DOH Medicaid Update March 2000 Vol.15, No.3

Office of Medicaid Management
DOH Medicaid Update
March 2000 Vol.15, No.3

State of New York
George E. Pataki, Governor

Department of Health
Antonia C. Novello, M.D., M.P.H., Dr. P.H.

Medicaid Update
is a monthly publication of the
New York State Department of Health,
Office of Medicaid Management,
14th Floor, Room 1466,
Corning Tower, Albany,
New York 12237

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The following drugs have been added to the list of drugs which are not included within the cost components of Article 28 Nursing Facility Rates:

Effective DateDrugDosageNDC#
October 26, 1999RescriptorTab 200 mg 00009-7576-01
December 6, 1999ZyprexaTab 15 mg 00002-4415-30

Claims for these drugs that are submitted more than 90 days from the dispensing date must be submitted with a copy of this article. Computer Sciences Corporation (CSC) must receive these claims no later than 12:00 noon on July 3, 2000. Questions regarding submission of pharmacy claims may be addressed to CSC at 1-800-522-5535.

Medicaid reimbursement for the HIV-1 viral load test
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The Health Care Financing Administration (HCFA) recently established a national limitation amount (NLA) for Medicare and Medicaid payments for the HIV-1 viral load test. The current reimbursed fee is $128.58. Based on cost and payment data, HCFA has established a Medicaid NLA of $117.59 for the HIV-1 viral load test (Medicaid CPT code Y8706). When billing Medicaid for the HIV-1 viral load test for dates of service on or after May 1, 2000 you will be reimbursed at $117.59, or your usual and customary charge to the general public, whichever is lower.

Schedule of Medicaid Seminars for New Providers

Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid Management Information System (MMIS), announces the following schedule of Introductory Seminars. Topics will include:

  • Overview of MMIS
  • Explanation of MMIS Provider Manual
  • Discussion of Medicaid Managed Care
  • Overview of Billing Options
  • Explanation of 90-day Regulation
  • Explanation of Utilization Threshold Program

Please indicate the seminar(s) you wish to attend below:

May 10, 10 AM
Poughkeepsie, NY (address to be announced - see below))

May 23, 10 AM
Computer Sciences Corporation
800 North Pearl Street, Third Floor
Menands, NY

May 25, 10 AM
The Galleries
Curtain Auditorium (enter through Public Library)
447 South Salina Street
Syracuse, NY

May 31, 10 AM
The Galleries
Curtain Auditorium (enter through Public Library)
447 South Salina Street
Syracuse, NY

July 19, 10 AM
Nassau County Department of Social Services
101 County Seat Drive
Mineola, NY

Other seminars may be scheduled as new programs are implemented or changes to existing billing procedures are announced.

Please complete the following registration information:

Provider Name:_________________________________Provider ID:________________________

Provider Category of Service:______________________Number Attending:___________________

Contact Name:_________________________________Phone Number:______________________

If the seminar address is not listed above, a CSC representative will contact you at least two weeks prior to the seminar date to confirm attendance and provide seminar address information. Each seminar will last approximately two hours. Providers who have questions about these seminars can call CSC at the following numbers:

Practitioner Services     (800) 522-5518  (518) 447-9860
Institutional Services     (800) 522-1892  (518) 447-9810
Professional Services     (800) 522-5535  (518) 447-9830

To register, please mail this completed page to:

Computer Sciences Corporation
Attn: Provider Outreach
800 North Pearl Street
Albany, NY 12204

Or, you may fax a copy of the completed page to: (518) 447-9240

Note: Please keep a copy of your seminar choice for your records. No written confirmations will be sent.

Thank you for participating in New York State's Medicaid program.


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The Office of Medicaid Management is announcing the implementation of a front end EMEVS prescriber license verification edit. Beginning in late Spring, an edit will be activated to verify that a prescriber or orderer license or MMIS ID number reported on EMEVS transactions is accurate and legitimate. This edit will be applied to all transactions that require the entry of a prescriber or orderer ID number. The edit will help protect providers against fraudulent orders and prescriptions written by sanctioned providers, without the need to check paper lists. The prescriber ID field on the EMEVS transaction will be matched against the State Education Department's (SED) license file and the Department of Health's (DOH) MMIS ID number file. Any transaction failing the match will be rejected, allowing the submitting provider an opportunity to correct the problem before resubmitting a claim. There has been a similar, back end edit, in place for a number of years. However that edit was not activated for pharmacy claims.

In order to give pharmacies an opportunity to purge their computer files of incorrect licenses or MMIS ID numbers, prior to activating the front end edit, the DOH will test reported license and MMIS numbers against a cycle of paid pharmacy claims. During April, the DOH will send each pharmacy its listing of prescriber license numbers and MMIS numbers that would have failed the new edit. The pharmacies will also be given a prescription number as reference for each failed license/MMIS number. This information will allow the pharmacies to identify and contact the prescriber to obtain their correct number. As an alternative, pharmacies can also contact SED on line at to obtain or verify license numbers.

Pharmacists are also urged to consult the NYS ProDUR/ECC User Manual - Table 2 Error Chart (page 52) for instructions on completing the prescriber ID field. The instructions describe the proper completion of NCPDP field 411 that identifies the prescriber number and prescriber type, and shows examples of how these must be entered. This field will be reviewed and edited for accuracy. Listed below is a chart identifying all prescriber types currently in use by the DOH.

Remember, when the MMIS identification number is used, be certain to leave the license type code field blank.

Medicaid enrolled physicians are reminded that they need to provide pharmacies with their MMIS ID number or SED license number when requested in the course of filling their patients' prescriptions.

Prescriber TypeType Code
Physician (MD or DO)01
Physician Assistant09
Out of State Physician (MD or DO)11
Out of State Dentist12
Out of State Physician Assistant19
Nurse Practitioner29
Out of State Optometrist35
Out of State Podiatrist36
Out of State Audiologist37
Out of State Nurse Practitioner39
Out of State Midwife39

If you have any questions, you can contact Sal Medak, Bureau of Performance Assessment and Reporting, at (518) 474-2239.

Smoking Cessation Supports
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The Department of Health has made a commitment to provide assistance to Medicaid recipients who want to stop smoking. Medicaid provides reimbursement for prescription and non-prescription smoking cessation drugs. The use of smoking cessation products in conjunction with as little as three minutes of counseling can significantly increase the smoking cessation success rate.

Counseling supports available to Medicaid recipients include a toll-free smoking help-line staffed by employees of the Roswell Park Cancer Institute.

NYS Smokers Quitline
1-866-NYQUITS (1-866-697-8487)

Smoking cessation directories, local referrals and educational materials may be available by contacting the Regional Tobacco Control Coalitions listed below.

Adirondack Tobacco Free Network
Saratoga, NY
Counties Served: Warren, Washington, Clinton, Franklin, Essex, Saratoga
Healthy Living Partnership
Cortland, NY
Counties Served: Tompkins, Cortland, Cayuga, Madison
Rural Three for Tobacco Free Communities
Cooperstown, NY
Counties Served: Delaware, Otsego, Schoharie
607-547-6045 ext. 243
Broome & Tioga Tobacco Free Coalition
Binghamton, NY
Counties Served: Broome, Tioga
Livingston County Tobacco Control Coalition
Mt. Morris, NY
Counties Served: Livingston
Smoke Free Dutchess
Poughkeepsie, NY
Counties Served: Dutchess
Capital District Tobacco-Free Coalition
Albany, NY
Counties Served: Albany, Rensselaer, Schenectady
518-459-4197 ext. 322
Mohawk Valley Coalition for Tobacco Concerns
Mohawk, NY
Counties Served: Oneida, Herkimer
Smoke-Free Genesee/Orleans/
Batavia, NY
Counties Served: Genesee, Orleans, Wyoming
716-343-9620 ext. 135
Chautauqua-Cattaraugus Tobacco Free Initiative
Mayville, NY
Counties Served: Chautauqua, Cattaraugus
Monroe County Smoking & Health Action Coalition
Rochester, NY
Counties Served: Monroe
Southern Tier Tobacco Awareness Coalition
Elmira, NY
Counties Served: Chemung, Schuyler, Steuben
Chenango Tobacco Coalition
Norwich, NY
Counties Served: Chenango
Nassau-Suffolk Tobacco Control Task Force
Hauppauge, NY
Counties Served: Nassau, Suffolk
Sullivan County Tobacco Task Force
Liberty, NY
Counties Served: Sullivan
914-292-0100 ext. 2731
Communities for a Smoke-Free Living Project
New York, NY
Counties Served: NYC-Five Boroughs
Onondaga County Tobacco Education and Action
Syracuse, NY
Counties Served: Onondaga
Tobacco Action Coalition of the Finger Lakes
Rochester, NY
Counties Served: Ontario, Seneca, Wayne, Yates
Communities for a Tobacco-Free New York State
White Plains, NY
Counties Served: Putnam, Orange, Westchester, Rockland
914-949-2150 ext. 209
Project Action
Amsterdam, NY
Counties Served: Montgomery, Fulton, Hamilton
Tobacco Prevention Awareness & Cessation Coalition
Watertown, NY
Counties Served: Jefferson, Lewis
Erie-Niagara Tobacco-Free Coalition
Buffalo, NY
Counties Served: Erie, Niagara
Rural Health Network
Oswego, NY
Counties Served: Oswego
Ulster County Tobacco Control & Prevention
Kingston, NY
Counties Served: Ulster

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The "RP" modifier has previously been used when claiming for the dispensing of a complete pair of eyeglasses due to loss, theft, or damage. The policy for the use of this modifier has been expanded to require that the "RP" modifier be used when individual component parts of eyeglasses (lenses and/or frames) are repaired or replaced due to change of refraction or damage to the component(s). The "RP" modifier should be affixed to the procedure codes for the materials. When billing for these repair/replacement situations of less than a full pair of eyeglasses, procedure code 92370 (repair and refitting of spectacles) must be used. The reason for the repair or replacement must be documented in the patient's records. For those optical providers using the Wallkill Optical Laboratory, the reason for the order for replacement components for eyeglasses must be notated on the prescription order form. If you have any questions regarding this policy you may call 518-473-5953.

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Pursuant to revised NYS General Business Law, effective January 1, 2000, Medicaid policy is revised as follows:
Hearing aid(s) shall be provided to the recipient for a trial period of at least forty-five days prior to billing for the aid by the dispenser.
Please retain this notice in your MMIS Hearing Aid Provider Manual. Questions can be directed to the Bureau of Program Guidance at (518) 486-3209.

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As a result of a rate adjustment retroactive to January 1, 1999, the number of billing units for Epogen was increased from 24 to 99. Remember that each billing unit is equal to 1000 service units of the drug. The Epogen rate codes are 3106 for hospital-based providers and 1806 for freestanding clinics. Adjustments need to be made to those "paid" claims that were billed without this new standard in mind. REMEMBER, IN THIS INSTANCE, THE CORRECT MANNER TO RECEIVE ADDITIONAL FUNDS IS TO ADJUST YOUR PREVIOUSLY PAID CLAIMS. DO NOT VOID ANY PREVIOUSLY PAID CLAIMS AND THEN TRY TO RESUBMIT THESE VOIDS AS NEW CLAIMS. If you need additional clarification of this issue, contact Ron Kaiser, of the Bureau of Medical Review and Payment, at (518) 474-8161.

The Medicaid Update: Your Window Into The Medicaid Program

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 )

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: