DOH Medicaid Update March 2002 Vol.17, No.3

Office of Medicaid Management
DOH Medicaid Update
March 2002 Vol.17, 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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New York State established the Disaster Relief Medicaid program in New York City in response to the September 11, 2001 attack on the World Trade Center. Providers were notified via a letter dated September 26, 2001 which described the program.

DRM recipients received a numbered form titled "Temporary Medicaid Authorization" (DSS-2831A). Providers were directed to accept this form as proof of DRM eligibility.

Under the DRM program, recipients have been authorized to receive health benefits for four months. The period of eligibility for each recipient is shown on the upper right hand corner of form DSS-2831A. The last date of eligibility (end date) is the last day of the month. Depending on when a recipient's DRM coverage began, their end date may be January 31, 2002, February 28, 2002, March 31, 2002, or April 30, 2002.

Individuals and families who had Medicaid coverage prior to September 11, 2001, continued to receive their regular Medicaid benefits and have the standard plastic Common Benefit Identification Card (CBIC) as proof of eligibility.

We are transitioning DRM recipients to the regular Medicaid and Family Health Plus programs as their coverage ends. Our goal is to provide continuing health care coverage during the transition period for DRM recipients whose coverage ended January 31, 2002. We provided specific information concerning the transition to Medicaid providers via a letter dated January 18, 2002. In this letter, we advised what forms of documentation would establish that recipients were continuing to be eligible for health care coverage. NOTE: Some of the instructions were specific to form DDS-2831A with end dates of 1/31/02.

It is important that providers read carefully and follow the instructions contained in the January 18, 2002 letter. If you did not receive this letter and require a copy, or if you have any questions concerning DRM, please contact Computer Sciences Corporation, Provider Relations Staff using the following telephone numbers:

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

Thank you for your continued efforts to provide necessary care, services and supplies to our recipients.

Asthma and The Medicaid Program
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During 2001, the Medicaid program encouraged providers to assist Medicaid recipients with preventing and managing the incidence of asthma. Several Medicaid Update articles were printed and made available for you to use as a resource for you and your patients. These articles can be located:

  • Treatment Guidelines for Asthma (February)
  • Patients and The Asthma Action Plan (February)
  • Assessing for Triggers of Asthma (April)
  • Asthma and Secondhand Smoke & From the Medical Director, Components of Asthma Diagnosis and Treatment (May)
  • Assessment and Diagnosis of Asthma (June)
  • Issues In Caring For People With Asthma (July)
  • Asthma and Exercise (August)
  • Asthma: The Clinician/Patient Partnership (November)

The American Lung Association
has more information for you and your patients.

Available online at

Or call
1 (800) 556-3725


Providers! Inquires About Participating In The Family Health Plus Program
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If you are a provider who is interested in providing medical care under the Family Health Plus program, please be advised that Family Health Plus is a managed care product, not a fee-for-service program. If you participate in any managed care plans, please contact the Provider Relations Department of that plan to determine if you may participate in Family Health Plus.

If you do not participate with a managed care plan, and would like to be a Family Health Plus provider, please contact a participating plan. A listing of participating plans is available on the Family Health Plus website.

Student Athletes Can Be Winners Even With Exercise-Induced Asthma
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Athlete Athlete

Lifelong physical fitness is an important goal for all people. Students with asthma frequently restrict their physical activity; however, this restriction is unnecessary. The National Heart, Lung and Blood Institute's National Asthma Education and Prevention program encourages a partnership among students, families, physicians, and school personnel in managing and controlling asthma so students can be active. Today's treatments can successfully control asthma so that students can participate fully in physical activities most of the time.

Key Actions Necessary to Keep Students Physically Active

  • Recognize, Avoid & Control Asthma Triggers
  • Develop & Follow an Asthma Management Plan
  • Ensure that Students with Asthma Have Convenient Access to Their Medications
  • Modify Physical Activities to Match Current Asthma Status
  • Recognize Symptoms & Take Appropriate Actions

Asthma varies from student to student and from season to season. At times, physical activity programs for students with asthma may need temporary modification, such as varying the type, length, and/or frequency of activity. Students with asthma should be included in activities as much as possible. Remaining behind in the gym or library or frequently sitting on the bench can set the stage for teasing, loss of self esteem, unnecessary restrictions of activity, and low levels of physical fitness.

For more information on the National Heart, Lung and Blood Institute's National Asthma Education and Prevention Program, please access the following website:

Source: Asthma, Physical Activity in the School, NIH Publication No. 95-3651

REMINDER: The NYS 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.

March 28th

American Diabetes Alert Day

For more information contact the

American Diabetes Association
(800) 342-2383


High Hospitalization Rates in Children with Type 1 Diabetes
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Children with insulin-dependent (type 1) diabetes are hospitalized three times as often as the general pediatric population. Physicians caring for these children strive to lower excessively high blood-sugar levels (glycemic control) that can lead to diabetes-related eye, kidney, and other complications, while minimizing the acute risks associated with the maintenance of tight glycemic control. A significant acute risk for these children is severe hypoglycemia that may result in convulsions or coma, leading to emergency department visits and possible hospitalization.

According to a study done at Children's Hospital in Boston and Harvard Medical School, the primary factor that reduces hospitalizations for children with type 1 diabetes is frequent self-monitoring of blood glucose levels. Blood Glucose Monitoring (BGM) provides information on which to base adjustments in insulin dosages, meal plans, and exercise regimens to ultimately improve glycemic control. An HbA1c of 7 percent or less is considered good glycemic control.

The researchers from Children's Hospital in Boston and Harvard Medical School reported that children who performed BGM five or more times a day had HbA1c levels of 8 percent compared with 9.1 percent for those who performed BGM once per day. Researchers found that children with type 1 diabetes overall rate of hospitalizations was 13 per 100 person-years, but it was significantly higher, 25 per 100 person-years, in patients with HbA1c greater than 9 percent. Poorer control is associated with the older age child, advanced puberty and longer duration of diabetes. Doctors treating children with type 1 diabetes need to stress good diabetes management, particularly BGM, to decrease emergency department visits, hospitalization and long term complications.

Source: AHRQ Research Activities, no. 256, December 2001; Journal of Pediatrics 139, pp. 197-203, August 2001

The Medicaid Program reimburses for medically necessary care, services and supplies for the diagnosis and treatment of diabetes. For information regarding Medicaid coverage of services related to diabetes, please access the following web site:

Please also contact the Bureau of Program Guidance at (518) 474-9219.

For more information on diabetes, contact the Diabetes Control Program at (518) 474-1222 or access the Department's web site at:

Tobacco Free Awareness
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To support New York State's continuing anti-tobacco initiative, various Department of Health (DOH) educational materials are available to encourage tobacco prevention and treatment. A tobacco education kit that includes reproducible educational and fill-in-the-blank materials, news releases, public service announcements and proclamations, and DOH publications is available cost-free.


To obtain the Tobacco Free Awareness materials, please contact:

Bureau of Community Relations
New York State Health Department
Corning Tower, Room 1748
Empire State Plaza
Albany, NY 12237
(518) 474-5370

Reminder: Medicaid covers prescription and non-prescription smoking cessation agents to provide assistance to Medicaid recipients who want to stop smoking. We appreciate your participation in making New Yorkers healthier. For more information on Medicaid's smoking cessation coverage policy, contact the Pharmacy Policy & Operations Unit at (518) 486-3209.

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This article specifies the appropriate medical documentation necessary to support requests for bed rail covers, shields and pads for persons living in residential programs operated or certified by the Office of Mental Retardation and Developmental Disabilities (OMRDD), including Community Residences (CR)Individualized Residential Alternatives (IRA) Family Care (FC) and persons receiving services from OMRDD who are living at home.

Effective immediately, State and voluntary providers serving developmentally disabled individuals must include a copy of the Risk Profile Checklist and the Bed Safety Checklist with a request for bed rail safety equipment to ensure that a medical professional has reviewed the bed safety needs of the individual. The Durable Medical Equipment provider must attach a copy of the checklists and an order with the request for prior approval to the Department of Health (DOH).

OMRDD providers have been informed of this procedure. They have also been advised to indicate the individual's living arrangement on the top of the checklists (i.e., FC, CR, IRA, At Home).

Prior approval requests should not be submitted for persons residing in community-based Intermediate Care Facilities (ICFs) or Developmental Centers (DC), because funding for safety equipment is included in the Medicaid per diem rate paid to these facilities.

Please direct questions concerning the checklists to the ordering provider. Questions regarding the prior approval process should be directed to the DOH Bureau of Medical Review and Payment at (800) 342-3005 or (518) 474-3575.

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...using the valid billing code for non-drug items

A substantial number of pharmacy inquiries to the Medicaid program result from invalid billing codes (e.g., NDC, UPC) for non-drug items, such as enteral products and medical-surgical supplies, via the online ProDUR/ECC system. Billing code errors cause problems with processing claims, which result in payment delays, and consumes considerable staff time at the retail pharmacy level.

Valid billing codes for non-drug items are listed in the MMIS Pharmacy Manual (Rev. 4/01) on pages 4-9 thru 4-32.

When submitting an online ProDUR/ECC transaction for non-drug items, NCPDP Field 437, ALTERNATE PRODUCT CODE (APC), must be used for the entry of these alphanumeric billing codes. Further instructions on the proper completion of this field are found on pages 8 thru 10 of the ProDUR/ECC Provider Manual.

  • For additional questions on the use and proper completion of NCPDP Field 437, (Alternate Product Code), call eFunds Provider Relations staff at 1-800-343-9000.
  • For a MMIS Pharmacy Manual and/or a NYS ProDUR/ECC Provider Manual, call Computer Sciences Corporation at 1-800-522-5535 or (518) 447-9830.
  • For questions on the accurate use of billing codes for non-drug items listed in the MMIS Pharmacy Manual, call the Bureau of Medical Review and Payment at (518) 474-8161.

Providers! Are You Changing Your Address?
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If you change your address, you should notify the Medicaid Program.

Write your provider name, provider number, category of service, telephone number, and new address on a signed sheet of paper. Indicate if this new address is meant to change your correspondence address and/or your pay to address, and mail to:

Bureau of Enrollment
Office of Medicaid Management
New York State Department of Health
99 Washington Avenue, Suite 611
Albany, New York 12210-2806

Or call (518) 486-9440 for a Medicaid Provider Change of Address Form.

Pharmacy and DME Provider Manual Revisions
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During March 2002, revised New York State Fee Schedules will be sent to all enrolled Pharmacy and DME providers. Coding and fee changes will be effective for dates of service on or after April 1, 2002. Below is a suggested coding crosswalk and overview for some of the major changes.

ProductApril 2001April 2002
#Gastrostomy tubeB4084 (each)B4086 (each)
Insulin (low-dose) syringe w/needleZ2203 (each)S8490 (100's)
Gloves, disposableA4927 (pair)Z2561 (pair)
#Spacer without maskZ2638 (each)S8100 (each)
#Spacer with maskZ2639 (each)S8101 (each)
#Incontinence pants, reusableS8400(each)A4360/S8401(each)
#Diapers, disposableS8402 (each)A4360/S8401(each)
Blood pressure apparatus (kit)A4660(each)Z2660 (each)
Elastic ankletZ2700 (each)A4464 (each)
DME, Orthotics, Prosthetics  
Heavy duty hospital bedE0298K0549/K0550
#Bedside railsE0310now requires DVS
#Elevating leg restE0990K0048 (now requires DVS)
#Solid tireK0066now requires DVS
#Pneumatic tireK0067now requires DVS
#Pneumatic tire tubeK0068now requires DVS
Wheeled mobility partsZ4519K0108
Head protectors/helmets (soft & hard)Z4752/Z4753L0110
Unlisted DMEZ4650E1399, A9900, K0108
Parts not otherwise listedZ4913E1399, A9900, K0108
#Pick up, delivery, home serviceZ4914A9901
Home visit (orthotists, prosthetists)Z5000/Z7000L9900

(NOTE: "#" indicates EMEVS Dispensing Validation System (DVS) authorization is required; "____" indicates prior approval is required.)

  • If you do not receive a Fee Schedule by March 15, 2002, please contact Computer Sciences Corporation, Provider Relations, at (800) 522-5535 or (518) 447-9830.
  • Questions regarding coding changes should be directed to the Bureau of Medical Review and Payment at (518) 474-8161.

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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:

April 17, 2002 10 AM
Conference Center
143 Grant Street
White Plains, NY

April 24, 2002 10 AM
H. Lee Dennison Building
1st Floor Media Room
100 Veterans Memorial Highway
Hauppauge, NY

May 15, 2002 10 AM
Suffern Free Library
210 Lafayette Avenue
Suffern, NY

June 12, 2002 10 AM
Dutchess County Dept. of Social Services
60 Market Street
Poughkeepsie, NY

July 17, 2002 10 AM
Washington County Municipal Center
Building B, Training Room
383 Broadway
Fort Edward, NY

Each seminar will last approximately two hours.

Direct questions about these seminars to CSC as follows:

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

Please complete the registration information using the link to the form below:

To register, please mail the completed page to:

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

Or, 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.

Payment Guidelines
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We are reaffirming the following payment guidelines to ensure the timely payment of Medicaid claims submitted by Comprehensive Medicaid Case Management providers.

  • The client must be Medicaid eligible at the time the provider provides services. It is the responsibility of the provider to verify Medicaid eligibility at each visit via the Electronic Medicaid Eligibility Verification System (EMEVS) before providing services to the Medicaid client.
    Medicaid eligibility may be verified via the EMEVS Card Swipe procedure, by using the Audio Response Unit (eFUNDS at 1-800-997-1111), or by using the software package that dials EMEVS from your Personal Computer (which may be obtained from eFUNDS Provider Relations at 1-800-343-9000).
  • The client must be enrolled with an Exception Code 35 in the Welfare Management System (WMS) Restriction/Exception Subsystem (R/E) by the local department of social services (LDSS) responsible for the client's Medicaid benefits. If you bill monthly, the enrollment "From" date of the enrollment request must be the first of the month of service. If the client is not Medicaid eligible on the date of service, the LDSS will be unable to enroll the client with the R/E Code 35, and thus, the claim will be rejected.

Enrollment in the WMS R/E Subsystem accomplishes the following:

  1. It identifies the client as an appropriate member of the target population;
  2. It confirms that the client has freely chosen to participate in the program;
  3. It links the client to the provider number of the specific Case Management Program providing service; and,
  4. It establishes a specified "From and Thru Date". Claims for Case Management services provided outside the enrollment time frames will not be paid.
  • The client must be enrolled in the Case Management program providing services. Registration in that program in the WMS R/E Subsystem will only continue as long as the client is willing to accept services from that provider. If the client decides to change providers, the LDSS must be notified so that the registration will be changed to reflect the new provider's Identification Number effective as of the date the new provider rendered Case Management services.
    A Medicaid eligible client is referred to a Case Management provider either by the LDSS, another agency, or through self-referral. The client may choose to accept professional services from the referred provider, to seek service from another provider, or to reject case management services completely.
  • If the client has been determined to be Medicaid eligible,is enrolled in the WMS R/E Subsystem, and is enrolled with the Case Management Program providing services, the initial Medicaid claim submission should be no sooner than two weeks after the provider received verification of successful enrollment in Case Management by the LDSS.

To assist Case Management Providers with enrollment, disenrollment, and changes to the Case Management information in the WMS R/E Subsystem, the Office of Medicaid Management (OMM),in conjunction with LDSS, is offering forms, plus instruction sheets for enrollment and disenrollment of recipients into Comprehensive Case Management. These forms are modeled on form used in New York City, and are being offered for use by OMM and the LDSS providers serving the rest of the State.

Please contact your LDSS Case Management contact to obtain forms and instructions. Return completed forms to your usual contact person in the LDSS responsible for the Medicaid coverage of the client to whom you are providing Case Management services. Please enclose a self-addressed, stamped envelope, so that verification of the processed enrollments, disenrollments, and/or changes can be returned to you promptly.

If the enrollment or disenrollment forms have not been returned to the provider within 30 days of the date they were sent to the LDSS, the provider should contact the LDSS to determine the status of the enrollment/disenrollment/change. It is the provider's responsibility to keep track of the form requests sent to and returned from the LDSS. Providers may not submit a claim until successful enrollment verification has been sent to them by the LDSS.

The LDSS responsible for the client's Medicaid eligibility is also responsible for notifying providers within ten calendar days of the denial of a registration, or termination of an existing registration. The LDSS IS NOT responsible for notifying providers when a client loses Medicaid eligibility. Providers are encouraged to notify the LDSS within ten calendar days of any changes which would affect the client's need or eligibility for Case Management services. Providers should also notify the LDSS on a timely basis when they no longer are providing Case Management services to the client.


OMRDD Clients

OMRDD (Office of Mental Retardation and Developmental Disabilities) clients receive Medicaid Service Coordination (MSC) directly from OMRDD. Each recipient who receives MSC services must be authorized for the services by OMRDD through one of the 13 Developmental Disabilities Service Offices (DDSOs). These DDSOs enter R/E Code 35 into the WMS R/E Subsystem for appropriate clients. In a limited number of counties where the DDSOs cannot enter the code, the DDSO will send a letter to the LDSS to initiate the entry of the R/E code 35 by the LDSS.

REPLACEMENT of EDIT 1120 with EDITS 01338, 01339 and 01340

Many providers have had claims for Case Management services provided to clients rejected due to Edit 1120 "Claim Information Does Not Match Restricted Recipient File". In order to clarify the reason for the Pend/Denial, beginning on February 1, 2002, Edit 1120 has been replaced by three new edits. These new edits more clearly state specific reasons why a claim pends or denies. The three new edits are:

Edit 01338 - "Recip not on the Rest Recip File" (The Recipient is not on the Restriction/Exception Recipient File) - This means that the recipient is not enrolled with a R/E Code 35 in the WMS R/E Subsystem.

Solution: Send the enrollment form to the LDSS and track the return of the form from LDSS indicating that successful enrollment to your provider ID has occurred. When you receive verification of enrollment from the LDSS, re-submit the claim two weeks after the LDSS transaction input date shown on the form.

Edit 01339 - "Recip not Authorized for CMCM on SVC DT" (Recipient not authorized for Case Management Services on the Service Date). This means that the client is correctly enrolled with a R/E 35 to your provider ID. However, the enrollment period on file does not include all or part of the dates of service for which payment is requested.

Solution: Check the enrollment form returned from the LDSS. Was the R/E 35 begin date you requested successfully entered? Are you billing for dates of service prior to the requested enrollment "From" date?
If the enrollment form returned by the LDSS indicated successful entry of R/E 35, check to see if the enrollment "From" date you requested was the correct date for which you provided service. Be aware that if you are a monthly biller, the "FROM" date must be the first of the month in which you began Case Management service. If you sent an incorrect "From" date of service for enrollment, re-send an enrollment form with the corrected "From" date. Note that this is a correction to your original "From" date request.
If the enrollment form returned by the LDSS has a reason stating that a current restriction already exists, follow the instructions given in the solution to Edit 01340 below.
If the enrollment form returned from the LDSS has a reason stating that the "Individual Has No MA Coverage For The Enrollment Request", it means that the client was not enrolled with a WMS R/E 35 for the "From" date of service you requested because the client was not Medicaid eligible on that date. This indicates that you did not verify the client's eligibility through EMEVS. Contact the LDSS to enroll the client with WMS R/E 35 with the "From" date equal to the client's first date of Medicaid eligibility. Resubmit the claim two weeks after the LDSS has enrolled the client with WMS R/E 35.

EDIT 01340 - "Claim Prov. Not Equal Rest Recip File Prov" (Claim Provider is not equal to the Restriction/Exception Recipient File Provider). This means that the client is enrolled with a R/E Code 35 but is enrolled to a different provider.

Solution: The enrollment form returned by the LDSS would have a reason stating that the current restriction already exists and the name of the "other" provider listed on the returned enrollment form. You, the new provider, should then contact the "other" provider asking that the "other" provider send a disenrollment form to the LDSS. This would allow the"other" provider to disenroll the client from their care, and for you to begin service with an appropriate "From" date by sending your enrollment form to the LDSS. Resubmit the claim two weeks after the LDSS has enrolled the client with you as the provider.

Questions regarding this article can be directed to the Bureau of Policy Development and Agency Relations at (518) 473-5873.

First Statewide Conference on Antibiotic Resistance
Wednesday, April 17, 2002, 4:30 - 9:00pm
Bulmer Technology Center
Hudson Valley Community College
Troy, New York
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Program Description:

The conference will explore practical opportunities for judicious antibiotic use, including state of the art lectures, interactive discussions, poster sessions and project reports from across the State. The conference will feature Richard Besser, MD, Director of the National Campaign for Appropriate Antibiotic Use, Center for Disease Control and Prevention, who will share evidence and discuss with participants the national status of the antibiotic resistance problem. Expert speaker Jonathan Finklestein, MD, MPH, Harvard Medical School and Harvard Pilgrim Health Care, will discuss his experience and practical strategies used in promoting the judicious use of antibiotics in the community.

Educational Objectives:

  1. Understand the need for judicious antibiotic therapy of upper respiratory infections and the consequences of injudicious antibiotic use.
  2. Recognize and overcome societal barriers to judicious antibiotic use in everyday clinical practice settings.
  3. Make optimal antibiotic choices based on current patterns of bacterial resistance.
  4. Have a better understanding of the emergence and epidemiology of antibiotic resistance and to evaluate strategies for control of this epidemic in New York State.
  5. Discuss successful ways to satisfy patients while not prescribing antibiotics when they are not necessary.

The agenda will be as follows:

4:30pm Conference Registration, Poster Sessions and Hors d'oeuvres
5:00pm Welcome and Introduction
5:10pm National Status of Antibiotic Resistance Problem - R.E. Besser, MD
5:45pm Panel Discussion: Barriers to Judicious Antibiotic Use
6:45pm Break
7:00pm Working Dinner Buffet. Facilitated Table Discussion.
7:40pm Experience Promoting Judicious Antibiotic Use - J. Finklestein, MD, MPH
8:10pm Panel Discussion: Future Plans to Reduce Resistance
9:00pm Closing Remarks
Conference Registration:

The conference is a free program and includes hors d'oeuvres, poster session, the academic program, dinner, refreshment breaks, and all related materials. Please check one of the following registration categories:

Stakeholder______Physician______Nurse Practitioner______Physician Assistant______ Other______

Personal Information:

Office Phone:
Office Fax:
Home Phone:

To register for the conference, please fax or mail this page by April 10 to:

Elizabeth Villamil, MPH
New York State Dept of Health
Office of Medicaid Management
99 Washington Ave, Room 615
Albany, NY 12210
Fax #: (518) 473-5508

For additional information, please contact Richard Propp, MD, (518) 473-5876 or Elizabeth Villamil, MPH, (518) 473-5499.

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Effective for dates of service on or after November 19, 2001, laboratory providers may claim reimbursement for HIV viral load testing performed using Nucli-Sens HIV-1QT (NASBA) (bioMerieux Company).

Laboratories should use MMIS procedure code 87536 when billing for HIV viral load. The maximum reimbursable amount for code 87536 is $117.59.

HIV viral load testing is a covered service when clinically indicated, up to a maximum of six viral load tests per 12-month period per patient. Medicaid will reimburse for only one HIV viral load test per patient encounter.

Laboratories, Designated AIDS Centers, residential health care facilities and ordering practitioners are reminded of the following payment policies applicable to all laboratory testing, including HIV drug resistance testing:

  • Laboratories may not bill for tests performed when patients are designated as inpatient status. Medicaid payment to the hospital includes all necessary laboratory services.
  • HIV viral load tests are reimbursable fee-for-service directly to the testing laboratory. This includes tests ordered for:
    • Outpatients and inpatients of Article 28 residential health care facilities,
    • Patients of Designated AIDS Centers operating under the Tier AIDS payment structure, and
    • Patients of Article 28 certified outpatient clinics.
    • Medicaid regulations require that:
  • Payment be made to the provider actually performing the test, and
  • Only Medicaid-enrolled clinical laboratories with Department of Health approval to perform HIV viral load testing are entitled to reimbursement.

If you have further questions on coverage for HIV viral load tests, please contact Bureau of Policy Development and Agency Relations staff at (518) 473-2160.

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: