New York State Medicaid Update - September 2020 Volume 36 - Number 14

In this issue …

Private Duty Nursing Providers

Effective October 1, 2020, New York State Medicaid will increase private duty nursing fee-for-service rates for Licensed Home Care Agencies (LHCAs), Independent Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) who enroll in the Private Duty Nursing (PDN) Directory (Directory) for Medically Fragile Children (MFC). The enhanced fee will be implemented over a period of three years. These changes were authorized in the Fiscal Year 2021 enacted budget.

The enhancements include, but are not limited to:

  • increasing Medicaid fee-for-service (FFS) rates of payment over three years for providers who participate in the PDN Directory;
  • increasing the maximum age of coverage under the PDN program for MFC from 21 years to 23 years;
  • moving from county-based fees to State level-based fees;
  • establishing upstate and downstate regional fees; and
  • creating a new PDN Directory on the New York State Department of Health (DOH) web site. The purpose of the Directory is to ensure adequate access to PDN services by promoting the availability and ensuring delivery of PDN services for MFC up to the age of 23.

In order to assist providers and interested parties in staying up-to-date on process changes related to the PDN program, all are encouraged to sign up for the LISTSERV which can be found on the eMedNY website at: Information on training sessions can also be obtained on the website at:

Questions and Additional Resources

  • Enrollment and/or billing questions should be directed to the eMedNY Call Center at (800) 343‑9000.
  • FFS prior approval questions should be directed to the Office of Health Insurance Programs (OHIP) Call Center at (800) 342‑5000, or via email at or
  • Program updates and news will be posted on the eMedNY website and in upcoming Medicaid Update editions.

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Fee-For-Service Reminders from the Bureau of Dental Review

The Need to Bill Third-Party Insurers

Third-party insurers, including Medicare, provide reimbursement for various dental procedures. Since Medicaid is the payer of last resort, the provider must bill the member's third-party payers prior to requesting payment from Medicaid. If the third party is a commercial plan, Medicaid will reimburse the difference only if the total third-party payment(s) is (are) less than the lesser of the provider's fee charged to the general public or the fee developed by New York State Department of Health (DOH) for the specific procedure code. If the third party is a Medicare Advantage plan, Medicaid will reimburse eighty-five percent (85%) of the patient responsibility. Prior to initiating treatment which has been approved by a third-party insurance plan, the provider should obtain a prior approval from Medicaid to ensure that the treatment plan falls within the current guidelines of the Medicaid Program. Failure to do so may result in the denial of Medicaid benefits for these services.

When to Submit a Prior Approval Change of Request Form

If a change is needed or there exists a disagreement with a prior approval review and there is need to challenge a determination rendered by DOH on an existing finalized prior approval, a request may be submitted with supporting documentation and a detailed report using a "Prior Approval Change Request Form". This form may be submitted pre-operatively or post-operatively, if the requested change is submitted post-operatively, a copy of the treatment notes should be included with the request. The Prior Approval Change Request Form can be obtained at: or by calling eMedNY at (800) 343‑9000.

When to Submit a Claim for Payment for Fixed and Removable Prosthetics

Claims for fixed and removable prosthetics (including implant related prosthetics) are not to be submitted until the procedure has been completed and inserted in the patient's mouth. The final insertion date is the date of service.

Questions regarding this article should be directed to

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Medicaid Pharmacy Prior Authorization Programs Update

On July 23, 2020, the New York State Medicaid Drug Utilization Review (DUR) Board recommended changes to the Medicaid pharmacy prior authorization programs. The Commissioner of Health has reviewed the recommendations of the Board and has approved changes to the Preferred Drug Program (PDP) within the fee-for-service (FFS) pharmacy program.

Effective October 8, 2020, prior authorization (PA) requirements will change for some drugs in the following PDP classes:

  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
  • Central Nervous System (CNS) Stimulants
  • Acne Agents, Topical
  • Topical Steroids, High Potency
  • Glucagon-like Peptide-1 Agonists
  • Sulfasalazine Derivatives
  • Immunosuppressive, Oral
  • Phosphate Binders/Regulators
  • Hepatitis C Agents - In addition to the standard clinical criteria for non-preferred products, all products require prior authorization if there is no evidence of a Federal Drug Administration (FDA)-approved or compendia-supported diagnosis in history or if the patient is being retreated.

Detailed information on the DUR Board can be found at:

Information on the Medicaid FFS Pharmacy Prior Authorization (PA) Programs, including a full-listing of drugs subject to the Medicaid FFS Pharmacy Programs can be found at:

Obtaining a PA

To obtain a PA, providers should contact the clinical call center at: (877) 309‑9493. The call center is available 24 hours per day, 7 days per week, with pharmacy technicians, pharmacists, or provider agents available to assist 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 eMedNY website ( under the Medicaid EHR Incentive Program Administrative Support Service (MEIPASS) button.

Additional Information

Additional information can also be found on the following websites:

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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 09/15/2020

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 of NY Medicaid EHR Incentive Program.

Payment Year (PY) 2020 Soft Opening Period

As the timeframes between PYs become shorter, providers who are ready to attest will be given the opportunity to do so before the official PY opening, by means of a process called a soft opening. The soft opening will function in the same way an official opening does, with remediation and review processes that mirror what providers are used to. The main differences are that soft openings occur earlier in the year, and because of this the Meaningful Use (MU) criteria must be met sooner than normal if a provider wishes to attest during this period.

The PY 2020 Soft Opening period is happening now. Providers who have met the attestation criteria will be able to complete their attestations in the Medicaid EHR Incentive Program Administrative Support Service (MEIPASS). Providers may login to the MEIPASS system at: Providers are encouraged to gather and submit their attestation data during this time. The Soft Opening Period will continue until the Official Opening on January 1, 2021.

PY 2020 Pre-validation Period

If EPs or a group of EPs have already selected their reporting period and calculated their patient volume prior to the MEIPASS attestation system being opened for the PY, the EPs are able to complete a Pre-validation. A Pre-validation allows providers to submit their patient volume data for review and approval ahead of attestation and can allow the EPs to advance through the review process more quickly once MEIPASS begins accepting attestations.

Pre-validations for PY 2020 will be accepted from September 14, 2020 through December 14, 2020. If providers would like to take advantage of this service and avoid patient volume remediation during the official or soft opening attestation periods, they must begin the process of finding a suitable Medicaid patient volume reporting period. To submit a Pre-validation, simply select your Patient Volume Reporting period and fill out the appropriate Pre-validation form with the data for that period. Forms can be found on the Document Repository page of the EHR web site at:

Check Provider Participation

At minimum*, a provider must have completed and received an incentive payment for one PY in 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 PY 2019-2021. 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.

LISTSERV Communications

Additional information and program changes are announced periodically, especially as the program begins its final years. The NY Medicaid EHR Incentive Program uses 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.


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:

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 on 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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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