November 2008  
Volume 24, Issue 13  

The official newsletter of the New York Medicaid Program

New York State Medicaid Update

David A. Paterson, 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

Dear Medicaid Provider,



Welcome to the November 2008 edition of the Medicaid Update. In this time of ever present change in the health care industry, you need meaningful and beneficial information to stay ahead. This month's newsletter features important policy directives and billing reminders to keep you up to date.

Please don't hesitate to contact us or you can visit us online at to learn more about our latest initiatives.

We continually look for additional ways to keep you informed. If you have any ideas or comments about this publication, please e-mail us at

In this issue....


Policy and Billing Guidance

Update on Mandatory Managed Care for SSI and SSI-related Medicaid Enrollees
Policy Directive for Office of Mental Health (OMH) Authorized Program
Psychiatric Services Billing Reminder
ALP Providers Bulletin
Permission for Facilities or Programs to Order Transportation is Extended
Medicaid Coverage for Optometric Procedure Codes for the Diagnoses of Glaucoma
December 1 APG Implementation Delayed for Hospitals


Are You New to the Medicaid Pharmacy Prior Authorization (PA) Process
Incontinence Supply Billing Update


Smoking Cessation Services
Provider Services

Final Notice

Medicaid Update newsletter will move to electronic distribution
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In an effort to distribute the Medicaid Update in a more efficient manner, reduce costs, and be more environmentally minded, beginning January 2009, the Office of Health Insurance Programs will no longer produce a printed version of the newsletter.

The Medicaid Update will ONLY be available electronically. This new delivery system will allow our providers to receive policy sensitive bulletins faster. The newsletter will be delivered monthly to your designated e-mail address in a Portable Document Format (PDF).

To receive the Medicaid Update electronically, please send your e-mail address with your provider ID# by Monday, December 22, 2008 to the following e-mail:

Providers who are unsure about receiving an electronic-only version of the newsletter should bear in mind that the PDF newsletter can always be printed and read in hard copy.

You will receive your final printed newsletter by mail in December 2008 as we transition from print newsletters to electronic distribution.

The Office of Health Insurance Programs anticipates that most providers will take advantage of this new delivery system, however, those who cannot may send a written request, along with your MMIS provider ID#, to the following address by Monday, December 22, 2008 to:

NYS Department of Health
Office of Health Insurance Programs
Attention: Kelli Kudlack
Corning Tower, Room 2029
Albany, New York 12237

Don't be left out...send us your e-mail address and provider # today!

Did you know?
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The current and archived Medicaid Update newletters are posted on the DOH Website at the following address:


Please Submit Your Claims Promptly
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Medicaid regulations require that claims submitted within 90 days of the date of service. Information regarding this policy is located in the General Billing subsection, Information for All Providers section of your provider manual at the following Website address:

If you have any questions regarding the processing, review or disposition of claims over two years old, please contact us at (800) 342-3005, option #3.

Policy and Billing Guidance

Update on Mandatory Managed Care For SSI and SSI-Related Medicaid Enrollees
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New mandatory counties for SSI and SSI-related Medicaid enrollees


Mandatory enrollment of SSI and SSI-related Medicaid enrollees, including those with serious mental illness, is being phased in geographically throughout the State. As described in previous Medicaid Updates, mandatory enrollment of SSI and SSI-related individuals began in New York City in November 2005; in Nassau, Onondaga, Oswego, Suffolk and Westchester counties in the fall of 2007; followed by Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Allegany and Rockland in the early spring of 2008; Livingston, Monroe, Ontario, Seneca and Yates in the late spring of 2008; and Albany, Broome, Columbia, Greene, Herkimer, Oneida, Rensselaer, Saratoga and Cortland in late summer 2008.

Effective October 24, 2008, mandatory enrollment of SSI and SSI-related Medicaid beneficiaries began in the following counties:

  • Dutchess
  • Fulton
  • Montgomery
  • Orange
  • Otsego
  • Putnam
  • Schenectady
  • Sullivan
  • Ulster
  • Washington

How will SSI and SSI-related Medicaid enrollees enroll in managed care?

SSI and SSI-related beneficiaries in mandatory areas must choose a plan within 90 days of receiving a mailing that includes information about the Medicaid managed care program. Those who do not choose a health plan within the 90 day period will automatically be assigned to one.

For help enrolling or to request an exemption for enrollees in Dutchess, Putnam, Fulton, Schenectady, Montgomery, Sullivan, Orange, Ulster, Otsego and Washington counties as well as New York City, Nassau, Suffolk and Westchester counties, please call (800) 505-5678.

Enrollees in all other counties listed should contact their local department of social services.

How will this change the way enrollees who are SSI or SSI-related get their Medicaid benefits?

Once enrolled in a health plan, these individuals will keep their Medicaid benefits but get most of their health care from the health plan's network of providers, hospitals, physicians, and clinics.

They will continue to receive their Medicaid pharmacy benefits and most of their behavioral health benefits (mental health and substance abuse services) from the providers they currently see on a fee-for-service basis. Plan enrollees will receive a health plan identification card but will access carved out benefits, including behavioral health services using their regular Medicaid card.

What services are included in the managed care benefit package for SSI and SSI-related Medicaid enrollees?

The benefit package for SSI and SSI-related enrollees is a "health only" package and includes:

  • All medically necessary physical health care, including primary care physician visits associated with a behavioral health diagnosis;
  • All laboratory services, emergency room visits and transportation, including those associated with behavioral health services or diagnoses;
  • Inpatient hospital admissions including when the stay covers a combination of medical and behavioral health services but the DRG or rate code is not classified as behavioral health;
  • Drugs obtained and administered by a medical practitioner or facility, except for Risperdal Consta (J2794) which is reimbursed under Medicaid fee-for-service for all managed care enrollees; and
  • Chemical dependence detoxification services, including medically managed detoxification and medically supervised inpatient and outpatient withdrawal.

The benefit package does not include the following behavioral health services, which are billable directly to Medicaid fee-for-service:

  • Mental health inpatient and outpatient services;
  • Mental health services certified by the New York State Office of Mental Health for individuals with serious mental illness;
  • Chemical dependence inpatient rehabilitation services; and,
  • All chemical dependence outpatient services, including methadone maintenance treatment programs.

SS Card

Where can a provider get additional information about the managed care benefit package?

The complete Medicaid managed care benefit package description and all services billable directly to Medicaid fee-for-service that SSI and SSI-related enrollees are entitled to is online at:

For questions regarding Medicaid managed care for this population or a list of Medicaid rate and fee codes payable for Medicaid managed care enrollees, providers may call (518) 473-0122.

Providers are encouraged to check the Medicaid Eligibility Verification System (MEVS) at each visit, or at a minimum on the first and tenth of every month to determine Medicaid eligibility and managed care enrollment status.

Identification of SSI or SSI-related Medicaid Enrollees

Depending upon the method a provider uses to verify an enrollee's Medicaid eligibility, the following responses identify SSI or SSI-related enrollees:

  • MEVS will show an "S" in the category of assistance field.
  • On the VeriFone terminal, the category of assistance response will be returned after the anniversary date in the following format:
    MSG: COA=S
  • For telephone verifications, an SSI or SSI-related enrollee will be identified by "Category of Assistance S" after the anniversary month in the stated response. For enrollees with any other category of assistance, it will not be returned via the terminal or telephone.

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

NCPDP DUR Response Formats

Variable Eligibility and Claim Capture (5.1): Field 504 (message), position 21 will be "S" or space filled.

ePACES Response Details

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

Please note:

All benefit package services must be provided by network providers or by referral and may require prior authorization.

Policy and Billing Guidance

Policy Directive for Office of Mental Health (OMH) Authorized Programs
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Most OMH ambulatory providers may not bill Medicaid nor count services necessary to bill Medicaid when the service is rendered in an inpatient setting. The following instructions reflect current policy.

The following programs may never bill for services rendered to an inpatient:


  • Clinic
  • Continuing Day Treatment
  • Partial Hospitalization
  • Intensive Psychiatric Rehabilitation Treatment
  • Rehabilitation Services in Community Residences
  • Family Based Treatment
  • Teaching Family Homes
  • Personalized Recovery Oriented Service

The following are three exceptions to the prohibition for billing Medicaid for services provided to individuals in an inpatient setting.

  1. Intensive, Supportive or Blended Case Managers may count case management visits provided to an inpatient of a general hospital licensed under Article 28 of Public Health Law in the hospital or discrete psychiatric unit when the inpatient has an anticipated discharge within 90 days. The case management services must be required to facilitate the process of transition to Community Services. Providers may refer to the OMH policy letter, "Billing for Case Management for Institutionalized Persons," dated 11/27/01. You may obtain a copy of the letter by contacting OMH at (518) 474-6911.
  2. Assertive Community Treatment providers may render case management services in accordance with the rules of 14NYCRR Part 508.5(c) (4) which is available on the OMH Website at the following link:
  3. OMH Home and Community Based Services (HCBS) Waiver providers may bill for case management services provided to a child who is hospitalized under the rules and policy outlined in the Guidance Document, Section 400 found at the OMH Website:

Please note: Regarding items 1 & 2 above
Case management services provided to an inpatient of an OMH psychiatric center or psychiatric hospital certified solely under Article 31 of the Mental Hygiene Law may not be billed to Medicaid.


Psychiatric Services Billing Reminder
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To ensure compliance and avoid potential audit disallowances, please be aware of the following when billing procedure code 90862 - Pharmacologic Management, including prescription, use, and review of medication with no more than minimal medical psychotherapy:

  • Code 90862 is not intended to refer to a brief evaluation of the patient's state or a simple dosage adjustment of long term medication. This code refers to the in-depth management of psychopharmacologic agents with frequent serious side effects, and represents a very skilled aspect to patient care. A lower level Evaluation and Management (E&M) code may be more appropriate when the service is limited to a brief visit for the purpose of monitoring or changing drug prescriptions. Denied claims that can be supported with medical documentation for this in-depth service may be resubmitted on paper claim forms to Computer Sciences Corporation. All documentation must be in a legible format and support that the service was reasonable and medically necessary for the referenced diagnosis.
  • If a patient receives psychotherapy and pharmacologic management at the same visit, the psychiatric procedure codes 90801 - 90857, which include E&M services, should be used. The pharmacologic management is included as part of the E&M service by definition, and procedure code 90862 should not be billed in addition to these psychiatric procedure codes or E&M codes 99201-99440.
  • Pharmacologic management is included in procedure code 90870 - Electroconvulsive therapy and therefore procedure code 90862 is not to be reported with this service.


Claims and supporting medical documentation may be sent to:

Computer Sciences Corporation
PO Box 4601
Rensselaer, NY 12144-4601

Attention ALP Providers
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Providers enrolled under Category of Service (COS) 0267-Assisted Living Programs - are atypical providers and do not require a National Provider Identifier (NPI) for billing purposes. If you have any questions, please contact the CSC Call Center at (800) 343-9000.

Transportation Ordering Providers


Permission for facilities or programs to order transportation is extended
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The September 2008 Medicaid Update included an article entitled National Provider Identifier and Non-Emergency Transportation Prior Authorization," which indicated a change from the practice of allowing a facility or program to be identified as the ordering provider, to a new rule permitting only a practitioner to be identified as the ordering provider on non-emergency transportation prior authorization requests.

However, due to the implementation time necessary for orderers to change their practices in order to adhere to this policy, New York Medicaid has postponed this requirement until further notice. Consequently, a diagnostic and treatment clinic, hospital, nursing home, intermediate care facility, long term home health care program, home and community based services waiver program, or managed care program may order non-emergency transportation services on behalf of the ordering practitioner.

Questions regarding transportation policy can be directed to the Transportation Policy Unit at (518) 408-4825 or via e-mail at


Medicaid coverage for optometric procedure codes for the diagnosis of glaucoma
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Eye Chart

Effective immediately, Medicaid reimbursement will be available to optometrists for the following procedures:

CPT- 4 CODE - 76514 (Pachymetry) REIMBURSEMENT: $4.00

CPT- 4 CODE - 92135 (Scanning Computerized Ophthalmic Diagnostic Imaging) REIMBURSEMENT: $16.00

If you have any questions, please contact the Bureau of Policy Development and Coverage at (518) 473-2160.

Important APG Implementation Notice

December 1 APG implementation delayed for hospitals
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Please be advised that implementation of Medicaid's new Ambulatory Patient Groups (APG) payment methodology and primary care enhancements, originally scheduled for December 1, 2008, has been delayed.

The Department's discussions with the Centers for Medicare and Medicaid Services (CMS) on approval of the applicable State Plan Amendments are continuing and approval is expected by year end.

Providers should continue to submit claims for outpatient services to eMedNY using existing rate codes (not APG rate codes) until further notice.

Claims should be fully coded with CPT/HCPCS codes and ICD-9 diagnosis codes in anticipation of retroactive payment for outpatient hospital and ambulatory surgery claims back to December 1, 2008, based on the APG payment methodology. The Department will notify affected hospital providers of CMS approval of the State Plan Amendment immediately upon receipt of such approval. APG implementation will commence approximately 2 weeks thereafter.

Further instructions on the claiming process will be provided at that time. APG payments for Emergency Department services are still scheduled for a January 1, 2009, implementation.

Please direct any questions to the Department's APG e-mail at:

For current information on APGs please visit the APG Website at:

Are you new to the Medicaid Pharmacy Prior Authorization process or just looking for more information?
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Our Medicaid Pharmacy Prior Authorization (PA) Program's Desk Aid provides a brief overview of the three Pharmacy PA Program's and information on the Family Health Plus Pharmacy Benefit. Helpful pone numbers and Web sites are also provided. To access the Desk Aid directly, or follow these simple steps:

  • Visit our Web site at
  • Click on "Providers"
  • Click on "Prior Authorization Programs" then "Forms and Worksheets"
  • Under "Desk Aids," click on the link for Medicaid Pharmacy PA Desk Aid

If you have additional questions regarding our Medicaid Pharmacy Prior Authorization Programs, please contact an Education Specialist at (518) 951-2051.

Policy and Billing Guidance

Incontinence Supply Billing Update
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Pharmacy and DME providers and ordering practitioners are reminded of the following Medicaid policies regarding payment and coverage of incontinence supplies, including disposable diapers:

  • Diapers and underpads are covered only when medical need is documented by the ordering practitioner and maintained in the beneficiary's clinical file.
  • The dispensing provider must maintain documentation of the measurements (e.g., waist/hip size, weight) which supports reimbursement for the specific size of diaper dispensed.
  • Billing for multiple sizes of diapers for the same beneficiary is prohibited.
  • Personal hygiene products such as menstrual pads are not covered.
  • Supplies are reimbursed in monthly quantities per the fiscal order up to the maximum quantity allowed, as published in the Provider Manual.
  • Refills may be billed only when one week or less remains on the current month's supply and the beneficiary or caregiver has requested the refill. Documentation of the refill request must be maintained by the provider.
  • The beneficiary or caregiver must receive delivery. Electronic signatures for receipt of product are permitted only if retrievable and kept on file by the provider.

If Medicaid policies are not followed, providers may be subject to the following:

  • Service limit exceeded rejection messages through DVS;
  • Claims denials for Edit 00715 Procedure Conflicts with Previous Service;
  • Audit recoupment from the provider and/or ordering practitioner for quantity or frequency not supported by the medical record or not in compliance with Medicaid policies;
  • Other administrative actions as appropriate.

Please note: This article is not intended to address or modify the long-standing requirements related to the inclusion of supplies in facility rates.

Questions? Please call the Division of Provider Relations and Utilization Management at (800) 342-3005.

Provider News - Smoking Cessation


By providing counseling, pharmacotherapy, and referrals, you can double your patients' chances of successfully quitting.
For more information, visit or call the NY State Smokers' Quitline at 1-866-NY-QUITS (1-866-697-8487).

Do you suspect that a Medicaid provider or an enrollee has engaged in fraudulent activities?
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Call: 1-877-87FRAUD

Your call will remain confidential.

You can also complete a Complaint Form online at:


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Missing Issues?
The Medicaid Update, indexed by subject area, can be accessed online at:

Office of the Medicaid Inspector General: (518) 473-3782

Questions about an Article?
Each article contains a contact number for further information, questions or comments.

Questions about billing and performing EMEVS transactions?
Please contact eMedNY Call Center at: (800) 343-9000.

Provider Training
To sign up for a provider seminar in your area, please enroll online at:

For individual training requests, call (800) 343-9000 or email:

Enrollee Eligibility
Call the Touchtone Telephone Verification System at any of the numbers below:

(800) 997-1111    (800) 225-3040      (800) 394-1234.

Address Change?
Questions should be directed to the eMedNY Call Center at: (800) 343-9000.

Fee-for-Service Providers
A change of address form is available at:

Rate-Based/Institutional Providers
A change of address form is available at:

Comments and Suggestions Regarding This Publication?
Please contact the editor, Kelli Kudlack, at:

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.