • "D0140" listed on claim line #1.
  • "D9995" listed on claim line #2.
  • This claim will be denied by DOH; "D9995" must be entered on claim line #1.

"D9996" - Teledentistry – asynchronous; information stored and forwarded

Store-and-forward technology involves the asynchronous, electronic transmission of a member's health information in the form of patient-specific pre-recorded videos and/or digital images from a provider at an originating site to a telehealth provider at a distant site. Store-and-forward technology aids in diagnoses when live video or face-to-face contact is not readily available or not necessary, or in the case of the State of Emergency is imprudent. Pre-recorded videos and/or static digital images (e.g., pictures), excluding radiology, must be specific to the member's condition as well as be adequate for rendering or confirming a diagnosis or a plan of treatment. The following criteria apply:

  • "D9996" must involve at least two separate providers who are enrolled in the NYS Medicaid Program (one provider at the originating site and one provider at the distant site).
  • "D9996" reimburses at $0.00.
  • "D9996" must not be reported as a stand-alone procedure.
  • "D9996" must be entered on line #1 of the claim.
  • All services rendered must be entered on subsequent claim lines.
  • Services rendered should be appropriate for telehealth (teledentistry) and within the provider's scope-of-practice.
  • Approvable services entered on the subsequent lines reimburse at 75% of the fee listed on the NYS Medicaid Fee Schedule as per policy.
  • Claims may pend for manual review.

Dental Telephonic Services (D9991)

Telephonic service uses two-way electronic audio-only communications over the telephone to deliver services to a patient at an originating site by a telehealth provider located at a distant site. When telephonic services are rendered by a dentist, the provider must use procedure code "D9991", dental case management – addressing appointment compliance barriers.

"D9991" – Dental Case Management – addressing appointment compliance barriers. The following criteria apply:

  • "D9991" reimburses at $14.00
  • "D9991" may be reported as stand-alone procedure.
  • If the patient presents subsequent to the telephonic service for definitive treatment (e.g. extraction, palliative treatment, etc.) it is recommended that those services be submitted on a separate claim.
  • The place of service designation must identify the location where the service would have been rendered had it been a face-to-face encounter (e.g. Office POS – "11")
  • "D9991" (telephonic services) must be performed by a provider enrolled in the NYS Medicaid Program.

Note: Claim submissions delayed beyond 90 days of the date of service due to the current COVID-19 emergency may be submitted for consideration with Delay Reason Code "15".

Additional Information:


Questions regarding this policy may be directed to(800) 342‑3005 or via email 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 6/16/202

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.

Payment Year 2019 Final Deadline

The regular attestation period for Payment Year (PY) 2019 is now closed, but any providers who were granted an Attestation Deadline Extension (ADE) have until July 8, 2020 to submit their data in MEIPASS. Providers who have not been granted an ADE are no longer eligible to receive payment for this PY, but are encouraged to attest in upcoming PYs. As it is now more than halfway through the 2020 reporting year, providers are encouraged to begin preparations for their PY2020 attestations.


The NY Medicaid EHR Incentive Program will host quarterly Program Discussion Webinars on a variety of topics identified by support staff and the provider community. Providers who would like to have a particular topic discussed should submit requests by completing the Program Satisfaction Survey at: Schedule and registration information for all webinars, including Program Discussions, Stage 3, Security Risk Analysis, Public Health Reporting, Patient Engagement, and Health Information Exchange can be found at:

LISTSERV Communications

As the COVID-19 State of Emergency continues to evolve, additional information and program changes may be announced. The NY Medicaid EHR Incentive Program utilizes a LISTSERV messaging system to quickly communicate any changes or updates and recommends that providers and administrators subscribe in order to best be kept up to date. Information and instructions on how to subscribe can be found on the NY Medicaid EHR Incentive Program LISTSERV webpage at: Providers who experience any difficulty when attempting to subscribe should contact the support team for assistance.

Check Participation Status

At minimum*, a provider must have completed and received an incentive payment for one payment year in PY 2016 or earlier to participate for future years. Providers uncertain about their participation status are encouraged to reach out to the NY Medicaid EHR Incentive Program support team for assistance. Program participation status can be verified and reviewed using the provider's National Provider Identifier (NPI) and may assist in determining a provider's ability to attest in PY2019-2021. Providers who wish to check their participation status should contact the support team at (877) 646‑5410 (Option 2) or via email at:

*Providers must also meet all other relevant program requirements and metrics to be eligible to participate in the NY Medicaid EHR Incentive Program.

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
  • 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
MU Direct:
New York eHealth Collaborative (NYeC)
Phone: (646) 817‑4101
MU Direct:


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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eMedNY eXchange

The eMedNY eXchange is an access method used to submit and receive batch files in the eMedNY system via a web-based application on the website. The eXchange works like an email inbox; the user can send and receive files in an email-like fashion. Files are uploaded by the user and submitted to eMedNY for processing. Once a batch file is processed, responses are delivered to the user's inbox, where they remain available to the user for 28 days. Response files should be downloaded to the user's computer. The eMedNY eXchange login webpage can be by selecting the "Login eXchange" button on the right side of the eMedNY homepage.

To access the eXchange, users will first need to enroll in the electronic Provider Assisted Claim Entry System (ePACES) and successfully login to their ePACES account. The ePACES User ID and password are also used to access the eMedNY eXchange.

The eMedNY eXchange accepts and returns the following batch file types:

  • X12:
    • "837" - Dental, Professional and Institutional Claims
    • "835" - Remittance Advice
    • "834" - Medicaid Managed Care Benefit Enrollment and Maintenance
    • "820" - Premium Payment for Insurance Remittance Advice (Managed Care Plans only)
    • "270/271" - Eligibility Benefit Inquiry and Response
    • "276/277" - Claim Status Request and Response
    • "277CA" - Claims Acknowledgement
    • "278" - Prior Approval/Prior Authorization/Service Authorization Request and Response (except for DVS requests)
    • "TA1" - Interchange Acknowledgment
    • "999" - Acknowledgement for Health Care Insurance
  • NCPDP - D.0 - National Council for Prescription Drug Programs (Batch only)
    Note: Software is required to create and interpret X12 and D.0 files
  • Proprietary to eMedNY
    • "F-File" - Batch Rejection Message
    • "835S" - Supplemental record containing pended claim detail
    • "820S" - Supplemental record containing pended and denied Capitation claim detail
    • Facility Practitioner NPI Reporting (Batch)
    • PDF Remittance Advice
    • PDF Formatted Paper Prior Approval Roster

Additional Information and Questions:

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eMedNY Offers Online Medicaid Provider Training Webinars

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 webinar-based training. eMedNY offers various types of online training to providers and their billing staff. Webinar training sessions are conducted online and allow providers the ability to join the session safely from their computer and telephone. Many of the trainings planned for the upcoming months offer detailed information and instruction about Medicaid's web-based billing and transaction program, ePACES. PACES allows enrolled providers to submit the following type of transactions:

  • Claims
  • Eligibility Verifications
  • Utilization Threshold Service Authorizations
  • Claim Status Requests
  • Prior Approval Requests

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

Additional trainings are also available and highly recommended. Training topics, dates and times, and registration information is available on the eMedNY website at: Training descriptions should be reviewed carefully to identify the training that is appropriate for the provider's specific billing requirements. Webinar registration confirmation will be sent to the e-mail address provided. Registration questions should be directed to the eMedNY Call Center at (800) 343‑9000 .

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