DOH Medicaid Update November 1999 Vol.14, No.11

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On September 22, 1999 Commissioner Novello received Health Care Financing Administration (HCFA) approval for the "Continuing Care Networks (CCN) Demonstration in Monroe County". In 1996 the Department, in partnership with the Monroe County Community Coalition for Long Term Care, began to develop a Medicare and Medicaid waiver application for the demonstration in Monroe County. The final application was submitted to HCFA in April, 1998.

Through federal waivers, the demonstration expands both the New York and national experiments in integrating Medicaid and Medicare. The demonstration offers a full continuum of primary, acute and long-term care services to all Medicare beneficiaries, including those who are impaired or dually eligible for Medicaid and Medicare. In addition to providing a broad, capitated benefit package to a population of both well and impaired individuals, the demonstration tests a payment model, which introduces risk adjusters based on enrollees' level of functional impairment.

The CCNs will target Monroe County residents who are age 65 or older, entitled to Medicare or Medicare and Medicaid, and residing in the community or in a nursing home. The demonstration goal from the enrollee perspective is to combine all aspects of services for older people in order to decrease the use of hospitals and prevent or delay the use of nursing home care. For HCFA, the demonstration will also allow testing program and reimbursement options outside those permitted under current statute, and will add to the body of knowledge affecting future federal Medicare and Medicaid legislation. In New York, the demonstration will be the prototype for other Managed Long Term Care organizations moving toward an integrated Medicaid/Medicare service model as permitted under New York's 1997 Managed Long Care Finance and Integration Act.

The Office of Continuing Care is providing the administrative oversight for the demonstration, which is expected to begin enrollment in 2000.

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Deluxe Government Services (previously known as Deluxe Data or Deluxe Electronic Payment Systems) has enhanced the EMEVS Network to be Year 2000 compliant and to provide better service and capabilities. Changes include:

• improved voice for ARU (telephone),
• better POS (Verifone terminal) download support,
• support for multiple pharmacy claims per transaction,
• better multiple transaction per call processing,
• increased modem speeds for PC transactions,
• reduction of phone numbers,
• better diagnostics and management,
• easier development and software support,
• improved reliability.

Effective immediately begin using the telephone numbers listed below to submit transactions. All providers, whether upstate or in New York City, should use the numbers listed. For every transaction, always dial the primary number first. If you do not receive a response or have any problem in completing the transaction, try again using the backup number. Your next transaction should again use the primary number.

Access Method	Primary	Backup
ARU (telephone)	(800) 997-1111	(800) 394-1234
POS (Verifone terminal)	(800) 997-1119	(800) 394-2345
POS Download	(800) 888-3653	None
PC (low-speed)	(800) 997-1119	(800) 394-2345
PC (high-speed)	(800) 997-1110	(800) 394-4858

For faster network access follow these guidelines:

• Providers submitting transactions with a PC can use one of two numbers. PCs with modem speed limitations (4800 baud or less) should use the PC (low-speed) numbers. PCs with high-speed modems should use the PC (high-speed) phone numbers. These phone numbers will support a maximum rate of 28.8 baud, although modems capable of higher speeds can be used. Automatic synchronization will occur when the speed from the sending modem does not match the receiving modem.
• Providers using their own software or from a vendor other than Deluxe Government Services, should remove any modem restrictions. For assistance, you should contact your software vendor. For the fastest connection efficiency, it is recommended you set your software to 28.8 when using the PC (high-speed) number or 1200 for the PC (low-speed) number.
• Providers using the New York Medicaid Eligibility software supplied by Deluxe Government Services should change the override string to "Z". Do the following steps to make the change for version 4.1.0.5*:

* To check the software version, click on Help on the menu, then click on About. The version will be displayed. Version 4.1.0.5 is the preferred software version for Y2K. If you do not have this version, contact Bob Geier at (414) 341-3027.

Additional benefits for PC providers include:

• Submitting multiple claims per transaction for pharmacy (DUR). To do this, normal NCPDP transaction specifications must be followed. Previously only one (1) claim could be submitted per transaction. Now, a maximum of four (4) claims per transaction is supported.
• Submitting multiple transactions per call for all transaction types. Multiple transactions per call was always supported, but often terminated before the entire file was transmitted. This has been significantly improved. Submission of multiple transactions should be limited to 1500 transactions per call. Files larger than 1500 transactions should be submitted via ftp for maximum efficiency or another file means. For additional information on ftp and other submission options contact Bill Tschanz at (414) 0341-5370.

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Instructions to those providers who had been named plaintiffs in the above-cited action.

As you know, all edit correction and data submission opportunitiesended with the May 11, 1999 deadline. All opportunities for corrections, adjustments, and other changes, except voids, ended at that time. Voids continued to be processed per established lawsuit claiming instructions, until the September purge cycle. With the conclusion of the September purge cycle, all previously established lawsuit claims processing procedures, including those for voids, ceased to be operational.

Important note regarding voids: We have recently developed the capacity to accept lawsuit voids filed in the normal (standard) manner. This change, now in place, will enable providers to continue to submit voids, when appropriate, for lawsuit 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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Have you received denials for the following Managed Care edits?

EDIT  REMITTANCE REMARK
01172 Prepaid Cap Recipient - Service Covered Within Plan

• EXPLANATION - The recipient is enrolled in a Medicaid Managed Care Plan. The provider can not receive reimbursement through Medicaid Management Information System (MMIS). The provider must bill the Managed Care Plan identified through the Electronic Medicaid Eligibility Verification System (EMEVS) as an insurance code.

EDIT  REMITTANCE REMARK
01173 Prepaid Cap Recipient - Referral or Specialist ID Invalid

• EXPLANATION - The recipient is enrolled in a Partially Capitated Medicaid Managed Care Plan which provides primary care services and refers the recipient to other services. The provider may receive reimbursement through MMIS only with an appropriate referral from the Managed Care Plan identified through EMEVS as an insurance code.

Indicate the MMIS ID number of the Managed Care Plan as the Referring ID number as follows:

• Version 4 or Version 5 Electronic Specifications - Record Type 80 (positions 75-82)
  Claim A Electronic Specifications - D2 Record (positions 68-75) / Paper Claim A - field 34
  HCFA - 1500 - field 19C
  Pharmacy Electronic Specifications - D2 Record (positions 29-36) / Paper Pharmacy Claim - field 14
  Claim C Electronic Specifications - D2 Record (positions 66-73) / Paper Claim C - field 27

Avoid claim denials for Managed Care related edits 01172 and 01173 as follows:

1. When verifying recipient eligibility via EMEVS:
   • Be alert to the messages "ELIGIBLE PCP" or "ELIGIBLE CAPITATION GUARANTEE".
   • Identify the Managed Care Plan as indicated by the two-character INSURANCE CODE value.
   • Identify Managed Care Plan covered services by the COVERAGE (COV) CODES.
2. If the services are covered by a Partially Capitated Medicaid Managed Care Plan, remember to indicate the MMIS ID number of the Managed Care Plan as the referring ID number when billing MMIS. Do NOT use the ordering/referring provider's individual MMIS ID or license number.

EMEVS Managed Care Messages
EMEVS Insurance Codes identifying Managed Care Plans are located in the front of the billing section of the MMIS Provider Manual. EMEVS Coverage Codes are located in the front of the billing section of the MMIS Provider Manual and in the EMEVS Manual. Call Deluxe Government Services at 800-343-9000 for instructions and information regarding EMEVS messages.

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

Practitioner Services (800) 522-5518 (518) 447-9860
Institutional Services (800) 522-1892 (518) 447-9810
Professional Services (800) 522-5535 (518) 447-9830

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The Medicaid program takes very seriously its responsibility towards Medicaid providers and recipients. Please note that the Electronic Medicaid Eligibility Verification System (EMEVS)and the Medicaid Management Information System (MMIS) have been carefully tested, and are expected to function seamlessly into the new millennium.

In the July 1999 issue of the Medicaid Update, we advised providers that Computer Sciences Corporation (CSC) claims processing for the MMIS system was fully Y2K ready, and that the software modifications necessary to achieve Y2K readiness have been in place since July 1998.

In the September 1999 issue of the Medicaid Update, we advised providers that Y2K End-to-End Testing had been completed and claims with 1999 and 2000 service dates were tested in a year 2000 systems environment, with all files and the system clock adjusted accordingly.

All Providers
In the unlikely event that the EMEVS system does not function properly due to a Y2K malfunction and providers are unable to verify a recipient's eligibility, the Department is confident that as a provider and a responsible member of the health care delivery community, you will provide Medicaid recipients with any medically necessary essential service. If a Medicaid provider is unable to provide a medically necessary service, the patient should be referred to the nearest hospital or Emergency Room.

Regardless of a Y2K malfunction and if Medicaid eligibility can not be verified via EMEVS, claims should still be submitted to the MMIS for usual payment processing.

Questions concerning this section should be directed to the Bureau of Program Guidance at (518) 473-5490 or (518) 473-5569.

Pharmacy Providers
With Y2K quickly approaching, we want to remind pharmacy providers that many recipients may want to refill their prescriptions early.

Appropriate professional judgment should be exercised along with following current Department protocol for Drug Utilization Review (DUR) Overrides (e.g. Therapeutic Duplication).

Medicaid patients should be treated as any other patients as the end of the year approaches. For example:

a) many maintenance medications can be ordered for greater than a 30 day supply,
b) if a patient has a new / refill prescription, the patient should be encouraged to have the prescription filled as soon as possible,
c) should a verification system problem occur, pharmacies should use their normal operational protocol, and may decide to extend the patient a 1-2 day supply until the system problem is corrected.

Questions concerning this section should be directed to the Pharmacy Policy Unit at (518) 486-3209.
Thank you for your participation and continued support in the Medicaid program.

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Advanced Life Support vs. Basic Life Support Billing: It has come to our attention that some ambulance companies have been billing Medicaid for both basic life support services and advanced life support services when advanced life support service is provided. This type of billing is incorrect for those counties that have established separate rates for advanced life support and basic life support services. The provision of advanced life support services includes the delivery of basic life support services. When an ambulance is sent to the scene and it provides advanced life support services, only that service may be billed to the Medicaid program.

There are no specific instructions in the Medicaid Transportation Provider Manual on billing for these services. This article should be copied and filed in your Medicaid Transportation Provider Manual for future reference.

Advanced Life Support Assist/Fly-Car Service: Please note that advanced life support assist services can only be billed if a unique advanced life support assist reimbursement amount has been established by the local social services district and the New York State Department of Health prior to the provider billing. Providers of advanced life support assist/fly-car service should not bill the Medicaid program at the full advanced life support rate when the provider delivers the assist/fly-car service.

If you have any further questions on this transportation matter, you may contact Fred Perkins (518) 473-5337, or Tim Perry-Coon (518) 473-9851, at the Office of Medicaid Management.

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On October 6, 1999, a three-judge panel of the U.S. Second Circuit District Court of Appeals reversed the District Court's April 19, 1999 permanent injunction decision in the Rodriguez v. DeBuono lawsuit. The Rodriguez plaintiffs had successfully argued in the lower court that New York's design and implementation of task-based assessment programs used to determine the amount and allocation of personal care service (PCS) hours violates the Medicaid Act, Section 504 of the Rehabilitation Act, and the Americans with Disabilities Act (ADA). The Appeals Court determined that the plaintiffs' comparability claim was unfounded because New York's Personal Care Services Program (PCSP) does not include independent safety monitoring as a personal care services task for any personal care services recipients. Hence, the mentally impaired are not being treated differently from other PCS recipients when the State does not assess that segment of the PCSP population for this task. The Court applied similar reasoning in rebuffing plaintiffs' ADA claims. It ruled that the "ADA requires only that a particular service provided to some not be denied to disabled people." In the court's view, the State did not fund independent safety monitoring for physically disabled personal care services recipients; hence, mentally impaired recipients had no recognizable ADA claim to challenge its denial to them. Nor, in the Court's opinion, could plaintiffs use the ADA to compel the State to add a new benefit (independent safety monitoring) to the PCSP. Since the Second Circuit had previously granted the Department's request to stay the April 19, 1999 preliminary permanent injunction requiring safety monitoring be added to task-based assessment instruments, pending DOH appeal to the Second Circuit, there is no immediate impact on existing or future PCSP assessments and authorizations. Plaintiffs have moved to reargue the panel's decision, however.

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Medicaid payment is not currently available for Hepatitis C viral load tests. The Office of Medicaid Management is continuing to evaluate coverage of this procedure.

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This article is intended to provide clarification on payment criteria and documentation requirements for teaching physicians who may bill Medicaid when their services are not included in the facility's Medicaid payment.

Teaching physicians may bill for direct patient care services rendered while supervising a resident, provided that personal and identifiable services are provided to the patient in connection with the supervisory services; that the appropriate degree of documented supervision was provided; and that the teaching physicians are not salaried for patient care by the hospital.

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Teaching physicians must be present during the portion of the service that determines the level of service billed. They should personally document the extent of their participation in the history, examination, and complexity of the medical decision-making used to determine the level of service, as required by the Physicians' Current Procedural Terminology. If this documentation would be repeating information already obtained and documented by the resident, supervising physicians need only summarize comments that relate to the resident's entry, confirming or revising the following key elements:

1. relevant history/diagnostics;
2. findings from the physical examination;
3. assessment/diagnosis; and
4. plan of care.

Countersignature of the resident's medical record entry, or countersignature in combination with simple phrases such as, "OK" or, "I concur with the course of treatment" do NOT meet the requirement for summarized comments.

Primary Care Exception
With respect to evaluation/management visits in primary care settings where encounters entail medical decision making of low or moderate complexity, teaching physicians may bill for services rendered to a patient, even though the services were furnished without their presence, provided the Medicare Primary Care Exception conditions are met. These conditions include the requirement that teaching physicians:

1. supervise no more than four residents at a time;
2. be immediately available and have no other responsibilities at the time the patient is being seen
   by the resident;
3. assume management responsibility for the patients and ensure that the services rendered are
   appropriate;
4. review with the resident, during or immediately following each visit, the key elements of the
   services provided;
5. document the extent of their participation in the review and direction of services.

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Teaching physicians are responsible for preoperative, operative, and post-operative care. They should be present during all critical and key portions of these types of procedures, and should be immediately available to return to the procedure throughout the entire process.

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• Endoscopic Surgery
  Viewing an endoscopic procedure via a monitor in another room would not qualify for payment.
• Diagnostic Radiology and Other Diagnostic Tests
  If a resident prepares and signs the interpretation, teaching physicians must indicate that they personally reviewed the image and the resident's interpretation and either agree with it or edit the findings. Countersignatures would not qualify for payment.
• Hematology/Oncology
  Bone marrow aspirates and biopsies may be billed only when teaching physicians are present with the resident for the full duration of the procedure, and assure that adequate material has been obtained.
• Psychiatry
  Teaching physicians must concurrently observe the service by one-way mirror or video equipment, audio only equipment would not suffice.
• Maternity Services
  Teaching physicians must be present in the room for the delivery, and their presence must be appropriately documented in the record.
• Anesthesiology
  Teaching anesthesiologists may be paid when they are involved in a procedure with a resident, but must be present during induction and emergence. They may not bill for anesthesia time during concurrent supervision of more than one resident.
• Other Complex and Invasive Procedures
  Teaching physicians may bill only when they are present with the resident for the full duration of complex procedures such as interventional radiological and cardiology supervision and interpretation codes, cardiac catheterization, cardiovascular stress tests, and transesophageal echocardiography.

If further clarification of this policy is needed, please send your questions in writing to:

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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