New York State
September 2007
Volume 23, Number 9
Medicaid Update
The official newsletter of the New York Medicaid Program
Eliot Spitzer, Governor
State of New York
Richard F. Daines, M.D. Commissioner
New York State Department of Health
Deborah Bachrach, Deputy Commissioner
Office of Health Insurance Programs
News for All Providers
National Provider Identifier Registration Requirement
Important information regarding the need to register your National Provider Identifier
Fee-for-Service Enrollment and Maintenance Form Packets Will Soon Change
Fee-for-service providers will be able to keep their enrollment file up-to-date with forms that reflect National Provider Identifier information!
Reminder to Rate-Based Providers: You are Responsible to Maintain an Accurate Enrollment File
If you've changed any enrollment-related information, you must keep your enrollment file up to date!
eMedNY Website Highlight of the Month: Electronic Transactions Vendor List
There is a list available of vendors who can help make the claiming process easier!
eMedNY Update: Wondering About the Status of Your Submitted Claims?
Read this article about existing tools to assist providers seeking claims status information.
Your Provider Manual is Online!
Providers are reminded of their responsibility to check for updates to their Provider Manual.
Policy and Billing Guidance
Introducing the Medicaid Transportation New York City Prior Authorization Guidelines Manual
A manual is now available that summarizes the guidelines for ordering medical transportation on behalf of New York City Medicaid enrollees.
Preferred Drug Program News
The Preferred Drugs Program is expanding!
Preferred Drug Program List
The current list of preferred and non-preferred drugs.
Benefit Clarification for Intrauterine Devices
Coverage rules are clarified for Medicaid Managed Care, Family Health Plus and Family Planning Providers.
Additional Influenza Vaccine Code Now Available for Billing
Physicians, Nurse Practitioners and Ordered Ambulatory providers are notified of a new procedure code for influenza vaccination.
General Information
Computer Sciences Corporation Call Center Contact Information
The Call Center Telephone Tree has been enhanced!
Seminar Schedule and Registration
Whether you are new to billing or need a refresher, Computer Sciences Corporation offers training!
Health Care Providers: New Statewide Immunization Registry Coming Soon!
This article highlights the new requirements of the New York State Immunization Information System.
Free New Training Sessions Available for HIV/AIDS Case Management
More information regarding two new trainings for HIV/AIDS Case Management.
News for All Providers....
Important Information
National Provider Identifier Registration Requirement
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If you have a Medicaid identification number that is currently used on claims sent to the Medicaid Program, then you must register that identification number with a corresponding National Provider Identifier (NPI), unless you are exempt from the NPI Regulation. For a list of exemptions to the regulation, please go to:
http://www.emedny.org/hipaa/FAQs/Do_I_need_NPI_for_billing.html
- Individual providers must register their NPI with their individual Medicaid identification number.
- Organizations, such as hospitals and clinics, must register the organization's NPI with the organization's Medicaid identification number.
DO NOT register an individual provider's NPI with the organization's (or group practice) Medicaid identification number, or vice-versa.
Note: If your Medicaid identification number is used by other providers to bill their Medicaid claims, your NPI number needs to be registered. For example, some Medicaid claims require a service provider to identify the referring provider. If your Medicaid identification number is used as the referring provider by a service provider on their claim, then your NPI needs to be registered.
Questions? Please contact the eMedNY Call Center at (800) 343-9000.
Fee-for-Service Enrollment and
Maintenance Form Packets Will Soon Change!
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The New York State Medicaid Fee-for-Service Enrollment and Maintenance Form Packets will soon be updated to include National Provider Identifier (NPI) information.
In September 2007, the updated forms will be posted online at:
http://www.emedny.org/info/ProviderEnrollment/index.html
Computer Sciences Corporation will accept either the old or updated forms through October 14, 2007. However, only the new enrollment form will be accepted after this date. Old forms received on or after October 15, 2007 will be returned to the provider.
For providers who are required to obtain an NPI, any enrollment forms received on or after October 15, 2007 without an NPI will be returned to the provider.
Provider maintenance forms should include both the NPI and Medicaid identification number but the Medicaid identification number is required. Maintenance forms submitted without the Medicaid identification number will be returned to the provider.
Questions? Please call the eMedNY Call Center at (800) 343-9000.
Reminder to Rate-Based Providers!
You Are Responsible to Maintain an Accurate Enrollment File
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It is the responsibility of each provider to notify the New York Medicaid Program of ANY changes to the information which was supplied at the time of enrollment.
Such changes include, but are not limited to:
- ownership,
- tax identification number,
- telephone/contact information,
- addresses for correspondence and payments,
- service locations where appropriate,
- National Provider Identification (NPI) number,
- changes for organizations or individuals having direct ownership or a controlling interest of five percent or more in an enrolled agency, institution or organization.
Provider maintenance forms are available online at:
http://www.emedny.org/info/ProviderEnrollment/index.html
Change in Ownership
When ownership interest changes occur, the provider must complete and submit a new Disclosure of Ownership document to the Medicaid Program.
This form may be obtained by contacting the Rate Based Provider Unit via telephone at:
(Email requests should state "Request Disclosure Form" in the attention/subject line and contain the name and Medicaid provider identification number of the entity.)
Upon completion of the form, please return via postal mail to:
New York State Department of Health
Office of Health Insurance Programs
Division of Program Operations and Systems
Rate Based Provider Unit
150 Broadway
Albany, New York 12204-2736.
eMedNY Website Monthly Highlights
This Month's Highlight:
Electronic Transactions
Vendor List
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The eMedNY website is the primary source of information for our Medicaid provider community.
In addition to provider billing manuals, policy guidelines, fee schedules and companion guides, the website maintains documents to help providers better understand the Medicaid Program and assist with claims and other transaction submissions.
The electronic transaction Vendor List contains software vendors capable of supporting HIPAA electronic transactions.
Finding the Vendor List
See "HIPAA Vendor Listing" at:
http://www.emedny.org/hipaa/vendors/index.html
Using the Vendor List
Note
The Vendor List on www.emedny.org is for informational purposes only.
The Department, its affiliates and agents neither endorse nor recommend any company, organization, individual or product. The Department, its affiliates and agents have no interest in any of the listed parties and have no arrangements to promote their business or products.
Furthermore, being included in the list does not constitute a certification or guarantee of usefullness, quality or value of any listed party's services or products.
Page one of the list displays a legend of HIPAA transaction numbers that will correspond to the types of transactions for which the vendor will have software/services available. For example, electronic claims are submitted with either the 837P (professional), 837I (institutional) or 837D (dental) transactions.
The last column in the list displays each vendor's specific transaction type capabilities. The list also provides contact information for each vendor organization.
Benefits of Electronic Billing
The Vendor List information may be very useful for providers contemplating switching from paper to electronic billing. The advantages to switching are numerous:
- Speedier payments
Electronic claims process much more quickly than paper claim forms. - Speedier remittance notification
Electronic remittances are delivered 21/2 weeks sooner than paper remittance statements. - Reduced submission errors reduces rebilling efforts
Electronic billing software often provides a high degree of editing so claims are virtually error-free upon submission. - Convenient storage and retrieval of electronic records
Electronic information filing saves space and retrieval time. - Receive electronic or paper remittance statements
Providers may still choose which remittance type they receive, electronic or paper, regardless of the method used to submit claims.
If you are considering switching to an electronic billing and/or remittance system, please take the time to become familiar with the Vendor Information available to you.
Questions about website information should be directed to the eMedNY Call Center at:
(800) 343-9000.
Questions about products/services available from vendors should be directed to the vendor organization.
Wondering About the Status of Your Submitted Claims?
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Medicaid offers a number of tools to assist providers seeking claim status information without having to wait for remittance statements.
Claim Status Options
- ePACES allows providers to request claim status for claims that are submitted via ePACES, as well as through other submission methods. To request claim status for ePACES claims, providers just need to select from a list of submitted claims. The status of ePACES claims is usually available on the same day the claim is submitted.
For claims submitted via other methods, ePACES requires the key entry of a few pieces of claim data to retrieve the status on a claim (including the paid amount). Availability of status for claims submitted via other methods may vary depending on the submission method (paper or electronic) and the time it reached Computer Sciences Corporation (CSC) for processing. - ePACES "real-time" claim submissions are available for professional claims immediately (within seconds). This includes the paid amount.
- Electronic requests via a 276 Claim Status Request can be submitted as batch files. Submitters will need a software program to produce the requests in a HIPAA-compliant format and to interpret the 277 Claim Status Response.
- Claim Status Responses returned via ePACES or the 277 transaction contain the HIPAA-compliant response codes. To assist providers with obtaining more detail about the status reason, an edit mapping document is available at:
http://www.emedny.org/hipaa/Crosswalk/index.html
Click on the document entitled Edit Mapping for the 277 in Order of Status Code. The information provided there depicts eMedNY edit reasons associated with the HIPAA-compliant Claim Status Codes and, in some cases, an Entity Identifier Code., - Remittance: If you are currently receiving a paper remittance statement, then you are waiting 21/2 weeks after processing is completed to receive claim status information.
Electronic remittances (835 or 820) are available 21/2 weeks earlier. Providers wishing to receive electronic remittances will need a software program to interpret the HIPAA-compliant 835 remittance file. A list of vendors offering such software is available at:
http://www.emedny.org/hipaa/vendors/index.html
Providers/submitters who want to request routine claim status verification should avail themselves of the above tools. CSC Call Center staff is not able to perform routine claim status checks for providers and submitters waiting for their remittances to be delivered.
The Call Center is available to assist you with all methods of claims submission and will continue to assist you with claim problems.
Questions? Please call eMedNY Call Center staff at:
(800) 343-9000
Your Provider Manual is Online!
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As a provider, it is your responsibility to ensure you are current with the latest policy information.
Click on the link to your Provider Manual at http://www.emedny.org/ProviderManuals/index.html and you will find the archived versions and other important information regarding recent changes made to your Provider Manual.
Providers are also responsible for knowing the information included in the Information for All Providers sections, which include general Medicaid policy, general billing, inquiry and third party insurance information.
If you do not have access to the internet, contact the eMedNY Call Center at the number below to receive a paper copy:
(800) 343-9000.
Policy and Billing Guidance............
Attention Providers who Order Transportation for New York City Enrollees
Introducing the Medicaid Transportation
New York City Prior Authorization Guidelines Manual
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Providers are responsible for ensuring that the transportation services ordered are appropriate.
For example, if a person can normally use the bus or subway, then he or she is expected to use the bus or subway to get to and from medical appointments.
The prior authorization guideline manual clarifies the rules, required forms, and other important information needed for ordering fee-for-service medical transportation for New York City Medicaid enrollees, including:
- Provider categories allowed to order transportation;
- How and when to justify the need for transportation of an enrollee;
- Where practitioners may request prior authorization;
- Instructions for the proper completion of the prior authorization request forms; and
- Medicaid and Medicaid managed care policy contact information.
The Manual can be downloaded and/or printed online at:
http://www.emedny.org/ProviderManuals/Transportation/index.html
Paper copies can be obtained by calling the eMedNY Call Center at:
(800) 343-9000.
Questions? Please contact the Medicaid Transportation Unit at (518) 474-5187 or email MedTrans@health.state.ny.us
Preferred Drug Program News
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Expansion of the Preferred Drug Program
The Medicaid Preferred Drug Program (PDP) is expanding to include additional drug classes.
Prescriptions written on or after October 3, 2007, for non-preferred drugs in the following drug categories, will require prior authorization:
- Cyclooxygenase II (COX II) Inhibitors
- Central Nervous System (CNS) Stimulants
- Ophthalmic Prostaglandin Agonists
- Selective Alpha Adrenergic Blockers
- Urinary Tract Antispasmodics
The most current Preferred Drug List is included on the following pages and can also be found at:
Prescribers are required to complete the prior authorization process before prescribing non-preferred drugs. To obtain prior authorization for a non-preferred drug, call the staffed Clinical Call Center at (877) 309-9493 and follow the appropriate prompts.
Requests for prior authorization may also be faxed to (800) 268-2990. Faxed requests can take up to 24 hours to process.
The PA worksheet/ fax form can be found at:
Please Note
Information on recent changes to the PDP can be accessed by calling the Clinical Call Center at (877) 309-9493 and selecting option # 9.
Did you know...
Educational materials have been developed for Medicaid enrollees to help them understand how the PDP may impact their pharmacy coverage. Brochures are available in English and Spanish. Prescribers and pharmacists can request a supply by calling:
(518) 951-2040.
For clinical concerns or preferred drug program questions, please call:
(877) 309-9493.
For billing questions, please call:
(800) 343-9000.
For Medicaid pharmacy policy and operations questions, please call: (518) 486-3209.
New York State Medicaid Preferred Drug List
All non-preferred drugs in these classes will require prior authorization.
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| I. ANALGESICS | |
|---|---|
| Cyclooxygenase II (COX II) Inhibitors | Cyclooxygenase II (COX II) Inhibitors |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Celebrex® | none |
| Narcotics - Long Acting | Narcotics - Long Acting |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Duragesic® fentanyl patch Kadian® morphine sulfate SR Oramorph SR® |
Avinza® MS Contin® Opana ER® oxycodone HCL CR Oxycontin® |
| II. ANTI-INFECTIVES | |
| Anti-Fungals | Anti-Fungals |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Fulvicin U/F® Grifulvin V® (tablet) Gris-PEG® griseofulvin (suspension) Lamisil® |
Grifulvin V® (suspension) itraconazole (capsule) Penlac® Sporanox® (capsule, solution) |
| Anti-Virals | Anti-Virals |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| acyclovir (tablet, capsule, suspension) Famvir® Valtrex® | Zovirax® (tablet, capsule, suspension) |
| Cephalosporins - Third Generation | Cephalosporins - Third Generation |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Cedax® (capsule, suspension) cefpodoxime proxetil (tablet) Omnicaf®(capsule, suspension) Suprax® | Spectracef® Vantin® (tablet, suspension) |
| Fluoroquinolones | Fluoroquinolones |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Avelox® Avelox ABC Pack® Cipro® (suspension) ciprofloxacin (tablet, suspension) ofloxacin | Cipro® (tablet) Cipro XR® ciprofloxacin ER Factive® Floxin® Levaquin® (tablet, solution) Maxaquin® Noroxin® Proquin XR® Tequin® |
| Hepatitis C Agents | Hepatitis C Agents |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| PEG-Intron® PEG-Intron Redipen® Pegasys® Pegasys Convenience Pack® | none |
| III. Cardiovascular | |
| Angiotensin Converting Enzyme Inhibitors (ACEIs) | Angiotensin Converting Enzyme Inhibitors (ACEIs) |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Altace® benazepril captopril enalapril maleate lisinopril moexipril trandolapril |
Accupril® Aceon® Capoten® fosinopril sodium Lotensin® Mavik® Monopril® Prinivil® quinapril Univasc® Vasotec® Zestril® |
| ACEIs + Calcium Channel Blockers | ACEIs + Calcium Channel Blockers |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Lortrel ® Tarka® | Lexxel® |
| ACEIs + Diuretics | ACEIs + Diuretics |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| benazepril/HCTZ captopril/HCTZ enalapril maleate/HCTZ lisinopril/HCTZ moexipril/HCTZ |
Accuretic® Capozide® fosinopril HTC Lotensin HCT® Monopril HCT® Prinzide® quinapril/HCTZ Quinaretic® Uniretic® Vaseretic® Zestoretic® |
| Angiotensin Receptor Blockers (ARBs) | Angiotensin Receptor Blockers (ARBs) |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Avapro® Benicar® Cozaar® Diovan® Micardis ® | Atacand® Exforge® Teveten® |
| ARBs + Diuretics | ARBs + Diuretics |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Avalide® Benicar HTC® Diovan HTC® Hyzaar® Micardis HCT® | Atacand HCT® Teveten HCT® |
| Beta Blockers | Beta Blockers |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| acebutolol atenolol betaxolol bisoprolol funerate Coreg® labetalol metoprolol tartrate nadolol pindolol propranolol (tablet, solution) propranolo ER (capsule)l timolol maleate | Coreg® Corgard® Inderal® Inderal LA ® InnoPran XL® Kerlone® Levatol® Lopressor® metoprolol succinate Sectral® Tenormin® Toprol XL® Trandate® Zebeta® |
| Beta Blocker + Diuretics | Beta Blocker + Diuretics |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| atenolol/chlorthalidone bisoprolol funerate/HCTZ metoprolol tartrate/HCTZ propranolol/HCTZ |
Corzide® Inderide® Lopressor HCT® Tenoretic® Ziac® |
| Calcium Channel Blockers (Dihydropyridine) | Calcium Channel Blockers (Dihydropyridine) |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Afeditab CR® amolodipine Dynacirc ® Dynacirc CR® felodipine ER isradipine nicardipine HCL Nifediac CC® Nifedical XL® nifedipine nifedipine ER nifedipine SA Sular® |
Adalat CC® Cardene® Cardene SR® Norvasc® Plendil® Procardia® Procardia XL® |
| Cholesterol Absorbtion Inhibitors | Cholestrol Absorption Inhibitors |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Zetia® | none |
| HMG-CoA Reductase Inhibitors (Statins) | HMG-CoA Reductase Inhibitors (Statins) |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Advicor® Altoprev® Crestor® Lescol® Lescol XL Lipitor® pracvastatin simvastatin Vytorin® |
Caduet® lovastatin Mevacor® Pravachol® Zocor |
| Triglyceride Lowering Agents | Triglyceride Lowering Agents |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| fenofibrate gemfibrozil Lofirba® Tricor |
Antara® Lopid® Lovaza (formerly Omacor®) Triglide |
| IV. Central Nervous System | |
| Central Nervous System (CNS) Stimulants | Central Nervous System (CNS) Stimulantsl |
| PREFERRED AGENTS | NON-PREFERRED AGENTS - PA Required Effective 10/03/07 |
| Adderall XR® amphetamine salt combo Concerta® dextroamphetamine dextroamphetamine SR caps Focalin® Focalin XR® Metadate CD® Metadate ER® Methylin® Methylin®chewable Methylin ER® Methylin® solution methylphenidate methylphenidate ER Ritalin LA® | Adderall® Cylert® Daytrana® Desoxyn® Dexedrine® Dexadrine Spansule® Dextrostat® pemoline Provigil®CC Ritalin® Ritalin SR® Vyvanse® |
| Sedative Hypnotics/Sleep Agents | Sedative Hypnotics/Sleep Agents |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Ambien CR® chloral hydrate estazolam flurazepam temazepam triazolam zolpidem |
Ambien® Dalmane® Doral® Halcion® Lunesta® Prosom® Restoril® Rozerem® Somnote® Sonta® |
| Serotonin Receptor Agonists (Triptans) | Serotonin Receptor Agonists (Triptans) |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Imitrex®(tablet, nasal, injection) Maxalt®(tablet, MLT) Relpax® | Amerge® Axert® Frova® Zomig® (tablet, nasal, ZMT) |
| V. ENDOCRINE AND METABOLIC AGENTS | |
| Bisphosphonates | Bisphosphonates |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Fosamax® (tablet, solution) Fosamax® Plus D | Actonel® Actonel®with Calcium Boniva® |
| Calcitonins - Intranasal | Calcitonins - Intranasal |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Miacalcin® | Fortical® |
| Thiazolidinediones (TZDs) | Thiazolidinediones (TZDs) |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Actos® Actoplus Met® Avandia® Avandamet® Avandaryl Duetact® | none |
| VI. GASTROINTESTINAL | |
| Anti-Emetics | Anti-Emetics |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Kytril®(tablet, solution) Zofran®(tablet, solution, ODT) | Anzemet® |
| Proton Pump Inhibitors (PPIs) | Proton Pump Inhibitors (PPIs) |
| PREFERRED AGENTS | NON-PREFERRED AGENTS - PA Required |
| Nexium® Prevacid®(capsule) Prilosec®OTC |
Aciphex® Nexium Packet® omeprazole Prevacid (solutab, packet) Prevacid NapraPAC® Prilosec® Protonix® Zegerid® (capsule, packet) |
| VII. IMMUNOLOGIC AGENTS | |
| Immunomodulators - Injectable | Immunomodulators - Injectible |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Enbrel® Humira® | Kineret® |
| Immunomodulators -Topical | Immunomodulators -Topical |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Elidel® Protopic® | none |
| VIII. OPHTHALMICS | |
| Antihistamines - Ophthalmic | Antihistamines - Ophthalmic |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Patanol® Pataday® | Elestat® Emadine® ketotifen® Optivar® |
| Fluroquinolones - Ophthalmic | Fluroquinolones - Ophthalmic |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| ciprofloxacin ofloxacin Vigamox® |
Ciloxan® (solution, ointment) Ocuflox® Quixin® Zymar® |
| Prostaglandin Agonists - Ophthamic | Prostaglandin Agonists - Ophthamic |
| PREFERRED AGENTS | NON-PREFERRED AGENTS - PA Required Effective 10/03/2007 |
| Travatan® Travatan Z® Xalatan® | Lumigan® |
| IX. OTICS | |
| Fluoroquinolones - Otic | Fluoroquinolones - Otics |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Ciprodex® Floxin® | Cipro HC® |
| X. RENAL AND GENITOURINARY | |
| Phosphate Binders/Regulators | Phosphate Binders/Regulators |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Fosrenol® Phoslo Renagel® | none |
| Selective Alpha Adrenergic Blockers (Used for Benign Prostatic Hyperplasia) | Selective Alpha Adrenergic Blockers (Used for Benign Prostatic Hyperplasia) |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Flomax® Uroxatral® | none |
| Urinary Tract Antispasmodics | Urinary Tract Antispasmodics |
| PREFERRED AGENTS | NON-PREFERRED AGENTS - PA Required Effective 10/03/07 |
| Detrol LA® Enablex® oxybutynin oxybutynin syrup Vesicare® | Detrol® Ditropan® Ditropan® (syrup) Ditropan XL® oxybutynin ER Oxytrol® Sanctura® |
| XI. RESPIRATORY | |
| Anticholinergics - Inhaled | Anticholinergics - Inhaled |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Atrovent® Atrovent HFA® Combivent® ipratropium Spiriva® | Duoneb® ipratropium/albuterol solution |
| Antihistamines - Second Generation | Antihistamines - Second Generation CC |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| OTC loratadine OTC loratadine-D | Allegra® (tablet, capsule, suspension) Allegra-D® Clarinex® Clarinex-D® fexofenadine Semprex-D® Zyrtec®CC Zyrtec-D® |
| Beta2Adrenergic Agents - Inhaled Long Acting | Beta2Adrenergic Agents - Inhaled Long Acting |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Foradil® Serevent Diskus® | Brovana® |
| Beta2Adrenergic Agents - Inhaled Short Acting | Beta2Adrenergic Agents - Inhaled Short Acting |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| albuterol Maxair Autohaler® Proventil HFA® Ventolin HFA® Xopenex® Xopenex HFA® | Accuneb®
Alupent® metaproterenol ProAir HFA® Proventil® |
| Corticosteroids - Inhaled | Corticosteroids - Inhaled |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Advair Diskus® Advair HFA® Asmanex® Azmacort® Flovent HFA® QVAR® | Aerobid®
Aerobid-M® Pulmicort Turbuhaler®(Flexhaler, Turbuhaler) CC Symbicort® |
| Corticosteroids - Intranasal | Corticosteroids - Intranasal |
| PREFERRED AGENTS | NON-PREFERRED AGENTS - |
| Nasacort AQ® Nasonex® | Beconase AQ® Flonase® flunisolide fluticasone Nasarel® Rhinacort Aqua® Veramyst® |
| Leukotriene Modifiers | Leukotriene Modifiers |
| PREFERRED AGENTS | NON-PREFERRED AGENTS |
| Accolate® Singular® | none |
CC-Clinical Criteria (Please see: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_clinical_criteria.pdf)
NYS Medicaid Pharmacy Clinical Call Center 877-309-9493
NYS Preferred Drug Program http://newyork.fhsc.com
Attention Medicaid/Family Health Plus
Managed Care Organizations
and
Family Planning Providers
Benefit Clarification for Intrauterine Devices
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Medicaid Managed Care
For those Medicaid managed care plans that include family planning services within their contracted benefit package, the purchase of an intrauterine device (IUD) and its insertion or removal is a health plan covered service.
When a Medicaid managed care member receives an IUD from a contracted network practitioner or clinic, the health plan should reimburse the practitioner or clinic for the IUD and its insertion or removal at plan negotiated rates. Since an IUD is a health plan benefit and part of a provider visit, clinics and practitioners contracting with an enrollee's health plan to provide family planning services, should not bill Medicaid fee-for-service for the IUD and should not refer the member to a pharmacy with a prescription.
Under the free access policy, when the Medicaid Managed Care member receives the IUD from a qualified non-network practitioner or clinic, the non-network provider bills Medicaid fee-for-service at established rates and fees.
Clients enrolled in a Medicaid managed care plan that does not include family planning services can access these services, including purchase, insertion or removal of an IUD from a qualified Medicaid fee-for-service provider who bills Medicaid fee-for-service at established rates and fees.
The Medicaid pharmacy formulary does not include IUDs, nor are the devices listed as a Medical/Surgical Supply, and therefore, IUDs may not be purchased by a Medicaid beneficiary using a prescription. IUDs are not available through a pharmacy. The purchase, insertion and removal of an IUD is always considered a practitioner or clinic procedure and its insertion or removal is included within a practitioner visit, part of a clinic visit or a covered health plan service.
For additional information concerning managed care and fee-for-service coverage of IUDs, please see the December 2006 Medicaid Update article entitled, "Ordered Ambulatory Reimbursement for Intrauterine Devices, Ordered Ambulatory fee-for-service and Medicaid Managed Care".
Family Health Plus
In the Family Health Plus (FHPlus) program, IUDs are also not considered a pharmacy item. The purchase, insertion and removal of an IUD is considered a practitioner or clinic physician procedure, and its insertion or removal is included within a practitioner visit or may be part of a clinic rate.
For FHPlus enrollees in health plans that do not include family planning services, an IUD can be obtained from qualified Medicaid fee-for-service clinics and practitioners.
Medicaid fee-for-service billing codes are as follows:
CPT codes for billing IUDs:
J7300 Intrauterine Copper Contraceptive
J7302 Levonorgestrel-releasing Intrauterine Contraceptive System
CPT codes for insertion or removal of IUDs:
58300 Insertion of Intrauterine Device
58301 Removal of Intrauterine Device
Reimbursement for the IUD is limited to the acquisition cost from the manufacturer or the customary charge, whichever is less. Claim charges shall not exceed the lesser value.
If any further information is required, please see the Physician Provider Manual at:
http://www.emedny.org/ProviderManuals/Physician/index.html
Questions regarding enrollees in a managed care plan may be directed to the Division of Managed Care and Program Evaluation, Bureau of Managed Care Program Planning at: (518) 473-7467.
Questions regarding enrollees not in a managed care plan may be directed to the Division of Financial Planning and Policy, Bureau of Policy Development and Coverage at: (518) 473-2160.
Fraud impacts all taxpayers.
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Do you suspect that an enrollee or a provider has engaged in fraudulent activities?
Please call:
1-877-87FRAUD
Attention Physicians, Nurse Practitioners, and Ordered Ambulatory Providers
Additional Influenza Vaccine Code Now Available for Billing
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Effective for dates of service on and after September 1, 2007, the following procedure code will be available for billing:
90656 - Influenza virus vaccine, split virus, preservative free, when administered to three years and older, for intramuscular use.
When billing for enrollees under the age of 19 years, the vaccine must be obtained from the Vaccines for Children (VFC) program. Reimbursement for the administration of the vaccine (for those enrollees under 19 years of age) will be made at $17.85. The procedure code must be appended by the -SL modifier.
When billing for adults, insert your acquisition cost per dose plus a two dollar ($2.00) administration fee in the amount charged field of your claim form.
Questions may be referred to the Pre-Payment Review Group at (518) 474-8161.
Nursing home inspection results are now reported online. Go to:
General Information............
Computer Sciences Corporation
Call Center Contact Information
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Effective September 1, 2007, Computer Sciences Corp. enhanced the Call Center Telephone Tree. Please read below for more information.
Main Telephone Number
(800) 343-9000
Hours of Operation
For provider inquiries pertaining to non-pharmacy billing or claims, or provider enrollment:
Monday through Friday
7:30 a.m. - 6:00 p.m. Eastern Standard Time
For provider inquiries pertaining to eligibility, service authorizations, DVS, and pharmacy claims:
Monday through Friday
7:00 a.m. - 10:00 p.m. Eastern Standard Time
Weekends and Holidays
8:30 a.m. - 5:30 p.m. Eastern Standard Time
Option 1: If you are a Physician, Dentist, Private Duty Nurse, Nurse Practitioner, Clinical Social Worker or Ophthalmic Provider:
- Sub-option 1: For New Enrollment into the NYS Medicaid Program, ePACES Enrollment and TSN/ ETIN applications.
- Sub-option 2: For explanation of eligibility response, UT service authorization and POS Device Support.
- Sub-option 3: For NYC Transportation Prior Approvals.
- Sub-option 4: For Claims, Billing, remittance, form orders and prior approval questions.
Option 2: If you are a Pharmacy Provider:
- Sub-option 1: For New Enrollment into the NYS Medicaid Program, ePACES Enrollment and TSN/ ETIN applications.
- Sub-option 2: For all other questions including explanation of eligibility response, claims, billing, remittance and prior approval questions including DIRAD.
Option 3: If you are a Hospital, Clinic, Long Term Care Facility, Nursing Agency, Child Care Agency or Home Health Agency:
- Sub-option 1: For New Enrollment into the NYS Medicaid Program, ePACES Enrollment or TSN/ ETIN applications.
- Sub-option 2: For explanation of eligibility response, UT service authorization or POS Device Support.
- Sub-option 3: For NYC Transportation Prior Approvals.
- Sub-option 4: For Claims, Billing, remittance, form orders and prior approval questions.
Option 4: If you are a DME, Hearing Aid, Laboratory, or Transportation Provider:
- Sub-option 1: For New Enrollment into the NYS Medicaid Program, ePACES Enrollment and TSN/ ETIN applications.
- Sub-option 2: For explanation of eligibility response, UT service authorization or DVS Transactions including POS Device Support.
- Sub-option 3: For Claims, Billing, remittance, form orders and prior approval questions.
Option 5: For MOAS and threshold override application provider support.
Seminar Schedule and Registration
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- Do you have billing questions?
- Are you new to Medicaid billing?
- Would you like to learn more about ePACES?
If you answered YES to any of these questions, please consider registering for a Medicaid seminar. Computer Sciences Corporation (CSC) offers various types of seminars to providers and their billing staff. Many of the seminars planned for the upcoming months offer detailed information and instruction about Medicaid's web-based billing and transaction program - ePACES. ePACES seminars are designed for specific provider types.
ePACES is the electronic Provider Assisted Claim Entry System which allows enrolled providers to submit the following type of transactions:
- Claims
- Eligibility Verifications
- Utilization Threshold Service Authorizations
- Claim Status Requests
- Prior Approval Requests
Professional providers such as physicians, nurse practitioners and private duty nurses can even submit claims in "REAL-TIME" via ePACES.
Real-time means that the claim is processed within seconds and professional providers can get the status of a real-time claim, including the associated paid amount without waiting for the remittance advice to be delivered.
Fast and easy seminar registration, locations and dates are available online at:
http://www.emedny.org/HIPAA/Provider_Training/Training.html
At this website, review the seminar descriptions carefully to identify the seminar appropriate to meet your training needs. Registration confirmation will be instantly sent to your email address.
If you are unable to access the Internet to register, you may also request seminar schedule and registration information through CSC's Fax on Demand at:
(800) 370-5809;
request document number 1003
for a list of seminars and registration information to be faxed to you.
CSC Regional Representatives look forward to meeting with you at upcoming seminars!
Questions about registration? Please contact the eMedNY Call Center at (800) 343-9000.
Coming Soon!
New Statewide Immunization Registry
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There have been some exciting developments in the effort by the New York State Department of Health (NYSDOH) to create a statewide web-based registry application!
Changes to the New York State Immunization Information System
The statewide immunization registry, also known as the New York State Immunization Information System (NYSIIS), will be changing from a regional set of voluntary applications to a mandatory statewide internet-based system.
The NYSDOH has awarded a five-year contract to Electronic Data Systems (EDS) to develop, implement and support the web-based immunization registry. EDS is a national company highly regarded in the registry field and currently supports registries in nine other states and territories.
Mandatory Reporting Legislation
The new mandatory reporting legislation, outlined in Article 21, Title 6, Section 2168 of the Public Health Law, was passed during the 2006 New York State legislative session. The following are the key requirements and authorizations found in the new legislation:
- Beginning January 1, 2008, health care providers will be required to report all vaccines administered to persons less than 19 years of age and their immunization histories, if not previously reported, to the New York State Department of Health's (NYSDOH) statewide immunization information system. This requirement will be phased in and training for providers will be available.
- The legislation requires NYSDOH to develop an implementation plan that will start January 1, 2008, and be phased in along with education and training for providers.
- In order to populate NYSIIS, the legislation authorizes the transfer of birth certificate information on children, retroactive to January 1, 2004.
- The new legislation authorizes health care providers administering immunizations to persons under 19 years of age in New York City to continue reporting to the Citywide Immunization Registry (CIR).
The Role of the Immunization Information System
Registries, also known as Immunization Information Systems (IIS), play a significant role in improving public health and are becoming more prevalent. Currently, there are approximately 50 IISs operating throughout country.
The important role that an IIS can play was demonstrated in the aftermath of the Hurricane Katrina disaster, which displaced thousands of people. Louisiana's IIS was able to provide the immunization histories of over 55,000 children, allowing them to enter schools without being revaccinated.
Benefits of the Immunization Information System
An immunization information system offers the following benefits to providers:
- Provides record consolidation of immunization information from multiple providers into a single reliable record. This record can then be used to provide official immunization records for schools, day cares, and camp entry requirements.
- Aids in managing immunizations so that children receive only the vaccines they need within the appropriate timeframes.
- Clarifies complex and changing immunization schedules and emerging vaccine combinations.
- Allows provider offices with electronic medical systems to submit data without duplicate entry.
- Generates reminder and recall postcards and/or mailing labels to send out to parents to remind them when their child's immunizations are due or have been missed.
- Decreases time spent by office staff seeking immunization histories from previous providers.
- Generates timely immunization reports (e.g. Health Plan Employer Data and Information Set (HEDIS), Clinical Assessment Software Application (CASA), and other quality improvement initiatives).
More Information
For more details on the new legislation and NYSIIS, look for the NYSIIS web page available on the Health Provider Network (HPN) and Health Information Network (HIN).
Free New Training Sessions Available for HIV/AIDS Case Management
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You are invited to attend the following FREE trainings (funded by the New York State Department of Health, AIDS Institute):
Ensuring Success
Navigating the Child Welfare System in HIV Case Management; and
Substance Use and HIV/AIDS
Improving Outcomes in Case Management Service Provision.
Learn more about these trainings by visiting the Department website at:
http://www.health.state.ny.us/diseases/aids/training/index.htm,
or contact Melody Van Alstyne at:
(518) 956-7876, or
register online at:
http://www.pdp.albany.edu/About/Programs/AIDS/coe_courses.cfm
Missing Issues?
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Hard copies of the Medicaid Update are sent to your correspondence address on file with the Medicaid Program. If you've moved, be sure to update your enrollment information!
The Medicaid Update, indexed by subject area, can be accessed online at:
http://www.health.state.ny.us/health_care/medicaid/program/update/main.htm
Hard copies can be obtained upon request by emailing:
medicaidupdate@health.state.ny.us
PROVIDER SERVICES
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Questions About an Article?
For your convenience each article contains a contact number for further information, questions or comments.
Questions about billing and performing MEVS transactions?
Please contact CSC Provider Services at: (800) 343-9000, or via e-mail at:
emednyproviderrelations@csc.com
Provider Training
To sign up for a provider seminar in your area, please enroll online at: http://www.emedny.org/training/index.aspx or call CSC at (800) 343-9000.
Patient Eligibility
Call the Touchtone Telephone Verification System (800) 997-1111, (800) 225-3040 or (800) 394-1234.
Address Change?
Questions should be directed to CSC at (800) 343-9000, option 5.
Fee-for-service Provider Enrollment
A change of address form is available at:
http://www.emedny.org/info/ProviderEnrollment/index.html
Rate-based/Institutional Provider Enrollment
A change of address form is available at:
http://www.emedny.org/info/ProviderEnrollment/index.html
Comments and Suggestions Regarding This Publication?
Please contact the editor, Timothy Perry-Coon at MedicaidUpdate@health.state.ny.us
Medicaid Update is a monthly publication of the New York State Department of Health containing information regarding the care of those enrolled in the Medicaid Program.
