DOH Medicaid Update August 2001 Vol.16, No.8

Office of Medicaid Management
DOH Medicaid Update
August 2001 Vol.16, No.8

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


Return to Table of Contents

For years it was thought that asthmatics could not and should not take part in team sports and vigorous activities. It is now known that this concept was incorrect. Physical activity at play or in organized sports is an essential part of a child's life, and full participation in physical activities should be encouraged. Exercise improves a child's self esteem, confidence and psychological and physical well-being. Most children with well-controlled asthma can participate in regular physical activities and exercise programs with minimal difficulties.

Children with asthma have different levels of tolerance to exercise; individual teaching and education can be done so children learn to pace themselves in order to participate at their appropriate levels. Many children with asthma experience coughing, wheezing or excessive fatigue when they exercise. Treatment immediately prior to vigorous activity or exercise usually prevents Exercise-Induced-Bronchospasm (EIB). If symptoms occur during usual play activities, a step up in long-term therapy is warranted. Poor endurance or EIB can be an indication of poorly controlled persistent asthma; an appropriate use of long-term control medication can reduce EIB. Activity should be limited or curtailed only as a last resort. The inability to participate in athletic programs and/or recreational sports can be a handicap for children and adults alike.

The New York State Medicaid Program reimburses for medically necessary care, services,and supplies for the diagnosis and treatment of asthma. For more information, please contact the Bureau of Program Guidance at (518) 474-9219.

Source: Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (Bethesda, MD): National Institutes of Health, National Heart, Lung and Blood Institute, NIH Institute: 1997).

How Practitioners Can Help
First in a five part series
Return to Table of Contents

Woman at Desk


Physicians, dentists and other clinicians (including physician assistants, nurse practitioners, pharmacists, nurses and occupational therapists) have a unique opportunity to intervene with patients who use tobacco. Smokers cite a physician's advice to quit as an important motivator for attempting to stop smoking. The first and most important step in treating tobacco use and dependence is to systematically identify tobacco users at each office or clinic visit.

Specific actions that can be taken to systematically identify all tobacco users at every visit:

  • Implement an office wide system that ensures that, for EVERY patient at EVERY clinic or office visit, tobacco-use status is queried and documented.
  • Expand the vital signs to include a query on tobacco use or use an alternative universal identification system such as the following:
    • Placement of tobacco use status stickers on all patient charts;
    • Electronic medical records or computer reminder systems indicating tobacco use status

Effective identification of tobacco use status not only opens the door for successful interventions (e.g., physician advice) but also guides clinicians to identify appropriate interventions based on patients' tobacco use status and willingness to quit.

Source : Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. October 2000.


The New York State Medicaid Program covers both prescription and non-prescription smoking cessation agents.

For more information on Medicaid's smoking cessation coverage policy, contact the Pharmacy Policy & Operations Unit at (518) 486-3209.

Diabetes and Exercise
Return to Table of Contents

Children Playing

The recent Surgeon General's Report on Physical Activity and Health underscores the pivotal role physical activity plays in health promotion and disease prevention. It recommends that individuals accumulate 30 minutes of moderate physical activity on most days of the week. In the context of diabetes, it is becoming increasingly clear the epidemic of type 2 diabetes sweeping the globe is associated with decreasing levels of activity and an increasing prevalence of obesity.

For people with type 1 diabetes, the emphasis must be on adjusting the therapeutic regimen to allow safe participation in all forms of physical activity consistent with an individual's desires and goals. The benefit of exercise in improving the metabolic abnormalities of type 2 diabetes is probably greatest when it is used early in its progression from insulin resistance to impaired glucose tolerance to overt hyperglycemia requiring treatment with oral glucose-lowering-agents and finally to insulin.

General guidelines that may be helpful in regulating the glycemic response to exercise are as follows:

  • Metabolic control before exercise
    • avoid exercise if fasting glucose levels are >250 mg/dl and ketosis is present. Use caution if glucose levels are >300mg/dl and no ketosis is present
    • ingest added carbohydrate if glucose levels are <100mg/dl.
  • Monitor blood glucose before and after exercise
  • Identify when changes in insulin or food intake are necessary
  • Learn the glycemic response to different exercise conditions
  • Review food intake
  • Consume added carbohydrate as needed to avoid hypoglycemia
  • Ensure that carbohydrate-based foods are readily available during and after exercise

Before beginning an exercise program, the individual with diabetes mellitus should undergo a detailed medical evaluation with appropriate diagnostic studies. Identification of areas of concern will allow the design of an individualized exercise prescription that can minimize risk to the patient. Preparing the individual with diabetes for a safe and enjoyable exercise program is as important as the exercise itself. The young individual in good metabolic control can safely participate in most activities. The middle aged and older individual with diabetes should be encouraged to be physically active, taking into consideration one's physical limitations. Ultimately, all patients with diabetes should have the opportunity to benefit from the many valuable effects of exercise.

Source: Diabetes Care, Volume 24, supplement 1, January 2001, pps.s51-s55.
Please visit the Department's website at or the following websites and for information regarding diabetes and exercise.

Return to Table of Contents

The following updates the "Inquiry Section" of ALL MMIS provider manuals regarding Medicaid Prior Approval and Medical Review Information responsibilities, addresses and contact numbers. You should remove these pages and replace the appropriate pages in your existing "Inquiry Section."

The verification process via EMEVS (Electronic Medicaid Eligibility Verification System) must be completed to determine current recipient eligibility and which County has financial responsibility for the recipient. Once completed, consult the list below for the appropriate office to contact for Prior Approval and Medical Review information.

Prior Approval and Medical Review Information

Bureau of Medical Review and Payment
Office of Medicaid Management
99 Washington Avenue, Suite 800
Albany, NY 12210-2808
(800) 342-3005
(518) 474-3575

All Counties except
those counties listed below
for specific services listed

  • Physician
  • Private Duty Nursing Services
    Statewide, except for the Counties of Broome, Chemung, Erie, Oneida, Onondaga, Schenectady, Suffolk, Tompkins and Westchester (see below).
  • Eye Services
  • Dental
    Statewide, including Medicaid orthodontic prior approval for Westchester County recipients, only.
  • Pharmacy
    Statewide, except for Buffalo Area Office (see below)
  • Hearing Aids
  • Durable Medical Equipment
    Statewide, except for Metropolitan Regional and Buffalo Area (see below).
  • Out-of-State Services
    Statewide, except for Buffalo Area (see below)
  • Dispensing Validation System (DVS)
    Statewide requests for override of frequency/quantity limits for medical reasons only

Counties Processing Private Duty Nursing Prior Approvals
Return to Table of Contents

Medical Services Unit
Broome County Department of Social Services
36-42 Main Street
Binghamton, NY 13905
(607) 778-2707
Chemung County Human Resources Center
425-447 Pennsylvania Avenue
Elmira, NY 14904
(607) 737-5454
Erie County C.A.S.A.
Erie County Department of Social Services
Franklin Street
Buffalo, NY 14202
(716) 858-2375
Oneida County Office of Continuing Care
Oneida County Department of Social Services
520 Seneca Street, 2nd Floor
Utica, NY 13502
(315) 798-5456
Onondaga County Long Term/Resource Center
Onondaga County Department of Social Services
5065 W. Seneca Turnpike, S-1 Building
Syracuse, NY 13215
(315) 435-5000
Schenectady County Dept of Social Services
107 Nott Terrace, 3rd Floor
Schenectady, NY 12308
(518) 386-2253
Suffolk County Medical Services Bureau
Suffolk County Department of Social Services
Box 1800
Hauppauge, NY 11788-8900
(631) 854-9835
Tompkins County Long Term Care
Tompkins County Department of Social
320 West State Street
Ithaca, NY 14850
(607) 274-5278
Westchester County Dept of Social Services
Division of Medical Home Care Services
270 North Avenue
New Rochelle, NY 10801
(914) 637-5902

OfficeRecipient's County of
Fiscal Responsibility
Medical Prior Approval Unit
Metropolitan Regional Office
New York State Department of Health
3 Penn Plaza
New York, NY 10001

Durable Medical Equipment (212)268-6645

Except for Intravenous (IV) and enteral supplies:
Contact Bureau of Medical Review and Payment
Kings (Brooklyn)
NY (Manhattan)
Richmond (SI)
Buffalo Area Office
New York State Dept. of Health
584 Delaware Avenue
Buffalo, NY 14202

General Inquiry (800) 462-8407
Physician (800) 462-8407
Private Duty Nursing Services (except Erie County) (800) 462-8407
Eye Services (800) 462-8407
Durable Medical Equipment (800) 462-8407
Out-of-State Services (800) 462-8407
Pharmacy (800) 462-7552 (716) 847-4650
Bureau for Families with Special Needs
NYC Department of Health
111 Livingston St.
Room 2022
Brooklyn, NY 11201

Director (718) 643-7339
Medical Administrator (718) 643-7154
Medical Prior Approvals (718) 643-7759, 7154, 7158
Transportation(CSC) (800) 243-7842
Kings (Brooklyn)
NY (Manhattan)
Richmond (SI)

Return to Table of Contents

Statewide HIPAA Coalition

A number of months ago, the Office of Medicaid Management (OMM) and the Department of Health (DOH) joined the New York Health Plans Association, Iroquois Health Alliance, Healthcare Association of New York State, Medical Society of the State of New York, and other healthcare provider associations to form the Multi-Industry Statewide HIPAA Coalition. The Coalition is a collaborative effort to:

  • promote HIPAA compliance and standards implementation readiness within our healthcare community;
  • identify and provide HIPAA education/awareness opportunities; and,
  • seek any other multi-industry collaboration opportunities.

Members are currently in the process of developing HIPAA education and training strategies. It is anticipated that education/training sessions may be available later this year. You are urged to contact your respective association for more information on available HIPAA education/training opportunities.

Medicaid HIPAA Education

OMM is working with Computer Sciences Corporation (CSC) to develop an education/training plan. We intend to schedule regional education/training seminars. These seminars will focus on new Medicaid electronic claim requirements and changes to the provider manuals necessary for us to comply with the HIPAA standards. At this time, it is difficult to anticipate a tentative timeframe for these seminars, but we hope to have more details within the next three months.

HIPAA Systems Activities

OMM and CSC staff are in the process of assessing and analyzing the impact the HIPAA Transactions and Code Sets will have on all our system processes. We do know that the Transactions and Code Sets will require extensive coding conversions, and the development of work around solutions for many of the gaps identified between the HIPAA standards and our current MMIS billing requirements. In addition to its impact on the claim submission process, HIPAA will also impact how we share claim status information, remittance statements, eligibility information, how we process prior approvals, etc. We will share all pertinent information with you as we proceed. In the meantime, we encourage you to work closely with your vendors, billing services, clearinghouses and with your own staff, to properly assess your business functions and determine what modifications may be necessary to assure HIPAA compliance by the October 16, 2002 date.

HIPAA Implementation Plan

We are preparing a Medicaid HIPAA Implementation Plan. The Plan will detail all program and systems activities and tasks, with accompanying timeframes, necessary to assure timely compliance. The Plan will be segregated by Transactions and will outline specific tasks to be completed for each Transaction, accompanied by tentative completion dates. Some of the tasks within the Plan include gap analyses of all Transactions, design and code conversions, unit and system testing, and beta pilot and testing. We will share pertinent portions of the Plan with the provider community as soon as the Plan is finalized and approved. We anticipate to have the Plan completed later this Fall. The Medicaid Update will most likely be used as the media for sharing the Plan.

Questions About HIPAA?

As indicated in previous HIPAA News articles, there are a number of websites where much information may be obtained about all provisions of HIPAA. The most important one may be the Health and Human Services (HHS) website,, which provides text of the HIPAA Administrative Simplification law and all its provisions. Other websites related to HIPAA and Medicaid include:

If you have any questions specific to New York Medicaid current HIPAA implementation efforts, please contact Mario Tedesco, Medicaid HIPAA Coordinator, at, or by phone at 518-257-4496.

The Ventilator Rental Fee Has Changed
Return to Table of Contents

Effective for order dates on and after September 1, 2001, an increased maximum monthly rental fee will be available to Durable Medical Equipment Providers for the provision of ventilators.

Code E0450    Volume ventilator, stationary or portable, with back-up rate feature, used with invasive interface (e.g. tracheostomy tube)    $731.00/month

Code E0450 is to be used for all types and designs of volume ventilators, including, but not limited to, features such as pressure limitation, dual control, pressure support, pressure control, printer, and inspiratory time setting. Volume ventilators will only be rented and prior approval is required. As with all rentals, the monthly fee includes

  • all necessary equipment, parts and supplies
  • delivery and services for equipment set-up
  • maintenance, repair costs and replacement of worn essential accessories or parts
  • loading or downloading software
  • backup or secondary equipment as needed.

Questions may be directed to the Bureau of Medical Review and Payment at (518) 474-8161.

Return to Table of Contents

Effective December 1,1998 local social service districts were required to identify those Public Assistance and/or Medicaid recipients mandated by the local district to go into alcohol and substance abuse (ASA) treatment as a condition of eligibility. The identification, Welfare Reform code 83, appears on the Electronic Medicaid Eligibility System (EMEVS) and the managed care organization (MCO) enrollment rosters. (Code 83 may only be applied to a client case when the LDSS requires the individual to receive the ASA service as a condition of eligibility.)

Except for the five circumstances listed below, MCOs are not responsible for the provision and payment of the LDSS-mandated ASA services. Mandated services must be delivered by providers certified by the Office of Alcohol and Substance Abuse Services (OASAS).

For Medicaid managed care enrollees, this exception (code 83) allows for Medicaid fee-for-service reimbursement to OASAS-certified providers who deliver LDSS-mandated OASAS services. This exception may not be used by providers to obtain fee-for-service reimbursement for managed care capitated benefit services other than the delivery of LDSS-mandated ASA services.

Under any of the following five circumstances, the MCO maintains responsibility for delivery and payment of the ASA base benefit package:

  1. An enrollee requested evaluation visit from a MCO network provider;
  2. Evaluation and treatment services when the prepaid capitation plan or other designated MCO practitioner refers the patient to a provider for evaluation and/or treatment;
  3. Court ordered services;
  4. ASA services when such ASA treatment is underway and the local district is satisfied with the level of care and treatment plan; or,
  5. Medically complicated inpatient detoxification services in acute settings.

For a copy of the November 6, 1998 policy letter and related questions please contact either Ilyana Meltzer, DOH, at (518) 473-7467 or Marie Spada, OASAS at (518) 457-6184.

Important Change For Your Provider Manual
Return to Table of Contents

The following information updates page 5-19 of the Laboratory Services MMIS Provider Manual. You should remove this page and attach it to your existing page 5-19.

Code 86294 should read: Immunoassay for tumor antigen, qualitative or semiquantitative (e.g., bladder tumor antigen) (see Rule 15)

Code 86300 should read: Immunoassay for tumor antigen, quantitative CA 15-3 (27.29) (see Rule 15)

If you have any questions regarding the above corrections, you may contact the Bureau of Medical Review and Payment

The New York State Court of Appeals Rules
Citizenship and Alien Eligibility Changes
Return to Table of Contents

The New York State Court of Appeals has released a decision regarding persons with alien status, and their eligibility for Medicaid. Pursuant to this decision, an otherwise eligible alien who is either:

  • permanently residing in the United States under color of law (PRUCOL); or,
  • is a qualified alien subject to the five-year ban,

is no longer limited only to Medicaid coverage for treatment of an emergency condition.

  • Otherwise eligible qualified aliens who entered then United States on or after August 22, 1996 and are subject to the five-year ban can be eligible for Medicaid benefits with State and local funds.
  • Otherwise eligible Medicaid non-qualified aliens who are PRUCOL can be eligible for Medicaid benefits with State and local funds.
  • Only those individuals who are not citizens, qualified aliens, or PRUCOL are limited to emergency medical services under the Medicaid program

Qualified aliens include:

  • persons lawfully admitted for permanent residence;
  • persons admitted as refugees;
  • persons granted asylum;
  • persons granted status as Cuban and Haitian entrants;
  • persons with deportation withheld;
  • persons admitted as Amerasian immigrants;
  • persons paroled into the United States for at least one year;
  • persons granted conditional entry; or,
  • persons determined to be battered or subject to extreme cruelty in the United States by a family member.

PRUCOL aliens include:

  • persons paroled into the United States for less than one year;
  • persons residing in the United States pursuant to an Order of Supervision;
  • persons residing in the United States pursuant to an indefinite stay of deportation;
  • persons residing in the United States pursuant to an indefinite voluntary departure;
  • persons on whose behalf an immediate relative petition has been approved and their families covered by the petition;
  • persons who have filed applications for adjustment of status that INS has accepted as "properly filed" or has granted;
  • persons granted stays of deportation;
  • persons granted voluntary departure;
  • persons granted deferred action status;
  • persons who entered and continuously resided in the United States before January 1, 1972;
  • persons granted suspension of deportation; or
  • other persons living in the United States with the knowledge and permission or acquiescence of the INS and whose departure the INS does not contemplate enforcing. (Examples include, but are not limited to: permanent non-immigrants, pursuant to P.L. 99-239, applicants for deferred action or voluntary departure status, and aliens granted extended voluntary departure status for a specified time due to conditions in their home countries.)

Appropriate documentation of an individual's alien status is required in order to determine eligibility and establish Medicaid coverage. If a provider assists an individual in preparation or submission of an application for Medicaid, documentation of the individual's alien status should be collected and submitted with the application.

If a provider is aware that an affected alien has Safety Net Assistance but no Medicaid coverage, the Safety Net Assistance recipient should be advised to contact his/her Temporary Assistance worker to request Medicaid coverage.

For Medicaid coverage of emergency medical treatment of an individual who is NOT a citizen, qualified alien, or PRUCOL, a provider will continue to complete the form DSS-3955 Certification of Treatment of Emergency Medical Condition.

If you have questions regarding this article, or for more information, telephone Shirley Race at (518) 474-9130.


Return to Table of Contents

The New York State Smokers' Quitline is offering free posters "New York State Medicaid Covers Stop Smoking Medications." The colored posters come in 2 sizes; 11" x 17" and 22" x 28" and are available in English or Spanish.

To order, call the New York State Smokers' Quitline at:
1-866-NYQUITS (1-866-697-8487)

Adjustments and Voids
Return to Table of Contents

Adjustments and voids can only be made to previously paid claims.

Adjustments are submitted to change one or more pieces of information on a previously paid claim.

Voids are submitted to negate a previously paid claim.


Denied claims can not be adjusted or voided.
Provider ID, group provider ID, recipient ID, and category of service can not be adjusted.


  • No 90-day letter attachment is required for the submission of adjustments or voids.
  • The time limit for submitting adjustments or voids is six years from the date of service.
  • The remittance statement will reflect both the new payment amount (zero, if voided) and the previous payment amount being recouped. The net payment will be the difference between those two amounts.
  • The fifteen-digit claim reference number of the most recently paid claim must be indicated on the adjustment or void claim.(Do not confuse the claim reference number with the invoice number or the remittance number.)
  • Only one claim line (procedure) of the original invoice may be adjusted or voided per invoice. If multiple claim lines (procedures) need to be adjusted or voided, a new invoice must be completed for each claim line, since each line is assigned a unique claim reference number (CRN).
  • Providers are responsible for submitting adjustments or voids to correct claims that have been overpaid due to billing errors or late reimbursement by a primary carrier. Overpayments, which providers cannot attribute to those reasons, should be reported to Computer Sciences Corporation in writing or by calling one of the phone numbers listed below.
  • Incorrect claim reference number, provider ID, or recipient ID submitted on the adjustment or void claim will result in a denial stating "No matching history record for adjustment/void."

Complete instructions for submission of adjustments or voids are found in the billing section of the Medicaid Management Information System (MMIS) Provider Manual.

Providers making inquiries or requesting billing training by Regional Representatives should contact Computer Sciences Corporation by calling the appropriate number below. Please be prepared to supply your Medicaid Provider ID number.

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

Important News for Medical Practitioners
Return to Table of Contents

Childhood lead poisoning continues to be one of the most prevalent health concerns for young children in New York State. Due to the age of New York housing, the percentage of that housing in deteriorated condition, and the risk of exposure from home repairs and renovations, over 10,000 children are identified annually with harmful lead levels.

  • The United States Centers for Medicare and Medicaid Services, (formerly known as the Health Care Financing Administration) requires all children enrolled in Medicaid to be tested at one and two years of age.
  • Testing between 3 and 6 years of age is required if a child was not tested previously.
  • The New York State Department of Health law and regulation requires health care providers to test all children at ages one and two.

Testing Methodology

Venous blood is the preferred specimen for blood lead testing. Capillary blood may be used with appropriate collection procedures, in order to minimize contamination of the specimen with lead from dust on the skin. The Erythrocyte Protoporphyrin (EP) test is no longer acceptable for lead screening as significant number of children with elevated blood levels by current standards will have normal EP results.

Providers are to treat children in accordance to Center for Disease Control (CDC) guidelines covering patient management and treatment, including follow up blood tests and initiating an on-site investigation to determine the source of lead.

If you have any questions regarding this article, please contact Judith Lenihan at(518) 473-6020.

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: