DOH Medicaid Update September 1999 Vol.14, No.9

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Pharmacy review staff report that they are still processing Viagra override recoupments. Department policy is "no overrides permitted for Viagra". Reasons for denial include concomitant nitrates, early refills (31 days between refills required) and early fills due to change in dose. These claims were paid and they will be recouped by the Department. No overrides for Viagra are allowed.

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

Effective Date	Drug	Quantity	NDC#
June 30, 1999	Norvir	Cap 100 mg SG	00074-6633-22
May 5, 1999	Agenerase	Sol 15 mg/ml	00173-0687-00
July 12, 1999	Risperdal	Tab 0.25 mg	50458-0301-04
July 12, 1999	Risperdal	Tab 0.25 mg	50458-0301-50
July 12, 1999	Risperdal	Tab 0.5 mg	50458-0302-06
July 12, 1999	Risperdal	Tab 0.5 mg	50458-0302-50
August 28, 1998	Risperdal	Sol 1 mg/ml	50458-0305-03
April 26, 1999	Nebupent	Neb 300 mg	63323-0877-15

Claims for these drugs 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 December 1, 1999. Questions regarding submission of pharmacy claims may be addressed to CSC at 1-800-522-5535.

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This is to inform you of corrections to the New York State Department of Health Prospective Drug Utilization Review/Electronic Claims Capture (Pro DUR/ECC) *Standards Manual and the New York State Department of Health Prospective Drug Utilization Review/Electronic Claims Capture (Pro DUR/ECC) *Provider Manual.

Medicaid co-payments apply to the following services:

• pharmacy
• inpatient hospital care
• non emergent or non urgent emergency room visits
• clinic visits
• sickroom supplies
• clinical laboratory and ordered ambulatory radiology

Note: There is no co-payment for home care or personal care services. However, persons receiving home care or personal care services are NOT exempt from co-payments for the services listed above.

Please make the following pen and ink changes to pages 13, 23 and 49 of your copy of the DUR/ECC Standards Manual and page 11 of the DUR/ECC Provider Manual.

DUR/ECC Standards Manual

• page 13
  1. Under Prior Authorization/MC Code and Number - Field 416, change 008 to read: "008 = Co-pay Exempt - OMH Community Residence and/or TBI"

• page 23
  1. Under Value/Comments change 008 to read: "008 - Co-pay exempt - OMH Community Residence and/or TBI"
  2. Under Value/Comments change Innnnnnnn008 to read: "Innnnnnnn008 = Prior Approval Number and Exempt from Co-pay - OMH Community Residence and/or TBI"
  3. Under Value/Comments change 400000000008 to read: "400000000008 = Exempt from Co-pay - OMH Community Residence and/or TBI"

• page 49
  1. Under Value/Comments change 008 to read "008 = Co-pay exempt - OMH Community Residence and/or TBI"
  2. Under Value/Comments change Innnnnnnn008 to read: "Innnnnnnn008 = Prior Approval Number and Exempt from Co-pay - OMH Community Residence and/or TBI"
  3. Under Value/Comments change 400000000008 to read: "400000000008 = Exempt from Co-pay - OMH Community Residence and/or TBI"

DUR/ECC Provider Manual

• page 11
  1. Under Prior Authorization/MC Code and Number - Field 416, change 008 to read: "Co-pay Exempt - 008 = OMH Community Residence and/or TBI"

Medicaid co-pay policy questions should be directed to Linda Ross at 518-473-4055; systems questions related to co-pay should be directed to DeLuxe Electronic Payment System at 1-800-343-9000.
*The DUR/ECC Provider Manual is used by pharmacies participating in the Medicaid program. The DUR/ECC Standards Manual may be used by pharmacy software companies.

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Below is a corrected listing of prepaid health plan codes which are reported to you when you request eligibility verification for a Medicaid recipient via the Electronic Medicaid Eligibility Verification System (EMEVS). This listing replaces these codes published in the May 1999 Medicaid Update. Please keep this information for easy reference.

EL	Medical Group of Western New York PCMPIII	(716)882-1212
JD	Middletown Prepaid Mental Health Plan (PMHP)	(914)342-5511 x3525 (800)597-8481*
JE	Mohawk Valley Prepaid Mental Health Plan (PMHP)	(315)738-4426 (800)597-8481*
JF	New York Psychiatric Institute Prepaid Mental Health Plan (PMHP)	(212)543-5412 (800)597-8481*
JG	Pilgrim Prepaid Mental Health Plan (PMHP)	(516)761-2704 (516)761-2129 (516)761-2225 (800)597-8481*
JH	Rochester Prepaid Mental Health Plan (PMHP)	(716)473-4379 (800)597-8481*
JI	Rockland Prepaid Mental Health Plan (PMHP)	(914)359-1000 x2235 (800)597-8481*
JJ	St. Lawrence Prepaid Mental Health Plan (PMHP)	(315)393-3000 x3529 (800)597-8481*
JK	South Beach Prepaid Mental Health Plan (PMHP)	(718)667-2823 (800)597-8481*
JL	Binghamton Prepaid Mental Health Plan (PMHP)	(607)773-4158 (800)597-8481*
JM	Bronx Prepaid Mental Health Plan (PMHP)	(718)931-7089 (800)597-8481*
JN	Buffalo Prepaid Mental Health Plan (PMHP)	(716)885-2261 x2009 (800)597-8481*
JO	Capital District Prepaid Mental Health Plan (PMHP)	(518)447-9611 x6971 (518)447-9611 x6808 (800)597-8481*
JQ	Creedmoor Prepaid Mental Health Plan (PMHP)	(718)464-7500 (800)597-8481*
JR	Elmira Prepaid Mental Health Plan (PMHP)	(607)737-4740 (800)597-8481*
JS	Hudson River Prepaid Mental Health Plan (PMHP)	(914)452-8000 x7293 (800)597-8481*
JT	Hutchings Prepaid Mental Health Plan (PMHP)	(315)473-4980 x4087 (800)597-8481*
JV	Kingsboro Prepaid Mental Health Plan (PMHP)	(718)221-7393 (800)597-8481*
JW	Manhattan Prepaid Mental Health Plan (PMHP)	(212)961-8700 (800)597-8481*

* This is the OMH Customer Relations 800 #. Use only if you receive no answer at the local plan number.

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Enteral Formulae and Enteral Supplies: The correct billing code for PRODUCT 80056 is B4154 #Enteral formula; Category IV etc., BR. Claims for this enteral product on any other code will be denied. Effective for dates of service on and after October 1,1999, claims for food thickener (e.g., Thick-It) will require EMEVS dispensing validation using the following new codes:

Code	Product	Quantity	Price
Z2111	#Food thickener, regular strength, per ounce	up to 180/mo	$0.51
Z2112	#Food thickener, concentrated strength, per ounce	up to 180/mo	$0.79

Durable Medical Equipment: Effective for order dates on and after October 1, 1999, the following DME items require EMEVS Dispensing Validation.

Effective October 1, 1999, these DME items no longer require prior approval utilizing form DSS-3615.

Code	Product	Price
E0630	#Patient lift, hydraulic with seat or sling	$1035.36
E0730	#TENS, four lead (dual channel), larger area/multiple nerve stimulation	$76.25
A4630	#Replacement batteries for medically necessary transcutaneous electric nerve stimulator (TENS) owned by patient	$2.46

Please note these changes in your Manual to insure correct claim submission.

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In the July, 1999 issue of the Medicaid Update we advised providers that:

1. Computer Sciences Corporation's (CSC's) claims processing system was fully Y2K ready, and that the software modifications necessary to achieve Y2K readiness had been in place since July, 1998.
2. Claim submission requirements for providers will remain virtually unchanged. No modifications are being made to any of the existing claiming formats. Providers will continue to use current rules when completing fields calling for entry of calendar year

   (4 digits for: NCPDP 3.2 for pharmacy claim capture via EMEVS, HCFA Version 5, and the YOB field for HCFA version 4; and 2 digits for all other claim formats and media).

3. The fiscal agent's claim testing process uses some aspects of the production system and production files to test provider-submitted test claims and test claim files. Test claims with future dates cannot be accommodated in an on-site environment without jeopardizing normal production cycles and claim payments.
4. To assure the Department, Federal and State Y2K readiness reviewers, and providers that the New York State Medicaid Management Information System will continue to successfully process claims after January 1, 2000, the Department instructed the fiscal agent to replicate the entire production system off-site so that a complete production cycle could be run with current and future dated claims in a post 12/31/99 environment. Details of this "End-to-End" testing and a summary of results follow.

Y2K End-to-End Testing

The testing was conducted during the weeks of July 19 and 26, 1999, at the CSC contracted disaster recovery site in Philadelphia. 128,798 claims were tested, representing every provider type, and every kind of claims input (paper, mag media, electronic) for each provider type. Claims with 1999 and 2000 service dates were tested in a year 2000 systems environment, with all files and the system clock adjusted accordingly. Claims with service periods that spanned the two centuries were tested, as well as claims with the dates 9/9/1999, 12/31/1999, 1/1/2000, 2/28/2000, 2/29/2000, 3/1/2000, and 12/31/2000, among others.

The selected claims had previously been processed at CSC, so that the adjudication results were known and could be compared against the results of the Y2K adjudication process. Claims were processed beginning at data input and carried through the entire system to include check and remittance production. The comparisons showed that the claims processing results were completely consistent with the previously processed claims.

Questions concerning this article should be directed to Al Fike, Division of Information and System Support, at (518) 473-8681.

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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