DOH Medicaid Update January 1999 Vol.14, No.1

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The Year 2000 (Y2K) issue continues to be New York Medicaid's highest system priority. We are making good progress and all Medicaid related systems for which we are directly responsible are scheduled to be Y2K ready by early 1999. We have attempted to keep the impact of our Y2K activities as minimal as possible for providers and vendors. We feel this has been accomplished and most providers will see no change in claims processing and billing due to Y2K systems changes. Following is a Y2K status of New York Medicaid's major computer systems and Y2K related information concerning these systems.

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Claims Processing

Computer Sciences Corporation (CSC), the Medicaid fiscal agent that processes Medicaid claims, will use systematic logic within the Medicaid Management Information System (MMIS) to default the century as necessary. For billers, claiming specifications and formats will remain the same as currently used. The only exception to this methodology is the addition of Version V billing format. Version V is similar to Version IV but is Y2K ready, with the use of eight character date fields. ONLY hospitals and clinics currently use Version IV for Medicaid billing. They will be able to use Version IV or Version V in the future (even after January 1, 2000). The new Version V format is available from CSC at this time. To obtain the Version V specifications, providers may call CSC's Provider Relations Institutional Unit at 1-800-522-1892 or (518) 447-9810.

Remittances

New York State Medicaid remittances will remain the same as they currently are. Paper remittances will not carry the century but only the two character year. Tape remittances will also remain the same. There are currently two remittance formats in use, a 300 character format and a 340 character format. Only the 340 character format includes century in the date fields. All new providers currently receive the 340 character remittance. If you would like to switch to the 340 character remittance, or simply get the specifications to review, please call CSC's EMC Control Unit at (518) 447-9256.

PACES

PACES is an electronic claiming system developed by CSC for use in New York Medicaid billing. The PACES system is Year 2000 ready, providing the user with the ability to enter the century in all date fields. PACES generates claim output which is submitted to CSC in various formats. The claim formats do not carry the century as part of the date information, but systematic logic within the MMIS system will default the century component of date related information. The PACES requires no user changes for billing into the Year 2000.

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Deluxe Electronic Payment Systems (DEPS) administers the Electronic Medicaid Eligibility Verification System (EMEVS) for the New York Medicaid program. There are five methods of accessing EMEVS data. The various methods are listed below along with their Year 2000 status and what needs to be done by DEPS and Medicaid providers to ensure Y2K readiness. Other EMEVS claims processing systems are also discussed in relation to Y2K.

Verifone Trans 330

The Trans 330 eligibility verification terminal is the standard EMEVS device used by many providers. All the Trans 330s must migrate to the latest, Y2K ready software (version 0140). Currently, nearly one-half of these devices used by providers have the version 0140 software. If the provider needs to know what version they have, they can simply unplug the device. When it is plugged back in, the second display (prior to the date and time) will say "NYM0140". Providers can call the EMEVS Help Desk for assistance and instructions for getting the new version 0140 software downloaded. The telephone number is 1-800-343-9000. This download of the 0140 software will be done over the telephone lines with limited effort on the provider's part. In the near future, DEPS will contact all providers still using the old software and arrange for the upgrade to the version 0140 software.

PCs Using EMEVS Software

Providers using EMEVS software on their PCs to access EMEVS information will need to upgrade to Version 13 for Y2K. Currently, over 60% of the EMEVS PC traffic is on Version 13. The latest release of the New York State Eligibility PC software is called Version 13, release 4.1.0.5. A copy of release 4.1.0.5 has been sent to all providers who are registered users of the State software.

CPU Link to EMEVS

CPU providers will need to upgrade to Version 13 to be Y2K compliant. In August, 1998, DEPS sent a letter to all CPU users that have not yet converted to Version 13. DEPS will assist the CPU providers in upgrading to the CPU EMEVS format (Version 13).

Batch Authorization System

Providers that use the Batch Authorization system will also need to upgrade to Version 13. DEPS sent the new batch specifications to all Batch Authorization providers in December, 1998.

EMEVS Telephone Verification

EMEVS information is also available through telephones. This method of inquiry will remain the same as it is currently done. There is no need for providers to do anything. EMEVS will make any necessary modifications internally.

Other EMEVS Systems

In addition to Medicaid eligibility verification, the EMEVS system also performs several other functions for providers. Drug Utilization Review (DUR ), service authorizations, some prior approvals, and provider post and clear transactions are provided through the EMEVS system. We expect these functions to be performed the same as they currently are by the provider. Any necessary Y2K changes will be made internally.

In summary, New York Medicaid and it's contractors have made Y2K the highest system priority. We are currently near full Y2K readiness for all our Medicaid systems and will be fully ready in early 1999. Y2K systems testing has been going on for many months and will continue into 1999. Our early Y2K readiness will allow us sufficient time to test our systems thoroughly. We will keep you apprised of our Y2K status through articles in the Medicaid Update. Also, any pertinent provider information concerning Y2K and New York Medicaid will be printed in the Medicaid Update. However, we urge all providers to take all necessary actions to assure their system is Y2K compliant.

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The provider enrollment "density" criteria applied to pharmacy applicants for New York City has been modified effective January 1, 1999. The changes consider the health care needs of Medicaid clients and expanded health services offered by the pharmacy industry. The new density criteria defines the number of pharmacies within a specified geographic area, based on need for services to clients. The revised criteria takes into consideration the number of pharmacies within a zip code, and client need as evidenced by volume of claims. Zip codes are stratified into low (0-10 pharmacies), medium (11-15 pharmacies) and high (16 and above pharmacies) density. Next, each zip code is further delineated according to high and low claim usage (measured against the borough average per pharmacy). In circumstances where adequate pharmacy services are already in place, new applicants will be considered only by providing unique services or demonstrating special circumstances. In these cases, exemptions may be approved.

The new criteria has been reviewed and discussed with representatives from both the chain and independent pharmacy associations listed below.

These associations have been provided listings of the five boroughs of New York City containing the number of pharmacies and claims information for each zip code.

This information can also be obtained by contacting:

The statistics will be updated and distributed semiannually.

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SYNAGIS is a new intramuscular injection used to immunize certain high-risk children, especially those with histories of prematurity and bronchopulmonary dysplasia, against respiratory syncytial virus, (RSV), the leading cause of bronchiolitis and pneumonia in infants. The RSV season typically starts in November and lasts through April. SYNAGIS injections should be initiated at the start of, and then administered monthly, throughout the RSV season.

The Medicaid Program recommends the following guidelines for identifying children who should be considered for RSV immunization:

• Children under two years of age with chronic lung disease (CLD), formerly designated as bronchopulmonary dysplasia (BPD), who require medical therapy such as oxygen, bronchodilators, diuretics, or steroids at the onset of the RSV season.
• Infants age 6 months or less at the onset of the RSV season who were born at 30 weeks gestation or less.
• Infants age 12 months or less at the onset of the RSV season who were born at 28 weeks gestation or less.
• Selected other infants under six months of age at the onset of the RSV season who were born at 30-35 weeks gestation with additional risk factors which include, but are not limited to, history of difficult neonatal intensive care course, especially prolonged intubation.

Synagis is contraindicated in children with cyanotic congenital heart disease.

The outcomes of SYNAGIS utilization will be reviewed by the Medicaid Program.

Medicaid reimburses for SYNAGIS when billed by Medicaid-enrolled physician and pharmacy providers. It can be administered in the home by Medicaid-enrolled Home Health Care provider professional staff. Similarly, it can be administered by pediatric long term care facility licensed caregivers. Physician providers may bill on a paper claim under code 90749 (unlisted immunization procedure), attaching a copy of the invoice to the claim. Insert the acquisition cost plus a two dollar ($2.00) administration fee in the "amount charged" field on the claim form. Pharmacy providers should enter the SYNAGIS NDC number into the on-line billing system as they would for any prescription pharmaceutical. Please note the following dispensing limits (edits) which have been programmed into the on-line billing system which pharmacy providers use:

a) effective date of November 1,1998.
b) age of 24 months or under at the onset of RSV season.
c) maximum of one dose, up to 200 mg., per patient per month.

For further information on Medicaid billing for SYNAGIS, please contact the following:

Physician providers: (518) 473-5956
Pharmacy providers: (518) 486-3209

For further prescribing information on SYNAGIS, please refer to Pediatrics, November 2, 1998, volume 102, pages 1211-1216. The New York State district of the American Academy of Pediatrics may be reached at (212) 305-2867.

Prepared by Richard Propp, M.D. and Anne Budin, R.N. of the New York State Department of Health, Office of Medicaid Management. We express our appreciation to the neonatologists, pediatricians, and pediatric infectious disease consultants who contributed to this article.

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These instructions apply only to those providers who are named plaintiffs in the above-cited action.

This article will:

• remind providers that the submission of edit corrections ended with the December 1998 purge run - except as noted in the following;

• remind providers of the special steps taken by the Department in the September, October and December payment cycles to resolve Edit 162 and Edit 140 failures and, of the final error correction opportunity that had been created; and

• remind providers of the limited remaining opportunities to submit documentation to permit adjudication of claims pended for Edits 127, 262 or 1281.

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1. The Department has previously informed you that the opportunity for submission of edit corrections of lawsuit claims ended with the last scheduled purge run for calendar year 1998.
2. The Department has also informed you that it had devised and implemented a special matching process against paid claims history not available to the MMIS fiscal agent, as a final effort to resolve Edit 140 and Edit 162 claims. Claims for which a match had been found were then resubmitted by the fiscal agent. The result was that many of the existing failed claims were then able to pass those edits starting in cycle 093. Providers should check remittances for cycles 093, 106 and 112 to determine results for their individual claims. Most of the special matches occurred in cycles 093 [primarily Edit 140 claims and some Edit 162 claims] and 106 [primarily Edit 162 and some Edit 140 claims].
   While most of the resubmitted matched claims that had previously failed either Edit 140 or Edit 162 paid in the above cycles, some others either pended or denied for other reasons. Providers who had claims that had failed either Edit 140 or Edit 162, and that subsequent to the special processing described above, failed some other edit, were advised of one additional opportunity to correct these edit failures. Edit corrections for claims that had failed as described will be processed in the March 1999 purge cycle. Providers still have until the cut-off for the March 1999 purge cycle to submit edit corrections for these claims only. The final dates for submission of allowable edit corrections are: February 10 for paper and, February 19 for electronic/mag media. Information helpful in resolving procedure code Edits 170 or 204 can be found in any of the last several issues of the Medicaid Update.
3. Providers may continue to send in the required documentation to confirm Medicare data for all claims that are pended for Edits 127, 262 or 1281 until May 11, 1999, as June 1999, will be the final Medicare lawsuit claims processing cycle.

Providers responding to any of these three edits should continue to send in a copy of the appropriate Provider Remittance Statement along with a copy of the applicable Explanation of Medicare Benefits [EOMB] to:

PLEASE NOTE: To ensure prompt and accurate adjudication of these pended claims, it is essential that the documentation that is submitted is clipped together and properly highlighted, to permit reviewers to rapidly and accurately read and assess the information being reviewed. Failure to properly follow instructions concerning appropriate preparation and submission of this documentation, will cause unnecessary delays in the adjudication process, and may ultimately result in non-payment if the reviewers are unable to match documentation to specific claims.

For assistance, please call your CSC Healthcare Systems representative at:

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Effective February 1, 1999, all Medicaid prior approval requests for Durable Medical Equipment which have been handled by the Department of Health's New Rochelle Area Office will be reviewed and processed at the Metropolitan Regional Office in New York City.

This only affects requests for recipients who reside in the following counties: Nassau, Suffolk, Westchester, Rockland, Orange, Sullivan, Ulster, Dutchess and Putnam.

Please forward your prior approval requests to the following address:

If you have any questions, please call (212) 613-4934.

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A revised EMEVS Provider Manual will be mailed to all active providers. The mailing will commence during the last two weeks in January, 1999. The revised manual replaces any previous issue you may have received. The manual contains instructions on accessing the EMEVS system for eligibility status, service authorizations and Dispensing Validation System (DVS) numbers. It does not contain New York State Medicaid Policy information. Policy information can be found in the MMIS Provider Manual.

If you do not receive a revised EMEVS manual by March 31, 1999, please call Computer Sciences Corporation at the appropriate number for your provider type. The numbers are:

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The State Department of Health welcomes your comments or suggestions regarding the Medicaid Update.

Please send suggestions to the editor, Timothy Perry-Coon:

NYS Department of Health
Office of Medicaid Management
Bureau of Program Guidance
99 Washington Ave., Suite 720
Albany, NY 12210
(e-mail MedicaidUpdate@health.state.ny.us )

The Medicaid Update, along with past issues of the Medicaid Update, can be accessed online at the New York State Department of Health web site: http://www.health.state.ny.us/health_care/medicaid/program/main.htm