DOH Medicaid Update June 1999 Vol.14, No.6

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Providers are reminded that the list below represents the only types of attachments that, under normal circumstances, may be submitted with paper claim forms.

Types of Valid Attachments

• 90-Day Letter
• Sterilization Consent Form
• Hysterectomy Consent Form
• Copy of original enrollment letter for initial claims submission by new providers
• By Report Attachment - such as operative report and cost of acquisition invoice (Use only when the procedure requires the attachment)
• Hearing Aid Confirmation of Benefit Statement
• Orthodontic Loss of Eligibility documentation - Current Physically Handicapped Children Program treatment authorization and review, and remit showing denial for ineligibility
• Supporting documentation as requested by the Department of Health and indicated, for example, by the remittance statement message "rebill on paper with documentation"
• Reports/documentation needed to explain exceeding procedure frequency limitation
• Reports/documentation needed to explain two providers billing same/similar service
• Medicare Explanation of Benefits only when needed to adjudicate claims that will pend for edit 01141 and edit 00200
• Certain articles from the Medicaid Update when specifically requested by the Department of Health

Claims submitted with attachments that are not valid will be returned to the provider along with a rejection letter. Providers may remove the invalid attachments and resubmit the claim and rejection letter to Computer Sciences Corporation (CSC) for processing.

Providers making inquiries or requesting billing training by Regional Representatives should contact CSC by calling the appropriate number below. Please be prepared to supply your Medicaid Provider ID number.

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The following drug has been added to the list of drugs that are not included within the drug cost components of Article 28 Nursing Facility Rates:

Effective Date	Drug	NDC #
March 1, 1999	Crixivan	00006-0574-65

Claims for this drug that are submitted more than 90 days from the dispensing date must be submitted with a copy of this article. Computer Sciences Corporation (CSC) must receive claims no later than 12:00 noon on September 1, 1999. Questions regarding submission of pharmacy claims may be addressed to CSC at 1-800-522-5335.

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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 all edit correction and data submission opportunities ended with the May 11, 1999 deadline. Only voids may continue to be submitted after that date.

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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If you have a newly hired physician who needs to enroll in the Medicaid Program, please note that the physician application was revised on 7/1/98. Enclosed with the new application are detailed instructions and a checklist of what must be provided to process the application.

After September 1, 1999, all physician enrollments must be submitted using the new application. If an application is received on a previous version of the form dated prior to 7/1/98, it will be returned with a copy of the new application to be completed. This will cause a delay in the enrollment process.

To obtain copies of the new application forms please call the Provider Enrollment Unit at (518) 486-9440 or write to:

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Effective June 1, 1999, Viagra is available as a reimbursable drug under the New York State Medicaid Program. Prescribers must attest to medical necessity and maintain documentation of physical examination to verify that necessity.

Viagra is restricted to males 19 years of age and older. Prescribers must initiate prescriptions only after a physical examination. A phone diagnosis will not be permitted. Patients must have a diagnosis of erectile dysfunction. Prescribers should not issue a prescription for Viagra if the patient has used any nitrates or drugs containing nitrates within the past 180 days. Prescriptions will be limited to an original prescription with up to two refills. A maximum limit of six tablets per 30 days will be adhered to. Each new prescription will require a medical examination to assure the medication is appropriate and effective.

Early refills on prescriptions or overrides for lost prescriptions will be prohibited. The pharmacy provider will receive a Therapeutic Duplication (TD) indicator for these claims. Do not override. Payment will be denied in this instance; this serves as a forewarning of this action. These prescriptions will be subject to all Drug Utilization Review (DUR) edits to assure the patient is not currently receiving any contraindicated drugs.

A six-tablet maximum per 30 days will be upheld. Lost prescriptions will not be replaced. Early refills and vacation supply requests will not be honored.

Approval through the Dispensing Validation System (DVS) will also be required prior to dispensing Viagra. Additional information will be provided to pharmacists regarding this requirement.

For more information contact the Pharmacy Policy Unit at (518) 486-3209.

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Pharmacy providers were notified of a policy change regarding clients enrolled in Medicaid managed care in a Pharmacy Provider letter dated February 12, 1999. Under this change, Medicaid will pay claims for pharmaceutical "carve out" clients during their guaranteed eligibility period.

The DUR on-line system has now been modified to allow electronic claims capture (ECC) and DUR processing for prescriptions dispensed to Medicaid Managed Care Guarantees. The guarantees are identified on the EMEVS file by coverage codes 31 and 33 (Eligible Capitation Guarantee). These claims will no longer be denied and will not be subject to Copay processing. The claims should be submitted like any other DUR transaction and will be subject to the DUR/ECC edit process. This applies to all managed care enrollees except those in Managed Long Term Care (MLTC) plans.

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The following systems information refers to clients in MLTC plans. With the exception of Family Planning drugs, all prescriptions for clients in MLTC plans should be submitted to the specific MLTC plan. Pharmacy providers must be part of the specific MLTC plan network to submit claims on behalf of a client. Current MLTC plans are:

Plan Name	Plan Code
Elderplan	85
Community Health Care Services	AN
Comprehensive Care Management	C7
Eddy Senior Care	E7
Independent Living for Seniors	IL
Independent Living Services	IS
Broadlawn Health Partner	LE
Senior Network Health	MZ
VNS Choice	VC
Partners in Community Care	GD

• The "H" (pharmacy coverage) will be returned in the additional message field as part of the scope of benefits. The MLTC plan code will also be returned in the additional message field.
• Only claims for family planning drugs can be submitted and will be subject to regular DUR/ECC editing. These claims will not be subject to Utilization Threshold or Copay processing. All other claims should be billed to the MLTC plan. Do not bill a MLTC plan unless you are a member of the specific MLTC plan network - you will not be reimbursed.
• Claims for coverage codes 31 and 33 which are not for Family Planning will be denied for new Table 7 denial code 719 "BILL MANAGED CARE PLAN, MA ONLY COVERS FAMILY PLANNING DRUGS". Although there are no MLTC recipients currently classified as guarantees, the system changes were added in case classifications change in the future. Do not bill a MLTC plan unless you are a member of the specific MLTC plan network - you will not be reimbursed.
• Claims for coverage codes 30 and 32 which are not for Family Planning drugs will be subject to third party (NCPDP Fields 308 and 431) editing and should not be submitted. Improperly submitted claims will deny for Table 7 denial code 717 "RECIPIENT HAS OTHER INSURANCE". Do not bill a MLTC plan unless you are a member of the specific MLTC plan network - you will not be reimbursed.

Please note: Pharmacies should contact their software companies in case modifications are needed.

If you have any system questions once this is implemented, please call Deluxe Electronic Payment Systems at 1-800-343-9000.

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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