DOH Medicaid Update April 1999 Vol.14, No.4

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The Pharmacy Provider Manual (Rev. 4/99) was recently updated and mailed to you. Please make the following corrections in your copy:

Page 4-9	Calculation instruction at the top of the page, change to read "The calculation for pricing Enteral Therapy formulae is as follows: Number of calories per can divided by 100 equals number of caloric units per can."
Page 4-14	Price for code A4253, change to $39.29.
Page 4-25	Quantity/Size for code A4221, change to up to 4/month.

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The Durable Medical Equipment Provider Manual (Rev. 4/99) was recently updated and mailed to you. Please make the following corrections in your copy:

Page 4-5	Price for code A4253, change to $39.29 .
Page 4-15	Quantity/Size for code A4221 , change to up to 4/month.
Page 4-16	Calculation/ instruction at the top of the page, change to read " The calculation for pricing Enteral Therapy formulae is as follows: Number of calories per can divided by 100 equals number of caloric units per can. "
Page 4-48	Add EMEVS indicator (#) to codes Z5720, L3217, L3260, L3265.
Page 4-48	Delete EMEVS indicator (#) from code L3218.
Page 4-50	Code L4320, change code number to L3420.
Page 4-64	Underline code L5987 .
Page 4-82	Code L7520 , add to the description, (more than 2 hours requires prior approval.)

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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 that the March 1999 purge cycle was the final error correction opportunity afforded to providers with previous Edit 162 and Edit 140 failures;
• remind providers that they may still submit documentation to permit adjudication of claims pended for Edits 127, 262 or 1281 until the final deadline of May 11, 1999;
• inform providers that May 11, 1999 is also the deadline for submission of adjustments ; and,
• advise providers that voids may continue to be submitted even after May 11, 1999.

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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 previously informed you of a special process used as a final effort to resolve Edit 140 and Edit 162 claims. Providers who had had claims that had failed either Edit 140 or Edit 162, and after special processing had failed some other edit, had also been advised of the one additional opportunity to correct these edit failures. That opportunity ended with the March 1999 purge cycle.
3. Providers may still continue to send in the required documentation to confirm Medicare data for any claim that pended for Edits 127, 262 or 1281, until May 11,1999. The June 1999 purge cycle - #138 - will be the final cycle in which Medicare Lawsuit claims will be processed for payment. Note: All remaining unresolved lawsuit claims will be denied and reported out in remittances in a regular payment cycle shortly after cycle 138.
4. May 11, 1999 is also the final deadline for submission of adjustments (to previously paid claims).
5. Providers will continue to be able to submit (claim) voids even after May 11, 1999.

Please Note: Additional details about submission of documentation for any of these claims can be found in the December 1996/January 1997 Medicaid Update. Providers responding to any of these three edits should 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:Documentation submitted is required to be clipped together and properly highlighted, to permit accurate review . Failure to properly follow these instructions may result in non-payment if reviewers are unable to match documentation to specific claims.

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

Practitioner services: 1-800-522-5518 or (518) 447-9860
Institutional services: 1-800-522-1892 or (518) 447-9810
Professional services: 1-800-522-5535 or (518) 447-9830

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This is a reminder that in order to receive payments from New York State Medicaid, providers are required to inform the Medicaid Program within fifteen (15) days of any change in direct or indirect ownership or control interest in the enrolled provider. For purposes of Medicaid regulations, an ownership or control interest means a person or corporation that:

1. Has an ownership interest totaling five percent (5%) or more in a disclosing entity;
2. Has an indirect ownership interest equal to five percent (5%) or more in a disclosing entity;
3. Has a combination of direct and indirect ownership interests equal to five percent (5%) or more in a disclosing entity;
4. Owns an interest of five percent (5%) or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least five percent (5%) of the value of the property or assets of the disclosing entity;
5. Is an officer or director of a disclosing entity that is organized as a corporation; or
6. Is a partner in a disclosing entity that is organized as a partnership.

Changes of ownership or control interest must be reported to the New York State Health Department, Office of Medicaid Management, by filing an amended, signed ownership and control interest disclosure form. Ownership interest is defined as possession of equity in the capital, the stock or the profits of a provider.

Based upon the information supplied, you may also be required to complete a new Medicaid Provider Enrollment Application to reflect the structural change to your business. Copies of the required disclosure forms for fee for service providers such as physicians, dentists, pharmacies and durable medical equipment dealers may be obtained from:

New York State Department of Health
Office of Medicaid Management
Bureau of Enrollment
99 Washington Avenue, Suite 611
Albany, NY 12210

Institutional providers such as hospitals, nursing homes, home health agencies and freestanding clinics may obtain the disclosure forms from:

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Are you unsure which Computer Sciences Corporation inquiry unit to call when you have questions about your remittance statement, preparing and submitting claims, obtaining paper claim forms, or other billing issues? Please refer to the following lists to determine the appropriate inquiry unit phone number for your category of service.

Institutional Services Unit (800)522-1892 or (518)447-9810 Assisted Living Program Child Care Clinic Comprehensive Medicaid Case Management Program C/THP (Clinic) Day Treatment Dental Clinic Health Maintenance Organization Home and Community Based Services Home Health/Long Term Home Health Hospice ICF-DD Inpatient Laboratory (Hospital) Nursing Services (Registry) Office of Mental Health Certified Rehabilitation Services Personal Care Personal Emergency Response Services Residential Health Care Facility (Nursing Home) School Supportive Health Services

Practitioner Unit (800) 522-5518 or (518) 447-9860 Chiropractor/Portable X-ray Supplier (QMB Services) Clinical Psychologist Clinical Social Worker (QMB Services) C/THP (Physician) Dental Nurse Practitioner Nursing Services (Individual R.N. or L.P.N.) Ophthalmic Physician Podiatry (QMB and children only) Rehabilitation Services

Professional Services Unit (800) 522-5535 or (518) 447-9830 Durable Medical Equipment (DME) Hearing Aid Laboratory (Free Standing) Pharmacy Transportation

Providers making inquiries or requesting billing training by Regional Representatives should contact Computer Sciences Corporation (CSC) by calling the appropriate number for your category of service listed above. Please be prepared to supply your Medicaid Provider ID number.

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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