DOH Medicaid Update September 2004 Vol. 19, No.9

Office of Medicaid Management
DOH Medicaid Update
September 2004 Vol. 19, No.9

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

HIPAA Compliance Deadline
October 6, 2004
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The Medicaid HIPAA compliance deadline of October 6, 2004 is fast approaching. We urge all trading partners that have not already done so to complete their HIPAA conversion as quickly as possible. After October 6, 2004, Medicaid will only accept and process electronic transactions and claims submitted in a HIPAA-compliant format. Electronic transactions and claims submitted in a non-HIPAA compliant format will be rejected.

The October 6 deadline applies only to electronic transactions and claims submitted to Medicaid. It does not apply to outbound transactions (835, 820), or paper claims submissions.

In an effort to facilitate our trading partners' HIPAA conversion initiatives, Health Department and Computer Sciences Corporation (CSC) 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 by the October 6 date. We are scheduling regular conference calls with provider and vendor organizations, focusing on issues that may be impeding timely compliance. In addition, the Department and CSC have embarked on an aggressive outreach campaign, contacting as many trading partners as possible, offering support and technical assistance. We have also expanded the and the websites, providing valuable technical resources to assist our partners with all aspects of their conversion efforts.

The Edit/Error Knowledge Base is a new tool that we introduced in May to help our trading partners identify edits/errors and the probable corrective action necessary. 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. Enhancements to the Edit/Error Knowledge Base are being made regularly and trading partners are urged to take advantage of this valuable resource. The tool will expedite the testing process and facilitate the identification and correction of claiming errors. It is available at under the News and Resources Tab, Edit/Error Knowledge Base.

A number of our trading partners still have not registered to test through EDIFECS and/or with CSC. 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 October 6, 2004, which would result in an inability to submit HIPAA claims and receive payment. Complete information on the Medicaid HIPAA testing process requirements is available at

Providers utilizing clearinghouses or service bureaus to submit their Medicaid claims are urged to communicate regularly with these entities to ensure they are proceeding aggressively with their HIPAA compliance program. Providers should not assume that these entities will achieve timely HIPAA compliance, but should proactively monitor their progress. With the final compliance deadline of October 6, 2004 less than a month away, providers must take all necessary steps to become HIPAA compliant and avoid any disruption in claims processing and payment flow. Please remember that providers are ultimately responsible for claims submitted to Medicaid, whether by them directly or by some other entity on their behalf.

Questions regarding Medicaid HIPAA compliance and this article should be directed to the CSC HIPAA Support Helpline at (800) 522-5518.

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In order to prepare for the implementation of eMedNY Phase II, Replacement Medicaid System, CSC, under the direction of New York Department of Health (NYSDOH), is preparing new Companion Guides. Initial drafts of the following change control documents associated with the Companion Guides will be available beginning September 15, 2004 on the web site for:

  • 837 Dental
  • 837 Professional
  • 837 Institutional
  • 835 Health Care Claim Payment Advice
  • 820 Payroll Deducted and Other Group Premium Payment for Insurance Products
  • 276/277 Health Care Claim Status Request and Response
  • 270/271 Health Care Eligibility Benefit Inquiry and Response
  • 278 Health Care Services Review - Request for Review and Response-DVS/SA
  • 278 Health Care Services Review - Request for Review and Response-PA
  • 278 Inquiry and Response Confirmation

Please note that the Companion Guides will not be considered final until later this Fall. The initial drafts are intended to give a preview of changes to help providers plan for the March 2005 deployment of the eMedNY Phase II.

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The June issue of the Medicaid Update announced the upcoming implementation of eMedNY Phase II, the replacement of the current Medicaid Management Information System (MMIS). The eMedNY Phase II implementation is scheduled for March 2005.

The enhancements to the current claims processing system, featured by eMedNY Phase II and federal regulations that govern the implementation of new healthcare systems, require changes that will impact the manner in which providers interact with the Medicaid program. The purpose of this article is to provide notification of some of those changes.

Communication Changes

Magnetic Media

Physical media such as tape, diskette, and cartridge will not be supported by eMedNY Phase II as of implementation date. Trading partners that currently use this type of media for claim submission will need to migrate to CPU-to-CPU, FTP, or eMedNY Exchange and will need to obtain user IDs and passwords.

As with the inbound submissions, remittance advices will generally not be sent on physical media. Individual providers and managed care plans that choose to receive the HIPAA 835 or the 820 transactions will receive these as electronic transmissions. Providers and managed care plans will still have the choice of receiving paper remittance advices instead of the 835 or 820 transactions.

Paper Forms

In order to accommodate systems changes and to comply with the Centers for Medicare and Medicaid Services (CMS) regulations, the usage of paper forms will undergo significant changes as follows:

  • NYS Form A, HCFA-1500, and Pharmacy forms will be accepted with modifications in format and provider-type users.
  • NYS Form B and Form C will be discontinued.
  • The standard CMS UB-92 Form will be adopted for rate-based providers.
  • The current Prior Authorization/Prior Approval forms will be modified.
  • The current Threshold Override Application (TOA) form will be modified.

Samples of the new paper forms for Phase II are available at in the "eMedNY Phase II Paper Forms" featured link.

NYS Claim Form A

This form will be accepted, with modifications, only for dental providers billing on a fee-for-service basis (category of service codes 0180 and 0200), providers with category of service codes 0160 or 0287 with specialty code 912, and transportation providers (categories 0601, 0602, 0603, 0605, 0606).


The modified version of this form will be accepted for the current users and for the fee-for-service provider types currently using Form A and Form C. The following chart indicates the provider categories that are expected to use the modified NYS HCFA-1500 under eMedNY Phase II.

Service Category CodeService Category Name Current FormeMedNY Form
0140QMB Chiropractor & Portable X-rayNYS-HCFA 1500NYS-HCFA 1500
0162Free Standing Clinic- Ordered Ambulatory LabClaim Form A NYS-HCFA 1500
0163, 0389Free Standing Clinic- Ordered Ambulatory
Part A & B (other than Lab)
Claim Form ANYS-HCFA 1500
0164, 0261, 0262, 0283, 0321-0325,
0386, 0387, 0442, 0443, 0604
DME and Hearing AidClaim Form CNYS-HCFA 1500
0281Hospital-based Ordered Ambulatory LabNYS-HCFA 1500NYS-HCFA 1500
0282Hospital-based Ordered Ambulatory
(Other than Lab)
0401, 0402, 0404, 0405,
0407, 0408, 0422, 0423
Vision CareNYS-HCFA 1500NYS-HCFA 1500
0460PhysicianNYS-HCFA 1500NYS-HCFA 1500
0469Nurse PractitionerNYS-HCFA 1500NYS-HCFA 1500
0500PodiatristNYS-HCFA 1500NYS-HCFA 1500
0521Nurse LPNClaim Form ANYS-HCFA 1500
0522Nurse RNClaim Form ANYS-HCFA 1500
0523Hospital Registry LPNClaim Form ANYS-HCFA 1500
0524Hospital Registry RNClaim Form ANYS-HCFA 1500
0525MidwifeClaim Form A NYS-HCFA 1500
0560Clinical Social WorkerNYS-HCFA 1500NYS-HCFA 1500
0580Clinical PsychologistClaim Form ANYS-HCFA 1500
0621Occupational TherapistClaim Form ANYS-HCFA 1500
0622Physical TherapistClaim Form ANYS-HCFA 1500
0623Speech Pathologist / Speech TherapistClaim Form ANYS-HCFA 1500
1000Free Standing LaboratoryNYS-HCFA 1500NYS-HCFA 1500

NYS Pharmacy Claim

The modified Pharmacy form will be accepted for categories of service 0161, 0288, and 0441.


All rate-based providers that currently bill on Form A or on Form B will be required to use the CMS standard UB-92 form. The following chart indicates all the provider categories that are expected to use the UB-92.

Service Category CodeService Category NameCurrent Form eMedNY Form
0121Child CareClaim Form BUB-92
0123Residential Treatment Facility Claim Form A UB-92
0160Free-Standing Day Treatment CenterClaim Form BUB-92
0164 School Supportive Health ServicesClaim Form A UB-92
0165Hospice Claim Form BUB-92
0220Managed Care CapitationClaim Form AUB-92
0260, 0260
with specialty 798
Free-standing Home Health Care
and Long Term Home Health Care
Claim Form A UB-92
0263TBI WaiverClaim Form AUB-92
0264Personal Care Agency; Limited Licensed Home CareClaim Form A UB-92
0265Case Management ServicesClaim Form AUB-92
0266Personal Emergency Response SystemClaim Form AUB-92
0267Assisted Living Program (ALP)Claim Form BUB-92
0268OMH Rehabilitative ServicesClaim Form AUB-92
0269HCBS WaiverClaim Form AUB-92
0284, 0284
with specialty 798
Hospital-based Home Health Care
and Long Term Home Health Care
Claim Form A UB-92
0286Skilled Nursing Facility (Inpatient)Claim Form BUB-92
0287Hospital-based Day Treatment CenterClaim Form BUB-92
0381Long Term Care (LTC) Skilled Nursing FacilityClaim Form BUB-92
0383LTC Day CareClaim Form BUB-92
0384Intermediate Care Facility (ICF-DD)Claim Form BUB-92
0385LTC Mental Retardation (Outpatient)Claim Form BUB-92
0386NH-based Home Health CareClaim Form AUB-92
0388 w/specialty 798NH-based Long Term Home Health CareClaim Form AUB-92

CSC will schedule seminars to train providers in the new billing requirements. Schedules will be announced in the Medicaid Update, the eMedNY website, and special mailings at a later time. Also, dates relevant to the transition from the current forms to the new forms (i.e. cutoff date for accepting old forms, effective date for accepting new forms, etc.) will be announced at a later time.

Providers that fill paper claims using a software program will need to modify their software to accommodate the changes.

CSC will continue notifying providers of matters related to the eMedNY Phase II implementation. Please keep looking for further information in the Medicaid Update, in CSC's and Department websites listed below, and expect future mailings with general information or information applying to specific provider types.

Please visit the following websites often to stay up-to-date on the planned changes for eMedNY Phase II:

If you have any questions about the contents of this article, please call CSC Provider Services at (800) 522-5518.

Schedule of Medicaid Seminars for New Providers
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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

*October 27, 2004     Registration begins at 9:30 AM     Seminar begins promptly at 10:00 AM

Suffolk County Department of Social Services
Michael Jones Conference Room
3085 Veterans Memorial Hwy
Ronkonkoma, NY 11779

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

Please complete the following reservation information:

Provider Name: ____________________________________

Provider ID: ________________________

Provider Category of Service: _________________________

Number Attending: ___________________

Contact Name: ____________________________________

Telephone Number: __________________

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


Please submit reservation early to attend sites marked with (*) because seating is limited. Each seminar will last approximately two hours.

Reservations for the October 27th Seminar will NOT be accepted after October 20th.

If there are any questions about these seminars please contact the CSC Call Center at (800) 522-5518 or (518) 447-9860.

To reserve, please mail this completed page to:

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

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

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

Pharmacy Reimbursement Changes
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Pharmacy reimbursement for prescription drugs under the New York State (NYS) Medicaid program is limited to the lower of the billing pharmacy's usual and customary price charged to the general public, or the upper limit established by the Federal Government (FUL) for specific multiple source drugs, or the estimated acquisition costs (EAC) established by the NYS Department of Health.


Recently enacted legislation has resulted in changes in the Medicaid pharmacy reimbursement rates. The following changes to estimated acquisition costs definitions will apply to payments that are issued for services provided on and after October 1, 2004:

  1. Sole or Multi-source Brand Drugs
    The average wholesale price (AWP) of the prescription product, minus twelve and seventy-five hundredths (12.75) percent. State and federal requirements for the dispensing of brand-name drugs must be met.
  2. Multi-source Generic Drugs
    The lower of AWP minus sixteen and one-half (16.5) percent, or the FUL. If an FUL has not been assigned by the Centers for Medicare and Medicaid services (CMS), the State based maximum acquisition cost (MAC), when established by the NYS Commissioner of Health, will be applied.

The legislation also directs that a State Maximum Allowable Cost (SMAC) be developed and applied to the Medicaid pharmacy reimbursement for generic products as an interim payment prior to the availability of an FUL.

In addition, the legislation requires the Commissioner to approve specialized HIV pharmacies which meet specific programmatic and operational criteria. When these pharmacies are approved, the estimated acquisition cost will be defined as follows for these pharmacies:

  • Sole or multi-source brand drugs
    AWP minus twelve (12) percent. State and federal requirements for the dispensing of brand-name drugs must be met.
  • Multi-source generic drugs
    AWP minus twelve (12) percent, or the lower of the established FUL or NYS MAC, when established by the Commissioner of Health.

Additional information regarding the SMAC, as well as information regarding how specialized pharmacies will be identified and approved, will be distributed in the future.

If you have questions, contact the Medicaid Pharmacy Policy and Operations Staff at 518-486-3209.

The Medicaid program now covers the over-the-counter (OTC) formulation of omeprazole called Prilosec OTC™. Prilosec OTC™ is the only proton pump inhibitor (PPI) available over-the-counter. Prescribers may use their prescription blanks to write fiscal orders for Prilosec OTC™.

Currently, the Medicaid program covers a large variety of over-the-counter products used to treat heartburn which include calcium carbonate, magnesium hydroxide and aluminum hydroxide preparations.

These traditional antacids cost the Medicaid program approximately 30 to 40 cents a day!

A cost comparison of various short term PPI therapies is outlined below. It is important that patients with gastrointestinal disorders are provided the most clinically appropriate and cost effective treatment.


OTC and Prescription Proton Pump Inhibitor Options
(please refer to product literature for indications, dosage and administration requirements)

Drug NameStrengthEstimated
Medicaid Cost
per Tablet/Capsule
Medicaid Cost
for 14 Days of Therapy*
Prilosec (omeprazole) OTC™20mg$ 0.68 $ 9.52
Omeprazole10mg$ 3.25$ 45.50
Omeprazole20mg$ 3.65$ 51.10
Aciphex (rabeprazole)20mg$ 4.13$ 57.82
Nexium (esomeprazole)20mg $ 4.28$ 59.92
Prevacid (lansoprazole)30mg $ 4.28$ 59.92
Prilosec (omeprazole)20mg$ 4.06$ 56.84
Prilosec (omeprazole)40mg$ 5.83$ 81.62
Protonix (pantoprazole)20mg$ 3.37$ 47.18

* Based on once daily dosing

Questions regarding this article may be directed to the Pharmacy Policy and Operations staff at (518) 486-3209 or

Mandatory Generic Drug Program Update
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The New York State Medicaid Mandatory Generic Drug Program requires prior authorization for brand-name prescriptions with an A-rated generic equivalent.


When the FDA approves new generic drugs, Medicaid allows the equivalent brand-name drug to be dispensed for a period of six months, without prior authorization, to assure that there is an adequate supply of the new generic readily available. The Medicaid Program will begin posting brand name drugs and the effective date of the prior authorization requirement in the Medicaid Update and on the Department's web that meet this standard.

The following list of drugs have had generic equivalents available for six months or more, and will require prior authorization, effective November 1, 2004. (Remaining refills of current prescriptions which were written prior to this date, but are filled on or after November 1, 2004, will not require prior authorization. However, when a current prescription expires, a prior authorization will be required for the patient to continue to receive the brand-name drug.)

Brand Name Drugs Requiring Prior Authorization
Effective November 1, 2004

AUGMENTIN 200-28.5 AND 400-57 SUSPEN
AUGMENTIN 500-125 AND 875-125 TABLET


A limited number of brand-name drugs with generic equivalents are exempt from this requirement and are listed below.

Current Drugs Exempt From the Prior Authorization Process


These exemptions:

  • do not preclude the prescribing of their generic equivalents; and,
  • should not be considered an opinion on the bio-equivalency of the generic versions.

Prior Authorization Process

For complete information on the prior authorization process, including the process to request a drug exemption, please visit the Department of Health's web site at:


If you prescribe a generic drug, no prior authorization is necessary

Questions regarding this article may be directed to the Pharmacy Policy and Operations staff at (518) 486-3209 or

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Effective September 1, 2004, enrolled laboratories will be eligible for Medicaid reimbursement for travel expenses associated with in-home phlebotomy services, i.e., blood draws, provided under circumstances outlined below.

Ordered testing and its scheduling must be medically necessary, and the patient must be eligible for in-home phlebotomy as documented by a medical practitioner and defined below. This must be specified by the ordering practitioner on the laboratory requisition or on other documentation retained by the laboratory.

A recipient is eligible for in-home phlebotomy if:

  • the recipient is homebound, which means he or she has a condition due to illness or injury that precludes access to routine medical services outside of his/her residence without special arrangements for transportation, i.e., ambulance, ambulette, and taxi with assistance in areas where public transportation is unavailable; or has a condition that makes leaving the residence medically contraindicated; and,
  • the recipient is participating in a Medicaid-covered home care program or is currently receiving a Medicaid-covered home care service, i.e., personal care services, certified home health agency (CHHA) services, consumer-directed personal assistance services, and the Long Term Home Health Care Program (LTHHCP).

Travel expenses are NOT a covered service if they are solely to:

  • draw blood from patients in a skilled nursing facility;
  • draw blood from a recipient who receives medical services in his or her residence from a professional whose scope of practice authorizes the drawing of blood; or,
  • pick-up and transport a specimen collected by a home health care provider or anyone other than a laboratory representative.

Laboratories may claim reimbursement for in-home phlebotomy travel expenses

  • Travel expenses should be claimed using code P9604.
  • Maximum reimbursement is $7.50 one way, $15.00 round-trip, regardless of distance.
  • The laboratory is entitled to only one fee for one-way or round-trip travel to a single address, regardless of the number of specimens collected or the number of recipients drawn at that location.
  • There is a limit of 12 claims per recipient per year for in-home phlebotomy service; this allows for 12 round-trips or 12 one-way trips, or any combination of no more than 12 round or one-way trips.
  • The number of specimens collected per trip must be documented.
  • To calculate the appropriate reimbursement amount for claiming travel to and from in-home phlebotomy services, multiply the number of trips or stops (including the return trip to the laboratory) by $7.50 and divide this amount by the number of patients seen.
  • The laboratory will pro-ration when the claim is submitted based on the number of patients seen on that trip.
  • The "same address" is defined as a building or complex with the same entrance and egress off of a public road, such as an apartment complex.

Rules for billing, including pro-rating for multiple recipients:

  1. One recipient at one site: A laboratory representative travels from the laboratory to the home of one recipient and returns to the laboratory without making any other stops. The trip out and back is paid as a round-trip. The laboratory should submit a single line claim for $15.00 (2 x $7.50 = $15.00).
  2. One recipient at each of multiple sites: A laboratory representative travels in a circuit from the laboratory to the home of each of six recipients and returns to the laboratory. Each segment is paid as a one-way trip at a flat rate of $7.50. The laboratory is entitled to a total of $52.50 (7 x $7.50 = $52.50) but, since a separate claim must be submitted for each recipient, $52.50 must be divided by the number of recipients, which is six. Each of the six recipient claims would be submitted for $8.75.
  3. Multiple recipients at a single address: A laboratory representative travels from the laboratory to an apartment complex, draws blood from six recipients and returns to the laboratory. The laboratory is entitled to one round trip fee of $15.00, but, since a separate claim must be submitted for each recipient, the $15.00 must be divided by the number of recipients, which is six. Each of the six recipients' claims would be submitted for $2.50.
  4. Multiple recipients at one address + one recipient at each of several additional sites: A laboratory representative travels from the laboratory to an apartment complex and draws blood from three recipients; he then continues his circuit to three separate residences, and draws blood from one recipient at each, and returns to the laboratory. The laboratory should bill as follows:
    • The laboratory is entitled to $7.50 for the trip segment from the laboratory to the apartment complex;
    • For each of the three recipients drawn at separate addresses, the laboratory is entitled to $7.50 trip segment. The laboratory is also entitled to $7.50 for the return to the laboratory. The total would be four times $7.50, or $30.00.
    • The total number of stops are 5 (one stop from the laboratory to the apartment complex, stops at three recipients' homes and the return trip to the laboratory). The laboratory is entitled to a total of $37.50 (5 x $7.50 = $37.50), but since a separate claim must be submitted for each recipient, $37.50 must be divided by the number of recipients which is six. Each of the six recipient's claims would be submitted for $6.25.

NOTE: For all examples, the amount charged and units to be billed per recipient must be entered on the claim. On the HCFA-1500 form, enter the amount charged in field 24H and enter two units in field 24G representing a round trip. For electronic claims the amount charged is reported as proprietary claim A, C3 Record, positions 35-41, and the units are reported as proprietary claim A, C3 Record, positions 25-26. For electronic HIPAA - 837P claims the amount charged is reported in Loop 2400, SV102 and the units in Loop 2400, SV104.

Please direct questions on this policy to staff of the Bureau of Policy Development and Agency Relations at (518) 473-2160.

New Edit On Submitted Claims!

Service Provider Number
Should Not Be The Same As
Billing Provider Number
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In the Fall, Medicaid will implement an edit verifying that the service provider's Medicaid provider identification (ID) number is not the same as the billing provider's Medicaid provider ID number.

This edit will impact most provider types who are required to supply service provider information on their claims.


This edit will not apply to:

  • providers who are not required to provide service provider information (if you are not required to furnish service provider information, your claim may be denied if you furnish this information); and,
  • providers who are instructed to enter the service provider ID number even when it is the same as the billing provider ID number (e.g., self-employed optometrists and self-employed opticians).

Providers should consult their provider manual for instructions on completing the service provider ID number field.

If you have any questions, please contact Computer Sciences Corporation Provider Relations at (800) 522-1892 or (518) 447-9810.

Important Information For Dental Providers

Recipients Eligible for Emergency Services Only
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On October 6, 2004, the provision of dental services to Medicaid clients eligible to receive 'Emergency Services Only' will be restricted to the procedure codes listed on the following page. All other dental procedure codes contained on claims for services provided to an 'Emergency Services Only' client will be denied on electronic claims, and will be subject to audit recoupment if paid through the paper claim format.


Any questions should be directed to the Bureau of Medical Review and Payment, Dental Unit, at (800) 342-3005, Option #2.

D0160     Detailed and extensive oral evaluation - problem focused

D0220     Periapical; first film

D0230     Periapical; each additional film

D0330     Panoramic film

D2920     Re cement crown

D2931     Prefabricated stainless steel crown; permanent tooth

D2932     Prefabricated resin crown

D6930     Re cement fixed partial denture

D7140     Extraction, erupted tooth or exposed root

D7250     Surgical removal of roots

D7510     Incision and drainage of abscess; intraoral soft tissue

D7520     Incision and drainage of abscess; extraoral soft tissue

D7530     Removal of foreign body

D7610     Maxilla [fracture]; open reduction

D7620     Maxilla [fracture]; closed reduction

D7630     Mandible [fracture]; open reduction

D7640     Mandible [fracture]; closed reduction

D7820     Closed reduction of dislocation

D7910     Suture of recent small wound up to 5 cm

D7911     Complicated suture; up to 5 cm

D7912     Complicated suture; greater than 5 cm

D7999     Limited to Surgical Extractions; when codes D7210, D7220, D7230, D7240 and D7241 would be used

D9110     Palliative (emergency) treatment of dental pain - minor proc.

D9220     Deep sedation - first 30 minutes

D9221     Deep sedation - each additional 15 minutes

D9241     IV conscious sedation - first 30 minutes

D9242     IV conscious sedation - each additional 15 minutes

This article provides an overview of the SSI/SSI-related Medicaid managed care and Special Needs Plan benefit package to assist mental health and chemical dependency providers whose patients may be enrolled in managed care or are considering enrolling in managed care. Instruction is also provided on how to identify SSI/SSI-related enrollees on MEVS and ePACES.

SSI Medicaid Managed Care Benefit Package
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Social Security Income (SSI) and SSI-related Medicaid managed care enrollees receive a health-only benefit package that includes:

  • medically necessary physical health care services (including lab and emergency room services); and,
  • detoxification services (Medically Managed Detoxification, and Medically Supervised Inpatient and Outpatient Withdrawal services).

The services that are included in the managed care benefit package must be coordinated through the enrollee's health plan.

The SSI health-only benefit package excludes all other behavioral health services. SSI and SSI-related beneficiaries obtain medically necessary inpatient and outpatient behavioral health services through the Medicaid fee-for-service program. The services that SSI/SSI-related enrollees must obtain on a fee-for-service basis include:

  • mental health inpatient and outpatient services;
  • mental health services certified by the New York State Office of Mental Health for individuals with serious mental illness;
  • chemical dependence inpatient rehabilitation services; and,
  • all chemical dependence outpatient treatment services (including MMTP).

For a complete description of the Medicaid Managed Care benefit, please see the Department of Health website at, Managed Care Model Contracts, Medicaid Contract, Appendix K.

Special Needs Plans (SNPs)

The SNP benefit package for SSI/SSI-related enrollees includes:

  • medically necessary physical health care services (including lab and emergency room services);
  • detoxification services (Medically Managed Detoxification, and Medically Supervised Inpatient and Outpatient Withdrawal services); and,
  • inpatient and outpatient mental health services.

The services that these SSI/SSI-related enrollees must obtain on a fee-for-service basis include:

  • mental health services certified by the New York State Office of Mental Health for individuals with serious mental illness;
  • chemical dependence inpatient rehabilitation services; and,
  • all outpatient chemical dependence treatment (including MMTP).

From the perspective of behavioral health services, some SSI or SSI-related children of SNP enrollees have the same health only benefit package as the SSI/SSI-related enrollees in the Medicaid managed care plans described above.

Client Identification

To identify an SSI or SSI-related recipient, MEVS will show an "S" in the category of assistance field. On the OMNI 3750 terminal, the category of assistance response will be returned after the anniversary date in the following format:


For telephone verifications, an SSI or SSI-related recipient will be identified by "Category of Assistance S" after the anniversary month in the stated response. For recipients with any other category of assistance, it will not be returned via the terminal or phone.

This information is then followed by managed care plan eligibility and covered services if applicable.

NCPDP DUR Response Formats

Variable Eligibility and Claim Capture (5.1): Field 504 (message), position 21 will be "S" or space filled.
Variable Eligibility (3.2): Field 504 (message), position 47 will be "S" or space filled.
Variable Claim Capture (3.2): Field 504 (message), position 49 will be "S" or space filled.
Fixed (RTDS 3A): Field 504 (message), position 60 will be "S" or space filled.

ePACES Response Details

Eligibility, Service Authorization, DVS and Claim transactions - the COA "S" will be displayed in the Medicaid Message section.

For questions on the Medicaid Managed Care and SNP benefit package, please call Bureau of Program Planning at (518) 473-7467.
For questions on client identification, please call Kate Cahill at (518) 473-0045.

Important Information For Orthodontic Providers

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Effective October 1, 2004, orthodontic cases for Medicaid-eligible clients up to 21 years of age who are the financial responsibility of any of the following counties will require review and prior approval by the Albany Dental Prior Approval Unit of the New York State Department of Health:

Chemung ClintonColumbiaDelaware
Dutchess Erie EssexFranklin
Fulton Genesee HamiltonLivingston
Madison MonroeOneida Ontario

With the issuance of prior approval, any Medicaid enrolled, board qualified or certified orthodontist participating in the Medicaid program with specialty designator 801 OR any clinic facility with specialty designator 912, will be able to provide care to clients eligible for orthodontic benefits under the program.

Medicaid approval will only be issued for cases presenting with severe handicapping malocclusions. The following procedure codes will now be subject to the prior approval process for clients from the above counties:

  • D8070  (Comprehensive orthodontic treatment of the transitional dentition)
  • D8080  (Comprehensive orthodontic treatment of the adolescent dentition)
  • D8090  (Comprehensive orthodontic treatment of the adult dentition - up to age 21)
  • D8670 (Periodic orthodontic treatment visit - as part of contract)
  • D8680 (Orthodontic retention)

The new prior approval review process does not apply to Medicaid patients who have an existing treatment authorization that was previously issued through the Physically Handicapped Children's Program (PHCP). For such patients, you may complete the currently authorized treatment year, after which you will be required to submit a new treatment request for prior approval evaluation. For continuing cases, attach a copy of the previous year's PHCP authorization with the prior approval request, along with progress notes.

Prior approval request forms completed pursuant to instructions contained in a recent letter to orthodontists and in the MMIS Dental Provider Manual, along with appropriate diagnostic aids and information (i.e., diagnostic radiographs AND intraoral photographs), should be sent to:

New York State Department of Health
Bureau of Medical Review and Payment
Dental Prior Approval Unit
150 Broadway, Suite 6E
Albany, New York 12240-2726

Orthodontists wishing to obtain the appropriate specialty designation should submit their requests to:

New York State Department of Health
Bureau of Medical Review and Payment
Provider Enrollment Unit
150 Broadway, Suite 6E
Albany, New York 12240-2726

Prior authorization for children covered by the Department of Health's Physically Handicapping Children's Program (PHCP) Dental Rehabilitation Program in these same 36 counties will change as of October 1, 2004, as well. Children will no longer need to attend screening clinics. Prior authorization requests will be transferred from the screening clinics to the Bureau of Dental Health in Albany.

Prior authorization requests for PHCP-enrolled non-Medicaid children and required documentation (DOH-4268, treatment plan, photographs of various views and of models, and, radiographs including panorex and cephalometric) should be submitted to the following address:

New York State Department of Health
Bureau of Dental Health
Room 542, Corning Tower ESP
Albany, New York 12237-0619

General dental conditions, including correction of cavities, prophylaxis and extractions, should be addressed by a general dentist prior to any request for orthodontics being submitted, whether for Medicaid or PHCP children.

Any questions regarding this new Medicaid prior approval requirement should be directed to the Bureau of Medical Review and Payment, Dental Prior Approval Unit, at (800) 342-3005, Option #2.

Any questions regarding the new PHCP prior authorization requirement should be directed to the Bureau of Dental Health at (518) 474-1961.

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Man and Report

This month's patient educational tools features an article on

"How to Read Nutrition Labels"

The Medicaid program encourages practitioners to copy and distribute the following information to their patients and to share them with their colleagues.


Healthy eating begins with knowing the facts about what you are putting in your mouth. Reading labels can help you make wise food choices. Knowing how to read the Nutrition Facts on a food label and not relying on phrases like "healthy" or "low-fat" is the first step.

Here's an example of a Nutrition Facts section. At the top, you'll see the serving size and the number of servings per container. The information on the label is for the serving listed.

Chili with Beans
Nutrition Facts
Serving size: 1 cup
Servings per container: 2
Amount per serving:
Calories 260Calories from Fat
 % Daily Value
Total Fat 8g13%
Saturated Fat 3g17%
Cholesterol 130mg44%
Sodium 1010 mg42%
Total Carbohydrate 22g7%
Dietary Fiber 9g36%
Sugars 4g 
Protein 25g 

The serving size on the food label may not be the same as the serving that you normally eat. If you eat twice the serving listed on the label, that is, 2 cups instead of 1, you will need o double all of the numbers in the Nutrition Facts section.

If you are trying to lose or maintain weight, the number of calories eaten counts. To lose weight, you need to eat less calories than you burn.

Total amounts are shown in grams, abbreviated as gms, or milligrams, shown as mg.

Total Fat:
Total fat tells how much fat is in a food serving.
It includes fats that are good for you, such as mono and polyunsaturated fats (from liquid and plant sources such as canola oil and nuts) and fats that are not so good such as saturated and trans fats (from animal sources such as meats, cheeses and eggs).

Mono and polyunsaturated fats can help lower your blood cholesterol and protect your heart.

Saturated and trans fat can raise your blood cholesterol and increase your risk of heart disease.

Fat has twice the amount of calories than protein or carbohydrate. Although mono and polyunsaturated fats are healthy, you will still need to pay attention to the total amount of calories eaten everyday in order to maintain or lose weight.

Cake Popcorn Muffin

Trans Fats:
Trans Fats are also known as hydrogenated and partially hydrogenated fats.

Trans fats are formed during the process of converting liquid oils into solid fats such as shortening and stick margarine. This process is called hydrogenation and it increases the shelf life and flavor stability of these fats.

Like saturated fats, these are bad for your heart and should be avoided.

Unfortunately many foods have trans fats. The biggest sources of trans fat for Americans are commercial products such as cakes, cookies, crackers, pies, breads, animal products and margarine, certain "buttered" microwave popcorn and items made with or fried in partially hydrogenated oil including some french fries, potato chips, and salad dressings. With a little persistence, you can either avoid or substitute foods without hydrogenated oils.

For example, you can choose potato chips with the ingredients listed as potatoes and salt instead of the brand that includes the hydrogenated oils. An example of a soft butter without hydrogenation is Smart Balance.

At this time, trans fats are not yet listed under "Nutrition Facts". You should look in the ingredients section for phrases such as "partially hydrogenated" or hydrogenated oil, fat or shortening to learn if they are present in the food you are buying. Manufacturers will be required to list the trans fats along with the other three types of fats in 2006.

Sodium is also known as "table salt". It is a hidden ingredient in many foods especially processed and canned goods such as canned soups, tomato sauces and boxed foods. Adults with normal blood pressure should not consume more than 2400 mg a day. Sodium "holds" water in the body and increases the work required of the heart, therefore also increasing blood pressure. If you need to lower your blood pressure, it would be helpful to limit your salt intake.

Peppers Fruit Pineapple Eggplant Squash Banana

Fiber is part of plant foods that is not digested. Dried beans such as kidney or pinto beans, fruits, vegetables and grains are all good sources of fiber. The recommendation is to eat 25-30 gms of fiber a day.

Sugar alcohols:
Sugar alcohols, also known as polyols, include sorbitol, xylitol and mannitol, and have fewer calories than sugars and starches.

List of ingredients:
Ingredients are listed in descending order by weight, meaning the first ingredient makes up the largest proportion of food. Check the list of ingredients to look for the things you might want to avoid, for example coconut or palm oil, which is high in saturated fat or partially hydrogenated oil which is high in trans fat.

Look for heart healthy ingredients such as soy; monounsaturated fats such as olive, canola or peanut oils; or whole grains, like whole wheat flour and oats.

Additional information on nutrition meal planning may be found at:

Or at

Food Stamps Nutrition Education Program, "Eat Smart New York",

Or you may call, NYS FSNEP coordinator, at (518) 473-0401 or email

Source: Reading Food Labels- Nutrition & Recipes- American Diabetes Association,

Literally means joint inflammation, i.e., swelling, redness, heat and pain caused by tissue injury or disease in the joint.

For Those Living with Arthritis, Gentle Exercise Can Help
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There are more than 100 forms of arthritis and rheumatic diseases. These diseases may cause pain, stiffness, and swelling in joints and other supporting structures of the body such as muscles, tendons, ligaments and bones.

Studies have shown that exercise helps people with arthritis in many ways. Exercise reduces joint pain and stiffness and increases flexibility, muscle strength, cardiac fitness, and endurance. It also helps with weight reduction and an improved sense of well-being. Before beginning an exercise program consult with your doctor.

Bike Rider

Three Types of Exercise Which May Be Beneficial

Range-of-Motion exercises (e.g. walking) help maintain normal joint movement and relieve stiffness. This type of exercise helps maintain or increase flexibility.

Strengthening exercises (e.g., weight training) help keep or increase muscle strength. Strong muscles help support and protect joints affected by arthritis.


Aerobic or endurance exercises (e.g., bicycle riding) improve cardiovascular fitness, reduce joint inflammation and control weight.

Exercising Tips for Those with Arthritis

  • Discuss exercise plans with your doctor.
  • Apply heat to sore joints (many people with arthritis start their exercise program this way).
  • Stretch and warm up with range-of-motion exercises.
  • Start strengthening exercises slowly, with small weights.
  • Progress slowly.
  • Use cold packs after exercising (many people with arthritis complete their exercise routine this way).
  • Add aerobic exercises only when ready.
  • Ease off if joints become painful, inflamed or red.
  • Choose the exercise you enjoy most and make it a habit.


If it has been a while since you have done regular physical exercise, start slowly and gradually work your way up to 30 minutes a day, three or more days a week. Start with 10 or 15 minutes at a time.

Let your body be your guide. And don't over do it! If you cannot carry on a conversation, or if you feel severe pain during exercise, you are pushing too hard.

Start and end your exercise at a slower pace to give your body a chance to warm up and cool down. For example, start and end your walk with five minutes at a slower speed. Some exercises may be more comfortable if you start with gentle stretching.

For more information:

Source: National Institute of Arthritis and Musculoskeletal and Skin Diseases,

This informational article can be used in your practice to bring awareness to New Yorkers about the
Expanded Syringe Access Demonstration Program.

This program provides an important safety net in situations where any person may need emergency access to syringes without a prescription. This can happen during travel, when someone leaves their syringes at home, or when someone's prescription runs out.


Many New Yorkers may be unaware of a program that provides more convenient access to hypodermic needles and syringes, without requiring them to have a prescription. A change in the New York State Public Health Law in 2000 by the NYS Legislature resulted in the New York State Public Health Law in 2000 by the NYS Legislature resulted in the Expanded Syringe Access Demonstration Program (ESAP). Under ESAP, persons at least 18 years of age can legally purchase or obtain up to ten hypodermic needles or syringes without a prescription. Obtaining syringes in this manner will require a non-refundable out-of-pocket expense to the person.

Pharmacies, health care facilities and health care practitioners may participate in ESAP if they register with the New York State Department of Health to be an ESAP provider. Currently, almost all major pharmacy chains, as well as many independent pharmacies, participate in the program.

  • Why is ESAP needed?
    • ESAP is a public health measure to help prevent blood borne diseases, which can occur from reuse of used syringes. The law requires that ESAP providers distribute the ESAP Safety Insert with each sale or furnishing of syringes. The ESAP Safety Insert provides information on preventing HIV and hepatitis, and other important public health issues. Safety Inserts are made available by the NYS Department of Health at no charge to ESAP-registered providers. ESAP makes it possible for individuals who need syringes to obtain them without a prescription when they need to.
  • Who benefits from ESAP?
    • Anyone who uses syringes benefits from ESAP. The program expands options for persons with diabetes and others who self-inject. For example, people are sometimes placed in situations where they need emergency access to clean syringes. This can happen to any one who is traveling and happens to leave their syringes at home, or when someone's prescription runs out.
  • Are there any other benefits from ESAP?
    • ESAP also promotes safe syringe disposal. The ESAP Safety Insert includes information on disposing of used sharps safely and another free brochure entitled "Household Sharps: How to Dispose of them Properly" provides even more information on safe disposal. This includes information on storing sharps in a puncture resistant container, such as a laundry detergent or bleach bottle, and where to dispose of used sharps. Many people may be unaware that hospitals and nursing homes are required by law to accept used sharps from the community for safe disposal.
  • Where can I find out more information about ESAP and safe syringe disposal?
    • You can find out more about ESAP and safe syringe disposal at the New York State Department of Health's web site. The web site includes a directory of ESAP providers by county/borough, and information on how to download or order materials related to ESAP and safe syringe disposal
    • You can call the New York State Department of Health, AIDS Institute at (212) 268-6987.
    • You can send an email to


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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:
Provider Services (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

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: