DOH Medicaid Update April 2005 Vol. 20, No. 5

Office of Medicaid Management
DOH Medicaid Update
April 2005 Vol.20, No. 5


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



Enrollment and Coverage for Newborns
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On August 9, 1999, Governor Pataki signed legislation (Chapter 412 of the Laws of 1999) requiring that the Department of Health (Department) ensure the timely enrollment of infants, whose mother is in receipt of Medicaid, into the Medicaid program. The statute took effect July 1, 2000. This statute mandates that hospitals report live births for women in receipt of:

  • Medicaid;
  • Family Health Plus; and the
  • Prenatal Care Assistance Program

to the Department, or its designee, within five (5) business days of the birth.

Hospitals may face a financial penalty if they fail to comply with this provision.

While the Department has attempted to balance efforts to assist hospitals in improving compliance with reporting accountability, it is clear from the ongoing findings that reporting accountability must be re- emphasized. The Department remains committed to assisting facilities in fulfilling their reporting responsibilities so that all eligible infants have access to medical care in New York State.

Furthermore, New York State Public Health Law, Section 4130.5, states when a birth occurs in a hospital, the person in charge of such hospital or his designated representative shall obtain the personal data, prepare the certificate, secure the signatures required by the certificate, and file it with the registrar. The physician in attendance or a physician acting on his behalf shall certify to the facts of birth and provide the medical information required by the certificate within five days after birth. This applies to all births in New York State.

In New York State, an infant whose mother is in receipt of Medicaid at the time of the infant's birth is entitled to Medicaid for at least the first 12 months from the date of birth. Therefore, if a woman with an infant in need of care presents with her active Medicaid card, providers should assume that the child is also eligible, even though the child may not yet have a Medicaid card.

Providers must also check the woman's Medicaid managed care status:

In most instances, an infant born to a woman who is enrolled in a managed care plan is considered enrolled in the same plan from date of birth, even if the managed care enrollment is not yet reflected on the system. Providers must not bill Medicaid fee for service, but must bill the plan for the infant's hospital stay.

Past issues of the Medicaid Update have addressed these issues: October 1999, July 2000, December 2001, June 2003, and October 2003. These articles can be accessed online at:

The Department continues to strive for 100% compliance in reporting newborns and ensuring medical coverage for these newborns.

Thank you for your assistance in ensuring that newborns receive quality care while their formal Medicaid eligibility is being processed.


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Your Provider Manual Is Going Online!
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The Department is beginning to make provider manuals available on the internet at:


Up to this time, the Medicaid program has relied on a paper provider manual.

  • Upon enrollment, the new provider receives a plastic binder containing policy and billing information.
  • When a change is made to the manual, replacement pages have been mailed to the affected provider group(s).

Now, the Department is updating all manuals and will migrate the material to the eMedNY website. New providers will no longer receive the binder of material, nor will changes to existing manuals be mailed to providers. Rather, all necessary information will be available online.

Manuals can be printed, and downloaded to your own computer!

Manuals are also available in hardcopy, upon request. Call Computer Sciences Corporation at (800) 343-9000

Prescribers and Pharmacists


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This is an update to our article of January 2005. This article clarifies:


  • Electronic Prescriptions
  • Faxed prescriptions
  • Oral orders
  • Entering the official prescription serial number on the Medicaid claim form.

Although the requirement to use forge proof prescriptions does not begin until April 19, 2006, several other changes and requirements regarding Medicaid prescriptions are taking effect as you were notified in the January 2005 Medicaid Update.


At this time, for purposes of the forge proof prescription program, an electronic prescription is a prescription electronically transmitted terminal to terminal including an electronic transmission from a physician's PC to a pharmacy's fax machine.

A "paper" prescription that is faxed is not an electronic prescription.

The use of electronic prescriptions will ensure patient safety and the integrity of the prescription. Electronic prescriptions and oral orders do not require the use of the official prescription form.

Please note that at this time prescriptions for controlled substances, brand-name drugs and for drugs that require prior authorization under the Medicaid program may not be transmitted electronically in the Medicaid program.


In the Medicaid program, all "paper faxed" prescriptions require the use of the official prescription form.

Any prescriptions that are faxed from a prescriber's fax machine ("paper faxed") must be on a prescription blank that meets the State Board of Pharmacy requirements or effective April 19, 2006, on the Official New York State Prescription blank.


Automatic refills of drugs and supplies are not allowed in the Medicaid program. Refills must be requested by the recipient or caregiver prior to each refill for any drug, medical surgical supply or enteral product. A pharmacy provider may contact a recipient to determine if a refill is necessary. The contact must be documented by the pharmacist and kept in the patient record.

Please refer to the January 2005 Medicaid Update for more information on refills.



Amendments to Department regulations at 18 NYCRR 505.3(b)(4) eliminated the requirement that a written order follow-up any refill of a telephone order for prescription and non-prescription drugs. The term "non-prescription drugs" refers to over-the-counter drugs.

Providers must document in the patient record support for these prescriptions and oral orders, in particular, pharmacy requirements for telephone orders [18 NYCRR 505.3(b) (5)].


Follow-up written orders must continue to support refills of oral orders for all non-drug orders, including but not limited to supplies, enteral nutrition products and medical equipment.


As stated in the January 2004 Medicaid Update, you can begin entering the official prescription serial number on the Medicaid claim form beginning June 1, 2005. The serial number has a bar code, and thus can be scanned onto the claim form. On April 19, 2006, entering the serial number will be mandatory. Please use field 454-EK, which is the claim segment of the NCDPD 5.1 format, to report the serial number. Future instructions will be sent concerning the new edits involving lost or stolen prescriptions and on use of overrides in lieu of serial numbers on the claim form for oral and electronic prescriptions and for refills.

Questions regarding faxed prescriptions and oral orders should be directed to:

Medicaid Pharmacy Policy and Operations staff at: (518) 486-3209 or

Questions regarding Medicaid Claims should be directed to: eMedNY Provider Services Unit at: 800-343-9000.

Fraud impacts all taxpayers.

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Do you suspect that a recipient or a provider has engaged in fraudulent activities?

Please call:


Your call will remain confidential.


Managed Care

Medicaid Managed Care Benefit Clarification

Coverage of
Residential Health Care Facility Services

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Effective January 1, 2005, the Medicaid managed care contract has been amended to clarify coverage of Residential Health Care Facility services.

The Medicaid Managed Care Residential Health Care Facility Benefit

A Medicaid managed care organization (MCO) is required to provide a full range of inpatient Medicaid Residential Health Care Facility (RHCF) covered services to Medicaid enrollees when the MCO has determined that RHCF level of care is medically necessary. There is no benefit limit on the number of covered inpatient RHCF days. Covered services include: medical supervision, 24-hour per day nursing care, assistance with the activities of daily living, physical therapy, occupational therapy, speech-language pathology services and other services as specified in the New York State Health Code for Residential Health Care Facilities and AIDS facilities. These services should be provided as determined and authorized by the MCO, when the enrollee:

  • is diagnosed by a physician as having one or more clinically determined illnesses or conditions that cause the enrollee to be so incapacitated, sick, invalid, infirm, disabled, or convalescent as to require at least medical and nursing care; and
  • has assessed health care needs, in the professional judgment of the enrollee's physician or a medical team that:
    1. do not require care or active treatment of the patient in a general or special hospital;
    2. cannot be met satisfactorily in the person's own home or home substitute through providing such home health services, including medical and other health and health-related services, as are available in or near his community; and
    3. cannot be met satisfactorily in the physician's office, a hospital clinic, or other ambulatory care setting because of the unavailability of medical or other health and health-related services for the person in such setting in or near his community.

Medicaid MCOs are also responsible for MCO authorized respite days and bed hold days.

There is no limit to the number of medically necessary days that an MCO may authorize and provide. However, the MCO's financial liability is limited by a 60-day calendar year stop loss. The MCO is financially responsible for all medically necessary authorized residential health care facility stays for an enrollee up to a 60-day calendar year stop loss. The MCO continues to reimburse the RHCF for days in excess of sixty (60) days per calendar year. However, the Department will reimburse the MCO for RHCF days in excess of the 60 day stop loss. The RHCF may not submit claims to the New York State Medicaid program, but must continue to submit claims to the MCO.

Permanent residents of RHCF are excluded from enrollment in Medicaid managed care. If a managed care enrollee becomes a permanent resident in the RHCF, the enrollee must disenroll from Medicaid managed care.

For purposes of Medicaid managed care, a nursing home patient is considered a permanent RHCF resident when the local department of social services (LDSS) or, in New York City, the Human Resources Administration (HRA), has determined that the individual requires RHCF care and is not expected to return home based upon medical documentation affirming the individual's need for permanent placement. The effective date of disenrollment for a permanent RHCF resident is the first day of the month following the resident's classification as a permanent resident.

Note: Once disenrolled from Medicaid managed care, permanent RHCF residents who are seeking Medicaid coverage of long term care services may need to contact the LDSS or, in New York City, HRA, for assistance in obtaining Medicaid coverage for RHCF services.

Questions? Contact Managed Care staff at (518) 473-7467.

All Providers

New York State Education Department
Profession Codes

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The New York State Education Department (SED) has begun issuing professional licenses under the following new profession codes:

09Medical Physicist- Diagnostic Radiology
11Medical Physicist- Medical Health
12Medical Physicist- Medical Nuclear
13Medical Physicist- Therapeutic Radiology
21Pharmacy - 3-Year License
54Contact Lens
59Dentistry Limited License
69Dental Hygiene Limited License
72Licensed Master Social Worker
73Licensed Clinical Social Worker
84Dental Hygiene Anesthesia
90Psychotherapy Visits

Until the eMedNY claims processing system is updated to accept these new profession codes, when the servicing, ordering, referring or prescribing provider is licensed with one of the above profession codes:

  • A) Enter the profession code and the license number or the Medicaid ID number of the servicing, ordering, referring or prescribing provider's immediate supervisor.
  • B) If the immediate supervisor's license is associated with one of the above profession codes, use the license and profession code of the next level of supervision.

Note: Certified Social Workers licensed with a profession code of 80 can continue to use that profession code until SED renews their license with profession codes 72 or 73.

Questions regarding these instructions? Contact CSC Provider Services at (800) 343-9000.



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Medicaid providers need to ensure that they do not employ, or are affiliated with, any individual who has been excluded from either the Medicare or the Medicaid program.

  • Pursuant to federal regulations and Department regulations at 18 NYCRR 515.5, an excluded person cannot be involved in any activity relating to the furnishing of medical care, services or supplies to recipients of medical assistance for which claims are submitted to Medicaid.
  • The same prohibition applies to activities related to the Medicare program. Activities include both furnishing and ordering (i.e., prescribing) medical care, services or supplies.
  • This prohibition extends to group affiliations and to employers (hospitals, nursing homes, pharmacies, etc.) who cannot be associated with, or employ, an excluded individual.
  • Eligible Medicaid providers are prohibited from submitting claims or ordering services for excluded individuals.

Providers violating this regulation can be subject to exclusion, a demand for restitution, and/or civil penalties.

We urge providers to undertake appropriate credentialing procedures to ensure compliance. A list of all excluded Medicaid providers is contained on the Department's website at:

Click "next" after reading the text, and click "download the complete list in delimited format".

Additionally, providers should also check the Health and Human Services/Office of Inspector General website (click Exclusion Database) for Medicare exclusions.

If providers wish to check the New Jersey list of excluded providers, the website is:

The above lists are not indicative of a person's ability to practice their profession in this state. For credentialing on that issue, you should check with the appropriate state licensure agency.


Historically, the Department has published a printed list of excluded providers (PVR-292) who, by reason of their exclusion, were not permitted to order services or supplies. This list was, in essence, a partial list of all excluded providers, since it only included providers who could cause orders to be made (e.g., physicians, dentists, optometrists, physician's assistants, podiatrists). Examples of providers, who were not listed, because they do not cause orders to be made, are pharmacies, durable medical equipment providers, registered nurses and transportation providers.

The complete list of excluded providers is now available electronically. As such, we are discontinuing mailing the printed PVR-292 listing after June 2005. For the months of April, May and June, we will mail an "add-deleted" list to supplement the paper PVR-292 issued in March 2005. As you are probably aware, there is an electronic edit in place in MEVS that precludes a filling provider (e.g., pharmacist) from submitting a Medicaid claim for an order made by an excluded provider. We believe the complete list of all excluded providers will facilitate your ability to perform proper credentialing and to accurately and quickly check a provider's Medicaid enrollment status.


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When submitting claims using NCPDP 5.1, you must bill the drug quantity accurately. Do not round up this amount. Electronic billing allows for seven characters before the decimal and three characters after the decimal.

Examples of Version 5.1 Decimal Billing:
00075-0624-30Lovenox 30mg/0.3 ml syringe0.3 ml per syringe
00085-1132-01Proventil HFA 90mcg Inhaler6.7 g per MDI
00085-1133-01IntronA 10MM Units/ml 2.5 ml vial2.5 ml per vial
00054-3090-36Butorphanol 10mg/ml 2.5 ml bottle2.5 ml per squeeze bottle

*Please Note: Until further notice, continue to bill Blood Products "per 10 units."

If you have any questions, please contact the Pharmacy Policy and Operations staff at:
(518) 486-3209.

Fee Schedules Have Been Revised!

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The 2005 provider fee schedules have been released!

Fee schedules can be accessed and printed at

Copies can be mailed, upon request, by call Computer Sciences Corporation Provider Services at (800) 343-9000




New York State
Occupational Health Clinic Network

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To meet the increasing demand for medical services related to the diagnosis, treatment and prevention of occupational disease, in 1987 the Department of Health established the New York State Occupational Health Clinic Network (OHCN).

The OHCN is unique in the United States as a public health based occupational disease clinical and preventive service and includes eight clinical centers, including one with statewide responsibility in the area of agricultural safety and health.

The clinics of the OHCN are a resource for health care providers treating patients with potential work-related illnesses and injuries. The clinics have diverse treatment teams of physicians, nurses, industrial hygienists and social workers that assist providers in assessing and managing their patients' work-related conditions and, if necessary, provide worksite and social work interventions. The OHCN's board certified occupational medicine physicians and staff are also experts in dealing with the Workers' Compensation system and assisting patients during the compensation process.

The OHCN clinics are open to workers, retirees and residents of New York State with potential work-related illness and injuries.

Because they receive public funding, they offer a sliding fee scale to assure access for uninsured and underinsured patients, and can bill directly to most major health insurance carriers.

Moreover, because of their occupational focus, the clinics are able to offer services that complement the care patients receive from their primary care physicians and other specialists. These specialty services include: occupational illness and injury prevention education, medical surveillance examinations, respirator fit testing and clearance examinations, fit for duty examinations and a variety of wellness safety programs.

Physicians in New York are encouraged to contact the OHCN in their region to determine how they can utilize the clinics' occupational health services for their patients with potential work-related conditions.

For additional information about the New York State Occupational Health Clinic Network (OHCN) representative in your region, contact the Department of Health at (800) 458-1158, or go on-line at:

Location of Occupational Health Clinics
Albany:Occupational &Environmental Health Center of Eastern New York; New Paltz Satellite
Buffalo:Union Occupational Health Center
Cooperstown:Specialty Clinic - New York Center for Agricultural Medicine Clinic
Long Island:Long Island Occupational & Environmental Health Center
New York City:Bellevue/NYU Occupational & Environmental Medicine Clinic
New York City:Mount Sinai - I. J. Selikoff Center for Occupational & Environmental Medicine;
Westchester & Queens Satellites
Rochester:Finger Lakes Occupational Health Services;
Elmira Satellite: Arnot Ogden Medical Center
Syracuse: Central New York Occupational Health Clinical Center; Binghamton Satellite


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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?
A change of address form is available at:

Provider Enrollment quesions should be directed to CDC at (800) 343-9000, option 5.

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: