New York State Medicaid Update - October 2020 Volume 36 - Number 15

In this issue …

Medically Fragile Children's Private Duty Nursing Providers Directory Goes Live

An online Private Duty Nurse (PDN) Directory for Medically Fragile Children (MFC), referred to as "the Directory", is now available on the New York State Department of Health (DOH) web site at: The New York State Medicaid Program now provides a list of fee-for-service (FFS) PDNs enrolled in the Directory. The purpose of the Directory is to ensure adequate access to PDN services by promoting the availability and ensuring delivery of PDN services for MFC with Medicaid up to the age of 23.

PDNs and agencies listed in the Directory indicate they are willing to accept inquiries to provide care to MFC. Providers listed in the Directory are expected to respond to all inquiries received. In addition, PDNs and agencies enrolled in the Directory will receive the enhanced rate of reimbursement for Medicaid members up to the age of 23. More information about the benefits of enrolling in the Directory can be found at:

Questions and Additional Resources:

  • Directory enrollment information is available at:
  • Enrollment and/or billing questions should be directed to the eMedNY Call Center at (800) 343‑9000
  • FFS prior approval questions should be directed to the Office of Health Insurance Programs (OHIP) Call Center at (800) 342‑5000, or via email at or
  • Program updates and news will be posted on the eMedNY website at: and in upcoming Medicaid Update editions.

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Download the Free COVID Alert NY App and Help Stop the Spread of COVID-19

COVID Alert NY is the official New York Exposure Notification System app created by the New York State Department of Health in partnership with Google LLC and Apple Inc.

The free smartphone app became available for download for users 18 years of age and older on the Google Play and Apple App Stores on October 1, 2020. After downloading the COVID Alert NY app, users will be able to use their smart phone as a resource in the fight against COVID-19 by receiving exposure alerts without compromising privacy or personal information. COVID Alert NY is part of New York's Contact Tracing Program and will enhance efforts to contain the spread of COVID-19 as well as keep New Yorkers app users informed.

COVID Alert NY helps users receive timely updates on COVID-19.

COVID Alert NY alerts app users if their phone has come into close continuous proximity — within 6 feet for at least 10 minutes — with a phone of someone who has used the app to indicate that they are positive for COVID-19. Knowledge of a potential exposure informs users to immediately self-quarantine and to seek testing, thereby reducing the potential exposure risk to their family, friends, neighbors, co-workers and others. COVID Alert NY uses the Bluetooth ® technology to exchange randomly generated codes for two phone's contact, with enabled Exposure Notification Service technology developed by Apple Inc. and Google LLC.

COVID Alert NY protects user privacy and personal information:

  • The app does not track user location or movement, use GPS, location services, or any movement or geographical information.
  • The app will never collect, transmit, or store personal information from users and is completely anonymous.
  • Users must explicitly choose to turn on exposure notifications – and can opt to turn it off at any time.

Additional information on the COVID Alert NY app can be found at:

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New York State Medicaid Electronic Visit Verification (EVV) Program and Deadlines for NYS Medicaid-funded Providers to Select and Implement an EVV System

Electronic Visit Verification

Electronic Visit Verification (EVV) systems verify when and where visits occur to provide health care services. These systems help ensure timely service delivery, provide tools for service gap reporting and monitoring, and aid in prevention of fraud, waste and abuse. In some cases, they may also reduce the administrative burden associated with paper time sheet processing and scheduling.

The 21st Century Cures Act (the Cures Act), which was signed into law on December 13, 2016, mandates that states require the use of an EVV system for all Medicaid-funded personal care services (PCS) and home health care services (HHCS) that require an in-home visit by a provider. The following are the New York State (NYS) compliance deadlines established by the Cures Act:

  • PCS – 1/1/2021*
  • HHCS – 1/1/2023

* NYS received a Good Faith Effort Extension, extending the deadline from 2020 to 2021 for PCS.

Those Subject to EVV

The Cures Act requires that any NYS Medicaid-funded PCS and HHCS that begin or end in the home be subject to EVV. Any provider billing Medicaid for personal care services that begin or end in the home for the following services is subject to EVV:

  • 1905(a)(24) State Plan Personal Care Benefit
    • Consumer Directed Personal Assistance (CDPA)
    • Personal Care Assistance (PCA I and II)
  • 1915(c) Home and Community Based Services (HCBS) waivers
    • Children's Waiver
    • Nursing Home Transition and Diversion (NHTD) waiver
    • Traumatic Brain Injury (TBI) waiver
    • Office for People with Developmental Disabilities (OPWDD) comprehensive waiver
  • 1115 Demonstration
    • CDPA
    • PCA I and II

More information about the applicable services can be found in the EVV Applicable Billing Codes document available at:

NYS EVV Choice Model

After carefully considering input from NYS Medicaid beneficiaries, family caregivers, providers, advocates, partner agencies and EVV solution providers, NYS has elected to proceed with the Choice Model for implementing EVV. More information about this decision is available in the "New York State Model Decision" section of the NYS EVV web site:

To implement the Choice Model, the NYS Department of Health (NYSDOH) is requiring that providers of NYS Medicaid-funded PCS select and implement an EVV system that meets the requirements of the 21st Century Cures Act by January 1, 2021. Providers of NYS Medicaid-funded HHCS are required to select and implement such systems by January 1, 2023. In addition, providers and Fiscal Intermediaries (FIs) are required to attest to their compliance with these requirements and to submit EVV data to NYSDOH, that will be aggregated for reporting and audit purposes. Providers that fail to timely comply with these obligations are at risk for their claims for services being denied and/or the issuance of an overpayment demand letter followed by recoupment procedures. Providers may also be subject to penalties.

NYS EVV Policies and Attestation

Information about NYS EVV requirements, policies, and the required EVV Attestation can be found within the EVV Program Guidelines and Requirements document posted to the EVV web site at: The link to complete and electronically sign the EVV Attestation is forthcoming and will be provided, once available, via the EVV LISTSERV® and EVV web site.

It is vitally important that providers join the NYS EVV LISTSERV® to remain up to date on additional policy guidance and attestation requirements. Providers and other stakeholders can subscribe to the NYS EVV LISTSERV® at: Include the following in the body of the email sign-up request: "SUBSCRIBE EVV-L FirstName LastName".

Submitting EVV Data to the NYS Data Aggregator

NYSDOH is implementing statewide EVV data aggregation through eMedNY. Providers must ensure that required data elements are submitted to the EVV agregator (eMedNY) in the specified format in order for the record to be successfully passed into and be stored in the eMedNY system. Providers subject to EVV should review the EVV Technical User Guide ( and the Interface Control Document (ICD) ( to learn how to successfully submit EVV Data to NYSDOH. The Electronic Visit Verification User Guide details how to get started with submitting the EVV record and the ICD contains the technical specifications required to create the EVV record.

NYSDOH has scheduled multiple public opportunities for stakeholder engagement, including EVV Technical Assistance calls. Technical Assistance Calls aim to coordinate implementation of the NYS EVV Choice Model. Calls focus on detailed statewide aggregator requirements, definitions of EVV data needs, submission interface, and testing collaboration. A calendar of upcoming EVV Technical Assistance calls, as well as information on how to register, can be found on the EVV web site at:

Questions and Additional Resources

More information about EVV can be found at the following links:

Questions should be directed via email to

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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 10/5/2020

Through the New York (NY) Medicaid Electronic Health Record (EHR) Incentive Program, eligible professionals (EPs) and eligible hospitals (EHs) in New York who adopt, implement, or upgrade certified EHR technology (CEHRT) and subsequently become meaningful users of CEHRT, can qualify for financial incentives. The Centers for Medicare and Medicaid Services (CMS) is dedicated to improving interoperability and patient access to health information. The NY Medicaid EHR Incentive Program is a part of the CMS Promoting Interoperability Program but will continue to operate under the current name of NY Medicaid EHR Incentive Program.

Payment Year (PY) 2020 Soft Opening Period

As the timeframes between PYs become shorter, providers who are ready to attest will be given the opportunity to do so before the official PY opening, by means of a process called a soft opening. The soft opening will function in the same way an official opening does, with remediation and review processes that mirror what providers are used to. The main differences are that soft openings occur earlier in the year, and because of this the Meaningful Use (MU) criteria must be met sooner than normal if a provider wishes to attest during this period.

The PY 2020 Soft Opening period is happening now. Providers who have met the attestation criteria are able to complete their attestations in the Medicaid EHR Incentive Program Administrative Support Service (MEIPASS). Providers may login to the MEIPASS system at: Providers are encouraged to gather and submit their attestation data during this time. The soft opening period will continue until the official opening begins on January 1, 2021.

PY 2020 Pre-Validation Period

If EPs or a group of EPs have already selected their reporting period and calculated their patient volume prior to the MEIPASS attestation system being opened for the PY, the EPs are able to complete a Pre-validation. A Pre-validation allows providers to submit their patient volume data for review and approval ahead of attestation and can allow the EPs to advance through the review process more quickly once MEIPASS begins accepting attestations.

Pre-validations for PY 2020 will be accepted from September 14, 2020 through December 14, 2020. If providers would like to take advantage of this service and avoid patient volume remediation during the official or soft opening attestation periods, they must begin the process of finding a suitable Medicaid patient volume reporting period. To submit a Pre-validation, providers should select the Patient Volume Reporting period and fill out the appropriate Pre-validation form with the data for that period. Forms can be found on the Document Repository page of the EHR web site at:

Check Provider Participation

At minimum*, a provider must have completed and received an incentive payment for one PY in 2016 or earlier to participate for future years. Providers uncertain about their participation status are encouraged to reach out to the NY Medicaid EHR Incentive Program support team for assistance. Program participation status can be verified and reviewed using the provider's National Provider Identifier (NPI) and may assist in determining a provider's ability to attest in PY 2019-2021. Providers who wish to check their participation status should contact the support team at (877) 646‑5410 (Option 2) or via email at

* Providers must also meet all other relevant program requirements and metrics to be eligible to participate in the NY Medicaid EHR Incentive Program.

LISTSERV Communications

Additional information and program changes are announced periodically, especially as the program begins its final years. The NY Medicaid EHR Incentive Program uses a LISTSERV messaging system to quickly communicate any changes or updates and recommends that providers and administrators subscribe in order to best be kept up to date. Information and instructions on how to subscribe can be found on the NY Medicaid EHR Incentive Program LISTSERV webpage at: Providers who experience any difficulty when attempting to subscribe should contact the support team for assistance.


The NY Medicaid EHR Incentive Program will host quarterly Program Discussion Webinars on a variety of topics identified by support staff and the provider community. Providers who would like to have a particular topic discussed should submit requests by completing the Program Satisfaction Survey at: Schedule and registration information for all webinars, including Program Discussions, Stage 3, Security Risk Analysis, Public Health Reporting, Patient Engagement, and Health Information Exchange can be found at:

New York State (NYS) Regional Extension Centers (RECs)

NYS RECs offer free support to help providers achieve Meaningful Use of CEHRT. Support provided by NYS RECs includes, but is not limited to, the following:

  • Answers to questions regarding the program and requirements
  • Assistance on selecting and using CEHRT
  • Help on meeting program objectives

NYS RECs offer free assistance for all practices and providers located within New York.

For Providers Located: Inside the five boroughs of NYC Outside the five boroughs of NYC
Phone: (347) 396‑4888
MU Direct:
New York eHealth Collaborative (NYeC)
Phone: (646) 817‑4101
MU Direct:


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

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

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

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Notification to Providers Regarding Changes to Compliance Certification Requirements

Pursuant to New York State Social Services Law (SOS) §363-d, providers are required to certify to the Department upon enrollment in the Medicaid program that they are satisfactorily meeting the requirements of SOS §363-d. Furthermore, compliance with the requirements of SOS §363-d is a condition of payment from the Medicaid program.

Effective immediately, providers are no longer required to complete the annual December certification, commonly referred to as the "SSL Certification," using the form located on the Office of the Medicaid Inspector General's (OMIG) website. Instead, a provider adopting and maintaining an effective compliance program will now record (attest to) this as part of their annual "Certification Statement for Provider Billing Medicaid." This annual certification shall occur on the anniversary date of the provider's enrollment in Medicaid. Providers can find their anniversary dates on their initial Medicaid enrollment welcome letters and reminders are mailed to providers in advance of this annual date for compliance certification.

All providers who are subject to the mandatory compliance program requirements in SOS §363-d will be impacted by these changes.

Questions regarding this notice should be directed to OMIG's Bureau of Compliance at (518) 408‑0401 or via email at

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Amendment to Third Party Health Insurance Program Requirements

The Fiscal Year 2020-2021 (FY21) enacted budget included amendments to New York State Social Services Law (SOS) §367-a(2)(b) and Insurance Law (ISC) §3212(e)(3)(C). The intent of these amendments is to clarify, but not limit, the previously existing prohibition on administrative denials by liable third parties.

Federal and State law prohibit liable third parties from denying Medicaid third party liability claims for administrative or procedural reasons, including but not limited to filing limits, claim format, failure to present card at point of service, retrospective reviews, or for failure to obtain prior authorization. Some carriers have erroneously denied claims for lack of prior authorization, resulting in the inappropriate transfer of liability for such claims to Medicaid. If Medicaid deems a service medically necessary and appropriate, the responsible third party must accept that determination and pay the claim. The only reasons a carrier should deny the claim is if a person was not eligible or if the service rendered was not included as a benefit. If providers receive inappropriate denials, they should appeal those decisions with the carrier based on this guidance.

In addition to the clarification on prohibited denials of Medicaid third party liability claims, the amendment to SOS §367-a(2)(b) establishes a Medicaid prompt payment standard. Upon receiving written notice of the claim for payment for healthcare services provided to a recipient of Medicaid who is covered by the third party, that liable third party must respond to the request for payment within 60 calendar days and shall not charge a fee to process or adjudicate a claim.

The Medicaid prompt payment standard will be in effect for written notices sent by the Department, its representative, or subrogee after April 1, 2020.

Questions regarding this notice should be directed to OMIG's Bureau of Third Party and Payment Oversight at

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Notification to Providers of Requirement to Attach Explanation of Benefits from Third-Party Payors to Medicaid Claims

To ensure that New York State (NYS) Medicaid is the payor of last resort when a Medicaid recipient is eligible for Medicare or has other third-party insurance benefits, providers must first bill Medicare or the other third-party insurance for services prior to submitting a claim to Medicaid. In the coming months, providers will be required to attach an Explanation of Benefits (EOB) for fee-for-service (FFS) claims when submitting a claim to Medicaid for services rendered to a recipient who is also eligible for Medicare or has other third-party coverage. If an EOB is not submitted with the claim, the claim will be denied. The Office of the Medicaid Inspector General (OMIG) will be providing additional information regarding the timeline and requirements for implementation of this initiative.

Please Note: Pharmacy claims, Medicare crossover claims, and non-covered procedure codes identified by NYS Medicaid are not subject to this requirement.

Questions regarding this notice should be directed to OMIG's Bureau of Third Party and Payment Oversight at Additional information will be provided in future Medicaid Update editions.

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Attention: Pharmacies Durable Medical Equipment, Prosthetics, Orthotics and Supply Providers, and Prescribers That are Not Enrolled in Medicaid Fee-for-Service

Beginning on April 1, 2021, per the State Fiscal Year (SFY) 2020-21 enacted budget, the pharmacy benefit for New York State (NYS) Medicaid Managed Care [Mainstream, Health and Recovery Plan (HARP) and Human Immonodeficiency Virus (HIV)-Special Needs Plan (SNP)] members will be transitioned to the NYS Medicaid fee-for-service (FFS) Pharmacy Program. Pharmacies and Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) providers must be enrolled in the FFS program as billing providers in order to continue to serve Medicaid Managed Care members. Information regarding DMEPOS that are subject to the carve-out can be found at:

Additionally, prescribers that are initiating prescriptions or fiscal orders for drugs or supplies subject to the carve-out will need to enroll. Prescribers can choose either to enroll as "Individual Billing Medicaid" (also known as Individual Biller) FFS billing providers or as Ordering/Prescribing/Referring/Attending (OPRA) non-billing FFS providers, in order to continue to serve NYS Medicaid Managed Care members. The Provider Enrollment Guide is found at:

The NYS Department of Health provider enrollment website (, contains the enrollment application, instructions, and forms necessary to enroll. Pharmacies and prescribers can verify current FFS enrollment status by visiting the Medicaid Enrolled Provider Listing at: Prescribers can additionally verify current enrollment status by using the tool found at: Enrollment information is listed below.

Pharmacies and DMEPOS Providers

Providers not enrolled as FFS billing providers or currently enrolled as NYS Managed Care non-billing providerson the Medicaid Enrolled Provider Listing and labeled as MCO (Managed Care Only) providers in the "Medicaid Type" field need to enroll as FFS billing providers, by visiting the applicable enrollment application:

When completing the application, providers must select the "Billing Provider" checkbox found on the top of page two of the application.

Important: Medicare enrollment as Participating Providers (accepting payment for Part B) is prerequisite in order to qualify for pharmacy or DMEPOS enrollment as billing providers in NYS Medicaid.

  • It is recommended that providers begin the Medicare enrollment process for their pharmacies or DMEPOS immediately in order to mitigate delays in enrolling.
  • Medicare enrollment is required prior to issuance of NYS Medicaid Provider Identification Numbers.


If prescribers are not enrolled as FFS Individual billing prescribers or OPRA prescribers and want to continue to prescribe for NYS Medicaid Managed Care members, prescribers will need to enroll as Individual Billers or as OPRA providers by visiting:

  • On the right side of the screen, prescribers navigate to the applicable provider type to print the instructions and enrollment form. The provider type is the same as the provider's licensed profession.
  • Important: Medicare enrollment is not required for Nurse Practitioners, Physicians Assistants, Dentists or Physicians. Other providers, who may be allowed to order drugs and DMEPOS items, are required to enroll in Medicare as a Participating Provider (accepting payment for Part B) as prerequisite in order to qualify as Individual Billing providers in NYS Medicaid. Presrcibers must review their provider type as found on the provider index ( for specific Medicare requirements.
  • If prescribers were previously enrolled as NYS Medicaid providers and NYS Medicaid enrollment has lapsed (i.e., providers are no longer actively enrolled), prescribers can keep their original Provider Identification Numbers (also known as MMIS IDs) by indicating "Reinstatement" on their applications.

All Providers

Completed applications will be reviewed by the NYS Department of Health. If more information is needed to process the applications, providers will be notified with details. Incomplete applications will not be processed. Once the applications are processed, written determinations will be sent to providers. If applications are approved, letters will be sent to providers containing the providers' MMIS ID Numbers, enrollment effective dates (when services may be provided to enrolled clients), and other information related to enrollment. Submission of an application is not a guarantee of enrollment in the NYS Medicaid program.

Additional Information and Questions:

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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