DOH Medicaid Update June 2004 Vol.19, No.6

Office of Medicaid Management
DOH Medicaid Update
June 2004 Vol.19, No.6


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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As announced in a February 6, 2004 letter and in the May 2004 Medicaid Update, the Department of Health (DOH) is closely monitoring the progress of trading partner testing and claims submission for the purpose of setting the final deadline for accepting only HIPAA (Health Insurance Portability and Accountability Act) compliant claims. Our assessment is nearing completion, and we are considering appropriate actions necessary to make providers aware of the urgency of the need to become HIPAA compliant. Those actions will be communicated to the provider community shortly; watch for direct mailings, and the July issue of the Medicaid Update.

Regardless of the final deadline date, providers must be aware that as of March 2005, with the implementation of the new Medicaid system, eMedNY, ONLY HIPAA-compliant electronic claims will be processed.

The Department and Computer Sciences Corporation staff continue to work with providers, vendors and provider organizations, offering technical assistance and support for testing and other efforts related to achieving HIPAA compliance. Recently, a new tool has been introduced to help our trading partners identify edits/errors and the probable corrective action. It allows claim submitters to see edit/error results of the prior week's claim cycle, and connects them to a web page describing the error, the potential cause and the solution. This new tool is available at under the "News and Resources" tab, and the "Edit/Error Knowledge Base."

Unfortunately, a significant number of our trading partners still have not registered to test their transactions on the website. If you are not yet testing, we urge you to expedite your compliance efforts and begin the testing process as soon as possible. Any further delay may jeopardize your ability to successfully complete testing prior to the final deadline, which would result in an inability to submit HIPAA claims and receive timely payment. Information on the Medicaid HIPAA testing process is available at

Providers using clearinghouses or service bureaus to submit their Medicaid claims should be in constant contact with them to ensure they are proceeding aggressively with their HIPAA compliance program. Providers should not assume that these vendors will achieve timely HIPAA compliance but should proactively monitor their progress. With the final compliance deadline date to be announced in the near future, providers must take all necessary steps to become HIPAA compliant as soon as possible to avoid any disruption in claims processing and payment flow.

If you have questions regarding this article, please contact the CSC Provider Services at (800) 522-5518.

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The New York State Department of Health is scheduled to implement the second phase of eMedNY in March 2005. Phase I of eMedNY, the Medicaid Eligibility Verification System (MEVS), replaced the functionality formerly provided by EMEVS. The transition to MEVS took place on November 16, 2002. eMedNY Phase II will replace the current Medicaid Management Information System (MMIS). Designed and operated by Computer Sciences Corporation (CSC), eMedNY will revitalize and modernize the MMIS.

Phase II of eMedNY has been designed to facilitate a smooth, efficient transition from the current MMIS. Enhancements to the current system, which include new functionalities, as well as Federal regulations that govern the implementation of new healthcare systems, require changes that will impact the manner in which providers interact with the New York State Medicaid program. An example is that a non-HIPAA format will not be accepted for electronic transaction submission (see the bolded notice above).

Some examples of eMedNY enhancements are: improved communication methods to support the capability of real-time claim submission and response; the availability of electronic remittance statements; and the availability of all provider manuals on our website, along with a host of other features aimed at enhancing processing efficiencies and information retrieval.

Please be on the lookout for direct mailings to providers about eMedNY Phase II changes, or visit the eMedNY web site at for upcoming information about eMedNY Phase II.

For questions about MMIS billing and claim processing-related issues, please contact CSC Provider Services at (800) 522-5518 or (518) 447-9860. For questions about MEVS and pharmacy billing, call (800) 343-9000.


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As part of the mandatory move toward HIPAA compliance, the Department will soon be terminating the non-HIPAA-compliant Medicaid Eligibility Field Software as a method of access for submitting MEVS Transactions. The import/export batch functionality of the Medicaid Eligibility Field Software will not be replaced.

Through its eMedNY contractor, Computer Sciences Corporation, the Department has replaced the Eligibility Field Software with a HIPAA-compliant web-based application known as the Electronic Provider Assisted Claim Entry System (ePACES).

We strongly urge Medicaid Eligibility Field Software users to begin their transition to ePACES immediately. ePACES is free, easy to use, readily available and will not require users to install customized software because the application will reside on a CSC server. Users will always have access to the most recent ePACES version.

However, because ePACES stores the data on CSC's server as opposed to the provider's individual PC, ePACES cannot support the batch functionality or the import/export process previously available on the Medicaid Eligibility Field Software.

Providers who wish to submit eligibility and service authorization transactions in a batch mode should consider FTP Batch as an alternative method of access. This is a convenient way to submit HIPAA-compliant transactions in a batch mode using your standard PC modem, telecommunications devices and protocols. You simply dial into the system box and send your file; responses are available for download within two to three hours.

More information on FTP Batch, including certification requirements and submission protocols, can be found at on the Manuals page under "MEVS Batch Authorization Manual."

Future editions of the Medicaid Update will contain information on another batch submission alternative, the eMedNY Exchange, a browser-based application that will allow HIPAA-compliant batch files to be sent in an easy, user-friendly manner via the Internet.

Questions about the termination of the Medicaid Eligibility Field Software, the FTP Batch functionality, or the upcoming eMedNY Exchange should be directed to CSC Provider Services at (800) 343-9000.

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Due to the new HIPAA guidelines, the message you receive when performing an eligibility check may be unclear. The Medicaid Eligibility Verification System (MEVS) Manual is available online and is a valuable resource for interpreting the MEVS message. The manual can be found at:

For example, the readout may appear to indicate that the recipient is enrolled in a managed care plan when in actuality the recipient is enrolled in Medicaid fee-for-service only. The following typifies this confusion:

Plan Eligibility & BenefitsFull MessageDescription
Elig/Ben Info:
Active Coverage
Information: Active Coverage
This field displays the client's level of medical coverage or other coverages. Refer to Section 10.0 on page 10.0.1. of the MEVS manual for Accepted Reason codes.
Serv Type CdService Type CodeWe will return one of the following values to further define coverage, exclusions and limitations:
30 = Health Benefit Plan coverage
48 = Hospital Inpatient
54 = Long Term Care
82 = Family Planning
86 = Emergency
Insr Type Cd:
Insurance Type Code: MCValues are:
C1 = Commercial
MP = Medicare Primary
MC = Medicaid

The fields and descriptions above can be found on page 9.0.3 of the MEVS manual.

For information on the messages you receive, contact Computer Sciences Corporation staff at (800) 343-9000.


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The Family Planning Benefit Program (FPBP) is a Medicaid program that allows recipients eligible for this coverage to access family planning services only. All enrolled Medicaid providers who provide family planning services to recipients with this coverage can be reimbursed for designated family planning services.

The eMedNY MEVS System will return the following responses when verifying a FPBP eligible recipient:

  • OMNI 3750 and ePACES: Limitations and Service type code - 82 (Family Planning);
  • Alternate access methods (PC,CPU, Batch): F (Limitations) and Service type code - 82 (Family Planning);
  • 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.

Billable family planning services include:

  • All FDA approved birth control methods, devices, and pharmaceuticals;
  • Emergency contraceptive services and follow-up;
  • Male and female sterilization; and
  • Counseling, preventive screening and family planning options before pregnancy.

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;
  • Screening for sexually transmitted diseases (STDs), cervical cancer, and urinary or female-related infections;
  • Counseling services related to pregnancy and informed consent, and STD/HIV risk counseling;
  • Comprehensive health history and physical examination, including breast exam and referrals to primary care providers. Mammograms are not included;
  • Screening and related laboratory tests for medical conditions that affect the choice of birth control, e.g., a history of diabetes, high blood pressure, smoking, blood clots, etc.; and
  • HIV counseling and testing.

Abortions, treatment for infertility, and follow-up care not related to family planning are not covered under this program.

Requirements for Payment:

  • Whenever family planning is provided (either through the FPBP or regular Medicaid), 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;
  • Family planning diagnosis codes in the V25 series must be used when required on the claim form;
  • 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.

If you have any questions regarding this program, contact the Office of Medicaid Management at or by calling (518) 473-2160.

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Effective March 9, 2004, Plan B emergency contraception has been covered by the New York State Medicaid program. This drug is covered through a prescription from a licensed provider.

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The American Lung Association of the City of New York provides lung health education, advocacy and research throughout the five boroughs of the City of New York, including a comprehensive tobacco control program, such as Freedom From Smoking cessation clinics and one-on-one counseling for adults and teens.

For more information, please contact the Association at:

(212) 889-3370 or visit their website at

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Effective August 1, 2004, the following residential and day programs certified, operated or funded by the Office of Mental Retardation and Developmental Disabilities (OMRDD), will become responsible for all Medicaid reimbursable personal care and home health aide services provided to participants in these settings:

  • Intermediate Care Facilities (ICF/DD)
  • OMRDD Day Treatment and Day Habilitation Programs
  • Supervised Community Residences (CR)
  • Supervised Individual Residential Alternatives (IRA)

Individuals in these residential and day programs who require assistance with personal care/home health aide tasks must receive those services from residence or program staff, or through the residence or day program's direct purchase of such services from qualified providers. As a result of this, providers will no longer be able to request or bill Medicaid for such personal care services or home health aide services.

System edits and adjudicated claim audits will ensure providers do not receive Medicaid reimbursement for personal care services or home health aide services provided on or after August 1, 2004 to individuals in OMRDD ICFs/DD, supervised community residences, supervised IRAs, Day Treatment and Day Habilitation programs. If an incorrect payment is made, recovery of the payment will be pursued.

Questions from providers regarding information contained in this article should be addressed to the Department of Health's Bureau of Policy Development and Agency Relations at (518) 473-2160.

OMRDD residential and day programs should contact the OMRDD Bureau of Rate Setting at (518) 474-8819.

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The March 2004 Medicaid Update article, "Providers of Group Practices: Requirements And Responsibilities," provided information and requirements for group practices. For Medicaid purposes, providers are required to bill either as individuals or in a group. The relationship among providers in a group can be:

  • Associates;
  • Employer-employee; or
  • Principal-independent contractor.

The compensation agreement between group members must be in writing and must be made available to the New York State Department of Health upon request. Following are the proper procedures for submitting claims as an individual practitioner and as a provider in a group practice.


As an individual provider (an individual practitioner or a business entity which is not required to enroll as a group), you cannot use your individual provider ID number to bill for Medicaid services provided by anyone else except when:

  • Supervising a physician assistant or certified social worker, or
  • When a locum tenens agreement is in effect.

The individual provider, when billing Medicaid, is required to:

  • Certify that the service was rendered;
  • Enter his/her individual Medicaid provider identification (ID) number on the claim (service provider ID number); and
  • Where services are provided at multiple locations, the provider MUST identify the place of ACTUAL SERVICE on the claim form.


A group of practitioners is defined in 18 NYCRR 502.2(f) as "...two or more health care practitioners who practice their profession at a common location (whether or not they share common facilities, common supporting staff, or common equipment)."

Practitioners are groups of physicians, podiatrists, dentists, physical therapists, nurse midwives and clinical psychologists. Additionally, clinical psychologists practicing with social workers, or physicians practicing with any combination of the following: physician assistants, nurse midwives, clinical psychologists, optometrists, social workers, physical therapists, nurse practitioners and/or podiatrists, are considered multi-service groups.

Regardless of the arrangement among practitioners (associates, employer-employee, principal-independent contractor), practitioners described above who practice in a group setting are required to enroll as a group and to comply with the requirements associated with group practices as detailed in the March 2004 Medicaid Update. When submitting claims for payment to the Medicaid program, these requirements include:

  • Certifying that the services were provided;
  • Entering the group Medicaid ID number in the "Medicaid Group Identification Number" field;
  • Entering the Medicaid ID number of the practitioner who actually provided the service in the "Provider Identification Number" field; and
  • Where services are provided at multiple locations, identifying the place of ACTUAL SERVICE on the claim form.

In summary, the claim form must contain the proper Medicaid ID number: in cases of group billings, identify the provider of the service; and, in cases of multiple locations, identify the site where the service was provided. Your compliance with these procedures is appreciated.

Questions regarding this article and from individual practitioners who are contemplating forming or joining a group practice can be directed to the Department's Medicaid Provider Enrollment Unit at (518) 486-9440.

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In concert with the federal Centers for Disease Control and Prevention, the New York State Department of Health, including the Medicaid program, supports the use of rapid, technologically simple devices, such as the OraQuick® rapid HIV test, in order to increase access to early HIV diagnosis and treatment and prevention services. To this end, effective for dates of service on or after June 1, 2004, physicians enrolled in the HIV Enhanced Fee for Physicians (HIV/EFP) Program will be eligible for Medicaid reimbursement for HIV antibody screening tests that he or she performs, personally or through practice employees, as an adjunct to the treatment of their patients.

Physicians performing HIV screens should use procedure code 86701, HIV-1 antibody, which has a maximum reimbursable fee of $12.27, up to a maximum of one test per six month period per patient.

Physicians that would like to enroll in the HIV/EFP Program should contact:

John Schnurr
HIV Ambulatory Care Administrator
New York State Department of Health
AIDS Institute
Room 459 Corning Tower
Albany, NY 12237
Phone: (518) 473-3786
Fax: (518) 473-8905

In order for a physician to be reimbursed for HIV tests, his or her physician office laboratory must be registered with Clinical Laboratory Improvement Amendments (CLIA), the federal laboratory oversight program, must hold certification appropriate for CLIA categorization of the test device being used and must be registered with Medicaid as a Physician Office Laboratory (POL). To date, the OraQuick® rapid HIV test is the only HIV test device categorized as waived; the OraQuick®device requires minimally a CLIA certificate of waiver, but may be performed under any level of certification.

Physicians may apply for a CLIA certificate by contacting the Physician Office Laboratory Evaluation Program at (518) 485-5352 for an application form. The application is also posted on the Centers for Medicare and Medicaid Services' website: Select the option "How to Apply for a CLIA Certificate: Form CMS-116." A completed application must be submitted to the address of the local State agency for the state in which you will conduct testing. Physicians conducting testing in New York State should send their completed CMS-116 form to:

Wadsworth Center
Physician Office Laboratory Evaluation Program
P. O. Box 509
Albany, NY 12201-0509

Physicians that already hold a CLIA certificate but are not enrolled with Medicaid as a POL must fill out the POL-CLIA information form below. A completed enrollment form must be submitted to the address listed at the top of the completed form.

If you require additional information related to Medicaid coverage for HIV tests, please contact the Bureau of Policy Development and Agency Relations staff at (518) 473-2160.

Office of Medicaid Management
New York State Department of Health
Fee for Service Provider Enrollment
150 Broadway, Suite 6E
Albany, New York 12204




  1. Please print or type all required information.
  2. A SEPARATE form must be submitted for EACH eligible physician in a group. If a physician works at multiple physician office laboratory sites, a SEPARATE form must be submitted for EACH SITE.
  3. Attach a copy of the most recently issued valid Clinical Laboratory Improvement Amendments (CLIA) certificate for your site. If your physician office laboratory does not currently have a CLIA certificate, please contact the New York State CLIA unit at (518) 485-5352.
  4. A letter of verification from the Centers for Medicare & Medicaid Services (CMS) or the New York State Department of Health's CLIA unit is also acceptable evidence of CLIA certification. To obtain a letter from the New York State CLIA unit, please call (518) 485-5352.

New York State Medicaid Provider ID Number:________________________

CLIA Certificate Number: __________________________________________________

Physician License Number: ________________________________________________

Physician Name: (LAST)__________________________(FIRST)__________________

Site Address: ____________________________________________________________

City: _________________________ State: ________________ Zip Code: ___________

Telephone Number (______) _________-__________.

Please circle the appropriate type of CLIA Certificate held for this site: (circle one):

  • Waiver
  • PPMP (Provider Performing Microscopy Procedures)
  • Registration
  • Compliance/Accreditation

This item should be completed by legally organized group practice(s) only:

NYS Medicaid Provider ID Number for Group (if applicable): _____________________

Name of Group Practice: ___________________________________________________

Site Address: ____________________________________________________________

City: __________________________ State:_________________ Zip Code: _________

DOH-4124 (4/04)

Affecting Article 28 Federally Qualified Health Centers,
Federally Qualified Health Center Look-Alikes, and
Rural Health Clinics
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In the December 2003 Medicaid Update, providers were advised that Medicaid payment is available for psychiatric social work services provided in Federally Qualified Health Centers (FQHCs), FQHC Look-Alikes, and Rural Health Clinics (RHCs) on and after November 1, 2003.

Please note that the new policy also applies to programs that are solely certified as Article 28 clinics (have an operating certificate issued only by the New York State Department of Health (DOH)) and have been designated by the Federal Centers for Medicare and Medicaid Services (CMS) to meet the criteria for these categories of health centers.

This policy does not apply to clinics that are certified under Articles 16, 31, and 32 of the Mental Hygiene Law. Such clinics should follow rules established by the Office of Mental Retardation and Developmental Disabilities (OMRDD), Office of Mental Health (OMH), and the Office of Alcohol and Substance Abuse Service (OASAS), respectively.

The following questions and answers (Qs and As) apply only to clinics certified solely by DOH (except for Q and A #14, which addresses clinics certified by both DOH and OMH:

Questions and Answers


Q.1    What is the difference between licensed social workers and certified social workers (CSWs), and what is a licensed master social worker?
Prior to September 1, 2004 (currently), social workers are certified by the State Education Department (SED). Certified social workers have a master's degree in social work (MSW) and meet certain certification requirements. If a social worker wants to qualify for private insurance reimbursement for doing psychotherapy, they must have either a "P" or "R" credential for psychotherapy. This endorsement is a requirement under State Insurance Law; currently there is no licensing for social workers.

Effective September 2004, the term "CSW" (and the "certification") will be replaced by the term "Licensed Master Social Worker" (LMSW) which will be the equivalent of the current CSW. A new term "Licensed Clinical Social Worker" (LCSW) will replace the current psychotherapy endorsements and will be the license required for a social worker who wants to bill private insurance in NYS for psychotherapy services.

Q.2    Is a clinic eligible for payment before 9/1/04 if the psychotherapy service is provided by a CSW?
Yes, however, in order to qualify for Medicaid pre 9/1/04, the CSW must have psychotherapy privilege certification by SED or be working under qualifying supervision in pursuit of psychotherapy privileges certification by SED. A social worker who holds a CSW prior to 9/1/04 will qualify to be grandfathered as a Licensed Master Social Worker beginning 9/1/04.

Q.3    Is a clinic eligible for payment on or after 9/1/04 if the psychotherapy service is provided by a certified social worker?
As noted in #1 above, effective 9/1/04 the licensure requirements and titles for social workers will change. (Prior to 9/1/04, social workers are certified, post 9/1/04 they will be licensed by SED). On or after 9/1/04, payment is available only for services rendered by a licensed clinical social worker (LCSW) or, a Licensed Master Social Worker (LMSW) who is working in a clinic setting under qualifying supervision in pursuit of licensed clinical social work status by SED. A social worker who holds a CSW prior to 9/1/04 will qualify to be grandfathered as a Licensed Master Social Worker beginning 9/1/04.

Q.4    What is qualifying supervision for a CSW working towards psychotherapy certification?
Supervision by a licensed psychiatrist, a licensed clinical psychologist or a CSW with a "P' or "R" designation satisfies the "qualifying supervision" requirement. Specifics can be found in Part 74.5 of the State Education Department regulations, and is available at:

Q.5    What is considered "qualifying supervision" for a LMSW working towards clinical social work licensure?
Supervision must conform to SED regulations.


Q.6    What are the standards and record-keeping requirements that must be met for Medicaid billing of social work services in an Article 28 FQHC clinic?
First, clinic services certified by DOH must be provided by or under the direction of a physician. As such, we would expect a written physician's order for the psychotherapy service. Also, a characteristic of psychotherapy provided in a DOH (Article 28) certified clinic is that the therapy is expected to be short term and of limited duration, and provided incidental to general health care. Long term psychotherapy, as a treatment for a severe emotional disorder, would normally be provided in a clinic certified by the Office of Mental Health under Article 31 of the Mental Hygiene Law.
In addition to the items that must be maintained in the recipient case record as specified in the Clinic Provider Manual (section 2.1.11), such case record must also include the following information at a minimum:

  • A signed and dated treatment plan that includes, but is not limited to, the recipient's diagnosis, the recipient's treatment goals and the number of sessions ordered by the physician/psychiatrist. The physician involved in the treatment must sign treatment plans and, in doing so, is ordering the service and certifying the medical necessity of those services.
  • Dated and signed progress notes for each visit/contact identifying the session content and duration, as well as changes in goals, objectives, and services. The clinical person who provided the service must write such notes.
  • Periodic assessment of recipient's progress towards goal.


Q.7    Can clinics receive reimbursement for clinical social work services provided on and after 11/1/03, or is the effective date for billing 9/1/04?
Article 28 clinics that are designated as FQHC, FQHC Look-alikes, or RHC may bill Medicaid for psychotherapy services provided by qualified social workers for services rendered on or after November 1, 2003. The ability to bill for psychotherapy by qualified social workers does not confer the right to operate a program of mental health services. Such a program would be subject to licensure by the Office of Mental Health.

Q.8    What are the requirements for a clinic to bill for these services?
In order to be eligible for reimbursement, a clinic must meet ALL of the following:

  • Be an Article 28 clinic (enrolled in Medicaid as either category of service 0160- diagnostic & treatment center or 0287- hospital based outpatient department);
  • Have designation by the CMS as a FQHC, FQHC Look-alike, or RHC;
  • Be approved by the Office of Health Systems Management (OHSM) to provide psychotherapy as noted on the clinic's operating certificate

Q.9    What procedure codes should a clinic bill?
Only individual psychotherapy is a covered service. Therefore, only procedure codes for individual psychotherapy should be billed using the appropriate CPT4 codes. Case management or medical social services are not billable as a clinic visit.

Q.10    What payment does a clinic receive for providing these services?
This service is considered a threshold visit. Therefore, clinics receive their facility's all-inclusive clinic rate.

Q.11    Must psychotherapy services be ordered by a physician?
Yes, a physician must order psychotherapy services.

Q.12    Can an Article 28, designated by CMS as an FQHC, bill for family counseling services?
Medicaid payment for social work services provided in a FQHC, FQHC Look-alike, or RHC is not allowed for group services. Family counseling may be billed for one member of the family only.

Q.13    If the primary entity or parent corporation Article 28 facility has been designated by CMS as a FQHC, FQHC Look-alike or RHC, may all sites affiliated with that parent corporation bill the FQHC rate for social work services?
No. It cannot be assumed that all sites of a FQHC are themselves eligible for FQHC status. FQHC status must be held by any site billing for social work services.

Q.14    Can a dually certified (e.g. Article 28/Article 31 certification) FQHC clinic, bill for psychotherapy services provided by a social worker in a group setting?
Medicaid reimbursement for psychotherapy services provided in Article 28 FQHC clinics is only available for individual, one-on-one services when rate codes 1610 or 2870 are billed. If group psychotherapy is needed, the patient should be referred to a clinic licensed by OMH, OASAS or OMRDD. Alternatively, clinics (including FQHCs) that are also certified as clinics by OMH (Article 31), OASAS (Article 32) and OMRDD (Article 16) may provide and bill for group psychotherapy consistent with the rules of these agencies. Please note that any clinic providing significant mental health services to persons with mental illness needs to be certified by the OMH and should apply for such licensure. In all cases, if group therapy is being rendered in an OMH, OMRDD, or OASAS clinic, the service must be billed using the group therapy rate codes authorized by these agencies.

Questions concerning this article should be referred to the Bureau of Policy Development & Agency Relations at (518) 473-2160.

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As part of a continuing effort by New York State to provide the benefits of the managed care program to Social Security Income (SSI) and SSI-related beneficiaries, the New York State Department of Health (DOH) in conjunction with the New York City Department of Health and Mental Hygiene (CDOHMH) and Human Resources Administration (HRA), will begin mailing managed care information in June 2004 to all SSI and SSI-related beneficiaries in the five boroughs of New York City who currently are not enrolled in a Medicaid managed care plan.

New York currently enrolls SSI beneficiaries on a voluntary basis. The mailing reminds beneficiaries that they have an opportunity to choose Medicaid managed care as an option for their health care needs. In the mailing, the DOH, CDOHMH and HRA address the ability of the Medicaid health plans to meet the special health care needs of individuals with disabilities.

SSI beneficiaries are a diverse population with a variety of disabilities and a wide range of service needs. Individuals in the SSI category may have been diagnosed with a chronic physical illness, a mental health problem or developmental disabilities.

The mailing instructs individuals with SSI who are considering the managed care option to choose a plan based upon where the individual wants to go for medical care. You may find that your patients, who have SSI, may ask you about Medicaid managed care and the Medicaid health plans in which you participate. In answering their questions, you should remember that the benefit package for SSI is a health only benefit and does not include chemical dependency (alcohol and substance abuse) and mental health services. These services are billed fee-for-service and do not require a referral from a managed care plan.

The following services are also not part of the Medicaid managed care benefit package and are not billed to the managed care plan, but are billed fee-for-service:

  • Personal care agency services;
  • Prescription drugs;
  • Medical supplies and enteral formula;
  • Hospice services;
  • Residential health care;
  • AIDS adult day health care;
  • Adult day health care;
  • Special services for those with developmental disabilities (long term therapy provided by Article 16 or 28 clinic treatment facilities, day treatment, Medicaid service coordination, and home and community based waiver services);
  • Case management services; and
  • HCBS services.

If you have any questions about Medicaid managed care for the SSI population, you may call (518) 473-0122.

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The New York State Department of Health reminds all licensed home care services agencies of the following agency responsibilities, pursuant to 10 NYCRR Part 766, with respect to Medicaid recipients whom such agencies have admitted for care, including the provision of private duty nursing services:

a) Establish written policies regarding the rights of patients, including the right to submit patient complaints about the care and services provided or not provided, be informed of the procedure for filing such complaints and have the agency investigate such complaints in accordance with the provisions of § 766.9(j) (pursuant to 10 NYCRR § 766.1(a));

b) Ensure that all staff delivering care in patient homes are adequately supervised and that the Department considers, as evidence of adequate supervision, whether staff regularly provide services at the times and frequencies specified in the patient's plan of care and in accordance with the policies and procedures of their respective services (pursuant to 10 NYCRR § 766.5(b));

c) Ensure the development of a written emergency plan which is current and includes procedures to be followed to assure health care needs of patients continue to be met in emergencies that interfere with the delivery of services, and orientation of all employees to their responsibilities in carrying out such a plan (pursuant to 10 NYCRR § 766.9(c)); and

d) Accept and retain for services only those persons whose health care needs can be safely and adequately met by the agency according to criteria specified in written agency policies and to employ or contract with a sufficient number of staff to coordinate, direct and deliver services to patients accepted for care in accordance with prevailing standards of professional practice (pursuant to 10 NYCRR § 766.9(g) and 766.9(i)).

All licensed home care service agencies to which, and independent providers to whom, the Department or a social services district has issued a prior approval for the provision of private duty nursing services are reminded that they are responsible for providing the Medicaid recipient with private duty nursing services in accordance with the prior approval.

If any licensed home care services agency or independent provider of private duty nursing services has diligently pursued all available means to provide the Medicaid recipient with private duty nursing services in accordance with the prior approval but is consistently unable, due to reasons outside of such agency's or independent provider's control, to provide authorized private duty nursing services in accordance with the prior approval, the agency or independent provider of private duty nursing services should contact the recipient's physician or, for recipients for whom the Department has issued the prior approval, may contact the Department's Office of Medicaid Management, Bureau of Medical Review and Payment, at (518) 474-8161.

Questions concerning this article can be directed to the Bureau of Medical Review and Payment at (518) 474-8161.

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

Please indicate the seminar you wish to attend below:

 July 1, 2004  10:00 AM
 Chautauqua County DSS
 Hall R. Clothier Building Auditorium
 3 North Erie Street
 Mayville, NY 14657

 August 4, 2004  10:00 AM
 Madison County DSS
 North Court Street
 Wampsville, NY 13163

 September 21, 2004   10:00 AM
 Putnam County DSS
 110 Old Route 6
 Carmel, NY 10512

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

Please complete the following registration information:

Provider Name:____________________________________Provider ID:________________________

Provider Category of Service:_________________________Number Attending:___________________

Contact Name:_____________________________________Phone Number:______________________

Please provide the names of all attendees on the lines provided below:



If there are any questions about these seminars, please contact the CSC Provider Services at 800-522-5518 or 518-447-9860.

To register, please mail this completed page to:

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

or, fax a copy of the completed page to: (518) 447-9480

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

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

Return to Table of Contents


Missing Issues?
The Medicaid Update, now indexed by subject area, can be accessed online at the New York State Department of Health website:
Hard copies can be obtained upon request by calling (518) 474-9219.

Would You Like Future Updates Emailed To You?
Email your request to our mailbox,
Let us know if you want to continue receiving the hard copy in the mail in addition to the emailed copy.

Do You Suspect Fraud?
If you suspect that a recipient or a provider has engaged in fraudulent activities, please call the fraud hotline at: 1-877-87FRAUD. Your call will remain confidential.

As a Pharmacist, Where Can I Access the List of Medicaid Reimbursable Drugs?
The list of Medicaid reimbursable drugs is available at:

Questions About an Article?
For your convenience each article contains a contact number for further information, questions or comments.

Do You Want Information On Patient Educational Tools and Medicaid's Disease Management Initiatives?
Contact Department staff at (518) 474-9219.

Questions About HIPAA?
Please contact the HIPAA Support Helpline at (800) 522-5518 or (518) 447-9860.

Address Change?
Please contact the Bureau of Medical Review and Payment at:
Fee-for-Service Provider Enrollment Unit, (518) 486-9440
Rate Based Provider Unit, (518) 474-8161

Billing Question? Call Computer Sciences Corporation:
Call Center (800) 522-5518 or (518) 447-9860.

Comments and Suggestions Regarding This Publication?
Please contact the editor, Timothy Perry-Coon at or via telephone at (518) 474-9219 with your concerns.

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: