DOH Medicaid Update March 2005 Vol. 20, No. 4

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The implementation of eMedNY Phase II is imminent. While the Department and Computer Sciences Corporation (CSC) have worked to make your transition to eMedNY as seamless as possible, the new system will require some changes in the manner in which providers interact with the New York State Medicaid program. The changes you need to implement may differ based on whether you bill electronically or by paper claim forms. These changes are outlined in the eMedNY Phase II HIPAA Transaction Information, which is accessible at the website www.nyhipaadesk.com, (click on the "News and Resource" tab and look below "Important Notice").

Understanding that some providers may have difficulty in making their required changes for eMedNY Phase II by the March 24 implementation date, the Department is offering a short-term Transition Plan to assist these providers in their migration. This Transition Plan will be available for only a three-month period, ending June 20, 2005. To utilize Transition Plan processing, providers will be required to submit an Application for Transition Processing signed by the CEO or highest ranking officer of the organization. A copy of the Application was mailed to all providers last month with the letter originally announcing the Transition Plan; to obtain another copy, call CSC Provider Services at (800) 522-5518 or (518) 447-9860.

This offer will not be available to providers that have not made their conversion to HIPAA. Non-compliant transactions will be accepted until March 21, 2005. Non-compliant claims filed after that date will be rejected from processing.

Providers should not wait until the June 20 deadline to implement their Phase II changes. Claims being submitted in a pre-Phase II format will require additional processing by the Department's fiscal agent (CSC). After May 9, 2005, this additional processing will result in a two-week delay in processing.

The transition plan for electronic submissions includes the following provisions:

• Providers that have not completed their eMedNY Phase II conversion will still be able to send pre-Phase II HIPAA compliant 837 claims to Medicaid during the transition period.
• Hospitals that bill for ordered ambulatory services may continue to submit their claims in the pre-Phase II Institutional (837I) transaction format after March 24, 2005 and until the post-Phase II transaction format is available.
• Providers will be able to continue to use their existing communication methods (MMIS Electronic Gateway or magnetic media) during the three-month contingency plan period while they complete their migration to eMedNY Phase II methods.
• Providers will be able to perform end-to-end testing by submitting both pre-Phase II compliant claims to the current Legacy MMIS location and eMedNY Phase II HIPAA-compliant claims to eMedNY at the same time, and comparing results; correctly formatted claims will be denied by the duplicate claim edits.

The transition plan for paper claims includes the following:

• Providers who will not be ready to submit the new Phase II paper claim forms can continue to use the old ones up through May 31, 2005. However, after May 31, 2005 only new Phase II paper claim forms will be accepted for processing.

This transition plan will not include:

• Support for non-HIPAA electronic transactions. Providers who are not HIPAA-compliant must complete their migration to HIPAA prior to March 21, 2005.
• Support for pre-Phase II HIPAA Eligibility and Service Authorization transactions. Providers must make minor changes to convert their Eligibility and Service Authorization requests to HIPAA Phase II compliance.
• Electronic Remittances (835 and 820 formats) will be formatted using eMedNY Phase II requirements. They will be delivered via eMedNY eXchange or file transfer protocol (FTP). For more information about eMedNY eXchange or FTP, please visit www.emedny.org. Providers will still have the option of selecting paper remittances.

Prior Authorizations and Utilization Threshold Override Applications modified as follows as eMedNY is implemented:

• New Phase II paper forms for Prior Authorizations and Utilization Threshold Override Applications (TOAs), will be required beginning March 21, 2005.
• New Phase II paper forms for Prior Approval types [01-Physician, 03-Dental, 04-Nursing Home/Bed Reservation, 06-DME, 07-Eye Care, 08-Hearing Aid, and 10-Private Duty Nursing], are required beginning on March 14, 2005.

The Department is committed to working with you to achieve a successful implementation of eMedNY Phase II. If you have any questions or need technical clarification, please contact the CSC Provider Services at 800-522-5518 or (518) 447-9860.

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The list of Medicaid reimbursable drugs is available on the internet by accessing the following website:

http://www.emedny.org/info/formfile.html

Once in the website, the list of Medicaid reimbursable drugs can be accessed in one of three ways:

1. View/Download PDF file
   This file gives you the list of the Medicaid reimbursable drugs in alphabetical order for each of the following: Rx (legend drugs) first, followed by federally scheduled (2-5) controlled drugs, over-the-counter (OTC) products and supplies.
2. View/Download Excel Spreadsheet
   This file can be downloaded and manipulated if desired. This file includes the same information as the PDF file on Rx (legend drugs) and federally controlled drugs. It does not include any headings or any OTC or supply product information. Please refer to PDF file for that information.
3. There is also a "Find Formulary File Information" function that can be used to search the file. Please refer to the Search tips listed on the website. For example, if you want the list of all NDCs for a drug:
   • in the field space, click on description
   • in value space, put in name of drug
   • sort by NDC

Ordering Providers:

          This information is updated once a month. Therefore, it does not reflect any changes made to the file within the month.

Pharmacy Providers:

          If you do not have internet access and want to check the availability of a NDC, you can submit a claim and reverse it if necessary.

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

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PROVIDER SERVICES
Return to Table of Contents

Comments and Suggestions Regarding This Publication?

Please contact the editor, Timothy Perry-Coon, at:

MedicaidUpdate@health.state.ny.us or

via telephone at (518) 474-9219 with your concerns.

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• Q: Over the past year I have been in situations where Medicaid recipients of male gender request to have a prescription for estrogen filled. Claims are rejecting with a message "Drug not valid due to recipient sex", where in the past, they did not. Please clarify this coverage issue for my customers and staff.
  • A: Recently, Medicaid's pharmacy claims processing system was upgraded to validate gender specific drug requirements prior to payment. Claims for pharmaceuticals that are typically indicated for females, like estrogen, will deny at the pharmacy if the patient's gender is listed as "male" on the eligibility file. Section 505.2 of NYCRR 18 states: "Payment is not available for care, services, drugs, or supplies rendered for the purpose of gender reassignment (also known as transsexual surgery) or any care, services, drugs, or supplies intended to promote such treatment."
• Q: Periodically we receive a letter referencing FUL. What is FUL and are these communications for my store's information, or is any action required?
  • A: FUL stands for Federal Upper Limit. The FUL program caps Medicaid payments for brand name and generic drugs that are therapeutically equivalent and meet certain criteria. As a result, the FUL program, which achieves savings by taking advantage of current market prices, helps to reduce pharmacy costs for both the states and the federal government.
    The Centers for Medicare and Medicaid Services (CMS) notifies all State agencies whenever there are price increases, decreases and labeler participation changes. New York State passes on this information regarding any changes that may have occurred. This is for informational purposes only and no action is required by your store.
• Q: Which drugs are covered for weight loss?
  • A: The New York State Medicaid program does not provide coverage for any drug indicated for the purpose of weight reduction. Section 1927(d) of the federal Social Security Act provides that drugs used for the purpose of weight loss or gain are excludable from Medicaid coverage. On the other side of this page is a notice you may wish to display in your store explaining that Medicaid does not cover all drugs.

Pharmacists & Prescribers! Do you have questions concerning Drug Coverage?

A review of our telephone statistics indicates a large percentage of incoming calls are inquiries concerning whether a drug or a particular NDC is covered by New York State Medicaid. This information can be directly accessed by viewing the list of Medicaid reimbursable drugs at: http://www.eMedNY.org/info/formfile.html. Using this website will save you time and our Pharmacy Policy staff will be free to answer policy-specific questions.

If you have any questions you would like to see published in "Ask the Pharmacist" please e-mail the Pharmacy Policy and Operations mailbox at ppno@health.state.ny.us and indicate in the subject field of your mail: Ask the Pharmacist.

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NEW YORK STATE DEPARTMENT OF HEALTH
ALBANY, NEW YORK 12237

Items which may be excluded from coverage:

• Agents used for weight loss or weight gain
• Agents used to promote fertility
• Agents used for cosmetic purposes or hair growth

Medicaid covers an extensive number of medically necessary drugs. However, not all drugs are covered.

Check with your pharmacist if you are not sure if a drug you were prescribed is covered by Medicaid.

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The Pharmacy Policy and Operations staff are aware that some of you may experience difficulty when entering the recipient identification number to the Voice Interactive Phone System (VIPS). The following tip should be helpful when accessing the VIPS.

Entering a recipient identification number is a two step process:

1. Entering the Recipient Identification Number
   The VIPS instructs you to record the identification number into your telephone's key pad by selecting the keys that correspond to the letters and numbers of the identification card.
   
   For example, if the identification number is AB12345Z , you will be recording numbers 2 2 1 2 3 4 5 9 via your key pad.
   
2. Verification of the Recipient Identification Number
   The VIPS will then verify the first two numbers you selected and ask you to identify the first two alphabetic characters of the identification number (AB 12345Z).
   
   a) VIPS will announce, "The first key you pressed was a 2. For the letter A, press 1". You should select the 1 to verify the letter A of the identification number.
   
   b) The VIPS continues: "The second key you pressed was a 2. For the letter A, press 1. B press 2." Now you should select the 2 to verify the letter B of the identification number.
   
   The VIPS now skips over the next five numerals to verify the last alphabetic character of the identification number, and continues: "The eighth key you pressed was a 9. For the letter W press 1. X press 2. Y press 3. Z press 4". Finally, you should select the 4 to verify the letter Z of the identification number.

Please remember to listen carefully to the voice prompts.

For questions regarding this article, please contact the Pharmacy Policy and Operations staff at: (518) 486-3209

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Medicaid recipients in New York City have the option to enroll in the following service areas for five Special Needs Managed Care Plans. Providers should make note of these codes in their Provider Manual under the heading "Recipient Other Insurance Codes".

Medicaid Provider Name	MEVS code on Verifone	10 characters in eMedNY window	Service Area
FidelisCare Healthier Life SN	OF	FIDELIS SN	Bronx, Brooklyn, SI, Manhattan, Queens
Healthfirst PHSP Inc SN	OH	HLTHFST SN	Bronx, Brooklyn, Manhattan, Queens
NYPS Select Health SN	OG	NYPSSEL SN	Bronx, Brooklyn, Manhattan
VidaCare Inc. SN	OD	VIDACARE SN	Bronx, Brooklyn, Manhattan
MetroPlus Partnership in Care Plan SN	OM	METROPLUS SN	Bronx, Brooklyn, Queens, Manhattan

* Please contact the health plans as follows for Special Needs Plan (SNP) benefit package information.

Special Needs Plans: Provider Relations

NYPS SelectHealth SN Provider Relations (866) 469-7774	VidaCare Inc SN Provider Inquiry (800) 556-0674	Fidelis Care Healthier Life SN Provider Relations Call Center (888) FIDELIS (888) 343-3547
MetroPlus Partnership in Care Plan SN Provider Relations Call Center (212) 908-8883		Healthfirst PHSP SN Provider Relations (888) 801-1660

Enrollees can call the New York Medicaid CHOICE Helpline at (800) 505-5678 to find out more about Special Needs Plans.

Questions regarding this article can be directed to the Department of Health at (518) 486-1383.

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

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Finding Your Way to a Healthier You:

Health and Human Services Secretary Tommy G. Thompson and Agriculture Secretary Ann M. Veneman announced the release of the Dietary Guidelines for Americans 2005 , the federal government's science-based advice to promote health and reduce risk of chronic diseases through nutrition and physical activity.

Almost two-thirds of Americans are overweight or obese, and more than half get too little physical activity. The sixth edition of Dietary Guidelines for Americans places stronger emphasis on reducing calorie consumption and increasing physical activity. This joint project of the Departments of Health and Human Services and Agriculture is the latest of the five-year reviews required by federal law.

The new guideline highlights how to:

• Make smart choices from every food group.
• Find your balance between food and physical activity.
• Get the most nutrition out of your calories.

A healthy eating plan is one that:

• Emphasizes fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products.
• Includes lean meats, poultry, fish, beans, eggs, and nuts.
• Is low in saturated fats, trans fats, cholesterol, salt (sodium), and added sugars.

Mix up your choices within each food group:

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Congestive Heart Failure (CHF) is a frequent cause of hospitalization, morbidity and mortality in Medicaid patients, accounting for more than 35,000 admissions in 2003*.

Common drug therapy for this condition includes:

• angiotensin converting enzyme inhibitors (ACEI),
• angiotensin receptor blockers (ARB), and
• the beta blockers, carvedilol, metoprolol and bisoprolol,

These drugs have been demonstrated to reduce hospitalization and mortality in CHF patients while improving their quality of life.

A recent New York State Drug Utilization Review study shows that among 17,578 eligible Medicaid recipients discharged from inpatient admissions with a primary or secondary diagnosis of CHF:

• 55% received an ACEI or ARB within 30-days of discharge.
• 41% received a beta blocker in the same time frame.
• 19% received both therapies.

The study also showed that compliance with therapy six-months after discharge appeared excellent, with a large percentage of original recipients receiving ACEI or ARB, beta blockers or both therapies. It has been reported in the literature that 80-90% of CHF patients can tolerate these medications and additional Medicaid patients may benefit from these therapies.

From 2000 to 2003, the use of ACEI or ARB has increased slightly, but the use of beta blockers and both therapies has increased by about 60%.

The American College of Cardiology has published their treatment guidelines on-line at:

http://www.acc.org/clinical/guidelines/failure/hf_index.htm

The American Heart Association has an extensive resource for patients on-line at:

www.americanheart.org/presenter.jhtml?identifier=1486.

* Information taken from the New York State Office of Medicaid Management Data Warehouse.

Graphs displaying the dispensing frequencies of ACEI or ARB and beta blockers for the counties with the greatest number of cases of CHF are provided below:

Graphs courtesy of the NYS Department of Health Office of Medicaid Management Data Warehouse

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In the December 2004 Medicaid Update , an article introduced the availability of the eMedNY eXchange. Additionally, the CSC website and provider correspondence, have discussed the eMedNY eXchange option.

It is advantageous for you to enroll in eMedNY eXchange, which is accessible through the eMedNY website at www.emedny.org

Although PA rosters for prior authorized long term care services will continue to be printed and mailed to you, enrollment in eMedNY eXchange will allow you to view, print and download your PA rosters weekly.

This will eliminate the delays associated with postal mailing and allow a long term care provider immediate access to their rosters. You will also have the option of downloading your rosters to a personal computer to assist you with your billing process.

Presently, somedistricts mail providers copies of the DSS 2932 (Prior Authorization form) indicating the PA number, client and hours of authorization, however, districts will no longer be required to complete the DSS 2932 form since the HIPAA compliant PA number will be generated by eMedNY.

We urge you to consider enrolling in eMedNY eXchange. You may do so by contacting Provider Services at (800) 343-9000 or via the internet at www.emedny.org.

When you enroll, you must indicate that you want an electronic version of your roster sent to your mail box.

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You will receive the Update about 3 weeks before the mailed copy!

Email your request, along with your provider identification number (found on the mailing address label of the update) to: MedicaidUpdate@health.state.ny.us.

Let us know if you want to continue receiving the hard copy in the mail, in addition to the emailed copy.

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As a result of recent changes in State Law, enrollees in Medicaid managed care plans are subject to Medicaid co-payments for pharmacy items.

Beginning April 1, 2005, enrollees in Medicaid managed care plans will have pharmacy co-payments as described below:

ITEM	CO-PAYMENT AMOUNT	DETAILS ABOUT CO-PAYMENT
Brand-Name Prescription Drugs	$2.00	One co-payment charge for each new prescription and for each refill NO CO-PAY FOR: Drugs to treat mental illness (psychotropic), tuberculosis, and birth control.
Generic Prescription Drugs	$0.50	One co-payment charge for each new prescription and for each refill NO CO-PAY FOR: Drugs to treat mental illness (psychotropic), tuberculosis, and birth control.
Over-the-Counter Medications	$0.50	One co-payment charge for each item ordered by a recognized practitioner NO CO-PAY FOR: Birth control items.

Consistent with fee-for-service Medicaid, the annual co-payment maximum per recipient per year is $100. The benefit year begins April 1 and ends on March 31 of the following year. Once the maximum has been reached, no co-payments will be required until the new benefit year begins.

CO-PAYMENT EXEMPTIONS

The same co-payment exemptions that apply to Medicaid fee-for-service recipients also apply to Medicaid managed care enrollees.

Medicaid managed care enrollees who cannot afford to pay and tell the pharmacist that they are unable to pay must be provided with the ordered pharmacy items. The pharmacy cannot refuse to provide pharmacy items because of a recipient's inability to pay. (Recipients still owe the unpaid co-pay amounts to the pharmacy and may be asked to pay or may be billed.)

Co-payment exemptions include:

• Recipients younger than 21 years old.
• Recipients who are pregnant.
  Pregnant women during pregnancy and for the two months after the month in which the pregnancy ends.
• Family planning (birth control) services. This includes family planning drugs or supplies like birth control pills and condoms.
• Residents of an Adult Care Facility licensed by the New York State Department of Health (DOH).
• Residents of a Nursing Home.
• Residents of an Intermediate Care Facility for the Developmentally Disabled (ICF/DD).
• Residents of an Office of Mental Health (OMH) or Office of Mental Retardation and Developmental Disabilities (OMRDD) certified residences.
• Enrollees in a Comprehensive Medicaid Case Management (CMCM) or Service Coordination Program.
• Enrollees in an OMH or OMRDD Home and Community Based Services (HCBS) Waiver Program.
• Enrollees in a DOH HCBS Waiver Program for Persons with Traumatic Brain Injury (TBI).

NOTE: Recipients who are eligible for both Medicare and Medicaid and/or receive Supplemental Security Income (SSI) payments are not exempt from Medicaid co-payments, unless they also fall into one of the groups listed above.

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The Department is beginning to make provider manuals available on the internet at:

http://www.emedny.org/providermanuals/index.html

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

• Upon enrollment, the new provider would receive a plastic binder containing policy and billing information.
• When a change was made to the manual, replacement pages would be mailed to the affected provider group(s).

Now, the Department is making an effort to update all manuals and 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!

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Provider/Subject                 Title of Article                Month

All Providers

• Automatic Refills    January
• Gifts, Inducements & Remuneration   January
• New Types of Common Benefit Identification Cards to be Issued   January
• Fee-For-Service Providers   January
• Prescribers and Pharmacists: Cialis    February
• Diagnosis of Occupational Diseases    February
• Enteral Products Classification List    February
• Providers Are You Changing Your Correspondence Address or Pay to Address?    February
• Provider Audit Protocols    March
• Providers of Group Practices - Requirements and Responsibilities in the Medicaid Program    March
• Common Physician Practice: Locum Tenens Arrangements/What Does the Agreement Allow?    March
• Prescribers and Pharmacy Providers: Medicaid Prescription Requirements Reminder    March
• Medicaid Posters and Brochures    April
• Prescription Requirements for Carve Out/Pass-Through Drugs    May
• Payment of Medicare Coinsurance    May
• Group Practice Reminders to Physicians, Dentists and Other Practitioners    June
• Medicaid Payments to Physicians for Rapid HIV Testing    June
• Medicaid Payment for Psychiatric Social Work    June
• New York City Providers: Voluntary Medicaid Managed Care for SSI and SSI-Related Beneficiaries    June
• Licensed Home Care Services Agencies and Independent Providers of Private Duty Nursing Services    June
• Admission to Rehabilitation Services - Recipient Restriction Program    July
• Hospital Responsibility for Outside Care: Reimbursement Policy    August
• Medicaid Policy for Erectile Dysfunction Drugs    August
• Prescribers of Erectile Dysfunction Drugs: Use Professional Judgment    August
• New Laboratory Service Available: Blood Draws in Recipients' Homes    September
• Service Provider Number Should Not be the Same as Billing Provider Number    September
• Mental Health and Chemical Dependence Providers: SSI Medicaid Managed Care Benefit Package    September
• Expanded Syringe Access Demonstration Program (ESAP)    September
• Provider Services Fax-on-Demand System Now Available    October
• Changes in Prior Approval Codes: Physician and Ophthalmic Providers    October
• Medicare, Medicaid and Elderly Pharmaceuticals Insurance Coverage Program    October
• Medicaid Purchases: Medicaid Part A Coverage    October
• Changes Affecting Prior Approvals/Prior Authorizations    November
• How Do I Request Sterilization and Hysterectomy Consent Forms    November
• Change in Graphics of the Common Benefit Identification Card    December
• Influenza    December
• Provider Manuals Online    December

Asthma

• Asthma Triggers    January
• Medicaid Posters and Brochures    April
• The Main Types of Asthma Medications    May
• Medicaid Guidelines for the Administration of Xolair   July

Billing

• Synagis Procedure Code Correction for Physician Billing    January
• Notice to New York State Hospitals Billing DRGs    February
• Revised Pharmacy Billing Procedure for Compounded Prescriptions    February
• DME and Pharmacy: Fee Schedule Provisions   February
• Preferred Physicians and Children's Program Billing Guidelines    March
• Clinics: Proper Billing Requirements    April
• Notice to Hospitals Billing DRGs    April
• Payment of Medicare Coinsurance   May
• Physician Billing for Drugs    May
• Medicaid Payments to Physician for Rapid HIV Testing    June
• Medicaid Payment for Psychiatric Social Work    June
• Update to Products of Ambulatory Care/Products of Ambulatory Surgery Groups   July
• Ambulette Transportation Providers: Additional Information Required for Billing    July
• National Drug Code: Billing Announcement    August
• Hospital Responsibility for Outside Care: Reimbursement Policy    August
• Orders and Providers of Apnea Monitors   August
• Pharmacy Reimbursement Changes    September
• New Laboratory Service Available: Blood Draws in Recipients' Homes    September
• Physician, Nurse Practitioner, Ordered Ambulatory Billing: New Drug Codes Effective Nov. 1, 2004,     October
• Quantity Changes for Infusion Supplies   October
• Medicare, Medicaid and Elderly Pharmaceuticals Insurance Coverage Program    October
• Inpatient Services Paid "Off-Line"    October
• Magnetic Media    November
• Ambulette Transportation Providers: Additional Information Required for Billing   November
• Reimbursement for Physician-Administered Drugs    November
• Physician Assistants    November
• Remittance Advices: eMedNy Transaction 820 and 835    December
• Pharmacy Provider: You Must Bill Medicare First   December
• NCPDP 5.1 Billing Requirements for Medicare Crossover Claims    December

Claims

• Timely Submission of Claims to Medicaid    February
• Timely Submission of Claims to Medicaid    May
• Service Provider Number Should Not be the Same as Billing Provider Number    September
• Non-Emergency Transportation: Electronic Claims and Procedure Codes   October
• Dental Claims HIPAA 837D Transaction Change in Oral Cavity Reporting    November
• Denial Reports Created    December
• Non-Emergency Transportation: Electronic Claims Submission    December
• Paper Claim Forms   December

Clinic

• Part-Time Clinics Can Learn from Past Actions    March
• Clinics: Proper Billing Requirements    April

Clinic Social Worker

• Medicaid Payment for Psychiatric Social Work    June

Dental

• Requirements and Expectations of Dental Clinics    March
• Dental Services Procedures    September
• Prior Approval of Orthodontic Services to Spread to Counties Outside of NYC, Nassau and Suffolk    September
• Dental Claims HIPAA 837D Transaction Change in Oral Cavity Reporting    November
• Do You have a Dental Mobile Van?    December

Diabetes

• Diabetes Prevention    February
• Be Smart About Your Heart: Control the ABC's of Diabetes    April
• Medicaid Posters and Brochures    April
• Take Time to Care About Diabetes    August

Disease Management

• Diagnosis of Occupational Diseases    February
• Pesticide Poisioning Registry    April
• A Message from the American Lung Association City of NY    June
• Medicaid Payment to Physicians for Rapid HIV Testing    June
• NYS Medicaid Smoking Cessation Policy    August
• Office of Women's Health Campaign    August
• Take Time to Care About Diabetes    August
• Arthritis and Exercise    September
• The Great American Smokeout    November

Drug Coverage

• Prescribers and Pharmacists: Cialis Information    February
• Coverage of Plan B by Medicaid    June
• Medicaid Guidelines for the Administration of Xolair    July
• Medicaid Policy for Erectile Dysfunction Drugs    August
• Prilosec OTC Coverage    September
• Mandatory Generic Drug Program Update    September
• Physician, Nurse Practitioner, Ordered Ambulatory Billing: New Drug Codes    October
• Effective November 1, 2004 Quantity Changes for Infusion Supplies    October
• Reimbursement for Physician-Administered Drugs    November
• Medicaid Coverage for Wireless Capsule Endoscopy    November
• Medicaid Coverage of Palivizumab (Synagis)    November

Durable Medical Equipment (DME)

• Enteral Formula Prior Authorization    February
• Enteral Products Classification List    February
• DME and Pharmacy: Fee Schedule Provisions    March
• Important Pharmacy and DME Contact Numbers    July
• Orders and Providers of Apnea Monitors    August
• Changes in Durable Medical Equipment Prior Approval, Rental and Pricing    October
• Durable Medical Equipment: Prior Approval Requests    November

Educational Tools

• Asthma Triggers    January
• How Your Doctor Diagnosis Asthma    February
• Tips to Eating Smart    March
• The Burden of Arthritis in NY    April
• The Main Types of Asthma Medications    May
• How to Read Nutritional Labels    September
• Dietary Fats and Your Health    October
• How Can I Reduce Unhealthy Fat From My Diet    November
• Eating Fruits and Vegetables Help Reduce Your Risk of Disease    December
• The Role of Proteins in Your Body    December

Eligibility

• Pharmacists-New Nursing Home Eligibility Edits and Messaging    February
• Medicaid Eligibility Field Software Soon to be Terminated    June
• Consult Your Medicaid Eligibility Verification System Manual When Reading Your Printouts    June

eMedNY

• eMedNY Phase II Implementation Getting Closer    June
• Companion Guides for eMedny Start Up    August
• eMedNY Update    August
• Draft Companion Guides for eMedNY Start Up    September
• Key Changes Under eMedNY Phase II    September
• Phase II Will Not Support Blocked Data    October
• Phase II Will Continue to Support the "Tilde"    October
• Remittance Advices: HIPAA Transaction 835 and 820    October
• Introducing the eMedNY Exchange    October
• Non-Emergency Transportation: Electronic Claims and Procedure Codes    October
• Changes Affecting Prior Approvals/Prior Authorizations    November
• Magnetic Media    November
• Remittance Advices: HIPAA Transaction 835 and 820    December
• eMedNY eXchange is Available    December
• Encounter Data Submission    December

Enrollment

• Fee-For-Service Providers    January
• Managed Care Special Needs Plans Expansion of Service Areas    January
• Part-Time Clinics Can Learn from Past Actions    March
• Providers of Group Practices-Requirements and Responsibilities in the Medicaid Program    March
• Pharmacy Providers: Are You Enrolled in Medicaid Yet?    May
• Submittal of Current Pharmacy License    October
• Medicare Requirement for Pharmacy Enrollment in the Medicaid Program    December

ePaces

• ePACES User System Requirements for Optimal Performance    March
• Medicaid Eligibility Field Software Soon to be Terminated    June
• HIPAA Notes for Medicaid    July

Family Health Plus

• Coverage of Plan B by Medicaid    June

Family Planning

• Services Available Under the Family Planning Benefit Program    June
• Coverage of Plan B by Medicaid    June

Fraud

• Audit, Control and Fraud: Medicaid's Crucial Role    March

HIPAA

• Urgent Medicaid HIPAA Update    May
• Vital Medicaid HIPAA Update    June
• Medicaid Eligibility Field Software Soon to be Terminated    June
• Urgent Medicaid HIPAA Update: Final HIPAA Deadline Date Set    July
• HIPAA Notes for Medicaid    July
• HIPAA Deadline Date    August
• HIPAA Compliance Deadline: October 6, 2004    September
• Provider Services Fax-on-Demand System Now Available    October
• HIPAA Companion Guides for eMedNY Phase II    November
• Deadline for End of HIPAA Exception Processing    November
• HIPAA Compliance Deadline: December 29, 2004    December
• Denial Reports Created    December

Home Health Care

• Licensed Home Care Services Agencies and Independent Providers of Private Duty Nursing Services    June
• New Laboratory Service Available: Blood Draws in Recipients' Homes    September

Hospital

• Notice to New York State Hospitals Billing DRGs    February
• Notice to Hospitals Billing DRGs    April

Managed Care

• Managed Care Special Needs Plans Expansion of Service Areas    February
• NYC Providers: Voluntary Medicaid Managed Care for SSI and SSI-Related Beneficiaries    June
• Expansion of Service Areas: Managed Care Special Needs Plan    August
• Mental Health and Chemical Dependence Providers: SSI Medicaid Managed Care Benefit Package    September
• Expansion of Managed Care: Special Needs Plans Service Areas    October

MEVS

• Consult Your Medicaid Eligibility Verification System Manual When Reading Your Printouts    June
• New Coverage Codes Announced    July
• New Coverage Codes Reminder: Resource Attestation to be Implemented    August

Nursing Home

• Prescription Requirements for Carve Out/Pass-Through Drugs    May

Pharmacy

• Automatic Refills Number    January
• Pharmacists-New Nursing Home Eligibility Edits and Messaging    February
• Revised Pharmacy Billing Procedure for Compounded Prescriptions    February
• DME and Pharmacy: Fee Schedule Provisions    March
• Pharmacy Providers: Are You Enrolled in Medicaid Yet?    May
• Important Pharmacy and DME Contact Numbers    July
• Pharmacy and Reimbursement Changes    September
• Submittal of Current Pharmacy License    October
• Ask The Pharmacist    October
• Pharmacy Providers: You Must Bill Medicare First    December

Physician

• Synagis Procedure Code Correction for Physician Billing    January
• Common Physician Practice: Locum Tenens Arrangements/What Does the Agreement Allow?    March
• Physician Billing for Drugs    May
• Group Practice Reminders to Physicians, Dentists and Other Practitioners    June
• Reimbursement for Physician-Administered Drugs    November
• Physician Assistants    November

Prior Authorization

• Enteral Formula Prior Authorization    February
• Prior Authorization Tips for Prescribers    May
• Second Generation Antihistamine Prior Authorization Reminder    October
• Changes Affecting Prior Approvals/Prior Authorizations    November

Products of Ambulatory Care (PAC)

• Update to Products of Ambulatory Care/Products of Ambulatory Surgery Grouper    July

Restriction

• Referral Process: Recipient Restriction Program    July
• Admission to Rehabilitation Services-Recipient Restriction Program    July

Residential Facilities

• Residential and Day Programs Now Responsible for Personal for Personal Care/Home Health Aid Services    June

Transportation

• Update to Products of Ambulatory Care/Products of Ambulatory Surgery Grouper    July
• Ambulette Transportation Providers: Additional Information Required for Billing     July
• Hospital Responsibility for Outside Care: Reimbursement Policy    August
• Transportation Providers and Subcontracting Transports    August
• Non-Emergency Transportation: Electronic Claims and Procedure Codes    October
• Ambulette Transportation Providers: Additional Information Required for Billing    November
• Do You Have a Dental Mobile Van?    December

Utilization Threshold

• Utilization Threshold Policy Reminders    July

Vision Care

• Medicaid's Fee-For-Service Vision Care Policy    August

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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 MedicaidUpdate@health.state.ny.us)

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: http://www.health.state.ny.us/health_care/medicaid/program/main.htm