February 2010    Volume 26, Number 3  

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





If you or your staff routinely provide injections or administer IVs, your patients may soon be asking some critical questions. Included in this article is a link to a brief survey about a new campaign targeted at providers and patients to promote safe injection practices. The New York State Department of Health (NYSDOH) has partnered with the Centers for Disease Control and Prevention (CDC) and the Safe Injection Practices Coalition (SIPC) to pilot this campaign to promote greater awareness to basic infection control procedures when healthcare providers administer any type of injection. Please take a moment to complete the survey available for viewing at: http://chws.albany.edu/injectionsafety.

A nine-month, federally-funded project will evaluate informational materials developed by SIPC as part of its "One and Only" campaign to educate providers and patients that it is never appropriate to reuse a needle or syringe from one patient to another, to access an intravenous infusion bag with a used syringe, or to misuse single-dose or multi-dose vials. A national initiative to promote the use of "One Needle, One Syringe and Only One Time" will be conducted following the pilot project. The two pilot sites (New York and Nevada) are states where serious outbreaks related to unsafe injection practices have occurred.

In the U.S. in the past decade, over 30 outbreaks of infectious diseases including hepatitis B virus (HBV) and hepatitis C virus (HCV) were traced to unsafe injection practices. In fact, SIPC estimates that more than 100,000 people in the U.S. have been asked to get tested for HBV and HCV in the past ten years, following exposure to unsafe injection practices.

This project was implemented to raise awareness of the critical need for safe injection practices among both healthcare providers and patients. It is believed that, grounded in knowledge about safe injection practices, patients will be able to have a frank discussion with their providers regarding an important issue that affects their own health.

The fundamental mission of the "One and Only" campaign is to ensure that the transmission of bloodborne pathogens through unsafe injection practices becomes what is aptly called a "Never Event." For more information, please visit: www.oneandonlyny.org.

Doctors and Nurses

In this issue....


ATTENTION: SCHOOL-BASED HEALTH CENTERS: Medicaid Coverage and Reimbursement Policy for Seasonal Flu, Pneumococcal, and H1N1 Vaccines
Current & Future Medicaid Medical Home Providers
Adult Day Health Care Transportation Changes
Annual Ambulette Survey No Longer Administered
Billing Agents Must Enroll as Medicaid Service Bureau
Prior Approvals For Managed Care Covered Services
Threshold Override Application (TOA) Form Revised
Self-Disclosure of Medicaid Overpayments


Pharmacy Drug Update


Medicaid Seminars Offered
Smoking Cessation Awareness
Provider Directory

Medicaid Coverage and Reimbursement Policy for Seasonal Flu, Pneumococcal, and H1N1 Vaccines Administered in School-Based Health Centers for Managed Care and Fee-for-Service Recipients
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Effective September 1, 2009, Medicaid implemented two major changes to fees and the payment policy for flu (seasonal/H1N1) and pneumococcal vaccine administration including:

  • Vaccine administration fees were increased from $2.00 to $13.23 for seasonal/H1N1 flu and pneumococcal vaccines for persons age 19 or older. Administration fees for seasonal/H1N1 flu and pneumococcal vaccines for persons under age 19 are $17.85.
  • All Article 28 clinics (hospital-based outpatient departments, diagnostic and treatment centers) are instructed to bill flu and pneumococcal vaccine administration fee-for-service using the ordered ambulatory fee schedule. This applies to Medicaid fee-for-service clinic patients as well as Medicaid fee-for-service patients referred to the clinic from community physicians, e.g,, ordered ambulatory. Flu and pneumococcal vaccine administration for Medicaid managed care and Family Health Plus (FHPlus) enrollees is billable to the enrollee's managed care plan.

School-Based Health Clinics (SBHCs) should bill Medicaid fee-for-service for administration of flu and pneumococcal vaccine to both Medicaid fee-for-service beneficiaries and managed care enrollees. Medicaid has implemented three new non-APG rate codes that will be carved out of the managed care benefit package, thereby allowing SBHCs to be reimbursed for the administration of these vaccines for fee-for-service and managed care recipients. These new rate codes should be billed for flu (seasonal/H1N1) and pneumococcal vaccine administered to all SBHC patients in Medicaid managed care as well as those in fee-for-service Medicaid.

The following chart outlines vaccine specific administration rate codes, the reimbursement rate for each of these rate codes, and the corresponding CPT codes for each vaccine. The CPT code for the specific vaccine must be listed on the claim. Note: Reimbursement is available for vaccine administration only since the vaccine is distributed free-of-charge through the Vaccine for Children's Program (seasonal flu and pneumococcal vaccine) or CDC (H1N1).

Immunization TypeCPT Code for VaccineRate Code for AdministrationRate Code DescriptionAdministration Fee
Seasonal Flu90655, 90656, 90657, 90658, 906601381Flu Seasonal Vaccines - Administration Only$17.85
H1N1906631382Flu H1N1 Vaccine - Administration Only$17.85
Pneumococcal90669, 907321383Flu Pneumo, Vaccines - Administration Only$17.85

Immunization Issues: Please contact the DOH Bureau of Immunization Call Center at (800) 808-1987 or visit the NYSDOH Website at: http://nyhealth.gov. Medicaid billing: Please contact the Division of Financial Planning and Policy, Bureau of Policy Development and Coverage at (518) 473-2160.

Current & Future Medicaid Medical Home Providers
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Medicaid providers applying to the National Committee for Quality Assurance (NCQA) for recognition as a Physician Practice Connection - Patient Centered Medical Home (PPCPCMH) should include a zip + 4 for each practice site for which they are seeking NCQA certification. NCQA recognition as a Medical Home is site specific; therefore, it is imperative that providers include the 4-digit zip code extension(s) of their practice location(s) in their application. This will enable NCQA to identify the correct location(s) of NCQA recognized medical practice(s) in order for NY Medicaid to render medical home incentive payments. Failure to include zip + 4 postal codes for practice sites may jeopardize incentive payments by NY Medicaid to NCQA recognized providers. For more information, please refer to the December 2009 Medicaid Update Special Edition. Questions? Please call the Division of Financial Planning and Policy at (518) 473-2160.

Adult Day Health Care Transportation Changes
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The New York State Department of Health (NYSDOH) has delayed implementation of the new fee-for-service fees paid for adult day health care (ADHC) program transportation. Effective January 1, 2010, new procedure codes and fees were announced for adult day health care transportation. The new fees announced at that time are no longer effective. The fees in effect on December 31, 2009, will continue through June 30, 2010. In the interim, the Department will work with counties, transportation managers, ADHC program staff, and transportation providers to transition to the new fees scheduled for implementation on July 1, 2010. Questions? Please call the Medicaid Transportation Policy Unit at (518) 474-5187 or via e-mail to MedTrans@health.state.ny.us.

Annual Ambulette Survey No Longer Administered
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Please be advised that effective January 2010, The Office of the Medicaid Inspector General (OMIG) will no longer administer the annual ambulette survey. Therefore, transportation providers are not required to complete or submit this survey for 2010. Please continue to refer to the Medicaid Update for future instruction in connection to this requirement.

Billing Agents Must Enroll as Medicaid Service Bureau
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Many Medicaid providers, including transportation providers, contract with vendors to submit claims to NY Medicaid. If you currently use a vendor to submit claims, please ensure that they are enrolled as a "Service Bureau" with NY Medicaid. Even if the vendor is enrolled in Medicaid as a provider, they must separately enroll as a Service Bureau in order to submit claims on behalf of another provider. The enrollment application is available online at: www.emedny.org/info/ProviderEnrollment/index.html. Questions regarding Medicaid transportation policy can be referred to (518) 474-5187 or via e-mail to MedTrans@health.state.ny.us. Please call the eMedNY Call Center at (800) 343-9000 with any Medicaid enrollment questions.

Prior Approvals For Managed Care Covered Services
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Providers must obtain any necessary prior approvals for Medicaid managed care and Family Health Plus (FHPlus) covered services from the enrollee's health care plan. Medicaid fee-for-service does not have authority to grant prior approvals for managed care covered services with the exception of prior approvals for "carved-out" services which are billed directly to fee-for-service Medicaid. Most fee-forservice Medicaid services do not require prior approval.

During eligibility verification, the Medicaid Eligibility Verification System (MEVS) returns a list of covered services for Medicaid Prepaid Capitation Plans using one of the following methods: MEVS Terminal (VeriFone), Telephone Verification (Audio Response Unit) or Alternate Access (ePACES, CPU-CPU, PC-Host or Batch Transmission). For MEVS and Alternate Access, the two-digit plan code and alphabetic coverage codes will be displayed. The telephone verification system will return the plan code and plan covered services (e.g., "Clinic", Dental", etc.). For more detailed information on eligibility verification, please refer to the eMedNY Provider Manuals at: http://www.emedny.org/ProviderManuals/index.html.

Most outpatient substance abuse services are carved-out of the managed care benefit package. Mental health and chemical dependency inpatient rehabilitation services are carved-out for SSI and SSI-related categories. Detoxification services are covered by managed care plans. Dental services and transportation services are optional benefits and are offered by some, but not all, Medicaid managed care plans. When not covered by the plan, these optional services are carved-out to Medicaid fee-for-service. Outpatient pharmacy benefits are carved-out for both Medicaid managed care and FHPlus enrollees. However, drugs furnished or administered in a provider's office or clinic setting remain in the managed care benefit package and the enrollee's managed care plan is responsible for any required prior approvals.

For additional information on managed care, contact the Division of Managed Care at (518) 473-0122. For information on fee-for-service prior approval requirements and procedures for specific medical or dental services, refer to the eMedNY Provider Manuals or contact the Division of Provider Relations and Utilization Management at (800) 342-3005. For information on prior authorization of pharmacy services, call (877) 309-9493 or refer to the Medicaid Pharmacy Program Website at: http://www.nyhealth.gov/health_care/medicaid/program/pharmacy.htm.

Threshold Override Application (TOA) Form Revised
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In 2009, in collaboration with research and clinical experts at the State University at New York (SUNY), two important changes took effect in the Medicaid Utilization Threshold (UT) program:

1) Each Medicaid member was assigned specific service limits for Physician/Clinic, Pharmacy and Laboratory services. Mental Health and Dental Services remain unchanged.

2) Each pharmacy refill is now counted within the service limits. A service authorization (SA) must be obtained for each refill on new and existing prescriptions.

Refreshed quarterly, these service limits are scientifically established based on each member's clinical information, including diagnoses, procedures, prescription drugs, age and gender. Member-specific service limits have significantly reduced the need for override requests. In the event that an override of a utilization threshold is necessary, the threshold override application (TOA) must include the medical assessment information to support the request for additional services. TOA requests received without the appropriate medical documentation will be returned to the originating provider for further clarification.


  • Check eligibility to verify the member's most up-to-date status.
  • Provider ID - Enter the 10-digit NPI # if enrolled in NY Medicaid. If the Provider is not enrolled, they should leave this field blank.
  • Provide description of medical condition that supports TOA request.
  • The TOA form must include an original requesting provider signature and date. Please print name under signature to assist with any follow-up contact.
  • Provider Information: Area Code/Phone/Extension - Please record the Provider's phone number with the area code and any applicable extension.


Can I continue to use the current form until supply runs out? Forms 00101 and 00102 will no longer be accepted after March 1, 2010.

Whom do providers contact to obtain SAs or request TOAs? Providers should call the eMedNY Call Center at (800) 343-9000.

Completed paper TOA forms (EMEDNY 000103) should be sent to CSC for processing: Computer Sciences Corporation, PO Box 4602, Rensselaer, New York 12144-4602.

The Utilization Threshold Guide is available for viewing at: http://www.emedny.org/HIPAA/Provider_Training/Training.html.

Self-Disclosure of Medicaid Overpayments
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The law that establishes the Office of the Medicaid Inspector General (OMIG) requires that all providers required to maintain an effective compliance program must make timely disclosure and repayment of overpayments obtained from Medicaid. These disclosures are one aspect of an effective compliance program. The OMIG has developed a self-disclosure protocol which allows providers to make their disclosures to the OMIG, and explains how those disclosures will be addressed. Further, recent substantive and procedural amendments to the Federal False Claims Act ("FCA") enacted under the Fraud Enforcement and Recovery Act of 2009 ("FERA") now allow whistleblowers to bring false claims actions against providers who knowingly and improperly keep government funds paid to them in error.

The OMIG is responsible for the statewide provider self-disclosure process for all Medicaid providers regardless of provider type. The OMIG conducts active outreach with various provider associations, professional societies, other state agencies and the New York State Bar Association (NYSBA) to encourage providers to come forward when they identify issues of fraud, waste, abuse or billing errors.

Self-Disclosure Basic Rules and Requirements:

  • OMIG is not interested in routine occurrences of overpayment that are normally resolved through typical methods of resolution such as voiding or adjusting claims.
  • All disclosures must be submitted in writing. It is recommended that all disclosure submissions follow the guidelines listed below.
  • All self-disclosures have an audit period limitation of six years from the date of reporting the disclosure (usually date of the disclosure letter submission). Claims older than six years are not subject to self-disclosure or OMIG audit and therefore not reportable.
  • Providers may submit a check with a self-disclosure made payable to the New York State Department of Health but the amount of overpayment will depend on the OMIG's review of documentation. After review and analysis, the provider will be notified by letter of the final repayment amount.

Self-Disclosure Submission Details:

Each self-disclosure should contain a letter providing details of the disclosure and an electronic file listing the claims involved. Recommended contents of each are as follows.

Complete description of circumstances surrounding the disclosure. This should include:

  • Provider Name, Provider Type, and NPI# of the billing provider. If claims were submitted under multiple NPIs, the Provider Name, Type, and NPI should be identified for each.
  • Description of the service provided including category of service and procedure codes.
  • Description of the methodology for documenting and billing the service.
  • Description of the error that occurred.
  • Description of how the error was found.
  • Estimate of the amount of the overpayment by NPI#.
  • Identifying the time period the claims encompass and why the search was not expanded beyond that period.
  • Provider actions taken to stop the error and prevent reoccurrence.
  • Identifying personnel involved in the error occurrences, personnel that identified the problem, and personnel involved in correcting the problem.
  • Identification of New York State Law or Medicaid Program rules/regulations implicated as the basis for overpayment.
  • Name, Phone Number, correspondence address, and e-mail address of the disclosure contact person.

An electronic file of claims involved in the self-disclosure should be submitted in excel format. The most popular method of submission is by CD via a secure courier (Fed Ex, UPS, etc.). Submission by e-mail is permissible but special arrangements are necessary to ensure firewall passage and data security. Each file submission should contain as many of the following data fields as possible:

  • Claim Reference Number (CRN) or Transaction Control Number (TCN) - {{CRN identified as TCN after March 2005. }}
  • Name of Provider on claim.
  • NPI # of Provider on claim.
  • NPI # on claim (if utilized).
  • Name of Patient on claim.
  • Medicaid ID of Patient on claim.
  • Date of Service on claim (Not the date billed).
  • Rate or Procedure Code on claim.
  • Amount paid to Provider by Medicaid (Current amount that includes retroactive adjustments).
  • Amount paid by Medicare or any other third party (if applicable).
  • Amount overpaid by Medicaid (if different from amount paid by Medicaid).

All self-disclosure letters, electronic files, etc., should be mailed to:

NYS Office of Medicaid Inspector General
Division of Medicaid Audit - Self-Disclosure
800 North Pearl Street, Albany, New York 12204-1822

Questions? Please visit our Website at www.omig.state.ny.us or by call (518) 473-3782 and request the OMIG Self-Disclosure Unit.

Several additions to the New York Medicaid list of reimbursable drugs were recently implemented which have resulted in changes to the Preferred Drug Program (PDP). Please see http://www.emedny.org/info/formfile.html for a complete listing.


On December 7, 2009, the proton pump inhibitors (PPIs) lansoprazole (generic Prevacid Rx) and Prevacid OTC became subject to the PDP. Lansoprazole has been added to the Preferred Drug List (PDL) as a non-preferred PPI and requires prior authorization. Prevacid OTC has been added to the PDL as a preferred PPI.

As a reminder, the following drugs within the PPI drug class are preferred:

  • Nexium (capsule)
  • Prevacid OTC
  • Prevacid Rx (capsule)
  • Prilosec OTC
  • omeprazole OTC

Preferred PPIs do not require prior authorization.

On December 21, 2009, valacyclovir became subject to the PDP. Valacyclovir (generic Valtrex) has been added to the PDL as a non-preferred oral anti-viral and requires prior authorization.

As a reminder, the following drugs within the oral anti-viral drug class are preferred:

  • acyclovir (capsule, suspension, tablet)
  • Valtrex

Preferred Oral Anti-Virals do not require prior authorization.

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.

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.