New York State Medicaid Update - February 2019 Volume 35 - Number 3

In this issue …

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New York State Medicaid Doula Pilot Program

This article supersedes the Doula Pilot Program article published in the December 2018 Medicaid Update. The following has changed since the December article:

  • The number of allowable prenatal visits has increased from three to four.
  • The fee for assistance during labor and delivery has increased from $300 to $360.
  • The pilot will launch in Erie County on March 1, 2019 for both fee-for-service (FFS) and Medicaid Managed Care (MMC) members.
  • The pilot will launch in Kings County for both FFS and MMC members at a later date.

On April 23, 2018, New York State (NYS) announced a comprehensive initiative to target maternal mortality and reduce racial disparities in health outcomes. This initiative includes a Medicaid pilot program to cover doulas.

A doula is a non-medical birth coach who provides physical, emotional, and informational support to pregnant clients before, during, and after childbirth. Certified doulas have been shown to improve health outcomes in both mothers and babies.

NYS Medicaid FFS and MMC Plans will launch a pilot program to reimburse doula services. The Medicaid pilot program will be implemented through a phased-in approach in order to ensure access to this new benefit. Phase 1 of the pilot launches in Erie County on March 1, 2019. The Department continues to work with doulas in Kings County to enroll as Medicaid providers and Phase 2 of the pilot will launch in Kings County when provider capacity is reached. The ZIP codes included in the doula pilot are outlined the Doula Provider Manual, which can be found at the following link:

Medicaid will reimburse doulas for providing up to four prenatal visits and four postpartum visits in addition to support during the labor and delivery process.

MMC Billing

Providers participating in MMC should contact the individual health plans to determine how each MMC plan will implement this policy. Questions regarding MMC reimbursement and/or documentation requirements should be directed to the enrollee's MMC plan.

FFS Billing

Providers should check the doula fee schedule for current reimbursement rates. The doula fee schedule can be found at the following link:

General Billing

General Billing instructions can be found at the following link:

Interpretation Services

Reimbursement is available for language interpretation services when necessary, which are provided by a third party. The doula cannot bill for interpretation services provided by her/himself. The doula will bill on behalf of the interpreter and would be responsible for paying the interpreter for services rendered. Additional information about language interpretation services and billing guidance can be found in the Doula Provider Manual at the following link: For an explanation regarding coverage of medical language of interpretation services please see the October 2012 Medicaid Update.

NYS Medicaid Doula Enrollment

Doulas must enroll in NYS Medicaid as independent service providers. When providing services to an MMC Plan member, please follow guidelines specific to the MMC Plan that the member is enrolled. However, all doulas providing services to MMC Plan members must first enroll in NYS Medicaid prior to enrolling in the Plan. Please refer to "Section 1 - Provider Enrollment" of the Doula Provider Manual for specific doula requirements for enrolling in the Medicaid program.

For additional information regarding the NYS Medicaid enrollment process and application forms, please visit the eMedNY web page at: Under the 'Provider List Filter' section, there is a link for "DOULA (Pilot Program)" that includes doula-specific information regarding enrollment.

Medicaid Updates

Updates to the doula policy guidelines are published in the NYS Medicaid program's Medicaid Update which is published monthly. All previously published Medicaid Update editions can be found at:

Provider Communications

Periodically, communications are posted on the Doula Provider Manual section of the eMedNY website. Additional information can be found at:

Doula FFS Fee Schedule

The doula FFS fee schedule can be found at:


The eMedNY LISTSERV® is a Medicaid mailing system that offers providers the opportunity to receive a variety of notifications from eMedNY. The email notifications are provided as a free service to subscribers and may include information on provider manual updates, fee schedules, edit status changes, billing requirements, and many other helpful notices. To sign up for the eMedNY LISTSERV® and receive notification of updates to manuals, communications, and other pertinent information by provider type visit:


Policy questions regarding Medicaid FFS should be directed to the Office of Healthy Insurance Programs, Division of Program Development and Management at (518) 473–2160. Questions regarding Medicaid FFS billing or claims should be directed to the eMedNY call center at (800) 343–9000.

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Maintaining and Updating Your Enrollment Records: A Telephone Number is Required for All Service Addresses

Effective March 1, 2019, applications and change of address forms will be rejected if a telephone number is not associated with each service address. The 21st Century Cures Act requires all state Medicaid programs to develop and maintain a Provider Directory. Required elements of the directory include:

  • provider name,
  • specialty,
  • service address, and
  • telephone number for each service address.

The New York State (NYS) Medicaid program has made a directory of providers enrolled in the fee-for-service program available at: Medicaid providers must immediately notify the NYS Department of Health of any changes to the provider enrollment agreement, including a change in service location and/or ownership. To keep the provider enrollment agreement up to date, use the maintenance forms found on the Provider Enrollment web page at:

Additionally, notification letters are continually sent to providers informing them of the requirement to complete a periodic revalidation of enrollment. Completion of these forms is required for continued enrollment in the NYS Medicaid program. Failure to complete and submit these forms will result in termination of the provider's enrollment.

For questions about the provider directory, maintaining the providers enrollment file, or the revalidation process, please contact the eMedNY call center at 800-343-9000 or via e-mail at:

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New York Medicaid EHR Incentive Program

Distribution to Eligible Professionals & Eligible Hospitals Since the Start of the Program in 2011*
Number of Payments:Distributed Funds:

*As of 1/25/2019

The New York (NY) Medicaid Electronic Health Record (EHR) Incentive Program promotes the transition to EHRs by providing financial incentives to eligible professionals (EPs) and hospitals. Providers who demonstrate Meaningful Use (MU) of their EHR systems are leading the way towards interoperability, which is the ability of healthcare providers to exchange and use patient health records electronically. The goal is to increase patient involvement, reduce costs, and improve health outcomes.

General Announcements

Beginning in Payment Year (PY) 2019 EPs attesting to MU in the EHR Incentive Program are required to meet the measures for MU Stage 3 and must use a 2015 edition of Certified EHR Technology (CEHRT). Additional resources are available on the Office of the National Coordinator for Health Information Technology (ONC) website at: For more information and assistance please contact the NY Medicaid EHR Incentive Program Support Team by phone at(877) 646–5410 , Option 2 or via email at

Greenway Health LLC CEHRT Product Announcement

Greenway Health LLC has identified that certain EHR products are calculating Promoting Interoperability (Meaningful Use) measures incorrectly and are working to resolve these issues. The NY Medicaid EHR Incentive Program understands this may impact EPs planning to attest for 2018 MU. If providers are using any of the Greenway Health LLC products listed on the NY Medicaid EHR Incentive Program website (, please email to receive instructions about the attestation process for 2018 MU.

Meaningful Use Stage 3 Objective and Measures

Meaningful Use Stage 3 establishes eight objectives, each with its own required activity to demonstrate that the EP is meaningfully using CEHRT. CMS calls these activities measures and EPs must either meet the measure(s) for each objective or show that they qualify for an exclusion to the measure. The eight objectives can be found under the Meaningful Use Measures tab at:

Live Event: Navigating the NY Medicaid EHR Incentive Program Website Webinar

On Tuesday, February 12, 2019, the NY Medicaid EHR Incentive Program hosted a live webinar to showcase the program website and its features. Participants were led through typical scenarios to depict where to find specific information on the most commonly searched topics. In addition, the program answered common questions received from EPs and showed attendees where to find answers to those questions on the website. A recording of the webinar and the steps used in the demonstration can be found at:

Regional Extension Centers

New York State (NYS) Regional Extension Centers (RECs) offer support to help providers meet their objectives.

Answers to questions regarding the program and requirements, assistance on selecting and using CEHRT, or assistance to providers on meeting program objectives is available. NYS RECs offer free assistance for all practices and providers located within New York.

RECs were established nationwide to assist primary care providers in the adoption and meaningful use of EHRs. RECs work to optimize the use of EHRs so that providers can become meaningful users, engage in new health care transformation and quality initiatives, and participate in payment delivery reform programs. NYS has two RECs available to provide support services to healthcare providers as they navigate the EHR adoption process and achievement of MU.

New York City Regional Electronic Adoption Center for Health (NYC REACH)

NYC REACH offers support services to providers located inside the five boroughs of NYC. For more information please visit the NYC REACH website at: For questions related to NYC REACH please call 1-347-396-4888 or email

New York eHealth Collaborative (NYeC)

NYeC offers support services to providers located outside the five boroughs of NYC. For more information please visit the NYeC website at: For questions related to NYeC please call 1-646-619-6400 or email

Please Complete the New York Medicaid EHR Incentive Program Customer Satisfaction Survey

Survey responses provide valuable feedback and assist the NY Medicaid EHR Incentive Program in:

  • developing webinars on the Health Information Exchange and the Patient Portal;
  • using the LISTSERV® to send messages that are relevant to EPs (please see details below to subscribe);
  • updating the program website for ease of use; and
  • hosting targeted training webinars such as the Navigating the EHR Incentive Program Website webinar to best assist providers.

The NY Medicaid EHR Incentive Program values provider insight. The survey can be found at:

Webinars and Q&A Sessions

A calendar with the date and times of each webinar listed below, as well registration information, can be found at:

EP Stage 3 Meaningful Use

This webinar provides guidance to EPs about the requirements to attest to MU Stage 3 for the NY Medicaid EHR Incentive Program. Topics covered include:

  • Medicaid Eligibility Criteria
  • Brief Overview of the CMS Regulations
  • MU Objectives and Measures
  • Clinical Quality Measures (CQMs)

Register at:

Meaningful Use Public Health Reporting

This webinar will provide an in-depth review of the MU Modified Stage 2 and Stage 3 Public Health Reporting Objectives, which are available to EPs. The webinar will also include information on how EPs can meet the Public Health Reporting Objective. Register at:

Security Risk Analysis (SRA)

This webinar provides guidance to EPs about the SRA requirements to meet MU Objective 1: Protect Patient Health Information. Topics covered include:

  • MU Objective 1: Protect Patient Health Information
  • SRA Toolkit
  • Safety Measures to Consider
  • Common Considerations and Creating an Action Plan

Register at:

NY Medicaid EHR Incentive Program Post-Payment Audit Education Series

NY Medicaid EHR Incentive Program has produced a series of Post-Payment Audit Educational tutorials to help you prepare in the event of a post-payment audit. Links to each of the below tutorials can be found at:

  • Tutorial 1: Audit Process Overview
  • Tutorial 2: Understanding the Audit Notification Email – Adopt, Implement, Upgrade (AIU)
  • Tutorial 3: Understanding the Audit Notification Email – Meaningful Use
  • Tutorial 4: Completing the Medicaid Patient Volume Spreadsheet
  • Tutorial 5: Submitting Documentation

Visit the Website

Additional information about the NY Medicaid EHR Incentive Program can be found at: Please use the links provided below to go directly to the web page for the following categories:


The EHR Incentive Program has a dedicated support team ready to assist. Please contact the program at: 1-877-646-5410 (Option 2) or via email at:

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Reporting of the National Drug Code is Required for all Fee-for-Service Physician-Administered Drugs

Effective April 1, 2019, in an effort to improve claims accuracy and completeness, an accurate National Drug Code (NDC) must be reported for all physician administered drugs billed on the Institutional claim form. Drugs obtained at the 340B price, indicated by the UD modifier, will also require the NDC. There will be no exceptions to this policy.

The eMedNY billing system will enforce this requirement effective July 1, 2019. This means that starting July 1, 2019, for any physician-administered drug billed under Ambulatory Patient Groups (APG) that does not include an accurate NDC, the line will not pay. Note, all APG fee schedule drugs will still require providers to code the number of units and acquisition cost for the claim line to pay.

Questions regarding Medicaid FFS policy should be directed to the Office of Health Insurance Programs, Division of Program Development and Management at(518) 473–2160 . Billing procedure questions should be directed to the eMedNY Call Center at 800- 343-9000. Questions regarding Medicaid Managed Care (MMC) policy requirements should be directed to the enrollee's MMC plan.

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New HCPCS Code to be Used When Billing for Voretigene Neparvovec-rzyl (LUXTURNA™)

Effective April 1, 2019, hospital claims for voretigene neparvovec-rzyl (brand name LUXTURNA™) should be billed to Medicaid using Healthcare Common Procedure Coding System (HCPCS) code "J3398". Hospitals submitting claims for LUXTURNA™ for the period April 1, 2018 through March 31, 2019 should bill using HCPCS code "J3590", unlisted biologic.

Per New York State Medicaid policy, drugs administered by subcutaneous, intramuscular, or intravenous methods are covered when provided for Federal Drug Administration (FDA)-approved indications and those recognized off-label indications listed in the drug compendia. Additional information regarding coverage criteria and billing guidelines for LUXTURNA™ are outlined in the March 2018 issue of the Medicaid Update.


  • Medicaid fee-for-service (FFS) coverage and policy questions may be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management at (518) 473–2160 .
  • Medicaid Managed Care (MMC) general coverage questions may be directed to OHIP Division of Health Plan Contracting and Oversight at: or (518) 473–1134 .
  • MMC reimbursement and/or billing requirement questions should be directed to the enrollee's MMC plan.
  • FFS claim questions should be directed to the eMedNY call center at (800) 343–9000.

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Credentialed Alcoholism and Substance Abuse Counselor Now Approved for Billing Within an Article 28 Setting for DSRIP Project 3.a.i and Integrated Outpatient Services

Effective January 1, 2019, an Article 28 facility that has been granted Integrated Outpatient Services (IOS) or Delivery System Reform Incentive Payment (DSRIP) Project 3.a.i authority may bill for services rendered by a Credentialed Alcoholism and Substance Abuse Counselor (CASAC). The CASAC must be properly supervised and medically directed. Clinics may bill for screening, individual and/or group counseling and other services, as applicable. For detailed guidance on permitted CASAC functions, please see the following link:

Federally Qualified Health Centers (FQHCs) that are integrated service providers may bill the Prospective Payment System (PPS) rate for CASAC services. If provided in a group setting, rate code "4011", FQHC Group Psychotherapy, should be billed.

Effective September 1, 2019, CASAC providers rendering services in an Article 28 setting will need their own individual National Provider Identifier (NPI). Until September 1, 2019 CASAC providers may use the Office of Alcoholism and Substance Abuse Services (OASAS) unlicensed practitioner ID number "02249145" consistent with OASAS policy. After September 1, 2019 billing will only be allowed using an NPI assigned to the specific provider rendering the service.


  • Medicaid fee-for-service (FFS) policy questions may be directed to the Office of Health Insurance Programs (OHIP), Division of Program Development and Management at (518) 473–2160.
  • Medicaid Managed Care (MMC) general coverage questions may be directed to OHIP Division of Healthcare Planning Contracting and Oversight at (518) 473–1134 or at
  • MMC reimbursement and/or billing requirements questions may be directed to the enrollee's MMC plan. The MMC directory by plan can be found on the New York State Department of Health's web site at:

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Reminder: Pharmacy Provider Enrollment is Required

Federal Requirement

As previously stated in the January 2018 Medicaid Update, Section 5005(b)(2) of the 21st Century Cures Act and Section 1932(d) of the Social Security Act requires all Medicaid pharmacy providers, including Medicaid Managed Care (MMC) network providers, to be enrolled with State Medicaid programs. This requirement also applies to all other enrollable provider types who wish to participate in the New York State (NYS) Medicaid program.

NYS Medicaid Pharmacy Enrollment

NYS Medicaid enrolls open door, full service, established community pharmacies located in New York under Category of Service (COS) code "0441" and according to the needs of the Medicaid member population and the availability of services from currently enrolled providers. A full-service pharmacy is one that dispenses a full range of prescription drugs and supplies (such as diabetic supplies, i.e., lancets and glucose test strips), has an active State registration, and is open and dispensing medications for one year or more.

Pharmacies may enroll in Medicaid as a billing provider (also known as a fee-for-service (FFS) provider) or as a Managed Care Only (non-billing) provider. Fee-for-service pharmacies require Medicare enrollment. Managed Care Only enrolled pharmacies are not required to enroll in Medicare. NYS Medicaid does not enroll out of state, mail order, compounding, infusion, Long Term Care (LTC), or specialty pharmacies as FFS billing providers unless the NYS Department of Health (DOH) determines an unmet need for such pharmacy enrollment. MCO plans determine their own networks.

All Medicaid enrolled pharmacies are subject to the Federal screening requirements and must further comply with all applicable federal and state laws and regulations.


Pharmacy providers who have not submitted their enrollment applications must do so immediately. Managed Care Organization (MCO) network pharmacy providers who do not enroll are subject to termination. Currently MCOs are evaluating their network to determine which pharmacy providers have not enrolled and contacting them about the enrollment requirement.


The following resources are available on the NYS DOH provider enrollment website at:

  • Provider enrollment forms and instructions
  • Medicaid FFS active provider listing (updated monthly)
  • List of NYS enrollable provider types
  • Frequently Asked Questions (FAQs)
  • PowerPoint presentations


Please contact the eMedNY call center at 800-343-9000 or via e-mail at

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Reminder: Medicaid Billing for Vaccines for Children

Vaccines for Medicaid members under 19 years of age, both fee-for-service (FFS) and Medicaid Managed Care (MMC), are provided free of charge by the Vaccines for Children (VFC) program. New York State (NYS) Medicaid should never be billed for the cost of any vaccine for persons under 19 years of age when it is available through the VFC program. This applies to both FFS and MMC members. Pharmacies that bill Medicaid for the cost of vaccines available through VFC are subject to recovery of payment.

Note: Although pharmacists may immunize patients 18 years of age for pneumococcal, meningococcal, tetanus, diphtheria, and pertussis vaccines, as well as influenza vaccine, this population is covered by the VFC program. All such vaccines for Medicaid covered patients 18 years of age are available for free through the VFC program.

Pharmacies that are not enrolled in the VFC program to obtain free influenza vaccine or are unable to obtain VFC-available vaccines, other than influenza for age 18, may choose to provide vaccines for members under 19 years of age at no charge to the member or Medicaid program, and be reimbursed an immunization administration fee of $17.85 by NYS Medicaid.

For guidance on the VFC program please refer to the NYS VFC Program web site at: For guidance on Medicaid pharmacy billing for immunizations please refer to the NYS Medicaid Program Pharmacists as Immunizers Fact Sheet available at:

Billing Instructions for FFS

Contact the eMedNY call center at (800) 343–9000 for questions regarding FFS billing.

Billing Instructions for MMC

Contact the plan. Information for the individual plans can be found at:

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The Medicaid Update is a monthly publication of the New York State Department of Health.

Andrew M. Cuomo
State of New York

Howard A. Zucker, M.D., J.D.
New York State Department of Health

Donna Frescatore
Medicaid Director
Office of Health Insurance Programs