DOH Medicaid Update February 2003 Vol.18, No.2

Office of Medicaid Management
DOH Medicaid Update
February 2003 Vol.18, No.2

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

Clinical Issues in Asthma and Diabetes:
Teleconferences Scheduled!

See below for Information!

How To Order Necessary Transportation
Return to Table of Contents

All Medicaid fee-for-service transportation must be prior approved by the Onondaga County Department of Social Services. If your patient requires taxi, wheelchair, van, or ambulance transportation to travel to your office or facility, prior approval must be obtained by calling, faxing or e-mailing to the numbers or address below.

Telephone: (315) 701-7500, Fax: (315) 475-8123, or e-mail:

If your patient is enrolled in a Medicaid managed care plan, please contact the managed care plan to arrange for necessary transportation services.

Questions? Please contact Kathleen Hart of the Onondaga County Department of Social Services at (315) 435-2813.

Return to Table of Contents


The American Heart Association Releases

"Get With The Guidelines"
"Get with the Guidelines" is a new guideline-based hospital program which provides tools and resources to assist medical professionals in building systems to translate what is known about vascular disease secondary prevention into what is done in clinical practice.

Studies have demonstrated significant improvement among patients when secondary prevention interventions are implemented while the patient is still in the hospital. For more information about the American Heart Association or "Get with the Guidelines", visit the American Heart website at:

Phone: (800) AHA-USA1 or (214) 373-6300
Mail: AHA National Headquarters, 7272 Greenville Ave., Dallas, TX, 75231

Return to Table of Contents

The New York State Department of Health, Office of Medicaid Management, in conjunction with the Island Peer Review Organization (IPRO), will present seven teleconferences on clinical issues in asthma and diabetes. The sessions will each last for sixty minutes.

The teleconferences are free of charge, fulfill criteria for continuing medical education credit and will include a question and answer session with clinical experts. There will be a recording of each teleconference topic (via digital replay) made available for 24 hour per day access via telephone for those clinicians who cannot make any of the teleconference times. The teleconferences include materials that will be sent to registered participants and will also be made available on the IPRO website.

Topics, Times and Speakers:

"An Update in the Management of Adult Asthma" - Dr. Jill Karpel, North Shore-Long Island Jewish Health System

  • March 11, 2003- 5:30 pm to 6:30 pm
  • March 19, 2003- 5:30 pm to 6:30 pm

"An Update in the Management of Pediatric Asthma" - Dr. Sujatha Ramesh, Children's Hospital of Buffalo

  • March 13, 2003- 7:15 am to 8:15 am
  • March 25, 2003- 5:30 pm to 6:30 pm

"Issues and Practical Approaches to Cardiovascular Disease Prevention and Management in Patients with Diabetes" - Dr. Daniel Lorber, New York Hospital Medical Center of Queens/Diabetes Control Foundation, or Dr. Ruth Weinstock, SUNY Syracuse/Joslin Clinic

  • March 18, 2003- 12:30 pm to 1:30 pm
  • March 20, 2003- 7:15 am to 8:15 am
  • March 26, 2003- 5:30 pm to 6:30 pm

You may register online on the IPRO website at: by phone: 516-326-7767, extension 410.


Black and Hispanic children with asthma are more likely to be hospitalized or utilize emergency department services due to poorly controlled asthma far more frequently than white children with asthma. A recent study conducted by the Asthma Care Quality Assessment (ACQA) Project has demonstrated that this disparity in asthma status may simply reflect a difference in the use of preventive medications for asthma.

The ACQA Project is an ongoing quality of care initiative for Medicaid-insured children in five managed care organizations in California, Washington, and Massachusetts. ACQA recently conducted a cross-sectional study utilizing both a telephonic parent survey and computerized medical records and claims data of children (aged 5-16 years) with asthma. Of the 1,658 children in the respondent group, 38 percent were black, 19 percent were Hispanic, and 31 percent were white. Black children had worse asthma status than white children on the basis of the American Academy of Pediatrics (AAP) asthma physical and emotional health scores, symptom-days, and school days missed in the past two weeks. Hispanic children had equivalent AAP asthma physical health score to the black children.

Despite having worse asthma than white children, black and Hispanic children with similar insurance and social demographic characteristics were 31 percent and 42 percent, respectively, less likely to be using inhaled anti-inflammatory medication (including inhaled steroids) to prevent the beginning or worsening of an asthma episode. Other asthma care processes, including rating of providers and asthma care, use of written management plans, use of preventive visits and specialists, having no pets or smokers at home, were equal or better for minority children compared with white children.

These study findings suggest that nonfinancial barriers, such as differences in health beliefs, and concepts of disease, fears about steroids, or communication barriers (including language) between doctors and patients may play an important role in sub optimal medication use. Increasing the use of preventive medications should be a focus for improving quality of care for minority children with asthma.

According to the National Asthma Education and Prevention Program, Guidelines for the Diagnosis and Management of Asthma-Update on Selected Topics 2002, use of inhaled corticosteroids are preferred for controlling and preventing asthma symptoms, and for improving lung function and quality of life. In addition, the Update reflects new data that provides reassuring evidence on the safety of inhaled steroid use at appropriate doses in children. The Update also concludes that combination therapy, adding long-acting beta 2-agonists to inhaled steroids, is more effective than simply increasing the dose of inhaled steroids for patients over age five who have moderate or severe persistent asthma.

Source: Pediatrics, May 2002, 109 (5), pp. 857-865.

The New York State Medicaid Program provides reimbursement for medically necessary care as defined by the NAEPP Expert Panel Asthma Guidelines, (including spacers, peak flow meters and nebulizers). For more information on Medicaid coverage, please contact NYSDOH, Office of Medicaid Management, Bureau of Program Guidance at (518) 474-9219.

Diabetes and Vision
Return to Table of Contents


February is
Low Vision Awareness

For More information go to:

According to the American Diabetes Association (ADA), people with diabetes are 25-30 times more likely than the general population to lose their sight from retinopathy, cataracts or glaucoma. Diabetic retinopathy is a highly specific vascular complication that affects individuals with either type 1 or type 2 diabetes. The prevalence of retinopathy is strongly related to the duration of diabetes. Early detection and treatment can substantially reduce severe vision loss or blindness.

ADA Recommendations for Eye Disease Prevention

Tight glycemic control

Blood Pressure Control

Systemic control of serum lipids

Smoking Cessation

Patients with type 1 diabetes should visit an eye care professional annually* for a dilated eye exam beginning five years after the onset of diabetes.
Women with type 1 diabetes who are pregnant should have a comprehensive eye exam in the first trimester and close follow-up throughout pregnancy.
Patients with type 2 diabetes should visit an eye care professional shortly after diagnosis of diabetes and annually* thereafter.

*Providers must bill the appropriate evaluation and management code for the annual eye exam.

Additionally, people with diabetes should visit their eye care professional if they experience any of the following symptoms between their routinely recommended eye examinations.

Visual Disturbances

Blurry vision
Difficulty reading
Double vision
One or both eyes hurt
Pressure in a eye
Spots or floaters
Changes in peripheral vision

For more information about diabetes and vision, the following websites are available:
Sponsored by Prevent-Blindness America

The American Diabetes Association

The National Eye Institute

The Medicaid Program reimburses for medically necessary care, services and supplies for the diagnosis and treatment of diabetes. More information regarding Medicaid coverage of services related to diabetes may be found on the NYSDOH website at:

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

Return to Table of Contents


Providers who performed Medicaid recipient name searches or inquiries about their weekly check amounts by calling (900) 555-2525 should note:
As of January 1, 2003, the (900) 555-2525 number was discontinued and replaced by (518) 473-4620.

Return to Table of Contents

Each year the Bureau of Health Economics of the New York State Department of Health determines the 20 most frequently billed Diagnosis Related Groups (DRG's). When payment for one of these DRG's is indicated, the remittance statement will list rate code 2996 rather than 2946.

Effective discharge date January 1, 2003, the Top 20 DRG's are:


DRG      Diagnosis Related Groups

143     CHEST PAIN
294     DIABETES AGE >35
775     BRONCHITIS & ASTHMA AGE < 18 w/o cc

Questions should be directed to the Bureau of Medical Review and Payment, Rate Based Provider Unit, (518) 474-8161.

The following article was first published in the September 2002 Medicaid Update. This article repeats the same information, and adds new information for laboratory billing.

Return to Table of Contents

  • Effective October 1, 2002, HIV genotypic and phenotypic drug resistance tests will no longer be included in the benefit package provided by managed care plans.
    • HIV drug resistance tests performed on or after October 1, 2002 should be billed to MMIS, rather than the managed care plan.
    • Medicaid managed care enrollees will obtain these services through the Medicaid fee-for-service program when ordered by an HIV specialist. As required for other Medicaid covered services excluded from the Medicaid managed care benefit package, enrollees will use their Medicaid card to obtain services from qualified Medicaid providers.
  • 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 should use MMIS procedure code 87901 when billing for the HIV genotypic assay. The maximum reimbursable amount for code 87901 is $350. Laboratories should use MMIS procedure code 87903 when billing for HIV phenotypic assay. The maximum reimbursement amount for code 87903 is $675.29. Laboratories should use MMIS procedure code 87904 for each additional 1 through 5 drugs tested (list separately in addition to code for primary procedure). Payment for HIV virtual phenotype testing will be effective December 1, 2002. Local code "Y8709" should be used for payment @ a price of $80.00
    • HIV drug resistance testing is a covered service when clinically indicated, up to a maximum of 3 tests (any combination of genotypic and phenotypic) per recipient per patient treatment year.
    • Laboratories may not bill on a fee-for-service basis for a test performed while a patient is in hospital inpatient status. Medicaid payment to the hospital includes all necessary laboratory services.
    • All ordered HIV drug resistance 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 regulation requires that:
    • Payment be made to the provider actually performing the test, unless the reference laboratory and the forwarding laboratory are subsidiary related (see June 2002 Medicaid Update); and
    • Medicaid-enrolled clinical laboratories with Department of Health approval to perform HIV drug resistance testing are entitled to reimbursement.

If you have questions about the Medicaid managed care benefit package, please contact Elizabeth Macfarlane at (518) 473-0122.

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

Clinic Billing
Billable Clinic Visits, Including
Administration of Medication as a Threshold Visit
Return to Table of Contents

For Medicaid patients, the basis of payment for most clinic services provided in hospital outpatient departments and diagnostic and treatment centers certified under Article 28 of the Public Health Law is the threshold visit. A threshold visit occurs each time a patient crosses the threshold of a facility to receive medical care without regard to the number of services provided during that visit. Thus, a threshold visit is counted each time a patient crosses the threshold at any of a facility's authorized sites to receive medical care. The visit is all-inclusive, i.e., it includes all of the services medically necessary and rendered on that date.

A threshold visit occurs each time a patient crosses the threshold of a facility to receive medical care without regard to the number of services provided during that visit.

To be billable under Medicaid, a clinic visit must include an identifiable medical service clearly and accurately identified in the medical record. When a Medicaid patient receives treatment during a threshold clinic visit that cannot be completed due to administrative or scheduling problems, the Article 28 facility may NOT bill additional clinic visits for the completion of the service. For example, the completion of clinical laboratory tests, blood draws or x-rays, that are scheduled subsequent to the initial clinic visit do not qualify for reimbursement, unless the patient is also seen for purposes of discussing the findings and for definitive treatment planning.

Further, the administration or dispensing of a prescription or non-prescription drug is likewise not billable under Medicaid because it does not constitute a unit of medical service. A clinic visit solely for the purpose of having medication dispensed by a medical professional does not qualify as a threshold visit in a clinic certified under Article 28 of the Public Health Law, even when the patient cannot self-medicate due either to a physical or mental disability. Visits for the sole purpose of medication administration that is not given in concert with a clinical service, or related clinical service, are NOT claimable.

In addition, Department regulations prohibit reimbursement as a threshold visit for pharmacy, nutrition, medical social services, respiratory and recreation therapy services in the absence of other medical services being rendered to the patient.

To see an explanation on this issue for Article 16 clinics certified by the Office of Mental Retardation and Developmental Disabilities, please see the December 1995 Medicaid Update article"Attention: OMRDD Day Treatment and Clinic Providers."

Questions about this article, or requests for copies of the December 1995 Medicaid Update article, can be directed to the Bureau of Policy Development and Agency Relations at (518) 473-2160.

Accurate Reporting of Servicing Providers Will Be Required
Return to Table of Contents

In April 2003, the Office of Medicaid Management will be activating edits that require identification of the servicing provider. These edits verify that the servicing MMIS provider identification numbers reported on the claims are accurate and legitimate. The servicing provider identification field on the claim will be matched against the Department of Health's MMIS identification number file.

Optical providers that employ other licensed opticians and/or optometrists (enrolled with categories of service 0401, 0402 or 0423) MUST complete the servicing provider identification number field.

  • On paper claims, the service provider identification number field is 22C. Field 22A must also be completed with the service provider name. Field 22B is left blank.
  • For electronic submission, the service provider identification number field is on the D2 record, positions 58-65.

Self-employed optometrists (enrolled with category of service 0422) and self-employed opticians (enrolled with category of service 0404) SHOULD NOT complete the servicing provider identification number field since the servicing provider and the billing provider are the same.

If you have any questions, please contact the Bureau of Policy Development and Agency Relations at (518) 473-2160.

Return to Table of Contents


Effective February 1, 2003, the Suffolk County Medical Services Bureau will no longer review or process prior approval requests for Private Duty Nursing services.

All administrative functions related to prior approval requests for Suffolk County private duty nursing recipients will be transferred to the State Health Department's Bureau of Medical Review and Payment in Albany.

Starting on February 1, 2003, please submit prior approval requests and required documentation to the following address:

NYS Department of Health
Medical Prior Approval Unit
Bureau of Medical Review and Payment
99 Washington Avenue, Suite 800
Albany, NY 12210-2808

Questions should be directed to the Suffolk County Medical Services Bureau at (631) 854-9835 or to the NYSDOH, Bureau of Medical Review and Payment at (518) 474-8161.

Print This Information and Keep With Billing Instructions

Return to Table of Contents

Effective January 1, 2003, all claims over two years old MUST INITIALLY be submitted directly to Computer Sciences Corporation within 90 days of the date control was passed to you. As part of the process your claim will be denied. A denial message (Edit 01292 - DOS Two Yrs Prior to Dte Recvd) will appear on your remittance statement. Requests for waiver of the regulation regarding submission of claims greater than two years from the date of service must then be submitted to the address below within 90 days of the Edit 01292 denial as noted on the remittance statement. Supporting documentation (cover letter of explanation, remittance statements, and notice of eligibility, fair hearing decision, evidence of agency error, etc.) must accompany your written request.

New York State Department of Health
Bureau of Medical Review and Payment
Suite 800 - Two-Year Review Unit
99 Washington Avenue
Albany, New York 12210-2808

Any waiver requests received without a copy of the remittance statement documenting an Edit 01292 denial will be returned without further processing.

If you have any questions on the processing, review or disposition of claims over two years old, please call (800) 562-0856.

Important Billing Information

Return to Table of Contents

Medicaid regulations require that claims for payment of medical care, services, or supplies to eligible recipients be initially submitted within 90 days of the date of service to be valid and enforceable, unless the claim is delayed due to circumstances outside the control of the provider. Acceptable reasons for a claim to be submitted beyond 90 days are:

  • Litigation;
  • Medicare and other insurance processing delays;
  • Delay in Medicaid eligibility determinations;
  • Rejection or denial of the original claim for reason(s) other than the 90-days rule;
  • Administrative delay in the prior approval process;
  • Interrupted maternity care; and
  • IPRO denial/reversal.

Please note that if a claim is denied or returned for correction, it must be corrected and resubmitted within 60 days of the date of notification to the provider. Claim not correctly resubmitted within 60 days, or those continuing to not be payable after the second resubmission, are neither valid nor enforceable. In addition, all claims must be finally submitted to the Fiscal Agent and be payable within two years from the date the care, services or supplies were furnished in order to be valid and enforceable as against the Department or a social service district.

Claims Over 90-days Old, Less Than Two Years Old

All claims initially delayed over 90 days must be submitted within 30 days from the time submission came within control of the provider. For paper claims, a cover letter must be attached which specifies one or more of the acceptable reasons noted above.

Resubmitted paper claim forms should be typed or printed legibly in order to reduce delays in processing. Claim forms including attachment(s) or required documentation may be submitted in batches (50 forms or less) and enclosed in a single envelope or package. The invoice number of each claim form in the batch must be specified on the cover letter.

Please send all paper claims less than two years old directly to:

CSC Healthcare Systems
P.O. Box 4444
Albany, New York 12204-0444

Be sure to send the original claim form and retain a xerox copy for your files.

  • Claims submitted via tape, diskette or modem must specify the appropriate late submission reason code. Refer to the MMIS electronic billing instructions issued by the Fiscal Agent for valid coding.

Claims Over Two Years Old

Claims submitted to CSC over two years old will be automatically denied. A denial message (Edit 01292 - DOS Two Yrs Prior to Dte Recvd) will appear on providers' remittance statements. The Department will consider claims over two years old for payment if the provider can produce documentation verifying that the cause of the delay was the result of one or more of the following:

  • Errors by the Department, a local social services district, or another agent of the Department;
  • Court ordered payments.

Initially, claims should be submitted to CSC for payment within 90 days of the date control was passed to the provider. Requests must then be submitted within 90 days of the Edit 01292 denial as noted on the remittance statement with all supporting documentation (cover letter of explanation, remittance statements, notice of eligibility, fair hearing decision, etc.) to:

New York State Department of Health
Bureau of Medical Review and Payment
Suite 800 - Two-Year Review Unit
99 Washington Avenue
Albany, New York 12210-2808

Please note: Claims submitted for review without the appropriate documentation, or those not submitted within the 90-day time period for review, will NOT be considered for payment.

If you have any questions on the processing, review or disposition of claims over two years old, please call (800) 562-0856.

Return to Table of Contents

The New York State Department of Health (NYSDOH) implemented the Family Planning Benefit Program (FPBP) effective October 1, 2002. This program provides Medicaid coverage for family planning services to all persons of childbearing age with incomes at or below 200% of the federal poverty level. This population will have access to all enrolled Medicaid family planning providers and family planning services currently available under Medicaid. The local social services districts are accepting applications from potentially eligible recipients for the FPBP. Entities (such as family planning and Prenatal Care Assistance Program providers) that have agreements (memoranda of understanding) with the local social services districts, will soon be assisting with applications for this program. Potentially eligible individuals will be screened for eligibility for Medicaid and Family Health Plus, unless they specifically request to be screened only for FPBP eligibility.

Family planning services under this program can be provided by all Medicaid enrolled family planning providers including hospital-based and free-standing clinics, federally qualified health centers or rural health centers, obstetricians/gynecologists, physicians, nurse practitioners, licensed midwives, pharmacies and laboratories that provide family planning related services.

Family planning services include:

  • All FDA approved birth control methods, devices, pharmaceuticals, and supplies
  • Emergency contraceptive services and follow-up
  • Male and female sterilization in accordance with 18 NYCRR Section 505.13(e)
  • Preconception counseling and preventive screening and family planning options

The following additional services are considered family planning only when provided during a family planning visit and when the service provided is directly related to family planning:

  • Pregnancy testing and counseling
  • Counseling services related to pregnancy and informed consent, and STD/HIV risk counseling
  • Comprehensive reproductive health history and physical examination, including clinical breast exam - excludes mammography
  • Screening for STDs, cervical cancer, and genito-urinary infections
  • Screening and related diagnostic testing for conditions impacting contraceptive choice, i.e. glycosuria, proteinuria, hypertension, etc.
  • HIV counseling and testing
  • Laboratory tests to determine eligibility for contraceptive of choice
  • Referral for primary care services as indicated

A recipient may require follow-up treatment for a condition identified during the family planning visit. However, Medicaid payment will not be available for that follow-up treatment. NYSDOH funded family planning providers must (consistent with Title X requirements) provide follow-up treatment for any STD or genito-urinary infections diagnosed during a family planning visit as part of their clinic visit rate. If an additional visit is required for the FPBP-enrolled client, Family Planning grant funds should be utilized. Treatment should be provided to the client at no cost. For providers who do not receive grant funds from the NYSDOH for family planning, treatment should either be provided, or, if necessary, clients should be referred appropriately, such as to the County Health Department, as in any other situation involving treatment of the uninsured.

Requirement for Payment:

  • To insure Medicaid payment, the family planning field on the claim form must be completed to indicate a family planning service has been provided. This applies to all providers billing for family planning services, e.g., physicians, laboratories, clinics, and nurse practitioners. If this field is not accurately completed, the service being claimed is not reimbursable. If the service provided is not related to family planning, it cannot be billed under this program.
  • Appropriate family planning diagnosis codes in the V25 series must be used when required on the claim form.
  • Providers can begin rendering services to recipients eligible for this program. Payment for services may be retroactive to October 1, 2002 for eligible recipients under normal retroactive coverage rules. Providers submitting claims after 90 days from the date of service should use one of the following acceptable 90 day reasons:
    • Delay in Medicaid Client Eligibility Determination
    • Administrative Delay (System was available for claim payment on November 18, 2002)
  • Family planning providers who order laboratory tests related to family planning must indicate on the laboratory requisition form or the written order for the laboratory test that the test is related to family planning

Systems Information:

When verifying a recipient's eligibility via the Medicaid Eligibility Verification System (MEVS):

  • eMedNY MEVS System will return the following responses for FPBP eligible recipients:
    • Alternate access methods (PC, CPU, Batch) will return Table 1 Response Code 018
    • On-line NCPDP Pharmacy transactions will be rejected for Table 7 Denial Response Code 719 (MA Only Covers Family Planning), unless the submitted Drug is a Family Planning Drug. When a Family Planning Drug is submitted, the transaction will be accepted if all other edits are passed and Response Code 018 is returned.
  • Systems support is available for payment of claims.

Frequently Asked Questions and Answers--Family Planning Benefit Program:

  • Q. Are prescriptions for reproductive health, such as antibiotics for STDs and genito-urinary infections, paid for through FPBP?
    • A. Typically these prescriptions are not covered on a fee-for-service basis. However, if pharmaceuticals were included in an all-inclusive clinic rate, these prescriptions would be covered as part of the clinic rate. If a non-grant funded provider of family planning services identifies an infection in need of treatment, and cannot provide the treatment at no cost to the client, the client should be referred to the County Health Department or other referral resources, as appropriate.
  • Q. How is a lab test, such as a pap smear, paid for?
    • A. In order for the pap smear to be covered as part of the FPBP, it must be ordered during a family planning visit. The provider must indicate on the lab requisition form or the written order that the lab test is related to family planning. The lab must place an "X" in the box following "YES" in field 22I, Family Planning, to indicate that the claim is related to a family planning service in order to receive payment for the family planning services rendered.
  • Q. What if a woman who was previously sterilized goes to a family planning provider for a gynecological exam?
    • A. The gynecological exam would not be covered because it would not be related to family planning since the woman was sterilized.
  • Q. Is emergency contraception covered?
    • A. Emergency contraception and follow-up visits are covered.
  • Q. Are RU 486, surgical abortions, or abortion-related services covered?
    • A. No. These services are not covered.
  • Q. Is a colposcopy, cryosurgery, or LEEP covered?
    • A. No, these procedures are not covered. According to the federal guidelines, these procedures are not considered services performed primarily for family planning purposes but rather procedures performed to identify and treat a medical condition, regardless of whether or not a woman is seeking to limit or expand the size of her family. If these procedures are needed to diagnose or treat suspected cervical cancer, the FPBP-enrolled woman should be referred to the regional Healthy Women Partnership for services. The list of Partnerships can be found on the DOH website:
  • Q. Can a private practicing physician in the context of a family planning visit order a lab test for STD screening or a pregnancy test?
    • A. Yes. If the physician, during a family planning visit, determines the need for a STD screening or a pregnancy test, the physician can order these lab tests. The physician must indicate on the laboratory requisition form or the written order that the ordered tests are related to family planning. The lab must indicate family planning on the claim form for payment.
  • Q. Is the treatment for breast or cervical cancer covered?
    • A. Treatment for breast or cervical cancer is not covered by the FPBP. Individuals with suspected breast or cervical cancer should be referred to the local Healthy Women Partnerships for screening and further diagnosis. Persons who are screened through the Healthy Women Partnerships and diagnosed as needing treatment for breast or cervical cancer may be eligible for the Breast and Cervical Cancer Treatment Program if they have no other coverage. The list of Partnerships can be found on the DOH website:
  • Q. Do all family planning providers need to indicate that services rendered are related to family planning?
    • A. Yes, providers must indicate that the claim is related to a family planning service in order to receive payment for the family planning services rendered.
  • Q. Are infertility services covered?
    • A. Infertility services are not covered.

If you have any questions, you may contact the Office of Medicaid Management at medicaid@health.state.ny.usor by calling (518) 473-2160.

Persons with mental illness returning to the community have need of multiple Medicaid funded services (mental health and substance abuse treatment, health and rehabilitation services, case management etc.). Medicaid providers of these services who are sensitive to the needs of this population can greatly enhance their potential for successful re-integration into the community.

It has become widely recognized that many people in jail or prison have a mental illness. Every day a few of these people re-enter their communities after their incarceration. In accordance with Kendra's Law, a new program called the Medication Grant Program will assist people with mental illness in applying for Medicaid prior to or immediately after their release from jail or prison. This new program is operating in 37 counties in New York State and in New York City. For people with mental illness, the return to the community from incarceration, especially from prison, presents some unique challenges for both the consumer and the provider who attempts to serve them. Thus, the need and importance of the Transitions Training program for providers.

Transitions Training is for administrators and supervisors of human service agencies that provide services to persons who are returning to the community from State prison and who may also have a mental illness.

The one-day program explores the effects of incarceration on an individual, both while incarcerated and after release from prison. The staff competencies and services needed to effectively serve this population are also reviewed. The training team consists of a mental health professional and men with mental illness who have experienced incarceration.

Anticipated outcomes for Medicaid providers who take Transitions Training includes an increased understanding of individuals in need of treatment upon release from prison, and a decrease in apprehension about working with an often-avoided population. The training is applicable to most Medicaid providers. Each training session may have a maximum of 25 participants. More than 40 mental health agencies in New York State have received Transitions Training and have given it high marks.

A September 10, 2002 interview about this program is archived on the Internet at An 18-minute promotional videotape about the program is also available.

For more information about the program, or to arrange for a training session for administrators and supervisors of a Medicaid funded program, contact Terence McCormick, Director of Community Forensic Services at the New York State Office of Mental Health, (518) 402-6376 or


Return to Table of Contents

When calling to obtain a prior authorization for Serostim, remember to enter the patient's weight in pounds, their height in inches and the patient's current Body Mass Index (BMI) . The following BMI chart is provided for your assistance.

Body Mass Index Table

To use the table:

  1. Find the appropriate height in the left-hand column labeled Height.
  2. Move across to a given weight.

The number at the top of the column is the Body Mass Index at that height and weight.

Pounds have been rounded off.

BMI192021 222324 252627 282930 313233 3435
Height (inches)Body Weight (pounds)
589196100105110115119 124129134138143148153158 162167
599499104109114119124 128133138143148153158163 168173
6097102107112118123128 133138143148153158163168 174179
61100106111116122127132 137143148153158164169174 180185
62104109115120126131136 142147153158164169175180 186191
63107113118124130135141 146152158163169175180186 191197
64110116122128134140145 151157163169174180186192 197204
65114120126132138144150 156162168174180186192198 204210
66118124130136142148155 161167173179186192198204 210216
67121127134140146153159 166172178185191198204211 217223
68125131138144151158164 171177184190197203210216 223230
69128135142149155162169 176182189196203209216223 230236
70132139146153160167174 181188195202209216222229 236243
71136143150157165172179 186193200208215222229236 243250
72140147154162169177184 191199206213221228235242 250258
73144151159166174182189 197204212219227235242250 257265
74148155163171179186194 202210218225233241249256 264272
75152160168176184192200 208216224232240248256264 272279
76156164172180189197205 213221230238246254263271 279287


Return to Table of Contents

Please Read and Save for Future Reference

Beginning April 1, 2003, enteral formula will require a prior authorization initiated by an authorized prescriber, in order to be covered by the Medicaid program.

Medicaid is initiating this program to ensure that only medically necessary enteral formulas are ordered, dispensed and reimbursed. Enteral formula is covered for tube feeding or for oral liquid administration when there is a documented diagnostic condition where caloric and dietary nutrients from food cannot be absorbed or metabolized. Enteral nutritional therapy is not covered for supplementation of daily protein-caloric intake where there is not a documented medical necessity or as a convenient food substitute.

When writing a fiscal order for an enteral formula, the prescriber will need to call the toll free voice interactive Enteral Prior Authorization Call Line at (866) 211-1736. If approval is given, an authorization number will be provided that must be written on the fiscal order. Then, the fiscal order is presented to the dispenser who calls the voice interactive Enteral Prior Authorization Call Line to complete the prior authorization process.

General Information for Prescribers:
Physicians, Nurse Practitioners, Midwives, Dentists

  1. The prescriber must call the toll free voice interactive Enteral Prior Authorization Call Line at (866) 211-1736 to initiate the prior authorization process.
  2. Once approval has been given and a prior authorization number is obtained, the prior authorization number must be written on the order and documented on the Prior Authorization Prescriber Worksheet. A prescription pad may be used for an order.
  3. The patient's medical record must include documentation of the patient's medical need for enteral formula. In addition, the completed prior authorization worksheet must be included in the patient's medical chart.
  4. Prior authorization is required for each generic category of enteral formula. It is effective for up to six months, or the initial fill and five refills.
  5. Each time a new order is written for an enteral formula, a new prior authorization must be obtained, and the new prior authorization number written on the order.
  6. An agent of the prescriber (an employee such as a medical assistant) may complete the prior authorization call and write the prior authorization number on the order.
  7. Prescribers do not have to initiate the enteral prior authorization process for orders written prior to April 1, 2003.
  8. If a prior authorization number is not on an order for an enteral formula, the dispenser will be prohibited from filling the order. The dispenser or patient will need to contact the prescriber to ask that the prior authorization process be completed, or if completed to ask for the necessary prior authorization number.


NYS Medicaid Program Enteral Formula Prior Authorization Prescriber Worksheet and Instructions

The NYS Medicaid Program Enteral Formula Prior Authorization Prescriber Worksheet is available only as a portable document format (PDF) file. Requests for the NYS Medicaid Program Enteral Formula Prior Authorization Prescriber Worksheet in an alternate format should be made by sending an e-mail note to:

General Information for Dispensers:
Pharmacy and Durable Medical Equipment Providers

  1. The prescriber initiates the prior authorization process and obtains the prior authorization number.
  2. The prescriber must write the prior authorization number on the order before the dispenser can fill the order and bill Medicaid.
  3. When a new order for an enteral formula is presented to the dispenser, it must include a prior authorization number. The dispenser must contact the toll free voice interactive Enteral Prior Authorization Call Line at (866) 211-1736 to validate the prior authorization number prior to dispensing. Failure to validate the prior authorization number will result in claims being denied.
  4. Multiple prior authorizations for multiple patients may be validated in a single phone call.
  5. Initial dispensing must occur on or after the date the prior authorization number is issued and within 60 days of the order date (subject to other State laws and Medicaid restrictions).
  6. A prior authorization is effective for the original dispensing and up to five refills within six months (subject to other State laws and Medicaid restrictions).
  7. The dispenser must include the prior authorization number on the submitted electronic or paper claim before the claim can be paid. This prior authorization number must also be included on claims for refills.
  8. eMedNY DVS authorization will continue to be required for all dates of service prior to April 1, 2003.Voice interactive prior authorization is not required for orders written prior to April 1, 2003, but dispensed on or after April 1, 2003. However, when these orders expire, a new prior authorization will be required for the enteral formula.
  9. Prior authorization does not guarantee payment Payment is subject to patient eligibility and other Medicaid guidelines.


Enteral Prior Authorization Call Line

(866) 211-1736


Pharmacy providers: (800) 343-9000
DME providers: (800) 522-5535

Policy questions, coverage criteria, HCPCS codes:

(518) 474-8161

Prior Approval - Only for enterals not authorized through the voice interactive
prior authorization system:

Obtaining prior approval forms: (800) 522-5518
Completing prior approval forms: (800) 342-3005


NYS Medicaid Program Enteral Formula Prior Authorization Dispenser Worksheet and Instructions

The NYS Medicaid Program Enteral Formula Prior Authorization Dispenser Worksheet is available only as a portable document format (PDF) file. Requests for the NYS Medicaid Program Enteral Formula Prior Authorization Prescriber Worksheet in an alternate format should be made by sending an e-mail note to:

Frequently Asked Questions


  • Q: Can categories of patients be exempted from the prior authorization process?
    • A: No. However, the prior authorization process should be relatively quick for orders for tube-fed individuals.
  • Q: How will patients know about this program?
    • A: Prescribers and dispensers may copy information in this article for distribution and discussion with patients. In addition, we have asked for assistance from advocacy groups and associations to help distribute information.
  • Q: What recipients are affected by enteral prior authorizations?
    • A: All orders for recipients who are covered under the Medicaid fee-for-service program are subject to this new requirement. Payment for enteral formula is included in the Medicaid rate paid to skilled nursing facilities, developmental centers and inpatient hospitals, and thus is not reimbursable on a fee-for-service basis.
  • Q: Does the Medicaid enteral formula prior authorization program apply to orders for Medicaid managed care enrollees?
    • A: Yes, because enrollees in Medicaid managed care plans are covered under the fee-for-service for enteral formula. Prescribers who are part of Medicaid managed care networks will need to get prior authorization when prescribing an enteral formula.
  • Q: Does the Medicaid enteral formula prior authorization apply to Family Health Plus, EPIC, ADAP or Child Health Plus B enrollees?
    • A: No
  • Q: Will I be able to obtain a prior authorization for a patient with temporary Medicaid authorization?
    • A: Yes, however, the dispenser will not be able to adjudicate the claim on-line until the patient's eligibility is posted on the Medicaid eligibility file.
  • Q: What if the patient wants to get a brand-name enteral product for which there are generic equivalents?
    • A: The conversation with the patient may be a good opportunity for the prescriber or dispenser to explain what generic products are, and why they might appear different but meet the medical need for enteral formula.


  • Q: How long will it take for a prescriber to do a prior authorization?
    • A: About four minutes.
  • Q: Can the prescriber ask for more than one prior authorization at the same time or do they have to call back for each order?
    • A: Multiple authorizations can be received with one phone call. You can get more than one prior authorization for the same patient, or authorizations for more than one patient during the same call. You will be asked at the end of each transaction if you want additional authorizations. Follow the instructions at the end of the call.
  • Q: How will you assure that providers can get through and not get busy signals?
    • A: We have greatly expanded our telephone capacity to address anticipated increased volume.
  • Q: How should a fiscal order for an enteral formula be written?
    • A: The requirements for a fiscal order for an enteral formula are: the name, address and telephone number of the ordering practitioner, the name and CIN of the recipient, the date ordered, the original signature of the ordering practitioner, the name of the item, quantity ordered (e.g., 1500 calories per day/one month supply), directions for use, and number of refills. For enterals, the prior authorization number must also be written on the fiscal order. A prescription pad may be used for the order.
  • Q: How often can enteral formula be dispensed?
    • A: A monthly supply of enteral formula is dispensed once a month. When one week or less remains on the month's supply, the order may be refilled. A new order for enteral formula will not be authorized for dispensing until ten days or less remain on the last refill of the current prescription.
  • Q: Can medical residents or physician assistants use the institution or clinic MMIS number when requesting a prior authorization?
    • A: No. Medical residents and physician assistants must use the supervision prescriber's MMIS number. An institution or clinic MMIS number will not be accepted.
  • Q: What happens to a patient who gets to the dispenser and it told that they need a prior authorization approval to get their order?
    • A. The dispenser may contact the prescriber who may then choose to use the prior authorization system. Recipients may also contact their prescriber to discuss their order. There is no provision to ensure payment for enteral formula without a prior authorization number.
  • Q: Can the dispenser substitute generically equivalent enteral products?
    • A: Yes. The federal government classifies the most used enteral products under one category. For example, Ensure, Boost, Resource and generic store brand complete nutrition formulas are considered equivalent. For specialized formulas, there may not be equivalent formulas made by another manufacturer.
  • Q: Does Medicaid pay for infant formula?
    • A: Standard milk-based infant formula is not covered by Medicaid. Special formulas for metabolic disorders or lactose intolerance are reimbursable. Families should access the WIC Program when seeking assistance in obtaining infant formulas.
  • Q: When does Medicaid require paper prior approval for enteral formulas?
    • A: Paper prior approval is required when the prescriber is not able to certify via the voice interactive system that the formula is medically necessary. Other specific instances include, if a patient receiving oral supplementation has a Body Mass Index categorized as obese by the Centers for Disease Control, if a product is categorized as B9998 Miscellaneous enteral formula, or when calories prescribed exceeds normal dietary guidelines, e.g., over 2000 calories per day.
  • Q: How is the paper prior approval process initiated and completed?
    • A: The prescriber should initiate the prior approval process by completing Section 1, Fields 1-26 of Form DSS-3615, "Order/Prior Approval Request". The dispenser receives this form and completes Sections 2 and 3 and mails the form for review to the appropriate Area Office indicated in the Inquiry Section of the MMIS provider manual.

Blank forms are available by calling Computer Sciences Corporation at (800) 522-5518 (within New York State) or (518) 447-9860 (out of state). The forms can also be obtained by writing to Computer Sciences Corporation, PO Box 4401, Albany, NY 12204.




The following list of enteral formulae is provided as a guideline for prescribers and dispensers. This is not an all-inclusive list, but is meant to assist providers in prescribing and determining the correct item code for billing. For products not listed below, providers are to use their judgment in selecting the appropriate product classification based upon the prescriber's order, general categorical descriptions, and Medicaid coverage criteria (see December 2002 Medicaid Update for coverage criteria). Powdered, liquid, fiber-added, calcium-added and high protein forms of the same formula are billed using the same HCPCS code. Please keep this information in the Enteral Therapy section of your MMIS Provider Manual. Italicized products are subject to coverage by the Women, Infants and Children (WIC) program.

Enteral Products And Item Codes
80056B4154Isocal HN PlusB4150Phenex 2B4154
AcerflexB4154Isocal IIB4150PhenylAdeB4154
AccupephaB4153Isocal-HNB4150PhenylAde Amino AcidB4155
AlimentumB4153IsolanB4150Phenylfree 2B4154
AlitraqB4154IsomilB4150Phenylfree 2HPB4154
Amin-AidB4154IsosourceB4150Phlexy-10 CapsulesB4155
Analog FormulasB4154Isosource 1.5B4152Phlexy-10 Drink MixB4155
Apple FiberB9998Isosource VHNB4154PKU2B4154
Aquasol EB9998Isosource-HNB4150PolycoseB4155
BoostB4150Jevity PlusB4150Product 3232AB4155
Boost BreezeB4150JuvenB4155Product 80056B4154
Boost PlusB4152KetoCalB4151ProfiberB4150
Calcilo XDB4154Ketonex 1B4154PromixB4155
Calories PlusB4152Ketonex 2B4154ProModB4155
Choice DMB4154LactAid tabletsB9998PropacB4150
Compleat PediatricB4151L-ElementalB4153Pro-Peptide VHNB4154
ComplyB4152L-Emental HepaticB4154Pro-PhreeB4155
Criticare-HNB4153L-Emental PediatricB4153Propimex 1B4154
CrucialB4153LipomulB4155Propimex 2B4154
Deliver 2.0B4152LonalacB4150ProSureB4155
DiabetisourceB4154Lorenzo OilB4154Protain XLB4154
Diabetisource ACB4154Magnacal RenalB4154ProvideB4154
DoucalB4154Maxamaid FormulasB4154ProViMinB4155
Egg/ProB4155Maxamum FormulasB4154PulmocareB4154
EleCareB4153MCT OilB4155ReabilanB4153
Elemental 028 ExtraB4154MeriteneB4150Reabilan-HNB4154
ElementraB4155MicrolipidB4155ReGain PlusB4154
Enfamil ARB9998ModucalB4155RenalcalB4154
EnliveB4150Modulen IBDB4154Re-NephB4154
Enriched Antioxident FormulaB4155MSUD FormulasB4154 Re-Neph FreeB4154
Ensure LightB4150Naturite PlusB4152ResourceB4150
Ensure PlusB4152NeocateB4153Resource ArginaidB4155
Ensure Plus HNB4152Neocate One +B4153Resource Arginaid ExtraB4154
EnteraB4150NeoproB4154Resource DiabeticB4150
Entera IsotonicB4150Nestle Flavor PktsB9998Resource DiabetishieldB4150
Entera OPDB4154Neutra-PhosB9998Resource For KidsB4150
Enteralife HNB4150NewtritionB4150Resource Fruit Bev.B4150
Enteralife HN-2B4150Newtrition HNB4150ReSource GlutasolveB4155
Entrition HNB4150Newtrition IsofiberB4150Resource Instant ProteinB4155
Entrition 1.5B4152Newtrition IsotonicB4150Resource PlusB4152
EpulorB4155Newtrition 1.5B4152RespalorB4152
Essential ProPlusB4155NitrolanB4150Restore-XB4155
Essential ProteinB4155NovaSource 2.0B4152Ross Carbohydrate FreeB4155
FiberlanB4150NovaSource PulmonaryB4154Sandosource PeptideB4154
FibersourceB4150Novasource RenalB4154Scandi ShakeB4152
Fibersource HNB4150NuBasicsB4150Similac PM 60/40B4154
FlavonexB9998NuBasics 2.0B4152SLDB4154
Forta DrinkB4150NuBasics Juice DrinkB4150SoyProB4155
Forta ShakeB4150NuBasics PlusB4152StressteinB4154
FortisonB4150NuBasics VHPB4150SubdueB4153
Generic Complete NutritionB4150Nutri-DrinkB4150 Subdue PlusB4153
Generic Complete Nutrition Plus*B4152NutramigenB4150 SumacalB4155
Gevral ProteinB4155Nutrassist-1.5B4152SuplenaB4154
GlucernaB4154Nutren JuniorB4150SustacalB4150
Glucena ShakeB4154Nutren-1B4150SustagenB4150
Gluco-ProB4154Nuten-1.5B4152Sympt-X GlutamineB4155
Glutamine Rapid ReleaseB4155NutriforusB4152TraumacalB4154
Glutapak-10B4155NutrihepB4154Traum-Aid HBCB4154
Glutarex-1B4154NutrilanB4150Travasorb HepaticB4154
Glutarex-2B4154NutriRenalB4154Travasorb -MCTB4154
GlutasolveB4155NutriVentB4154Travasorb RenalB4154
Glutasorb RTUB4153NutriVirB4153Travasorb StandardB4156
Hearty BalanceB4150OS 1B4154TwoCal-HNB4152
Hepatic-AidB4154OS 2B4154Tyrex-1B4154
Hominex-2B4154Osomolite-HN PlusB4150UCD-1B4154
HOM 1B4155Osmolite-HN PlusB4150UCD-2B4154
HOM 2B4155PediasureB4150UltracalB4150
HPF PlusB4155Pepdite One+B4153Ultracal HN PlusB4150
Immune System BoosterB4155Peptamen 1.5 DietB4153Ultracare KidsB4154
ImmunocalB4155Peptmen JrB4154VHC 2.25B4152
Imu-PlusB4155Peptamen VHPB4154Vari-FlavorsB9998
Impact 1.5B4154Peptinex DTB4153VitaneedB4151
Impact GlutamineB4153PepticalB4153Vivonex flavor pktsB9998
Impact RecoverB4154PerativeB4154Vivonex PediatricB4153
IntensiCalB4153PeriflexB4154Vivonex PlusB4154
IntroliteB4150PFD-2B4155Vivonex RTFB4153
IsocalB4150Phenex 1 B4154Vivonex-TENB4154

* Generic complete nutrition store brands include: CVS, Eckerd, Equate, Hannaford, Price Chopper, Rite Aid, Target

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: