New York State Medicaid Update - April 2014 Volume 30 - Number 4

In this issue...April 2014 NEW YORK STATE MEDICAID UPDATE

Policy and Billing Guidance

Attention: Office-Based Practitioners Who Provide Services to Dual Eligible Medicare/Medicaid Recipients

In accordance with Medicaid Redesign Team #164 (MRT #164), physicians currently receive 20 percent of the Part B coinsurance and receive no payment for services not covered by Medicaid. Effective June 1, 2014, system support will be in place to align additional practitioners with MRT #164. Those additional practitioners will include:

  • Nurse practitioner,
  • Licensed midwife,
  • Podiatrist, and
  • Licensed psychologist.

Medicaid reimbursement for services provided to Medicare/Medicaid (dually eligible) recipients is changing. Effective June 1, 2014, Medicaid will no longer reimburse certain practitioners any portion of the Medicare Part B coinsurance amount if the service is not covered by Medicaid. Medicare Part B generally pays 80 percent for outpatient Medicare covered services. This leaves a 20 percent patient responsibility.

As a reminder, if the patient has both Medicare and Medicaid coverage (dually eligible), private practitioners must bill Medicare prior to billing Medicaid for the Part B co-insurance. Most claims are submitted to Medicare and are automatically crossed over to Medicaid for processing.

Please note: The Medicare and Medicaid payment (if any) must be accepted as payment in full. Per state regulation NYCRR 18 § 360-7.7, a provider of a Medicare Part B benefit cannot seek to recover any Medicare Part B deductible or coinsurance amounts from a Medicaid recipient or a qualified Medicare beneficiary.

Attention Hospitals: Inpatient Provider Manual Updated

The Inpatient Billing Guidelines section of the Inpatient Provider Manual was recently updated. The updates include detailed instructions on claim submission for Alternate Level of Care (ALC) days.

Hospitals with distinct subdivisions for services that are billed on per diem rate codes 2852 (Psych) and 2853 (Medical Rehab) should use their corresponding ALC per diem rate codes when appropriate. The ALC claims must be split billed and submitted with rate code 2962 or 2963 for psychiatric stays, or rate code 2970 or 2971 for medical rehabilitation.

Also, please see information on properly using Patient Status codes on inpatient claims.

Please visit to view your provider manual.


Medicaid Pharmacy PriorAuthorization (PA) Programs Update

Effective April 10, 2014, the fee-for-service (FFS) pharmacy program will implement the following parameters. These changes are the result of recommendations made by the Drug Utilization Review Board (DURB) at the December 7, 2012, DURB meeting:

Antiretroviral (ARV) Medications - Drug Interactions

Point of service edit for contraindicated antiretroviral/non-antiretroviral combinations.*
Point of service edit for contraindicated antiretroviral/antiretroviral combinations.*
*Clinical Call Center must be contacted to override the edit

For claims that do not meet the clinical criteria, eMedNY point of service will return a rejected response "85 - Claim Not Processed", in NCPDP field 511-FB along with messaging "Call Magellan Call Center at 1-877-309-9493", in NCPDP field 526-FQ with additional details based on criteria failure. An example of this would be the new response messaging developed for the ARV drug interactions shown below:
* 75A3 - Drug Contraindication Failure

The pharmacist may be able to intervene by consulting the prescriber for an appropriate change in therapy to reduce the need for the prescriber to obtain PA.

To obtain a PA, prescribers must contact the clinical call center at 1-877-309-9493. The clinical call center is available 24 hours per day, 7 days per week with pharmacy technicians and pharmacists who will work with you, or your agent, to quickly obtain a PA.

Medicaid enrolled prescribers can also initiate PA requests using a web-based application. PAXpress(r) is a web-based pharmacy PA request/response application accessible through the eMedNY website at:® can also be accessed through Magellan Medicaid Administration at:

For more detailed information on the DURB meeting, please visit:

Below is a link to the most up-to-date information on the Medicaid FFS Pharmacy Prior Authorization (PA) Programs. This document contains a full listing of drugs subject to the Medicaid FFS Pharmacy Programs:

Injection Safety: What You Might Not Know

Feel you have every aspect of safe injections "well in hand"? Ready to test your knowledge? The New York One & Only Campaign is pleased to announce the release of a new podcast entitled "Injection Safety: What You Might Not Know". It includes an interview with Guthrie Birkhead, M.D., M.P.H., Deputy Commissioner, Office of Science, New York State Department of Health (NYSDOH), as Dr. Birkhead tackles tough questions about titration, batching and potential transmission of infectious disease by glucometer. Some of these questions have been posed by real-life practitioners.

Click here to listen to the podcast. Download a copy of the transcript.

EHR Update

NY Medicaid EHR Incentive Program (PDF, 1pg.)

Federal Government Delays ICD-10 Implementation

The ICD-10 code set implementation date has been moved from October 1, 2014, to no earlier than October 1, 2015. The delay was part of the Protecting Access to Medicare Act of 2014 recently passed by Congress and signed into law by President Obama on April 1, 2014. New York Medicaid will adhere to the new federal compliance timeframe for ICD-10 implementation and eMedNY will not accept ICD-10 codes until October 1, 2015 at the earliest.

The ICD-10 delay will have minimal impact on New York Medicaid current ICD-10 transition efforts and testing plans. As stated in previous communications, the eMedNY Provider Testing Environment (PTE) will be available to providers and vendors on July 28, 2014. Providers are urged to proceed aggressively withtheir ICD-10 transition and test at their earliest convenience. The delay should be seen as an opportunity to better assess and address remaining challenges and not as a reason to pause.

Please note: The ICD-10 FAQs posted at have been updated to reflect the October 1, 2015 compliance date.


Office of the Medicaid Inspector General:
For suspected fraud complaints/allegations, call 1-877-87FRAUD, (877) 873-7283, or visit

Provider Manuals/Companion Guides, Enrollment Information/Forms/Training Schedules:
Please visit the eMedNY website at:

Providers wishing to listen to the current week's check/EFT amounts:
Please call (866) 307-5549 (available Thursday PM for one week for the current week's amount).

Do you have questions about billing and performing MEVS transactions?
Please call the 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 e-mail:

Enrollee Eligibility:
Call the Touchtone Telephone Verification System at (800) 997-1111.

Medicaid Prescriber Education Program:
For current information on best practices in pharmacotherapy, please visit the following websites:

Need to change your address? Does your enrollment file need to be updated because you've experienced a change in ownership? Do you want to enroll another NPI? Did you receive a letter advising you to revalidate your enrollment?
Visit and choose the link appropriate for you (e.g., physician, nursing home, dental group, etc.)

Medicaid Electronic Health Record Incentive Program questions?
Contact the New York Medicaid EHR Call Center at (877) 646-5410 for assistance.

Do you have comments and/or suggestions regarding this publication?
Please contact Kelli Kudlack via e-mail at: