DOH Medicaid Update March 2004 Vol.19, No.3

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Computer Sciences Corporation (CSC), on behalf of the New York State Department of Health (DOH), has developed the Electronic Provider Assisted Claim Entry System (ePACES). ePACES is a web-based application that allows providers to request and receive HIPAA-compliant claim (professional, institutional, and dental), eligibility, claim inquiry, service authorization, and Dispensing Validation System (DVS) transactions.

Some providers are experiencing slow ePACES response times. This could be the result of a provider's configuration. The recommended PC and network requirements to run the ePACES web-based application include:

• a browser (minimum version: Netscape version 4.7 or Microsoft Internet Explorer version 4.01), and
• access to the Internet via a broadband connection (AOL Broadband, Road Runner, DSL connection, etc.), or dial-up connection (AOL dial-up, AT&T, Netzero dial-up, etc.) at 56Kbps or greater for optimal performance of ePACES.

Providers are not constrained in their choice of operating system. You can run Microsoft Windows, Macintosh, or Linux. Providers do not need to install any customized software on their computer.

For assistance in determining if your system meets these requirements, please contact your computer vendor or the IT (information technology) Department of your organization. Additional information on the ePACES software application may be found at http://www.emedny.org/HIPAA/SupportDocs/ePACES.html.

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The Office of Medicaid Management has the responsibility to audit providers who are billing for Medicaid services. Over the past year, routine reviews of documentation have been modified to include a component for medical necessity, where indicated.

In the past, many providers have complained that documentation reviews favored form over substance, and in some cases resulted in penalties that were excessive given the regulatory violations. In an attempt to provide more substantive feedback both to the provider community and to program managers, all billing audit protocols have been revised to include:

• verification of documentation issues through independent sources; and
• an evaluation of medical necessity and/or quality, where indicated.

The Medicaid program has been working with the Office of Mental Health, the Office of Mental Retardation and Developmental Disabilities, and the Office of Alcohol and Substance Abuse Services, to determine standards of care for use in determining medical appropriateness. The Island Peer Review Organization (IPRO) has conducted evaluations of medical necessity and quality. Results have been promising. It is expected that this approach will be expanded in the future using IPRO, other contractors, program experts and clinicians from the Department of Health or other program agencies, as necessary.

This approach will produce more effective audit results for both providers and the Medicaid program!

We ask for your cooperation in producing records should you be identified for an expanded review.

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In 2000, the Department promulgated new regulations (found at Title 10 New York Codes Rules and Regulations, Part 703) regarding the operation of part-time clinics. In conjunction with these changes, the Department and the Attorney General's Office have conducted reviews and investigations of part-time clinics. Our investigations have revealed common violations of State law and regulations by part-time clinic providers. These violations include:

• operation of sites in excess of the maximum 60 hours per month;
• operation of sites not approved by the Department;
• failure to obtain appropriate licensing from agencies such as the Office of Mental Health (OMH) where required;
• failure to adequately supervise and properly credential staff;
• operation of sites in prohibited settings such as adult homes;
• providing services outside the scope of the clinic's operating certificate;
• failure to prepare and maintain contemporaneous records to support claims for Medicaid payment; and,
• provision of questionable medical services, which were either not medically necessary or inappropriately billed.

Rules of Participation

Failure to comply with Department regulations can result in administrative sanctions (termination from the Medicaid program), liability for overpayments and criminal prosecution.

Additionally, part-time clinic providers must properly complete the Medicaid claim form:

• The form must include a proper identification of the part-time clinic site where the service was performed.
  • The proper identification of the clinic site is the part-time clinic billing identification number provided to you by the Office of Health Systems Management (OHSM) when you were approved to operate as a part-time clinic.
• When submitting a part-time clinic claim, enter your assigned part-time clinic billing identification number in the "Part-Time Clinic Certification Number" field in the Version 4 and Version 5 claim formats.
  • This field is a 13 byte alphanumeric field starting in position 26 of Record Type 15 (Provider Data).
  • The first 11 bytes of this field should contain the Part-Time certification number assigned to your clinic; the last two bytes should contain the letters "PT".
• Your claim must also use the correct MMIS part-time clinic rate code to be valid:
  • For hospital based part-time clinics, use Rate Code 2880.
  • For free-standing part-time clinics (diagnostic & treatment centers), use Rate Code 1629.

For further billing information, review the billing instructions in your provider manual and in the March 2003 Medicaid Update.

In the future, the Department may conduct a Medicaid provider re-enrollment of part-time clinics. This is separate from the clinic certification process conducted by OHSM. Providers will be notified in writing when to re-enroll.

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Physicians, dentists and other practitioners may be in individual practices or practice with others in a group. If the services are provided in a group setting, the group must be a definable and legitimate entity which is enrolled in the Medicaid program as a group provider.

All providers that submit claims to the Medicaid program for group reimbursement must identify:

• the Medicaid provider number of the individual who provided the services; and,
• the group Medicaid provider number (where services are provided in a legitimate group setting).

In this case, payment will be made to the group provider number. Use of any other provider number is prohibited.

Requirements of Individuals in the Group

• All individual practitioners in the group must be enrolled as Medicaid providers. Pursuant to federal and State regulations, no individual in the group may be a sanctioned provider.
• The group must immediately notify the Office of Medicaid Management (OMM), Bureau of Enrollment, in writing, of the following:
  1. Addition or deletion of group members
  2. Change in ownership of the group
  3. Change/addition in address or service location
• Any individual practitioner leaving a group must also notify OMM, in writing, with the effective departure date.
• Send written notification to:
  New York State Department of Health
  Office of Medicaid Management
  Fee-For-Service Provider Enrollment Unit
  150 Broadway, Suite 6E
  Albany, NY 12204-2736

  If your group has not complied with these requirements, it must do so immediately.

• Upon leaving the group, a practitioner may no longer use the group provider number. Likewise, a group may not use the provider number of an individual who has left the group.

Where an individual practitioner leaves the group and fails to notify the Department in writing, the individual's liability for group activity will continue (see subsequent section on Liability ). Since all Medicaid providers are individually liable for submitted claims that use their individual provider number, providers are strongly cautioned to guard against the inappropriate use of their Medicaid provider number.

Group Compensation

Members of the group will either be principals (associates), employees, independent contractors or a combination of the above.

• The compensation agreement between group members must be in writing, and must be made available to the Department upon request.
• Federal and State anti-kickback provisions provide for administrative and criminal penalties for improper compensation arrangements. Improper arrangements usually involve compensation paid on a percentage basis. (Since not all such arrangements are illegal, you may wish to seek the advice of counsel regarding these issues.)

Liability

Any individual practitioner in the group, or their designated agent (including billing agents), may certify a Medicaid claim for payment where the group number is used on the Medicaid claim. As stated above, an individual's Medicaid provider number may not be used to bill for services performed by other group members. Where a group provider number is used on the Medicaid claim, the individual provider of care must be identified.

When a group provider number is used in Medicaid claiming, regardless of who certifies the claim:

• all members in the group are liable for overpayments;
• all members are subject to administrative sanctions (termination from Medicaid) and could be subject to criminal penalties for such violations as filing a false claim;
• the unauthorized use of any individual's Medicaid provider number without their knowledge and consent is prohibited and is subject to administrative sanctions or prosecution; and
• where an individual leaves the group and fails to notify the Department in writing, liability for group submission of claims continues until such time as the Department receives written notification of the departure.

Submission of Claims to the Medicaid Program

When billing for any type of group practice (group of associates, or group employing other physicians or dentists):

• the group Medicaid identification (ID) number (assigned by the Department at the time of enrollment as a group) must be entered in the "Medicaid Group Identification Number" field of the claim form; and
• the physician, dentist, or other practitioner who actually provided the service must be identified by entering his/her Medicaid ID number in the "Provider Identification Number" field of the claim form (on HCFA-1500, field 25A; on paper Form A, field 1; on Electronic Form A, record D1, positions 10-17).

Where group services are provided at multiple locations, the place of actual service must be entered into the appropriate field on the claim form.

If you are submitting claims as an individual, you are required (with certain exceptions as stated below) to have rendered the service, certify as such, and utilize your individual provider number.

A physician, dentist, or other practitioner enrolled in Medicaid only as an individual provider must not use his/her individual provider ID number to bill Medicaid for services actually provided by another physician or dentist except for the following two situations:

• When a physician is supervising a physician assistant or certified social worker. In this situation, the physician assistant or the certified social worker must be identified in the "Service Provider" name field (HCFA-1500, fields 22A [name] and 22C [Medicaid ID/license]; Electronic Form A, record D2, positions 58-65). If using a license number by the State Education Department, also complete field 22B.
• When a locum tenens agreement is in effect. The Department's policy regarding locum tenens is stated in the following article, and can be found in the MMIS Physician Manual, Section 2.2.3 B, page 2-63.

If the group is affiliated with a hospital or other Article 28 entity, but is a separate and definable entity (that is the members of the group are not employees of the hospital), the group may not utilize the provider number of the hospital. The entity is required to enroll as a group and utilize the group Medicaid provider number for billing.

Sanctions

Administrative sanctions (exclusions and terminations) and the recovery of overpayments by the Department may result from improper claiming and from the failure to comply with group notification requirements as stated in this article. Additionally, the State Attorney General's Office will investigate egregious behavior.

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Federal law requires that payment for services be made to the provider of service. An exception to this requirement may be made when one physician arranges for another physician to provide services to his/her patients under a locum tenens arrangement.

The law allows such locum tenens arrangements:

• on an informal, reciprocal basis for periods not to exceed 14 days; or,
• for periods of up to 90 days with a more formal agreement.

Record of either arrangement must be maintained in writing to substantiate locum tenens payment.

Physicians who are enrolled in the Preferred Physicians and Children's Program (PPAC) or the Medicaid Obstetrical and Maternal Services (MOMS) Program must make locum tenens arrangements with physicians who are also enrolled in the PPAC or MOMS program in order to receive the enhanced fees associated with these programs. If locum tenens arrangements are made with physicians who are not enrolled in the respective programs, the locum tenens payment will be made at the regular Medicaid fee.

Locum tenens arrangements should not be made with any physicians who have been disqualified by the New York State Medicaid program.

The service authorization, which is cleared through MEVS, must be in the name of the billing physician, not in the name of the service provider, in a locum tenens arrangement.

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During March 2004, revised New York State fee schedules will be sent to all enrolled durable medical equipment and pharmacy providers.

These revised fee schedules contain important billing code and prior approval related changes that will become effective April 1, 2004.

If you do not receive a revised fee schedule by April 1, 2004, please contact Computer Sciences Corporation Provider Relations. DME providers call (800) 522-5535 or (518) 447-9830, and pharmacy providers call (800) 343-9000.

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General Expectations

• Dental clinics reimbursed on a rate basis (i.e., hospital outpatient departments, diagnostic and treatment centers, and dental schools) are required to follow the policies stated in the MMIS Dental Provider Manual (Section 2.2.3.1 General Policy).
• The provision of dental care and services are limited to those procedures presented in the Dental Fee Schedule, and are to be provided within the standards and criteria listed in the procedure code descriptions (Section 5.0).
• Dental care provided under the Medicaid program includes only essential services (rather than "comprehensive" services). Clinics and dental schools should refer to the Dental Manual to determine when dental services are considered "essential."

Findings From Audits

Recent audits and reviews of dental clinic services conducted by the Department have identified situations that have required facilities to implement corrective action. These situations generally fall into three categories:

1. Services not within the scope of the Medicaid program.
2. Services that do not meet existing standards of professional practice.
3. Miscellaneous Issues - Reminders and/or clarification of various administrative issues related to the provision of dental clinic services.

The Department wants all dental clinics to be aware of their responsibilities, as well as Department expectations, for the provision of dental services. Accordingly, we offer the following guidance to dental clinics:

1. Services Not Within The Scope of the Medicaid program:

   - dental implants;

   - aesthetic veneers, such as porcelain fused to metal crowns (for other than anterior teeth and maxillary first bicuspids);

   - fixed bridgework, except for cleft palate stabilization, or when a removable prosthesis would be contraindicated;

   - immediate dentures;

   - molar root canal therapy for patients 21 years of age and over, except when extraction would be medically contraindicated or the tooth is a critical abutment for an existing serviceable prosthesis;

   - crown lengthening;

   - replacement of dentures prior to required time periods (currently 4 years), unless appropriately documented and justified as stated in the Manual;

   - dental work for cosmetic reasons or because of the personal preference of the patient;

   - periodontal surgery, except for procedure code D4210 - gingivectomy or gingivoplasty, for the sole correction of severe hyperplasia or hypertrophy associated with drug therapy, hormonal disturbances or congenital defects;

   - adult orthodontics, except in conjunction with, or as a result of, orthognathic surgery;

   - placement of sealants for patients over 15 years old;

   - improper usage of panoramic x-rays (00330) along with intraoral complete series x-rays (00210).

2. Services Which Do Not Meet Existing Standards of Professional Practice:

   - partial dentures provided prior to completion of phase I restorative treatment which includes removal of all decay and subsequent fillings;

   - extraction of clinically sound teeth for the purpose of placing a partial denture;

   - infected teeth left untreated;

   - restorative fillings redone over a short time period without clinical indication;

   - restorative treatment of teeth that have a hopeless prognosis and should be extracted.

3. Miscellaneous Issues:

   - Patient medical histories should be updated periodically (annually at a minimum) and be maintained as part of the patient's dental records. The treating practitioner should refer to the patient history to avoid unnecessary repetition of services.

   - Non-emergency initial visits should include a cleaning, x-rays (if required), and a dental exam with a definitive treatment plan. Generally, this should be accomplished in one visit. However, in rare instances, a second visit may be needed for completion of these services. We would expect a notation in the record to indicate the reason for a second visit.

   - Quadrant dentistry should be practiced, wherever practicable, and the treatment plan followed in normal sequence.

   - Dental x-rays should be clear and allow for diagnostic assessment. They are performed based on patient need, age, prior dental history and clinical findings.

   - Facilities should use the Department's PVR 292 list (providers who may not bill or order services) when checking and verifying the credentials of the dental professionals that make up their staff. This list is currently available on the Department's website at: http://www.health.state.ny.us/health_care/medicaid/fraud/dqprvpg.htm

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Procedure codes W5000 and W5500, for dates of service on or after July 1, 2003, are no longer valid.

Commencing with dates of service on and after July 1, 2003, practitioners who participate in the Preferred Physicians and Children's Program (PPAC) have been instructed to bill Medicaid in the following manner:

• For services furnished in an office setting, use the CPT-4 Evaluation and Management Codes 99201 - 99205 and 99211 - 99215; and,
• For services furnished in an inpatient hospital setting, use the CPT-4 Evaluation and Management Codes 99221-99223, 99231-99233 and 99238-99239.

These changes were made to address national medical procedure coding protocols required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Although some providers have questioned this usage, at this time, these Evaluation and Management Codes are the only CPT-4 procedure codes eligible to receive enhanced PPAC reimbursement for well-child or newborn care.

If you are a PPAC provider, DO NOT use CPT-4 Preventive Medicine Codes (99381 - 99384, 99391 - 99394 or 99431-99435) when billing Medicaid for well-child or newborn care. Use of these codes will result in a lower Medicaid payment than you are entitled to!

Enrolled providers should have received updates to the MMIS Provider Manual in June 2003 that provided information on these codes (pages 6-1 through 6-3 and 7-99 and 7-100) and the maximum reimbursement associated with them.

For providers billing for well-child care under the Child/Teen Health Program (C/THP) guidelines:

• add the -EP modifier; and,
• complete the C/THP-EPSDT Referral Code Indicator in Field 22D of the Medicaid HCFA 1500 Claim Form to indicate that a C/THP service is being provided.

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Prescribers: Prescription Writing Requirements

Provide your State license number or your MMIS identification number on all prescriptions written for Medicaid recipients. This will ensure proper processing of your patient's prescription. When a prescription is written by an unlicensed intern or resident, the supervising physician's NYS MMIS number or State license number must be provided. Please refer to the December 2003 Medicaid Update for further information on prescription requirements.

Pharmacists: A facility MMIS number can only be used to process pharmacy claims under the Medicaid program as a last resort. Use of a large number of facility IDs by a pharmacy will result in closer scrutiny and review of the pharmacy's claims. If the prescriber's license number or MMIS number has not been provided, pharmacists should attempt to contact the prescriber to obtain their license number or MMIS number and to verify the prescriber's identity. If a pharmacist is certain that the prescription is from a legitimate prescriber and their license number or MMIS number is readily available in the records of the pharmacy, it is not necessary to record this number on the prescription.

Pharmacists: Prescription Claim Processing Requirements

The Medicaid program uses specific edits that aid in the detection of fraud, and the identification of prescribers who are not permitted to order Medicaid services. All pharmacy transactions/claims, whether submitted electronically or on paper, are subject to the same edits.

Specific prescriber information is required on all prescriptions under NYS law.* The prescriber's MMIS number or license number is also important for successful prescription processing and payment under the NYS Medicaid program.

*For more information regarding NYS Education Law, refer to the NYS Education Department at: Office of the Professions, State Education Building, 2nd Floor, 89 Washington Ave., Albany, NY 12234. Telephone: (518) 474-3817 or Web site:http://www.op.nysed.gov

Processing Pharmacy Claims using the NYS MMIS Number, NYS License Number and Out of State License Number

**A nurse practitioner or midwife who is licensed to prescribe will have the letter F preceding the six-digit license number. An optometrist who is licensed to prescribe will have the letter U, V or T preceding their license number. When entering license numbers for either of these provider types, the field should be populated as following:

e.g., For a NYS licensed nurse practitioner with a license number of F123456, the following is the correct entry format: 290F123456

Paper Claim Processing

In those instances when a paper claim is needed, refer to the MMIS Provider Manual. Checking the prescriber information on eMedNY prior to dispensing is as important to claim payment as verifying client eligibility and DUR information.

Paper claim submissions mimic ECCA submissions with regard to license types and format. For example, a physician licensed in New Jersey, license number 123456, would be reported as 11NJ123456 (ECCA); using a paper claim (non-ECCA) would be reported as license type 11, license number NJ123456.

Rejected Claims and Responses

If the prescriber information is not accepted, you will receive one of the following eMedNY responses:

• 056 if the prescriber information is blank or in the wrong format;
• 059 if the prescriber type is invalid;
• 066 if the prescriber is not permitted to order services;
• 067 if the prescriber is deceased; or
• 068 if the prescriber number is not found on the Medicaid license file.

If submitting via NCPDP, you will also receive an NCPDP reject code 25 M/I Prescriber ID.

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Obesity is fast becoming the largest public health crisis in America with nearly two-thirds of the population overweight and one-third obese. Obesity is second to smoking as the most preventable cause of death. Obesity is an epidemic among all age groups, particularly America's youth. Studies of restaurant servings between 1977 and 1998 reveal that portion sizes have increased across the board for most types of food. For some foods, the portion sizes have increased by as much as 50 percent.

Being in better control of your eating helps you feel in better control of other aspects of your life. Keep in mind that food is NOT the enemy. It has sustained us as a species for millennia. Eating should be an adventure and not a hurried ordeal. Awe the senses with aroma and rich flavor. Keep portion awareness in mind and visualize sensible portion sizes to win the battle over obesity.

A good guideline to help you understand portion sizes is to translate the abstract information represented by the serving size into something visual that's easily remembered. So instead of trying to memorize lists of ounces, cups and tablespoons, simply compare the serving sizes of particular foods to familiar physical objects. Below are a few examples of single servings.

Ways of Developing and Maintaining Portion Control

AT HOME

Use smaller dishes at meals.

Serve food in the appropriate portion amounts and don't go back for seconds.

Put away any leftovers in separate, portion-controlled amounts. Consider freezing the portions you likely won't eat for a while.

Never eat out of the bag or carton.

Beware of unconscious eating particularly in front of the television, computer or when talking on the telephone.

Don't keep platters of food on the table; you are more likely to "pick" at it or have a second serving without even realizing it.

AT RESTAURANTS

Ask for half or smaller portions.

Eyeball your appropriate portion, set the rest aside, and ask for a doggie bag right away. Servings at many restaurants are often big enough to provide lunch for two days.

Order two small appetizers as your main course.

If you have dessert, share.

AT THE SUPERMARKET

Beware of "mini-snacks" -- tiny crackers, cookies, and pretzels. Most people end up eating more than they realize, and the calories add up.

Choose foods packaged in individual serving sizes.

If you're the type who eats ice cream out of the carton, pick up ice cream sandwiches or other individual size servings.

If you, or someone you know, is in receipt of Food Stamps and want more information about good nutrition, Eat Smart New York may be able to help. To locate one of the 56 ESNY projects in your area, you may go to the FSNEP website at: http://www.otda.state.ny.us/otda/fs/FSNEP/FSNEP_default.htm

Or you may contact, Ms. Sandy Borrelli, NYS FSNEP coordinator, at (518) 473-0401, or email AV1820@dfa.state.ny.us

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Missing Issues?
The Medicaid Update, now indexed by subject area, can be accessed online at the New York State Department of Health website: http://www.health.state.ny.us/health_care/medicaid/program/main.htm
Hard copies can be obtained upon request by calling (518) 474-9219.

Would You Like Future Updates Emailed To You?
Email your request to our mailbox, MedicaidUpdate@health.state.ny.us. Let us know if you want to continue receiving the hard copy in the mail.

Do You Suspect Fraud?
If you suspect that a recipient or a provider has engaged in fraudulent activities, please call the fraud hotline at: 1-877-87FRAUD. Your call will remain confidential.

As a Pharmacist, Where Can I Access the List of Medicaid Reimbursable Drugs?
The list of Medicaid reimbursable drugs is available at: http://www.emedny.org/info/formfile.html

Questions About an Article?
For your convenience each article contains a contact number for further information, questions or comments.

Do You Want Information On Patient Educational Tools and Medicaid's Disease Management Initiatives?
Contact Department staff at (518) 474-9219.

Questions About HIPAA?
Please contact the HIPAA Support Helpline at (800) 522-5518 or (518) 447-9860

Address Change?
Please contact the Bureau of Medical Review and Payment at:
Fee-for-Service Provider Enrollment Unit, (518) 486-9440
Rate Based Provider Unit, (518) 474-8161

Billing Question?
Please contact Computer Sciences Corporation at (800) 522-5518 or (518) 447-9860.

Comments and Suggestions Regarding This Publication?
Please contact the editor, Timothy Perry-Coon at: MedicaidUpdate@health.state.ny.us or via telephone at (518 474-9219.

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The State Department of Health welcomes your comments or suggestions regarding the Medicaid Update.

Please send suggestions to the editor, Timothy Perry-Coon:

NYS Department of Health
Office of Medicaid Management
Bureau of Program Guidance
99 Washington Ave., Suite 720
Albany, NY 12210
(e-mail MedicaidUpdate@health.state.ny.us )

The Medicaid Update, along with past issues of the Medicaid Update, can be accessed online at the New York State Department of Health web site: http://www.health.state.ny.us/health_care/medicaid/program/main.htm