New York State Medicaid Update - November 2014 Volume 30 - Number 10

In this issue.....

Policy and Billing Guidance

Antibiotic Stewardship Highlighted during "Get Smart Week" November 17-23, 2014

It's Cold and Flu Season! New Yorkers are Urged to "Get Smart" About Antibiotics

ALBANY, N.Y. (November 10, 2014) - The New York State Department of Health wants New Yorkers to think twice before expecting treatment with an antibiotic when they become ill, because an antibiotic is not appropriate treatment for every illness. Acting Health Department Commissioner Dr. Howard Zucker explains, "Antibiotics-while powerful agents in fighting bacterial infections-have no effect on viruses."

In fact, the federal Centers for Disease Control and Prevention (CDC) and the New York State Department of Health (NYSDOH) say that overprescribing antibiotics has caused some germs to become resistant to certain medications. At the same time, fewer new antibiotics are being developed to fight these so-called "Superbugs."

"Get Smart Week" is a national coordinated effort of CDC, state and local health departments, and non- profit and for-profit partners. During "Get Smart Week," NYSDOH is asking not only patients but also their health care providers to think twice about appropriate treatment for a particular infection.

"Health care practitioners and patients need to work hand-in-hand to fight this problem. Many of the antibiotics currently on the market have become less effective against bacterial infections because they are inappropriately prescribed for viral illnesses. We want to stress again that antibiotics have no effect on viruses," said Dr. Zucker.

In September, President Obama signed an Executive Order calling for stepped up efforts to combat the rise of antibiotic resistant bacteria, including increased vigilance on the rise of antibiotic resistant bacteria, wiser use of existing antibiotics, and ramped-up efforts to develop a new generation of stronger antibiotics to fight this growing challenge.

Did you know (according to the CDC):

  • Up to 50 percent of all antibiotics prescribed for patients in the U.S. are not needed or are not optimally prescribed.
  • Antibiotics do not treat viral illnesses like colds and sore throat (except strep throat).
  • The body will fight the viral illnesses that cause most upper respiratory infections.
  • People should only use antibiotics that are prescribed by a healthcare provider; always follow the instructions on the label, properly dispose of leftover medication, and do not share antibiotics with anyone, not even a family member.
  • Each time people take antibiotics, they are more likely to carry resistant germs in their noses and throats; common antibiotics cannot kill these resistant germs.
  • Good hand hygiene (hand washing) is one of the best ways to keep from getting sick and spreading illnesses.
  • Appropriate antibiotic use can help protect adults and children.

"We want to see patients, healthcare providers, hospital administrators, and private physicians working together to employ effective strategies for improving appropriate antibiotic use, which will ultimately improve medical care and save lives," said Dr. Zucker.

New York State has obtained a CDC grant to educate healthcare providers and patients about antibiotic resistance and a second grant to work on reducing Carbapenem-resistant Enterobacteriaceae (CRE), an extremely resistant bacteria that usually affects hospitalized patients. These materials may be helpful in getting the word out about antibiotic resistance and appropriate prescribing.

For more information, contact the NYSDOH Public Affairs Group at (518) 474-7354, ext. 1

ATTENTION Topical Oxygen Wound Therapy (TOWT) Continues to be Covered Until Further Notice

Providers, Medicaid beneficiaries and Medicaid Managed Care Organizations (MMCOs) were notified in the October 2014 Medicaid Update that New York State Medicaid fee-for-service and Medicaid Managed Care were eliminating coverage of topical oxygen wound therapy (TOWT) effective December 1, 2014 and January 1, 2015, respectively.

This is to notify providers, Medicaid beneficiaries and MMCOs that the prior determination is rescinded and that Medicaid fee-for-service and Medicaid Managed Care will continue to cover TOWT in accordance with the Department's existing procedures until further notice.

Pharmacy Update

Reminder - Transmission of the Official Prescription Serialized Number is required for All NYS Fee-for-Service Medicaid Claims

Re-issuance of August 2014 article

When submitting claims for prescriptions written in New York State on an Official New York State Prescription form, the serialized number from the Official Prescription MUST be used.

In specific situations, valid prescriptions for prescription drugs and/or supplies may still be dispensed when not written on Official New York State Prescription Forms. The table below lists some of the specific situations when this is allowed and indicates the appropriate code to be entered in NCPDP field 454-EK in lieu of the Prescription Serial Number.

99999999* Oral prescriptions and products dispensed pursuant to a non-patient specific order *
EEEEEEEE* Prescriptions submitted electronically (computer to computer)**
NNNNNNNN* Prescriptions for carve-out drugs for nursing home patients (excluding controlled substances)
SSSSSSSS* Fiscal orders for supplies
ZZZZZZZZ* Prescriptions written by out-of-state prescribers or by prescribers within the US Department of Veterans Affairs

* Products dispensed pursuant to a non-specific patient order may include, but are not limited to, emergency contraceptives (e.g., Plan B) or pharmacist administered vaccines.

** Prescriptions submitted electronically, that do not transmit properly or default to a facsimile, must conform to the requirements of the NYS Education Law at:

Prescriptions received by the pharmacy as a facsimile must be an original hard copy on the Official New York State Prescription Form that is manually signed by the prescriber, and that serial number must be used. Prescriptions for controlled substances that are submitted electronically but fail transmission MAY NOT default to facsimile.

For questions on this billing requirement providers may contact the eMedNY Call Center at (800) 343-9000.

Medicaid Pharmacy Prior Authorization Programs Update

On September 18, 2014, the New York State Medicaid Drug Utilization Review Board (DURB) recommended changes to the Medicaid pharmacy prior authorization (PA) programs. The Commissioner of Health has reviewed the recommendations of the DURB and has approved changes to the Preferred Drug Program (PDP) within the fee-for-service (FFS) pharmacy program.

Effective December 11, 2014, PA requirements will change for some drugs in the following PDP classes:
  • Anticoagulants, Oral
  • Oral Agents for Pulmonary Arterial Hypertension (PAH), formerly titled Endothelin Receptor Antagonists for PAH.
The PDP has also expanded to include additional drug classes. Non-preferred drugs in the following classes will require a PA:
  • Agents for Opioid Dependence
  • Alpha-Glucosidase Inhibitors
  • Meglitinides
  • Opioid Antagonists
  • Sodium Glucose co-transporter 2 (SGLT2) Inhibitors
Also effective December 11, 2014, the FFS pharmacy program will implement the following clinical parameters recommended by the DURB:
  • Memantine ER (Namenda XR)
    • Confirm diagnosis for the FDA-approved indications:
      • Dementia or Alzheimer's disease
      • Absence of covered diagnosis in patient's claim history will require prescriber involvement
    • Step Therapy: Trial with memantine immediate-release (when product is commercially available)
  • Tetrabenazine (Xenazine)
    • Confirm diagnosis for the FDA and Compendia approved indications in patients ≥ 18 years:
      • Chorea associated with Huntington's disease
      • Gilles de la Tourette's syndrome
      • Tardive dyskinesia
  • Tasimelteon (Hetlioz)
    • Confirm diagnosis for the FDA-approved indication:
      • Non-24-hour sleep-wake disorder in totally blind patients only
    • Quantity Limit: 1 unit per day (30 units per 30 days)

DURB recommendations regarding Hepatitis C Virus (HCV) clinical criteria made at the September 18, 2014 DURB meeting became effective on October 16, 2014. For details on the HCV criteria, please refer to the October 2014 edition of the Medicaid Update:

For detailed information on the DURB recommendations, please refer to the meeting summary at:

The following is a link to the most up-to-date information on the Medicaid FFS pharmacy prior authorization programs. This document contains a full listing of drugs subject to the Preferred Drug Program, Clinical Drug Review Program, Drug Utilization Review Program, Brand Less than Generic Program, Dose Optimization Program and the Mandatory Generic Drug Program:

To obtain a PA, please call the NYS Medicaid Pharmacy Clinical Call Center at 1-877-309-9493. The clinical call center is available 24 hours per day, 7 days per week, staffed with pharmacy technicians and pharmacists who will work with you, or your agent, to quickly obtain PA.

Medicaid enrolled prescribers with an active e-PACES account can initiate PA requests through the web- based application PAXpress ® at:; through the eMedNY website at, as well as Magellan Medicaid Administration's website at



Mandatory Compliance Program Certification Requirement under 18 NYCRR §521.3(b)


Medicaid providers are required to implement and maintain a compliance program as described in NYS Social Services Law Section 363-d and 18 NYCRR Part 521. Any required provider must also certify annually that its compliance program meets the statutory and regulatory requirements. The certification must occur in December of each year.

At the time of certification, it is the responsibility of required providers to determine if:

a. it has a compliance plan that meets the requirements of SSL § 363-d and 18 NYCRR § 521.3 (c);
- and -
b. its compliance program is effective.

OMIG reminds all those who are required to have a compliance program that they must complete the certification on OMIG's website ( by December 31, 2014.

On December 1, 2014, OMIG will make the NYS Social Service Law Compliance Program Certification Form (Certification Form) for 2014 available on its website. The Certification Form for 2013 will remain active on OMIG's website until December 1, 2014 for newly enrolling Medicaid providers.

A webinar, entitled "OMIG Webinar # 23 - OMIG's Compliance Certification Process: December Annual and Enrolling Providers" is available on OMIG's website under the Resources tab - Webinars. Webinar #23 explains: who are required to adopt, implement and maintain an effective compliance program; what is required of mandatory compliance programs; what the certification obligation requires; and the form that must be used to certify starting on December 1, 2014.

In addition to the Webinar, the Compliance tab on OMIG's website provides tools and resources to help Medicaid providers determine if they are required to adopt, implement and maintain a compliance program under NYS Social Services Law Section 363-d and 18 NYCRR Part 521. The Compliance tab also provides resources that explain what is required of compliance programs.

Medicaid providers have an independent obligation to be aware of existing statutory and regulatory requirements of the Medicaid program. Additionally, OMIG recommends regular visits to its website to review the information and resources that are published under the Compliance Tab on OMIG's home page. The Compliance Library under the Compliance Tab provides copies of current forms, publications and other resources that could prove helpful in conducting a self-assessment and completing the certification form in December.

OMIG also recommends that required providers sign up for e-mail notices from OMIG by subscribing to OMIG's listserv. Anyone can become a subscriber at no cost by signing up on OMIG's home page. The listserv is a great way to keep informed of the introduction of new compliance tools and information on compliance. As additional compliance-related resources are posted by OMIG, those on OMIG's listserv will receive notices of their publication.

If you have any questions regarding New York State's mandatory compliance obligation for Medicaid providers, please contact the OMIG's Bureau of Compliance at (518) 408-0401 or by using the Bureau of Compliance's dedicated e-mail address

Claims Pending Review for Edits 00127 & 01283

Claims failing eMedNY edits 00127 (Medicare Paid Amount Reported Less Than Reasonable Amount), and 01283 (Upper Dollar Limit Exceeded) will be pended for up to 60 days so the provider can submit proof that the Medicare amounts submitted on the Medicaid claim match. The status of electronic claims pended for these edits are located on the provider's Supplemental Remittance file, sent with the HIPAA-compliant (835) remittance.

The corresponding HIPAA codes that will be reported on the 835 remittance:

  • 00127: Adjustment Reason Code 23 with no Remittance Remark Code
  • 01283: Adjustment Reason Code 16 and Remittance Remark Code M54

If the claim(s) is pended, the corresponding claim status response codes will be:

  • 00127: Claim status code 182
  • 01283: Claim status code 585

If you have claims pended for the above edits and you can provide documentation (i.e., Medicare Explanation of Medical Benefits (EOMB)) to support that your billing was appropriate, please follow these instructions:

Documentation should be sent to the Edit Review Panel for these edits ONLY.
Documentation sent for any other edits will be returned to the provider.


Send a copy of the Medicare EOMB to the address below. You must indicate the corresponding 16 digit Medicaid Transaction Control Number (TCN) found on your Medicaid remittance. The TCN shows in ePACES as Payer Claim Control number.

Mail the documentation to the following address:

Computer Sciences Corporation
Attn: Edit Review Panel
P.O. Box 4604
Rensselaer, NY 12144-4604

Documentation that is incomplete, illegible or unusable will be returned to the provider. CSC staff will review the documentation and adjudicate the claim(s) accordingly through the regular claim processing system. The adjudicated claims will appear on the provider remittance statement.

Questions should be directed to the eMedNY Call Center (800) 343-9000.


The implementation of ICD-10 diagnosis codes (and procedure codes for hospital inpatient billing) is October 1, 2015.

The New York State Department of Health (the Department) recently distributed a survey link to Medicaid providers to determine the level of readiness in our provider community. The survey results concern the Department because it appears that our provider community is far from ready for the October 1, 2015 implementation and provider payments could be severely impacted. In response to the survey:

  • 83% of providers responded that they have not yet assessed the impact of migrating to ICD-10 codes for their organizations.
  • Just over 70% of responders have not reviewed the ICD-10 information available at nor have they tested transactions with eMedNY.
  • Over 70% of providers do not know if their systems are ready or will be ready to test ICD-10 code transactions.
  • The majority of providers who replied to the survey "do not know if ICD-10 coding applies to us" or "do not know what ICD-10 is".

Providers are urged to not get caught at the last minute! Not being ready for October 1, 2015 may mean a significant interruption of your payments. Here's how to ready yourself:
1. Review CMS's ICD-10 site 10ImplementationTimelines.html, which includes preparedness checklists.

2. Review's ICD-10 information page, including testing information, FAQs about how ICD-10 codes impact your claims in 2015, and how to prepare, at

3. Do you have a vendor? Confirm they are ready and what your role will be.

Additionally, as detailed in previous Medicaid Update articles, the Provider Testing Environment has been available since July 28, 2014 for submitters and inpatient hospitals to test Medicaid claims with ICD-10 diagnosis codes. All submitters are urged to submit test files well in advance of the October 1, 2015 compliance date. This will ensure sufficient time to identify and correct coding or system deficiencies/errors.

eMedNY related ICD-10 questions may be referred to the CSC Call Center at 800-343-9000.

Fee-for-Service Provider Enrollment for Physicians

Until recently, physicians whose services to Medicaid beneficiaries were billable to the Medicaid Program were required to participate in the CAQH® Universal Provider Datasource® (UPD®) before enrolling with Medicaid. This is no longer a requirement.

Medicaid enrollment forms already submitted with a CAQH ID will be processed. No further action is necessary unless the physician/applicant is contacted by the Medicaid Program's Provider Enrollment office. Applicants should respond to a Provider Enrollment representative's request for additional or clarifying information.

Questions about this change can be addressed to

Continued Medicaid Enrollment for Durable Medical Equipment (DME) Providers

Federal regulation 42 CFR, Part 455.414 requires New York State Medicaid to revalidate your enrollment every five years. Revalidation involves completion of the enrollment form and, since the risk level for DME providers is either "moderate" or "high", a site visit is required.

You can save time and money by coordinating your New York State Medicaid revalidation with Medicare, another state's Medicaid program or CHIP Program. If you revalidate with New York within 12 months of your Medicare/state Medicaid/CHIP site visit, a New York site visit is not necessary and the New York application fee will be waived.

The Revalidation process for DME providers has begun. Revalidation letters have been mailed to DME providers actively submitting claims to Medicaid. Find out more about Revalidation by clicking on the links below.

Click here for a PowerPoint presentation on Revalidation
Click here for the DME Enrollment Form and Instructions

Home and Community Based Waiver (HCBS) Self-Direction Services

Effective October 1, 2014, the Office for People with Developmental Disabilities (OPWDD) has redesigned its self-directed services program within its HCBS Waiver. In compliance with federal guidance, self-direction is no longer conceived as a service unto itself, but as a means of delivering specific component waiver services. Accordingly, the former Consolidated Supports and Services (CSS) program was retired on September 30, 2014. Self-directed services formerly bundled together and billed monthly as the CSS service are now billed separately as the following component services of the participant's self-direction plan and budget:

  • Fiscal Intermediary Service
  • Support Broker
  • Live-In Caregiver
  • Individual Directed Goods and Services
  • Self-Directed Community Habilitation
  • Self-Directed Respite
  • Self-Directed Supported Employment

The participant's fiscal intermediary will retain responsibility for billing all self-direction component services to Medicaid. However, traditional agency-directed day habilitation and prevocational services previously included in some CSS bundles as "agency purchased services" will no longer be reimbursed by the fiscal intermediary. When a self-direction participant accesses traditional "agency purchased services," the service provider will bill its services directly to Medicaid in same manner as it bills the service for recipients without a self-direction plan.

A number of new Rate Codes have been obtained for the billing of the above services, and communication has been sent by OPWDD to their service providers. Interested parties who have not received information on the Rate Codes directly from OPWDD can contact OPWDD by email to

NY Medicaid Electronic Health Records (EHR) Incentive Program Update

The NY Medicaid EHR Incentive Program provides financial incentives to eligible practitioners and hospitals to promote the transition to EHRs. Providers who practice using EHRs are in the forefront of improving quality, reducing costs and addressing health disparities. Since December 2011, over $615.2 million in incentive funds have been distributed within 15,726 payments to New York State Medicaid providers.

The NY Medicaid EHR Incentive Program Support Team takes great pride in offering providers free high quality program support and services. Don't take our word for it, call us at 1-888-646-5410 to speak with a program analyst for one-on-one support or navigate to the NY Medicaid EHR Incentive Program Website to view our online services.

NY Medicaid EHR

Million Paid.
Incentive Program

Are you

Taking a closer look: NY Medicaid EHR Incentive Program website updated.

Have you seen the updates on the NY Medicaid EHR Incentive Program website at We are pleased to announce the website has been updated to better conform to EHR Incentive Program changes.

Previously, the NY Medicaid EHR Incentive Program website had instructions by Participation Year for both eligible professionals and eligible hospitals. In order to improve the clarity of the guidance, the website now has step-by-step guides broken down into the following categories:

Adopt/Implement /Upgrade (AIU) AttestationMeaningful Use Stage 1 (MU1) AttestationMeaningful Use Stage 2 (MU2) Attestation
Have Questions? Contact for program clarifications and details.

Important Changes in Medicaid Application Submissions for Modified Adjusted Gross Income (MAGI) Applications

This is a reminder to all hospitals, free-standing clinics and individual practitioners about changes to the Medicaid application process for MAGI individuals.

Due to the implementation of the Affordable Care Act, the majority of potential Medicaid beneficiaries are now evaluated through new MAGI eligibility guidelines. These groups include:

  • Pregnant Women and Infants;
  • Children;
  • Parents and Caretaker Relatives;
  • Adults (not pregnant) ages 19-64, not eligible for Medicare.

MAGI applicants are required to apply online at New York State of Health (NYSOH) for Medicaid or other insurance affordability programs, including Child Health Plus and tax credit information, to assist in the purchasing of private health coverage. If there are Certified Application Counselors (CACs) at your service location, they can assist individuals with the online NYSoH application.

If there are no CACs at your service location, general information on how to apply for Medicaid, can be supplied to MAGI applicants, however, no paper applications should be supplied, nor should the applicant be assisted with a paper application. Providers must direct potential MAGI applicants to the website: or to the call center at (855) 355-5777. The website and the call center can provide information about fully trained, face-to-face application assistance with appropriately trained staff (a Navigator or a CAC). The call center can also take a NYSoH application over the phone.

Please note: the Access New York Health Care Applications are not used for MAGI determinations, therefore, do not send Access NY Health Care applications to the NYSoH or to the local departments of social services for MAGI applicants.

Only the following individuals should continue to apply with the Local Department of Social Services (LDSS) using the Access NY Health Care Application:

  • Individuals age 65 and older, who are not parents or caretaker relatives;
  • Individuals who request coverage for community based long term care (CBLTC) services, including Managed Long Term Care, nursing home care and waiver services;
  • Medicare Savings Program (MSP);
  • Individuals age 19 and 20 living alone or age 21 through 64, who are not parents or caretaker relatives or pregnant, who are in receipt of Medicare;
  • Medicaid Buy-In for Working People with Disabilities enrollees (MBI-WPD);
  • Former Foster Care youth;
  • Residents of adult homes;
  • Residential treatment center/community residences operated by the Office of Mental Health (OMH); and
  • Presumptive Eligibility (PE) for Pregnant Women, continue to apply through a provider and are processed by the LDSS.

Questions should be directed to 518-474-9456.


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.