Office of Medicaid Management DOH Medicaid Update August 2002 Vol.17, No.8
State of New York George E. Pataki, Governor
Department of Health Antonia C. Novello, M.D., M.P.H., Dr. P.H. Commissioner
Medicaid Update is a monthly publication of the New York State Department of Health, Office of Medicaid Management, 14th Floor, Room 1466, Corning Tower, Albany, New York 12237
OUR 900 SERVICE LINE TELEPHONE NUMBER HAS BEEN CHANGED New Number for Name Searches and Check Amount Inquiries
Return to Table of Contents
The 900 number currently being used by providers to search Medicaid recipient names and inquire about weekly provider check amounts is being discontinued by AT&T, which supplies the (900) service to local telephone companies. The discontinuation process will be staggered throughout the State and will be completed January 2003.
Meanwhile, providers may continue to call (900) 555-2525. The system accepts the recipient's name, social security number and date of birth as input and returns the recipient's identification number. The system will also provide the provider's current Medicaid check amount. Both components require the provider to enter their provider identification number.
As providers lose access to (900) 555-2525, they may access the name search and check inquiry system by calling <(518) 473-4620
DENTAL SERVICES FOR MEDICAID MANAGED CARE ENROLLEES CLARIFICATION OF FEE-FOR-SERVICE COVERAGE Return to Table of Contents
Medicaid fee-for-service dental providers < will not be reimbursed for services provided to the following Medicaid managed care enrollees:
Medicaid managed care enrollees whose health plan covers dental benefits (unless the provider participates in the plan's dental network); and,
Medicaid managed care enrollees whose health plan does not cover dental benefits but who are in a guarantee period.
When a Medicaid beneficiary joins a Medicaid managed care plan, that individual is < guaranteed
A person in their guarantee period is eligible for only those services provided by the Medicaid managed care plan, and is not eligible for "carved-out" services or any other services provided on a fee-for-service basis (with the exception of family planning and pharmacy services). Therefore, an enrollee in a guarantee period whose plan does not cover dental benefits is not eligible for dental care provided on a fee-for-service basis during the guarantee period.
Providers should check the eligibility status of each Medicaid beneficiary before providing services to ensure that claims will be paid.
< Medicaid fee-for-service dental providers will not be reimbursed for services provided to Medicaid managed care enrollees who are in their guarantee period and whose plan does not provide dental benefits. Eligibility status for these enrollees will appear as follows:
Phone message: "Eligible capitation guarantee" No "j" is listed under "insurance code and coverage" Verifone message: "Elig capitation guarantee" No "j" is listed under "insurance code and coverage"
Phone message: "Eligible PCP" or "Eligible capitation guarantee"
A "j" is listed under "insurance code and coverage" Verifone message: "Elig PCP" or "Elig capitation guarantee" A "j" is listed under "insurance code and coverage"
Questions may be referred to the Bureau of Medical Review and Payment at (518) 474-8161.
In March 2002, Health and Human Services (HHS) Secretary Tommy G. Thompson warned Americans of the risk of "pre-diabetes," a condition affecting nearly 16 million Americans that sharply raises the risk for developing type 2 diabetes and increases the risk of heart disease by 50 percent. HHS supported research that demonstrates that most people with pre-diabetes will likely develop diabetes within a decade unless they make modest changes in their diet and level of physical activity.
HHS and the American Diabetes Association (ADA) are using the new term "pre-diabetes" to describe an increasingly common condition in which blood glucose levels are higher than normal but not yet diabetic, known as impaired glucose tolerance (IGT) or impaired fasting glucose (IFG).
HHS and the ADA convened an expert panel, which included physicians and other diabetes experts, with representatives from HHS' National Institutes of Diabetes and Digestive and Kidney Disease (NIDDK) and Centers for Disease Control and Prevention (CDC). The panel concluded interventions for pre-diabetes are critical for three reasons. First, simply having blood glucose levels in the pre-diabetes ranges puts a person at a 50 percent greater likelihood of having a heart attack or stroke. Second, research shows that the development of type 2 diabetes can be delayed or prevented through modest lifestyle improvements. Third, for many people, modest lifestyle improvements can "turn back the clock" and return an elevated blood glucose level to the normal range.
The panel's recommendation in their entirety will be published in the ADA's peer-review journal, Diabetes Care . The following is an abbreviated version.
Fasting blood glucose test OR Oral glucose tolerance test
If patient has IFG or IGT (FBS>110 but <126)
Lifestyle Changes
Modest wt loss of 5-7%
Physical activity 150 minutes/week
Routine use of prescription drugs as initial treatment not recommended
The expert panel also recommends the same "Pre-Diabetes" screening and treatment
protocol for:
Significantly overweight adults younger than age 45 with one or more of the following risk factors:
Low HDL cholesterol and high triglycerides
High blood pressure
History of gestational diabetes or gave birth to a baby more than 9 pounds
Belong to a minority group (African-American, American Indian, Hispanic Americans/Latinos, and Asian American/Pacific Islander are at increased risk for
type 2 diabetes)
Source: HHS News, U.S. Department of Health and Human Services, March 27, 2002
The Medicaid Program reimburses for medically necessary care, services and supplies for the
diagnosis and treatment of diabetes. For information regarding Medicaid coverage of services related
to diabetes, please contact the Bureau of Program Guidance at (518) 474-9219 or go to
http://www.health.state.ny.nysdoh/mancare/omm/2000/oct2000.htm.
On June 10, 2002 the National Asthma Education and Prevention Program (NAEPP) issued an update of selected topics to The Guideline for the Diagnosis and Management of Asthma. Coordinated by the National Heart, Lung and Blood Institute (NHLBI), NAEPP convened an expert panel to review and ensure that the asthma guidelines reflected the latest scientific advances. The Expert Panel first published the asthma guidelines in 1991 and revised them in 1997. The following is a synopsis of the expert panel's key updates and recommendations to the asthma guidelines:
Are safe, effective and the preferred first-line therapy for children with mild or moderate persistent asthma as well as adults with persistent asthma
Use of inhaled steroids, at appropriate doses in children is safe, and that the potential but small risk of delayed growth is well balanced by their effectiveness
Are preferred for controlling and preventing asthma symptoms, improving lung functions and quality of life
Addition of a long-acting inhaled beta2-agonist to an inhaled steroid for patients over age 5 who have moderate or severe asthma is more beneficial than increasing the dose of inhaled steroids
Additional research is needed on combination therapy for children less than age 5
New recommendations regarding the use of leukotriene modifiers as an alternative therapy for treating mild persistent asthma or as combination therapy in moderate asthma
Antibiotics are not recommended for the treatment of acute asthma exacerbation except as needed for comorbid conditions
Reaffirmed the benefits of a written asthma action plan for patient self-management
The 11-member NAEPP Expert Panel prepared the update after a systematic review of scientific evidence. The panel includes representatives from the fields of allergy and immunology, family practice, internal medicine, pediatrics, pharmacology, public health and pulmonary medicine.
Source: "Correction: Update on National Asthma Guidelines Released" NIH New Release, NHLBI, June 10, 2002.
A downloadable version of the Executive Summary of the NAEPP Expert Panel Report, Guidelines for the Diagnosis and Management of Asthma- Update on Selected Topics 2002, is available at:
The Medicaid Program reimburses for medically necessary care, services, and supplies for the diagnosis and treatment of asthma. For more information, please contact the Bureau of Program Guidance at (518) 474-9219.
CLARIFICATION FOR DENTAL PROVIDERS Billing For Procedure Code 01110 - Dental Prophylaxis Return to Table of Contents
In addition to its use in submitting claims for
If performed after active periodontal therapy, any need to utilize Procedure Code 01110 more often than the normal twice per year should be explained in the < Procedure Description
Procedure Codes 01110 and 04341 are not reimbursable on the same date of service.
If you have any questions regarding Dental Coverage, please call the Bureau of Medical Review and Payment at 518-474-3575 (touchtone selection #3) or 800-342-3005 (touchtone selection #3).
PHARMACIES, DME SUPPLIERS AND ORDERERS MAXIMUM CALORIC UNITS REDUCED FOR MODULAR ENTERAL FORMULAS Return to Table of Contents
Effective for dates of service on or after< September 1, 2002
Medicaid reimbursement for products billed using B4155 (and all other enteral formulas) is only available for feeding tube or oral administration when there is a < documented diagnostic condition where caloric and dietary nutrients cannot be absorbed or metabolized from food.
The reduction in the maximum caloric units for B4155 reflects the fact that modular components are not used for total nutrition. If greater than 75 caloric units per month is ordered (equivalent to more than 250 calories per day), documentation of medical necessity must be submitted with a prior approval request.
Questions may be referred to the Bureau of Medical Review and Payment at (518) 474-8161.
COMPARISION OF COSTS BRAND VS. GENERIC H-2 ANTAGONIST DRUGS
The Difference is Significant! Return to Table of Contents
According to the National Institute for Health Care Management, from years 2000 to 2005, drugs with combined annual sales of approximately $20 billion are scheduled to come off patent. The use of generic drugs has a potential to play an important part in containing drug costs.
Presently, three of the four prescription strength H-2 antagonists have generic equivalents. It is important to assure that patients with gastrointestinal disorders who require H-2 antagonist treatment are provided the most clinically appropriate and cost effective therapy. The cost of H-2 antagonist therapy to the Medicaid program is outlined below.
Cost/Month (as of 6/12/02)
$143.79
N/A*
N/A
$140.94
N/A*
N/A
$109.51
$37.26
66%
$105.83
$36.00
66%
$99.87
$9.22
91%
$80.28
$8.36
90%
$102.51
$20.47
80%
$93.06
$9.54
90%
Please refer to product literature for a complete list of indications, dosing regimens and administration requirements.
A generic drug is a copy of a brand name drug that is identical in safety, dosage, strength, quality, performance and intended use.
No. Generic drugs generally cost less than brand-name drugs, so some people believe that generic drugs must be second-rate imitations. This is
Yes. Generic drugs use the same active ingredients. They have the same benefits and risks as their brand-name versions.
In the United States, trademark laws do not allow a generic drug to look exactly like the brand-name drug. It may be a different size, color or shape from the brand-name version. However, a generic drug must have the identical active ingredients as its brand-name counterpart. If you have any concerns regarding your generic drug, speak with your pharmacist or physician.
No. Sometimes it takes many years before other drug companies can introduce generic versions, but only after they have been thoroughly tested by the manufacturer and approved by the FDA.
Speak with your pharmacist or physician for information on generic drugs. You can also visit the FDA website at: http://www.fda.gov/cder/ogd/index.htm or call the FDA toll-free hotline at (800) 532-4440 for
more information.
Must call the toll-free Prior Authorization Call Line at (877)309-9493 to obtain prior authorization.
The prior authorization number must be written on the prescription.
More information is available on the Department of Health's web site at www.health.state.ny.us.
Click on: Information for Providers-Medicaid-Medicaid Update. Nov. 2000 & Feb. 2002
The prior authorization number must be submitted on the pharmacy claim.
If you have any questions regarding the Serostim and Zyvox Medicaid prior authorization process, contact the Pharmacy Policy & Operations staff at (518) 486-3209.
<******Attention: Prescribers and Pharmacists******
When implemented, the prescriber must call the voice interactive Prior Authorization Call Line at (1-877-309-9493) and answer a brief set of questions. The requested information includes identifying information about the prescriber, patient and clinical justification why the patient requires the brand drug instead of the generic.
The prescriber must indicate DAW on the prescription. In addition, "brand medically necessary" or "brand necessary" must be written on the prescription in the prescriber's own handwriting.
The prescriber will be given a prior authorization number. This number must be written on the face of the prescription.
Once the prescription is presented at the pharmacy, the pharmacist must also contact the voice interactive Prior Authorization Call Line at (1-877-309-9493) and answer a brief set of questions to verify and validate the prior authorization number.
The pharmacist must include the prior authorization number on the submitted claim.
The Pharmacy Policy & Operations staff at (518) 486-3209
RECIPIENT RESPONSIBILITY GUIDELINES Medicaid Recipients Must Show Medicaid Card When Obtaining Medical Services Return to Table of Contents
This article is one in a series describing situations when it is inappropriate to bill a Medicaid recipient for medical services. For other articles, see the April 2002
(Medicaid Denies Payment...Can I Bill The Medicaid Recipient), March 2001
(Medicaid Managed Care Enrollees Cannot Be Billed), and July 1999
(Medicaid Recipients Cannot Be Billed). Copies of these articles are available via email request to: <
MedicaidUpdate@health.state.ny.us
The intent of this article is to clarify the Medicaid recipient's responsibility to show the Medicaid card, Disaster Relief Medicaid document or temporary Medicaid card
Medicaid recipients are issued plastic Medicaid identification cards or, at times, temporary authorizations (Temporary Medicaid Authorizations - a paper document). The recipient is responsible for showing the plastic card or temporary authorization document each time a medical service is received.
When the recipient presents the plastic card, the provider must determine eligibility at the time the service is provided by using either the card swipe or the verifone. It is important to determine Medicaid eligibility for each medical visit since Medicaid eligibility is date specific.
When the recipient presents a Temporary Medicaid Authorization (the paper document), there should be no obstacle to payment of the claim because of the recipient's ineligibility for Medicaid, for medical services provided within the dates of coverage listed on the form.
Swiping the Medicaid card and/or reviewing the paper authorization and making no further comment to the Medicaid recipient concerning payment for services, leads the recipient to assume that you, as the provider, will accept Medicaid payment for the service about to be provided. The Department supports that assumption and expects the provider to bill Medicaid, not the recipient, for that service.
If you swipe the plastic card and find that the individual is not eligible,
In emergency situations where questions regarding health insurance are not normally asked, the Department expects you to accept the patient as a Medicaid recipient. However, the recipient is responsible for providing both the ambulance company and the hospital emergency room billing staff with a Medicaid number when it is requested at a later time. If the recipient is not cooperative in providing his or her Medicaid information after the transport or emergency room visit has occurred,
you may bill the patient as private pay. We do, however, expect that you will make diligent efforts to obtain the Medicaid information from the patient.
If you have questions about this article, please contact the Provider Resources Unit at (518) 474-9219.
As you proceed with your HIPAA Transactions and Code Sets compliance effort, you may need to assess the viability of various available options. Do you rely on your vendor if you use one? Do you re-write your own billing system? Do you purchase translation software? Do you contract with a clearinghouse? One of these, or some other viable option, may offer you a best compliance solution. You need to assess your business processes and determine which available solution will work best
for you and/or your organization. In this installment of the "HIPAA News" we will share information about one of the more prominent options available - a clearinghouse.
The HIPAA Transactions and Code Sets Final Rule defines a health care clearinghouse as a public or private entity that processes information received from another entity in a nonstandard format into a standard transaction, or that receives a standard transaction from another entity and processes the information into nonstandard format for a receiving entity. To accomplish data conversion a clearinghouse uses a translator. A translator is a software application that may be installed on the front-end and/or back-end of a system. It is used to convert data from one format to another, but cannot create data that does not exist.
A clearinghouse will minimize the amount of system, data content and data format remediation required to be undertaken by providers because it provides a combination of software and services which focus on streamlining the submitting and receiving of electronic transactions.
Providers may need to enhance their information/data gathering processes, to insure they capture and forward sufficient data for the clearinghouse to convert and create a HIPAA transaction, but they will not need to revamp their business process, reducing time and cost to implement.
Providers will need to test transactions only once with the clearinghouse, and may use the same clearinghouse for transmissions to multiple payers. A clearinghouse can maintain an extensive trading partner database, insuring tracking and reporting of performance activity and editing.
Clearinghouses can help providers avoid information technology costs associated with maintaining and upgrading networks, regulatory compliance, enhanced reporting, data analysis and necessary functionality and business processes improvement.
Use of a clearinghouse will minimize the cost associated with the training of employees who will need to utilize state of the art technology to maintain a HIPAA compliant business system and required peripheral functionalities.
Clearinghouses are a covered entity and must be HIPAA compliant, insuring that conversions to HIPAA format will be less likely to contain data content/format errors.
There will be up-front investment costs.
Clearinghouse processes need to be monitored to ensure compliance with the HIPAA standards.
Per transaction fees continue indefinitely and may be extensive for high volume providers.
Additional charges may apply for HIPAA version updates and data content changes.
Providers need to consider the ability of a clearinghouse and whether it will be able to perform any desired extraneous functions.
The clearinghouse option may or may not be the right one for you or your organization. The limited information provided above certainly is not sufficient for you to determine whether a clearinghouse may be a best solution for you. A comprehensive assessment and analysis of your business processes may be necessary. Below are two firms that provide clearinghouses services and may be able to assist you. We are not familiar with either firm and are not advocating or recommending that you
use their services. A number of providers have asked for such information and we are sharing what we have available with you.
WebMD Envoy - Information is available at:
Healthcare Data Exchange (HDX)-Information is available at:
The Transactions and Code Sets compliance plan must be submitted no later than October 15, 2002. Information and instructions for completion and submission of the compliance plan are available on the Department of Health and Human Services website,
The compliance date for the Privacy Rule is April 14, 2003. For more information on the Privacy Rule, please view the Medicaid HIPAA website at:
The website provides a number of pertinent HIPAA links including the federal website, <
www.cms.hhs.gov/hipaa.
This is based on the recognition that unless needy individuals can actually get to and from providers of care and service, the entire goal of the Medicaid Program is inhibited at the start.
To ensure the timely payment of Medicaid claims from Nursing Home Providers, we are reaffirming the following guidelines governing claims.
Additional information is required for a Medicaid eligible recipient placed in a nursing home in order to adjudicate a claim successfully. Much of that information is obtained from the DSS-3559-THE LONG TERM FACILITY REPORT OF MEDICAID RECIPIENT ADMISSION/READMISSION OR DISCHARGE/TRANSFER - NOTIFICATION OF CHANGE IN STATUS. The DSS 3559 form is required from the facility for each recipient upon initial admission and for every readmission, transfer, discharge or
death of the recipient after admission.
The information input by the LDSS is sent weekly to CSC. CSC compares the information to the MMIS edits. If the edits are passed, the information is put on the MMIS file available for claiming. This is the <"Two Monday Rule"
This edit is returned when a recipient does not have Medicaid coverage for the date of service at the time the claim is adjudicated. The claim will be pended for up to 30 days and edit 00162 will be returned on the remittance statement. If, after 30 days, there is still no eligibility information on file, the claim will deny.
NOTE: Immediately rebill any denied claim when the roster begins to display the recipient's name.
Questions concerning a recipient's eligibility can be resolved through the LDSS.
This edit is returned when the LDSS records show that another insurance is paying for the cost of recipient care. Payment from Medicaid is prohibited until the other insurance is maximized. Any claim submitted would pend for up to 90 days and Edit 01131 will be returned on the remittance statement.
If a claim is pended and the remittance statement shows it is due to edit 01131, the provider should bill the "other insurance" for the cost of care of the recipient. If the claim for the recipient is denied by the "other insurance", a copy of the denial must be sent to the LDSS to activate the per-diem payment by Medicaid.
NOTE: If the LDSS has "other insurance" on file, a "1" will appear on the monthly roster in the field headed "PP EXC". If the "other insurance" is unknown to the provider, contact the LDSS.
This edit is returned when the recipient is Medicaid eligible but the Client Identification Number (CIN) of the recipient on the claim does not match any recipient on the Principal Provider (PP) file. This edit will cause the claim to pend for up to 90 days awaiting PP update from the LDSS; if not updated, the claim will deny after 90 days. This edit is returned when the recipient is Medicaid eligible but payment for LTC has not been authorized on the PP file.
The Provider should be sure that the DSS 3559 has been completed and sent to the correct LDSS. If this has been done, contact the LDSS to inquire about the status of the PP entry.
This edit is returned when the recipient is Medicaid eligible but is enrolled on the PP to the claiming provider ID for only some of the Dates of Service (DOS) claimed.
This edit will cause the claim to pend for up to 90 days awaiting PP update form the LDSS; if not updated, the claim will deny after 90 days.
Providers should remember that they should claim for the date of entry into a facility but not for date of discharge. Claiming date of discharge will cause the entire claim to pend then deny. Often, providers claim for time periods when a client has lost bed hold in their facility. Submitting the DSS - 3559 (see Eligibility section) accurately and timely when a client loses bed hold and is re-admitted will help facilitate the claiming process. If there is any question concerning dates of service, Providers should check the accuracy of the DSS - 3559 before contacting the LDSS.
NOTE: When this problem occurs, a claim should be submitted for the portion of the claim dates of service that agree with the PP file while the remainder is being resolved.
This edit is returned when the claim covers dates when the recipient is Medicaid eligible but is not authorized on the PP subsystem to your provider ID for the claim dates of service.
This edit will cause the claim to pend for up to 90 days awaiting PP update from the LDSS; if not updated, the claim will deny after 90 days. This edit is similar to edit 00971 but is for the entire time period being billed. Follow the procedures outlined in edit 00971.
This edit is returned when the claim covers dates when the recipient is Medicaid eligible but is only enrolled to the claiming provider for part of the service dates claimed and to another provider for the remainder of the service period being billed. This edit will cause the claim to pend for up to 90 days awaiting PP update from the LDSS; if not updated, the claim will deny after 90 days. Providers should check the accuracy of the DSS - 3559 previously sent before contacting the LDSS.
NOTE: A claim should be submitted for the portion of the claim dates of service that agree with the PP file while the remainder is being resolved.
This edit is returned when the claim covers dates when the recipient is Medicaid eligible but is enrolled to another provider for all of the dates of service being billed.
This edit will cause the claim to pend for up to 90 days awaiting PP updated from the LDSS; if not updated, the claim will deny after 90 days. This edit is similar to edit 00974 but is for the entire time period being billed. Follow the procedures outlined in edit 00974.
This edit is returned when there is no Prior Approval (P/A) on file to match the PP dates being billed even though the recipient is Medicaid eligible and is enrolled in the PP Subsystem to the correct ALP for the service period. This edit will cause the claim to pend for up to 60 days awaiting the Prior Approval file update by the LDSS. After LDSS update, CSC retains the P/A on file for 180 days after which it is purged from the MMIS file. If the P/A has not been updated by the LDSS, or if you do not bill for service within the 180 days, edit 00244 will be returned on the remittance statement. Contact the LDSS to re-enter a P/A to cover the billing dates.
A claim that has been pended is set to automatically recycle. There is no need to rebill while a claim is in pend status and recycling. If the eligibility file or PP file is updated within the pended timeframe for each edit, then the claim will automatically pay or deny. If there are questions concerning the reasons why a claim is pending or denying, contact a representative at following numbers:
To check Medicaid Eligibility and/or PP entry, dial the Electronic Medicaid Eligibility Verification System (EMEVS) Provider Help Desk at (800) 343-9000.
For questions concerning claim rejections and/or payment issues, call Computer Sciences Corporation at (800) 522-1892.
For specific case and recipient information contact the LDSS responsible for the recipient.
If you have contacted the numbers above and continue to need assistance, dial Michele Leonard, Office of Medicaid Management, Division of Information Technology,
at (518) 473-4040.
Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid Management Information System (MMIS), announces the following schedule of Introductory Seminars. Topics will include:
Overview of MMIS
Explanation of MMIS Provider Manual
Discussion of Medicaid Managed Care
Overview of Billing Options
Explanation of 90-day Regulation
Explanation of Utilization Threshold Program
Please indicate the seminar(s) you wish to attend below:
September 12, 2002 - - 10:00 AM
Chautauqua County Dept. of Social Services
Hall R. Clothier Bldg. Auditorium
3 North Erie Street
Mayville, NY 14657
October 1, 2002 - - 10:00 AM
Genesee County Dept. of Social Services
Suite 3 (Large Conference Room)
5130 East Main Street
*Batavia, NY
October 3, 2002 - - 10:00 AM or 1 PM
Lockport Public Library
Rear Entrance
23 East Avenue
Lockport, NY
Additional seminars may be scheduled as new programs are implemented or changes to existing billing procedures are announced.
Direct questions about these seminars to CSC as follows:
Practitioner Services (800) 522-5518 or (518) 447-9860
Institutional Services (800) 522-1892 or (518) 447-9810
Professional Services (800) 522-5535 or (518) 447-9830
Please complete the registration information using the link to the form below:
To register, please mail the completed page to:
Attn.: Provider Outreach 800 North Pearl Street Albany, NY 12204
Or, fax a copy of the completed page to: 518-447-9240
No written confirmations will be sent.
The Medicaid Update: Your Window Into The Medicaid Program
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 )
