January 2010    Volume 26, Number 1  

New York State Medicaid Update

The official newsletter of the New York Medicaid Program

David A. Paterson, Governor
State of New York

Richard F. Daines, M.D. Commissioner
New York State DOH



In this issue....

Important Information about the IRS 1099 Form
Important Provider Updates
Instructions for Beneficiaries Enrolled in Medicare Managed Care Plans
Medicare Automated Claim Crossover Update
Medicaid Seminars Offered
Smoking Cessation Awareness
Provider Directory

Important Information about the IRS 1099 Form
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Computer Sciences Corporation (CSC), the eMedNY contractor for the NYS Department of Health (NYSDOH), annually issues the Internal Revenue Service (IRS) Form 1099 to providers for the previous year's Medicaid payments. 1099 forms are issued with the individual provider's Social Security Number, or if a business, with the Federal Employer Identification Number (FEIN) registered with New York Medicaid. As with previous years, the IRS 1099 amount is not based on the date of the checks; rather, it is based on the date the checks were released to providers.

Since there is a two-week check lag between the date of the check and the date the check is issued, the IRS 1099 amount will not correspond to the sum of all checks issued for your provider identification number during the calendar year.

The IRS 1099 issued for 2009 will include the following:

  • Check dated 12/22/08 (Cycle 1635) released on 01/07/2009 through,
  • Check dated 12/14/09 (Cycle 1686) released on 12/30/2009.

NOTE:IRS 1099s are not issued to providers with yearly Medicaid payments less than $600.00. IRS 1099s for the year 2009 will be mailed no later than January 31, 2010.

Group Providers 1099 Information

Group practices that wish to have their Medicaid claims payment issued to the group must enter the group National Provider Identifier (NPI) on their claims. Funds for checks issued to groups will be associated with the group's tax identification number and will appear on the group's, Internal Revenue Service 1099 Form for the year in which checks were issued.

If a group NPI is not submitted on the claim, payment will be made to the individual provider NPI and the individual's associated tax number. Medicaid will issue a 1099 to the individual for the funds paid to that individual provider and their associated tax identification number.

If checks are made payable to an individual provider, but the checks are deposited into a group bank account, the individual provider will still be issued a 1099 for funds paid to the individual's NPI and associated tax number.

NOTE: The 1099 cannot be returned to Computer Sciences Corporation as it cannot be reissued under the group's tax number.


  • Step 1 - To correct the payment for these claims, voided claim transactions must be submitted for the individual provider. This will cause the payments to be negated and taken from subsequent payment made to the individual provider.
  • Step 2 - The group practice must then resubmit original claims with the group NPI entered on the claims. Medicaid will then make payment to the group and the funds will be associated with the group's tax identification number and the 1099 issued to the group.

Any voided and rebilled claims will only impact the 1099 amounts when the voids and rebilled claims are submitted in the same year the original payments were made.

For example, a voided claim submitted in the year 2010 will not impact the 1099 amount issued for the year 2009. Therefore, any claims paid in 2009 to an individual practitioner NPI that should have been paid to the group NPI would have to have been voided and rebilled in 2009 to affect a change to the 1099 issued for 2009.

Questions? Please contact the eMedNY Call Center at (800) 343-9000.

Important Provider Updates
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Doctors and Nurses

Private Duty Nursing Providers Update

As stated in the Medicaid Private Duty Nursing Manual Policy Guidelines, it is an unacceptable practice for an individual nurse to provide nursing services in excess of sixteen (16) hours in a 24 hour period.

Please review the Nursing Services Provider Manual for additional information at: www.emedny.org/ProviderManuals/NursingServices/PDFS/Private_Duty_Nursing_Policy.pdf.

Questions? Please call the Medical Prior Approval Unit at (800) 342-3005, Option #1.

Pharmacy Update

Effective April 1, 2010, the Office of the Medicaid Inspector General (OMIG), will require that the "Dispensing Pharmacist's" National Provider Identifier (NPI) be entered on all National Council Prescription Drug Plan (NCPDP) claims submitted electronically for payment by Medicaid. This initiative will ensure that pharmacists have a valid license and that prescriptions are not being filled by someone without a valid license (i.e. Pharmacy Technicians). The license of the Dispensing Pharmacist must include one of the following profession codes: 020 (Pharmacist), 021 (Pharmacist 3-year).

Pharmacies should enter the Dispensing Pharmacist's NPI in the following fields on the NCPDP claim:

  • 444-E9 Provider ID
  • 465-EY Provider ID Qualifier (must be 05, National Provider Identifier)

Some pharmacists may not possess an NPI. Since the NPI number has been considered a billing requirement, all Dispensing Pharmacist's must have an NPI. To apply for an NPI, please visit: http://www.cms.hhs.gov/NationalProvIdentStand/.

Any NCPDP claims submitted electronically without the Dispensing Pharmacist's NPI will be denied after April 1, 2010. This change will not impact those pharmacies billing on paper claim forms since the Dispensing Pharmacist field is not on the paper claim.

Questions? Please contact the eMedNY Call Center at (800) 343-9000.

New guidelines released for NYS Newborn Screening Program (NBS)


As noted in the February 2007 Medicaid Update, to ensure that Medicaid recipients whose newborn blood-spot specimen screens positive receive appropriate, medically necessary follow-up care, NYMAC (New York - Mid-Atlantic Consortium for Genetic and Newborn Screening Services) has released evidence-based diagnostic guidelines for clinical evaluation of many of the 45 conditions currently detected in the NBS program (for a list of these 45 conditions please see: http://www.wadsworth.org/newborn/babhealth.htm#listing). The new guidelines are available for viewing at: http://www.wadsworth.org/newborn/nymac/docs/DX_Guidelines.pdf.

Please note that the Krabbe guidelines at the New York State Newborn Screening Program website (http://www.wadsworth.org/newborn/krabbe.htm) are a description of the NYS NBS protocol for screening and confirmation of a child at risk for Krabbe disease. They are not to be used as treatment guidelines, though they do include information about monitoring the neurological functioning of a child at risk and the possibility of umbilical cord blood transplant.

The Sickle Cell Treatment Guidelines (http://www.wadsworth.org/newborn/sicklecell.htm) written by the NYS Sickle Cell Advisory Council (SCAC) are to be used as treatment guidelines by health care providers for care management and identification and treatment of complications. NYMAC was established in September 2004 as one of seven regional collaboratives in the country funded by the Genetic Services Branch of the Health Resources and Services Administration (HRSA)'s Maternal and Child Health Bureau. The charge to this group is to develop a regional approach to address the maldistribution of genetic resources in the New York - Mid-Atlantic region, which includes Delaware, District of Columbia, Maryland, New Jersey, New York, Pennsylvania, Virginia and West Virginia.

Questions? Please contact us at (518) 473-7552 or via e-mail to: nbsinfo@health.state.ny.us.

Cardiac Rehabilitation for Managed Care Enrollees

Effective January 1, 2010, Medicaid managed care and Family Health Plus (FHPlus) plans are responsible for covering medically necessary cardiac rehabilitation services provided by network providers, or by out-of-network providers with appropriate referrals and authorization. Medicaid managed care and Family Health Plus (FHPlus) plans will reimburse participating providers for cardiac rehabilitation services deemed by the plan to be medically necessary. Health plans may establish prior approval requirements for each phase of service and negotiate rates of payment with providers. Please refer to the December 2009 Medicaid Update article, "New York Medicaid to Cover Cardiac Rehabilitation for Fee-for-Service Enrollees," for additional information.

Questions? Please contact the Bureau of Managed Care Program Planning and Implementation at (518) 473-0122.

Instructions for Beneficiaries Enrolled in Medicare Managed Care Plans
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Effective February 2010, the NYS Department of Health (NYSDOH) will implement a new data source to identify Medicare managed care plans and update their Medicare managed care information (plan code and coverages) to eMedNY. The NYSDOH has developed the following billing guidelines to assist providers with proper and timely claim submission of electronic claims:

Medicaid Recipients with Medicare Managed Care (HMO/MCO) Coverage

  • Medicare Advantage plans are identified by a Claim Filing Indicator Code of 16 - Health Maintenance Organization (HMO) Medicare Risk - in loop 2320, data element SBR09. This code value will satisfy eMedNY's Medicare editing requirements.
  • eMedNY edit number 2016, "Medicare MCO Qualifier 16 conflicts with Part A/B Qualifiers" was implemented on February 1, 2007. This edit will fail when the claim contains a Claim Filing Indicator Code of 16 along with a code of MA - Medicare Part A or MB - Medicare Part B.
  • If the patient is enrolled in a Medicare Advantage plan there should be no Part A or Part B coverage entered on the claim for the same period.
  • Claims spanning a period of time where the patient did have Medicare coverage under both fee-for-service and a managed care plan must be split billed.

Instructions for Claims other than Nursing Homes

  • Medicaid will recognize the following Claim Adjustment Reason Codes (CARCs) as Patient Responsibility: 1 - Deductible, 2 - Coinsurance, 3 - Co-payment, and 122 - Psychiatric Reduction. The Claim Adjustment Group Code must be PR, "Patient Responsibility." All other CARCs with Claim Adjustment Group Code of "PR" will be treated as coinsurance.
  • For all claim types except Nursing Home claims, when the Claim Filing Indicator Code of 16 is sent, the Medicaid payment amount will equal the Patient Responsibility total amount.

Nursing Home Claims

  • If all days on the claim are reported as Medicaid Covered Days (loop 2300, QTY*CA) the system will determine the Medicaid value of the claim (Rate * Days = the amount Medicaid would have paid as the primary payer) and subtract the total of all prior payers' payments to receive the remaining balance.
  • For Medicaid recipients with nursing home inpatient coverage through a Medicare Managed Care plan, the Patient Responsibility - Deductible, Coinsurance, and copay as appropriate can be billed. All the days must be entered as Medicare Coinsurance Days (loop 2320, QTY*CD). The reimbursement amount will be the total Patient Responsibility (deductible, coinsurance and copay).
  • An eMedNY edit number 2059, "Medicaid Days invalid on Medicare Managed Care Claim" was implemented on February 1, 2007. If a Nursing Home claim has both Medicaid full days and Coinsurance days with MCO involvement, then the claim will be denied for edit 2059. The claim must be split and two claims must be billed separately.

Questions? Please contact the eMedNY Call Center at (800) 343-9000.

Medicare Automated Claim Crossover Update
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Effective December 2009 New York State Medicaid implemented an automated Medicare crossover process so providers will no longer have to bill New York Medicaid separately for the Medicare deductible, coinsurance or co-pay amounts for Medicare beneficiaries covered by Medicare Parts A & B. These types of claims are now sent directly by Medicare to New York Medicaid for processing and payment.


  • Medicare remittances will alert providers that the claim has been crossed over to New York Medicaid with a Remittance Remark Code of MA18. The electronic Medicare remittance indicator will be in Loop 2100, NM 1 Segment; NM 101 = TT and NM 103 will contain the name of the entity the claim is crossed over to.
  • There will be no changes to the Medicaid remittance statements (paper or electronic).
  • Crossover claims will be reported to providers on a paper remittance statement from Medicaid unless the provider has selected a Default ETIN with eMedNY. If a Default ETIN has been selected, the crossover claims will be reported on the electronic remittance for the Default ETIN. Providers may only select one Default ETIN for each provider ID (NPI) and a provider must be receiving electronic remittance from Medicaid to select a Default ETIN. There is a Default ETIN Selection form available at www.emedny.org.
  • Providers are strongly encouraged to verify Medicaid eligibility and providers who are required to obtain Service Authorizations from Medicaid still need to do so.
  • If a provider bills Medicare with an NPI that is not enrolled with New York Medicaid any crossover claim will be rejected by New York Medicaid and Medicare will send a notification of the rejection to the provider. A rejected claim will not appear on a provider's Medicaid remittance statement. To enroll an NPI with New York Medicaid providers should contact the Medicaid enrollment unit at (800) 342-3005.
  • Crossover claims appearing on the New York Medicaid remittance statement cannot be voided by the provider by submitting a voided claim transaction to New York Medicaid. Rather, the void needs to be sent to Medicare and Medicare will submit the void to New York Medicaid.
  • Crossover claims can be adjusted/replaced by the provider by submitting the adjusted claim directly to New York Medicaid following the usual Medicaid adjustment process or by submitting the adjusted claim to Medicare. Medicare will then cross over the adjustment to New York Medicaid.

Questions? Please contact the eMedNY Call Center at (800) 343-9000.

Medicaid Seminars Offered
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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 a variety 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 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

Physicians, nurse practitioners and private duty nurses can even submit claims in "REAL-TIME" via ePACES. With "real-time" the claim is processed within seconds and providers can get the status of a claim, including the paid amount without waiting for remittance advice.

Fast and easy seminar registration, locations, and dates are available on the eMedNY Website at: http://www.emedny.org/training/index.aspx.

Please review the seminar descriptions carefully to identify the seminar appropriate for your training requirements. Registration confirmation will instantly be sent to your e-mail address.

If you are unable to access the Internet to register, we can fax you a list of seminars and registration information to you through CSC's Fax on Demand at (800) 370-5809. Please request document 1000 for January - March seminar dates, 1001 for April - June seminar dates, 1002 for July - September seminar dates and 1003 for October - December seminar dates.

Note: Seminar schedule information is posted quarterly in CSC's Fax on Demand and Website at the beginning of each quarter. Please continue to check for updated information.

Questions? Please contact the eMedNY Call Center at (800) 343-9000.

No Smoking

By providing counseling, pharmacotherapy, and referrals, you can double your patients' chances of successfully quitting. For more information, please visit www.talktoyourpatients.org 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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Please Call: 1-877-87FRAUD or (212 417-4570)

Your call will remain confidential.

You can also complete a Complaint Form online at:



Provider Directory
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Office of the Medicaid Inspector General:
http://www.omig.state.ny.us or call (518) 473-3782 with general inquiries or 1-877-87FRAUD with suspected fraud complaints or allegations.
This contact information can also be used for Provider Self-Disclosures.

Questions about billing and performing MEVS 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: emednyproviderrelations@csc.com

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: http://www.emedny.org/info/ProviderEnrollment/index.html

Rate-Based/Institutional Providers
A change of address form is available at: http://www.emedny.org/info/ProviderEnrollment/index.html

Does your enrollment file need to be updated because you've experienced a change in ownership?
Fee-for-Service Providers please call (518) 402-7032
Rate-Based/Institutional Providers please call (518) 474-3575

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