New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance

Medicaid fee-for-service

The document and web page found at the following links contain or access general information for providers participating in the New York State Medicaid fee-for-service (FFS) program on policies and billing guidance for practitioner administered drugs:

The following table contains links to guidance for providers participating in the Medicaid FFS program for specific drugs or drug classes that are practitioner administered. Policy specific for each listed drug or drug class is offered as a link to the latest pertinent Medicaid Update article. Some drugs or drug classes have Clinical Criteria Worksheets available. The Worksheets are designed to ensure complete claim documentation and outlines, step-by-step, the clinical as well as claim documentation requirements for drugs subject to clinical criteria. Legible, completed worksheets along with manufacturer invoices showing drug acquisition costs including all discounts, rebates and incentives can be submitted with each Health Care Finance Administration (HCFA) Claim Form (HCFA 1500). The associated invoices must be dated within 6 months prior to the dates of service and/or should include the expiration dates of the drugs.

Linked Guidance
Policy
Specificity
Drug or Drug Class Name Policy/Guidance
in Medicaid
Update
Issue
Clinical Criteria Worksheet
Fillable PDF* File Microsoft Word™ File
Drug Esketamine (Spravato®) Nasal Spray August 2022 Spravato PDF Spravato Word
Drug Class Viscosupplementation with Hyaluronan or Derivative April 2022 Viscosupplementation PDF Viscosupplementation Word
Drug Goserlin implant (Zoladex®) March 2022 Zoladex PDF Zoladex Word
Drug Class Duchenne Muscular Dystrophy (DMD) January 2022 DMD PDF DMD Word
Drug Class Chimeric Antigen Receptor (CAR) T-cell Therapy October 2021 N/A**N/A
Drug Crizanlizumab-tmca (Adakveo®) May 2020 Adakveo PDF Adakveo Word
Drug Onasemenogene aberparvovec-xioi (Zolgensma®) November 2019 Zolgensma PDF Zolgensma Word
Drug Voretigine neparvovec-rzyl (Luxturna™) March 2018 Luxturna PDF Luxturna Word

* PDF - Portable Document Format
** N/A - Not Applicable

Medicaid Managed Care

Medicaid Managed Care (MMC) plan policies and billing guidance for practitioner administered drugs can be found at the MMC Pharmacy Benefit Information Center. Select a plan and then the link to practitioner administered drug policy and billing guidance.

MMC plans are required to comply with the requirements in the Medicaid Managed Care/Family Health Plus/ Human Immunodeficiency Virus (HIV) Special Needs Plan Model Contract Section 10-2, which can be found on the New York State Department of Health "Information for Health Care Providers" web page, and must ensure that covered services are provided in sufficient amount, duration and scope to reasonably be expected to achieve the purpose for which services are furnished.

Policy Updates

Updates to the practitioner administered drug payment policies are in the Medicaid Update, which is published monthly. The Medicaid Update Main Page has topics arranged alphabetically and contains search functionality.

Provider Communications

Periodically, communications are posted on the eMedNY website.This link to the Provider Manual Tab will lead to a web page with listed practitioner groups.Within many practitioner groups, the right-hand panel will have a "Featured Links" section that contains a link to that group's "communications."

Questions:

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