DOH Medicaid Update December 2002 Vol. 17, No. 12

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Over the past year, the Office of Mental Health (OMH) and the Department of Health (DOH) have been investigating methodologies that would enable Kids Oneida (KO), a community based behavioral health network serving children with a serious emotional disturbance, to receive reimbursement for children who are also enrolled in a medical managed care plan or in short term residential care in a child care facility. KO's enrollment as a managed care plan prohibited reimbursement for children in these situations.

Recent changes have been made to the MMIS system to no longer recognize KO as a managed care plan thereby allowing payment to both KO and a medical managed care plan. Effective August 1, 2002, KO, also known as Integrated Community Alternatives Network (ICAN), will appear on EMEVS (Electronic Medicaid Eligibility Verification System) as a Third Party Insurer with the identifier, "KO". Providers will no longer see the "KO" identifier as a Medicaid Prepaid Capitation Plan code on EMEVS.

Providers serving KO children for mental health care should continue to bill KO directly for services covered in their contract. OMH and DOH will monitor provider claims with payment entries in the Third Party field for services to children enrolled with KO.

If you have any questions contact Kids Oneida at (315) 792-9039.

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Health literacy is a measure of patients' ability to read, comprehend, and act on medical instructions. Poor health literacy is common among patients who have low educational attainment, immigrants, the elderly, racial and ethnic minorities, and patients with chronic conditions. Patients with poor health literacy levels have difficulties that range from reading labels on a pill bottle, interpreting blood sugar values or dosing schedules, to comprehending educational brochures and nutrition labels. Patients with poor health literacy have greater difficulties naming their medications and describing their indications, frequently hold beliefs that disrupt adherence to treatment regimens, and are more likely to have poor understanding of their condition and its management.

Inadequate health literacy may be a contributor to the disproportionate burden of diabetes related problems among disadvantaged populations. People with diabetes are required to self manage their chronic disease on a daily basis. The diabetes self-management regimen is one of the most challenging of any chronic illness. In a recent study conducted among patients with type 2 diabetes, it was found that poor health literacy resulted in poor blood-sugar control and higher rates of retinopathy. After adjusting for other socioeconomic and clinical factors affecting glycemic control, patients with inadequate health literacy had nearly one-half the odds of patients with adequate health literacy of achieving tight glycemic control (HbA1c of 7.2 percent or less) and two-fold greater odds of having poor glycemic control (HbA1c of 9.5 percent or more). These patients also were self-reported as having retinopathy. Although studies have demonstrated the positive impact of diabetes education, in this study diabetes education did not eliminate health literacy-related disparities and diabetes outcomes.

For health care professionals, the prevalence of poor health literacy and the strength and consistency of the association between health literacy and diabetes outcomes that were observed in this study is a key indicator for the need to change. The development of strategies to communicate more effectively with patients with poor health literacy is needed at the patient-clinician level.

A few proven strategies are to:

• Provide explanations and instructions in simple language
• Ask the patient to repeat back treatment instructions to ensure they understood
• Provide special health materials that are full of pictures and easy words, educational statistic show that one in five adults read below the sixth-grade level, and most health materials are written at the 10th grade level.

Source: JAMA: vol. 288 No. 4, July 24/31, 2002

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The National Asthma Education and Prevention Program (NAEPP) keeps clinical practice guidelines up to date by identifying selected Topics on asthma that warrant intensive review based on the level of research activity reflected in the published literature or the level of concern in clinical practice. The NAEPP's Expert Panel identified several key questions about asthma management and used a systematic review of the evidence, to prepare answers and update recommendations for clinical practice.

The Expert Panel issued an update of selected topics to The Guideline for the Diagnosis and Management of Asthma, in June 2002. The following is a synopsis of the Expert Panel's key updates and recommendations to the asthma diagnosis and management guideline:

• Inhaled Corticosteroids
  • 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
• Combination Therapy
  • Addition of a long-acting inhaled beta₂-agonist to an inhaled steroid for patients over age five 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 five
• Leukotriene Modifiers
  • 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 to Treat Asthma
  • Antibiotics are not recommended for the treatment of acute asthma exacerbation except as needed for co-morbid conditions
• Written Asthma Action Plans
  • Reaffirmed the benefits of a written asthma action plan for patient self-management

The NAEPP Expert Panel's Clinical Practice Updated Guideline Recommendations in chart format follow, included are:

• Stepwise Approach for Managing Infants and Young Children (5 Years of Age and Younger) With Acute or Chronic Asthma
• Stepwise Approach for Managing Asthma in Adults and Children Older Than 5 Years of Age: Treatment
• Usual Dosages for Long-Term-Control Medications
• Estimated Comparative Daily Dosages for Inhaled Corticosteroids

Updates the NAEPP Expert Panel Report 2, Guidelines for the Diagnosis and Management of Asthma

Source: "Correction: Update on National Asthma Guidelines Released" NIH New Release, NHLBI, June 10, 2002.

Stepwise Approach for Managing Infants & Young Children (5 Years of Age & Younger) With Acute or Chronic Asthma

Classify Severity: Clinical Features Before Treatment or Adequate Control		Medications Required To Maintain Long-Term Control
Symptoms/Day Symptoms/Night		Daily Medications
Step 4 Severe Persistent	Continual Frequent	Preferred treatment: High-dose inhaled corticosteroids AND Long-acting inhaled beta2-agonists AND, if needed, Corticosteroid tablets or syrup long term (2mg/kg/day, generally do not exceed 60 mg per day). (Make repeat attempts to reduce systemic corticosteroids and maintain control with high-dose inhaled costicosteroids.)
Step 3 Moderate Persistent	Daily >1 night/week	Preferred treatments: Low-dose inhaled corticosteroids and long-acting inhaled beta2-agonists. OR Medium-dose inhaled corticosteroids. Alternative treatment: Low-dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline. .................................................................. If needed (particularly in patients with recurring severe exacerbations): Preferred treatment: Medium-dose inhaled corticosteroids and long-acting beta2-agonists. Alternative treatment: Medium-dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline.
Step 2 Mild Persistent	> 2/week but < 1x/day >2 nights/month	Preferred treatment: Low dose inhaled corticosteroids (with nebulizer or MDI with holding chamber with or without face mask or DPI). Alternative treatment (listed alphabetically): Cromolyn (nebulizer is preferred or MDI with holding chamber) OR leukotriene receptor antagonist.
Step 1 Mild Intermittent	≤ 2 days/week ≤ 2 nights/month	No daily medications needed.

Quick Relief All Patients

Bronchodilator as need for symptoms. Intensity of treatment will depend on severity of exacerbations. Preferred treatment: Short-acting inhaled beta 2-agonists by nebulizer or face mask and space/holding chamber Alternative Treatment: Oral beta2-agonists With viral respiratory infection Bronchodilator q 4-6 hours up to 24 hours (longer with physician consult); in general, repeat no more than once every 6 weeks Consider systemic corticosteroid if exacerbation is severe or patient has a history of previous severe exacerbations Use of short-acting inhaled beta2-agonists > 2 times a week in intermittent asthma (daily, or increasing use in personal asthma) may indicate the need to initiate (increase) long-term control therapy.

 

Step Down Review treatment every 1 to 6 months, a gradual stepwise reduction in treatment may be possible. Step Up If control is not maintained, consider step up. First, review patient medication technique, adherence, and environmental control.

Note The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. Classify severity: assign patient to most severe step in which any feature occurs. There are few studies on asthma therapy for infants. Gain control as quickly as possible (a course of short systemic corticosteroids may be required); then step down to the least medication necessary to maintain control. Provide parent education on asthma management and controlling environmental factors that make asthma worse (e.g., allergens and irritants). Consultation with an asthma specialist is recommended for patients with moderate or severe persistent asthma. Consider consultation for patients with mild persistent asthma.

 

Goals of Therapy: Asthma Control
Minimal or no chronic symptoms day or night Minimal or no exacerbations No limitations on activities; no school/parent's work missed Minimal use of short-acting inhaled beta2-agonists (< 1x per day, < 1 canister/month) Minimal or no adverse effects from medications

Source: Executive Summary of the NAEPP Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma-Update on Selected Topics 2002.

The New York State Medicaid Program provides reimbursement for medically necessary care as defined by the NAEPP Expert Panel Asthma Guidelines, (including spacers, peak flow meters and nebulizers). For more information, on Medicaid coverage, please contact NYSDOH, Office of Medicaid Management, Bureau of Program Guidance at 518- 474-9219.

Stepwise Approach for Managing Asthma in Adults & Children Older Than 5 Years of Age:

Classify Severity: Clinical Features Before Treatment or Adequate Control			Medications Required To Maintain Long-Term Control
	Symptoms/Day Symptoms/Night	PEF or FEV1 PEF Variability	Daily Medications
Step 4 Severe Persistent	Continual Frequent	≤60 >30%	Preferred treatment: High-dose inhaled corticosteroids AND Long-acting inhaled beta2-agonists AND, if needed, Corticosteroid tablets or syrup long term (2mg/kg/day, generally do not exceed 60 mg per day). (Make repeat attempts to reduce systemic corticosteroids and maintain control with high-dose inhaled costicosteroids.)
Step 3 Moderate Persistent	Daily >1 night/week	>60%-<80 >30%	Preferred treatment: Low-to-medium dose inhaled corticosteroids and long-acting inhaled beta2-agonists. Alternative treatment (listed alphabetically): Increase inhaled corticosteroids within medium-dose range OR Low-to-medium dose inhaled corticosteroids and either leukotriene modifier or theophylline. .................................................................. If needed (particularly in patients with recurring severe exacerbations): Preferred treatment: Increase inhaled corticosteroids within medium-dose range and long-acting inhaled beta2-agonists. Alternative treatment (listed alphabetically): Increase inhaled corticosteroids within medium-dose range and add either leukotriene modifier or theophylline.
Step 2 Mild Persistent	> 2/week but <1x/day 2 nights/month	> 80% 20-30%	Preferred treatment: Low dose inhaled corticosteroids. Alternative treatment (listed alphabetically): cromolyn, leukotriene modifier, nedocromil, OR sustained release theophylline to serum concentration of 5-15 mcg/mL.
Step 1 Mild Intermittent	≤ 2 days/week ≤ 2 nights/month	≥ 80% < 20%	No daily medications needed. Severe exacerbations may occur, separated by long periods of normal lung function and no symptoms. A course of systemic corticosteroids is recommended

Quick Relief All Patients

Short-acting bronchodilator: 2-4 puffs short-acting inhaled beta2-agonists as needed for symptoms. Intensity of treatment will depend on severity of exacerbations; up to 3 treatments at 20-minute intervals or a single nebulizer treatment as needed. Course of systemic corticosteroids may be needed. Use of short-acting inhaled beta2-agonists > 2 times a week in intermittent asthma (daily, or increasing use in persistent asthma) may indicate the need to initiate (increase) long-term control therapy.

Step Down Review treatment every 1 to 6 months, a gradual stepwise reduction in treatment may be possible. Step Up If control is not maintained, consider step up. First, review patient medication techniques, adherence, and environmental control.

Note The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. Classify severity: assign patient to most severe step in which any feature occurs (PEF is % of personal best; FEV1 is % predicted). Gain control as quickly as possible (consider a short course of systemic corticosteroids); then step down to the least medication necessary to maintain control. Provide education on self-management and controlling environmental factors that make asthma worse (e.g., allergens and irritants). Refer to an asthma specialist if there are difficulties controlling asthma or Step 4 care is required. Referral may be considered if Step 3 care is required.

Goals of Therapy: Asthma Control
Minimal or no chronic symptoms day or night Minimal or no exacerbations No limitations on activities; no school/work missed Maintain (near) normal pulmonary functions Minimal use of short-acting inhaled beta2-agonists (<1 x per day, < 1 canister/month) Minimal or no adverse effects from medications

Source: Executive Summary of the NAEPP Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma- Update on Selected Topics 2002.

The New York State Medicaid Program provides reimbursement for medically necessary care as defined by the NAEPP Expert Panel Asthma Guidelines, (including spacers, peak flow meters and nebulizers). For more information, on Medicaid coverage, please contact NYSDOH, Office of Medicaid Management, Bureau of Program Guidance at 518- 474-9219.

Usual Dosages for Long-Term-Control Medications

Medication	Dosage Form	Adult Dose	Child Dose*
Inhaled Corticosteroids (See Estimated Comparative Daily Dosages for Inhaled Corticosteroids.)
Systemic Corticosteroids		(Applies to all three corticosteroids.)
Methylprednisolone	2,4,8,16,32 mg tablets	7.5-60 mg daily in a single dose in a.m. or qod as needed for control Short-course "burst" to achieve control: 40-60 mg per day as single or 2 divided doses for 3-10 days	0.25-2mg/kg daily in single dose in a.m.or qod as needed for control Short-course "burst": 1-2 mg/kg/day, maximum 60 mg/day for 3-10 days
Prednisolone	5 mg tablets 5 mg/5cc 15 mg/5mg/5cc
Prednisone	1, 2.5, 5, 10,20,50mg tablets 5mg/cc,5mg/5cc
Long-Acting Inhaled Beta2-Agonists (Should not be used for symptom relief or for exacerbations. Use with inhaled corticosteroids.)
Salmeterol	MDI 21 mcg/puff DPI 50 mcg/blister	2 puffs q 12 hours 1 blister q 12 hours	1-2 puffs q 12 hours 1 blister q 12 hours
Formoterol	DPI 12 mcg/single-use capsule	1 capsule q 12 hours	1 capsule q 12 hours
Combined Medication Fluticasone/Salmeterol	DPI 100,250, or 500mcg/50mcg	1 inhalation bid; dose depends on severity of asthma	1 inhalation bid; dose depends on severity of asthma
Cromolyn and Nedocromil Cromolyn Nedocromil	MDI 1 mg/puff Nebulizer 20mg/ampule MDI 1.75mg/puff	2-4 puffs tid-qid 1 ampule tid-qid 2-4 puffs bid-qid	1-2 puffs tid-qid 1 ampule tid-qid 1-2 puffs bid-qid
Leukotriene Modifiers
Montelukast	4 or 5 chewable tablet 10 mg tablet	10 mg qhs	4 mg qhs (2-5 yrs) 5 mg qhs (6-14 yrs) 10 mg qhs(>14 yrs)
Zafirukast	10 or 20 mg tablet	40 mg daily (20 mg tablet bid)	20 mg daily (7-11 yrs)(10 mg tablet bid)
Zileuton	300-600 mg tablet	2,400 mg daily (give tablets qid)
Methylxanthines (serum monitoring is important [serum concentration of 5-15 mcg/mL at steady state]).
Theophylline	Liquids, sustained-release tablets, and capsules	Starting dose 10 mg/kg/day up to 300 mg max; usual max 800 mg/day	Starting dose 10 mg/kg/day; usual max: <1 year of age: 0.2(age in weeks)+ 5 = mg/kg/day ≥ 1 year of age: 16 mg/kg/day

	Low Daily Dose		Medium Daily Dose		High Daily Dose
Drug	Adult	Child*	Adult	Child*	Adult	Child*
Beclomethasone CFC 42 or 84 mcg/puff	168-504 mcg	84-336 mcg	504-840 mcg	336-672 mcg	>840 mcg	>672 mcg
Beclomethasone HFA 40 or 80 mcg/puff	80-240 mcg	80-160 mcg	240-480 mcg	160-320 mcg	>480 mcg	>320 mcg
Budesonide DPI 200 mcg/inhalation	200-600 mcg	200-400 mcg	600-1,200 mcg	400-800 mcg	>1,200 mcg	>800 mcg
Inhalation suspension for nebulization (child dose)		0.5mcg		1.0 mcg		2.0 mg
Flunisolide 250 mcg/puff	500-1,000 mcg	500-750 mcg	1,000-2,000 mcg	1,000-1,250 mcg	>2,000 mcg	>1,250 mcg
Fluticasone MDI: 44,110, or 220 mcg/puff DPI: 50,100, or 250 mcg/inhalation	88-264 mcg 100-300 mcg	88-176 mcg 100-200mcg	264-660 mcg 300-600 mcg	176-440 mcg 200-400 mcg	>660 mcg >600 mcg	>440 mcg >400 mcg
Triamcinolone acetonide 100 mcg/puff	400-1,000 mcg	400-800 mcg	1,000-2,000 mcg	800-1,200 mcg	>2,000 mcg	>1,200 mcg

*Children ≤12 years of age

Source: Executive Summary of the NAEPP Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma- Update on Selected Topics 2002.

The New York State Medicaid Program provides reimbursement for medically necessary care as defined by the NAEPP Expert Panel Asthma Guidelines, (including spacers, peak flow meters and nebulizers). For more information, on Medicaid coverage, please contact NYSDOH, Office of Medicaid Management, Bureau of Program Guidance at 518- 474-9219.

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The Department, in conjunction with the State Office of Alcoholism and Substance Abuse Services (OASAS), has modified the Medicaid program effective December 2, 2002 to recognize outpatient chemical dependence services.

Outpatient alcoholism clinic and rehabilitation services and medically supervised ambulatory substance abuse services will be consolidated into a single system of outpatient chemical dependence treatment services, under a unified payment methodology.

This change is the result of legislation that combined the Division of Substance Abuse Services and the Division of Alcoholism and Alcohol Abuse Services into the Office of Alcoholism and Substance Abuse Services, to provide consolidated chemical dependence treatment. Additional legislation required the replacement of the discrete alcoholism and substance abuse programs and funding mandates with a single set of chemical dependence rules. Through the development of a new set of chemical dependence program regulations, OASAS is now positioned to fully integrate alcoholism and substance abuse programming in New York State.

The last step in the consolidation process is the adoption of new Medicaid fees. These new Medicaid fees are available to Article 32 providers only, and are reflected in 12 new chemical dependence rate codes. The Department and OASAS have already transmitted these new rate codes to all appropriate providers for Medicaid billing purposes.

Providers dually certified under both Article 28 and 32 will be notified of their clinic rate.

The consolidated outpatient chemical dependence services will greatly benefit Medicaid recipients by making treatment more accessible. Also, providers will have increased flexibility in making placement and ongoing treatment decisions, under a streamlined set of regulatory standards. Provider billing for outpatient chemical dependence services via the use of the 12 new MMIS rate codes and promulgated clinic rates will become effective for dates of services on or after December 2, 2002.

This Department will fully monitor the overall Medicaid expenditures for the provision of chemical dependence services to ensure that such services are being provided in the most cost effective and appropriate settings.

If you have any questions about these services, please call Mendez Avery, New York State Department of Health, Office of Medicaid Management, at (518) 486-5846.

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Effective for dates of service on or after December 1, 2002, laboratory providers may claim reimbursement for HIV drug resistance testing using the HIV Virtual Phenotypic test.

• Laboratories should use local procedure code Y8709 when billing for the HIV Virtual Phenotypic test. The maximum reimbursable amount for code Y8709 is $80.00. (Note: HIV drug resistance genotype code 87901 can be used with the Y8709 add-on code for a total reimbursement of $430.00).

HIV drug resistance testing is a covered service when clinically indicated, up to a maximum of three tests per recipient per patient treatment year.

Laboratories, designated AIDS centers, residential health care facilities and ordering practitioners are reminded of the following payment policies applicable to all laboratory testing, including HIV drug resistance testing:

• Laboratories may not bill for a test performed when a patient is hospitalized. Medicaid's payment to the hospital includes all necessary laboratory services.
• All other ordered HIV drug resistance tests are reimbursable fee-for-service directly to the testing laboratory. This includes tests ordered for:
  • Inpatients of Article 28 residential health care facilities;
  • Patients of designated AIDS centers operating under the Tier AIDS payment structure, and,
  • Patients of Article 28 certified outpatient clinics.
• Medicaid regulation requires that:
  • Payment be made to the provider actually performing the test unless the reference laboratory and the forwarding laboratory are "subsidiary related" (see June 2002 Medicaid Update, page 15), and,
  • Only Medicaid-enrolled clinical laboratories with Department of Health approval to perform HIV drug resistance testing are entitled to reimbursement.

Please direct questions to the NYS Department of Health, Bureau of Policy Development and Agency Relations, at (518) 473-2160.

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New York City Medical Assistance recipients are entitled to all necessary and appropriate transportation services to and from medical treatment. The New York City Medical Assistance Program's (MAP) transportation plan covers a full range of transportation services to accommodate the functional limitations, abilities and needs of Medicaid recipients. The provision of actual services is contingent on the Medicaid recipient's obtaining prior authorization through the medical practitioner.

Recipients are assumed to have access to means of travel other than those expressly provided by the Medicaid program. Recipients are expected to use available resources for travel to receive treatment covered by Medicaid. A recipient shall not view a trip to a medical practitioner any differently than a trip they may take for other activities of normal daily living. If a recipient has access to transportation (i.e., a private vehicle or funds for mass transit fare) to attend activities of normal daily living, he or she is expected to similarly use those resources to obtain occasional trips for medical services.

It is the joint responsibility of MAP and the medical practitioners to ensure that the least costly mode of travel, commensurate with medical need, is provided only to those persons who truly require transportation. In an effort to accomplish these goals, MAP and the NYS Department of Health developed forms and guidelines to be implemented by all medical practitioners servicing NYC MA recipients.

Medical practitioners are responsible for determining the most appropriate mode of travel (which may be either ambulette, non-emergency ambulance or livery services) required by the patient/recipient and arranging for the service when such mode is necessary. Prior authorization for livery, ambulette and non-emergency ambulance is requested when the medical practitioner completes the appropriate MAP medical justification form (MAP 2015) and submits the NYSDOH trip ordering form, the DSS 3897, to the NYSDOH fiscal agent, Computer Sciences Corporation (CSC). Do not forward the medical justification form (entitled "Medicaid Transportation Prior Approval Form", MAP 2015) to Human Resources Administration (HRA), NYSDOH or CSC. This document remains on file at the medical practitioner's location.

Prior authorization may be requested on behalf of a recipient by a licensed medical practitioner rendering care to or managing the care of an individual for which transportation is requested. If a medical practitioner refers a patient to another medical practitioner for specialty care, the medical practitioner making the referral may also order the transportation.

Requests for prior authorization, unless otherwise noted, must be fully supported with medical documentation and related information. A medical practitioner ordering transportation shall keep documentation for a period of six years in the recipient's medical record, justifying the need for travel by a particular mode. These materials must be made available for inspection by HRA pursuant to New York State Medicaid regulations.

Three factors shall be assessed in making the prior authorization determination:

1. transportation service must be to or from a Medicaid covered service;
2. when practicable, the trip shall be within five miles of the recipient's residence, the recipient's Common Medical Marketing Area; and,
3. the cost of travel must impede the ability of the recipient to obtain the Medicaid covered service.

Since most trips do not require advance review of the MAP 2015 by HRA, trips shall not be ordered by the medical practitioner when that practitioner determines that one of the prior authorization factors is not met. Services that require prior authorization review by HRA must meet all prior authorization factors. Failure to meet any one factor shall result in a denial of the prior authorization by HRA. MAP does not accept payment liability for trips that are denied prior authorization or for which prior authorization was not obtained according to HRA policy.

Should there be any doubt as to the requirements for prior authorization or how to obtain it, a recipient, their representative or any medical practitioner may contact HRA's Division of Medicaid Transportation (DMT) for additional information at (212) 630-1513 Monday through Friday from 9:00 am to 5:00 pm.

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The Office of Medicaid Management has received a grant from the Centers for Medicare and Medicaid Services (CMS) to participate in the CMS Medicaid Payment Accuracy Measurement (PAM) Project. The goals of this project are to assist states in developing PAM methodologies, conduct pilot tests of alternative approaches, and explore the feasibility of estimating payment accuracy for the Medicaid program at the national level. An essential part of this project will consist of a review of a sample of Medicaid claims and the corresponding medical records.

Beginning in November 2002, the Department will contact providers through its contractor for this project, IPRO, to obtain medical records for the services contained in the sample. If you are contacted, please respond timely to our request. This will facilitate the review and minimize the need for multiple contacts with providers in the sample.

Questions regarding this article should be directed to Payment Accuracy Measurement Project staff at (518) 474-9328.

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Edit 00705: SERVICE PAID CURRENT OR PREVIOUSLY CONFLICTING CLAIM

The service being billed matched a previously paid claim with regard to the following information: date of service, provider ID, recipient ID and procedure/rate code.

Note: The exception is Nursing Services. The service provider ID is also matched, in addition to the above information.

Edit 00727: CLAIM DUPLICATES SAME OR SIMILAR SERVICE PAID TO YOU OR ANOTHER PROVIDER

The service being billed matches a previously paid claim with regard to the following information: date of service, recipient ID and procedure/rate code. The previous claim was paid to a different provider.

When claims are automatically denied for edits 00705 and 00727, the Medicaid Management Information System (MMIS) remittance statement displays a pair of claim lines: the new claim which is denied, and directly below it the previously paid claim. In the remarks column, the remittance statement contains a previous payment date. If you are having difficulty finding the conflicting claim on the original remittance statement, please note the information below.

The previous payment date is usually a Monday and corresponds to a previous check date.

For claims that deny for edits 00705 and 00727 and show no conflicting claim line, contact New York State Department of Health (NYSDOH) or you may contact Computer Sciences Corporation (CSC) Inquiry for referral to appropriate NYSDOH numbers.

If, however, the previous payment date is a Wednesday, the last retroactive rate change in which the claim was involved is being referenced. If the claim was involved in a retroactive rate change since the original payment, MMIS will retain the retroactive remittance date as the last previous payment date. Review the retroactive remittance statement with a Monday date just past that Wednesday for the original adjudication date of the claim.

If the previous payment date is other than a Monday or a Wednesday, MMIS is referencing a processing date, which is usually a Friday. That will be the date in the upper right hand corner of the original remittance statement on which the original payment can be found.

Providers with inquiries or that want 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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Frames from the Medicaid Sample Kit

• Ordering/dispensing providers should show eligible recipients the complete line of Medicaid-reimbursable frames and explain that Medicaid pays only when a frame from the sample kit is selected and ordered from the Wallkill Optical Laboratory.
• The sample kit is the property of the NYS DOH/DOCS Eyeglass Project. If an optical provider ceases operation and/or no longer participates in Medicaid, the frame-fitting kit should be returned to the Wallkill Optical Lab. Also, if frame styles change due to a change in the DOCS contract, the old frames should be returned to Wallkill.
• If a sample frame is defective or breaks during normal handling, return it to the Wallkill Optical Lab for a replacement. The reason why the frame is being returned should be included. If a sample frame is lost, contact Hart Specialties for a replacement. You can obtain their telephone number from Wallkill.
• Particular concerns about the quality or workmanship of a certain frame (i.e., frequent allergic reactions reported or excessive number of repairs) should be discussed with the optical staff at the Wallkill Optical Lab.
• If a frame is repaired rather than replaced, a claim for the appropriate repair/refitting procedure code may be billed directly to Medicaid. We do not reimburse for materials to repair frames (i.e., screws, nose pads). Wallkill may, however, be able to provide optical dispensers with a reasonable supply of screws or nose pads. Wallkill should be contacted about how to order a back-up supply of eyeglass parts for repairing a recipient's original frame.
• From time to time, an optical dispenser may need to use part of a sample frame (i.e., broken temple) to repair a recipient's frame or a complete sample frame (i.e., unable to repair damaged frame) to replace a recipient's original frame. Prior to dispensing any frame parts or a complete frame, Wallkill Optical Lab should be contacted to check the recipient's eligibility. When this occurs, a completed order form should be faxed or mailed to Wallkill to order a replacement part or a new sample frame. (An explanation of the circumstances surrounding the need for a replacement frame must be maintained in the recipient's clinical records.)
• Occasionally, replacement of a broken frame may be preferable to repeated attempts to repair or replace parts. When billing the claim, the appropriate procedure code for repair/refitting should be used to identify the fitting of a replacement frame. (An explanation of the circumstances surrounding the need for a replacement frame must be maintained in the recipient's clinical records.)

We have revised the policy on ordering Uncut Lenses. See the information under "NOTE" below.)

To improve your service from Wallkill Optical Laboratory, the following policies apply when sending or faxing eyewear orders for Medicaid recipients:

Two Year Rule: If a recipient requires replacement of frames due to breakage or loss within two years of the last exam, the replacement frame will be the same style frame the recipient originally had. If the recipient has been to another provider, you may not know what the previous frame was when reordering eyeglasses that were lost. The previous frame will be duplicated. If a frame is received other than what was ordered, call Wallkill Optical Laboratory before the frame is sent back to verify if the frame was the original.

Bifocals: If the lens style block on the order form is left blank, Wallkill Optical Laboratory will supply the standard Medicaid bifocal that is an FT-28. If a bifocal other than an FT-28 is ordered, it should be noted under Lens Style and an explanation should be included under Special Instructions.

Patients' Own Frames: Recipients' own frames should be shipped to Wallkill Optical Laboratory by UPS or by some other service that can trace the shipment. A written list showing recipients' names, Medicaid numbers, and frame descriptions must be included with the frames so Wallkill can account for the patient's own frames that are received.

Uncut Lenses: With any order for uncut lenses, Wallkill needs the A, B, DBL, and ED measurements for the patient's own frames. NOTE: If "uncut" lenses (new prescription) and a new frame are ordered, include under Special Instructions the reason the lenses must be uncut. (In general, Wallkill provides dispensers with a complete pair of eyeglasses.)

Temples: Temples will be supplied in standard lengths unless otherwise stated under Special Instructions.

Faxed Orders: A cover sheet that lists the patients' names, Medicaid ID numbers, and the provider's telephone number must accompany all faxes. Please include the following items:

1. Provider information including provider number and locator code.
2. All patient information, especially name and Medicaid number.
3. Completed prescriptions including PD's and Segment Heights even for uncut lenses.
4. Lens style.
5. Reading only.
6. Glass or plastic.

Ordering Procedure: The Medicaid Optical Prescription Order form should be reviewed for accuracy and completeness prior to sending it to the DOH/DOCS Eyeglass Project. Incomplete or inaccurate orders require follow-up telephone calls or correspondence that delays processing.

All orders must be written clearly, especially patient name, Medicaid ID number and all prescription information.

If you have questions about the above article and/or the completion of the order form, please call the Wallkill Optical Laboratory at (800) 836-2636. If you have questions about general eye care policy, contact the Office of Medicaid Management at (518) 473-2160.

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Human Resources Administration Livery, Ambulette and Non-Emergency Ambulance Services Medicaid Transportation Prior Approval Form (January 2002) - Designed to be used by an ordering practitioner as a record of the decision to order Medicaid transportation for a NYC Medicaid recipient. The MAP 2015 form can be ordered by calling: (212) 630-1513.

Free Asthma Material (June 2002) - NYS Dept of Health has developed materials focused on asthma for pediatric patients and their caregivers to help combat asthma. The materials include brochures and posters, which can be viewed via the web at:

http://www.health.state.ny.us/diseases/asthma/index.htm

Materials can be ordered by writing or calling indicating the quantity requested (15, 25, 100), or by using the order form provided in the June 2002 Medicaid Update*:

NYS Dept of Health
(518) 465-0432
Distribution Center
Rensselaer, NY 12144-2415

Health Care Proxy Form (July 2002) - Designed to clearly inform health care providers about an individual's wishes in terms of extraordinary medical measures and to identify who will make decisions for the patient in the absence of specific directives. The Health Care Proxy form can be viewed via the web:

www.health.state.ny.us/professionals/patients/health_care_proxy/form.htm

Forms can be ordered by indicating the quantity requested (1, 25, 50, 100, 200), in writing, to the address below, or by using the order form provided in the July 2002 Medicaid Update*:

Health Care Proxy
Box 2000
Albany, NY 12220

Free Stop Smoking Materials (July 2002) New patient stop smoking materials (smoking cessation tear-off pads, pocketsize brochures and handout cards) for health care providers, pharmacies and community organizations are available through the NYS Smoker's Quitline. Materials can be ordered via the web at:
www.nysmokefree.com or by calling: (888) 609-6292

Free Diabetes Foot Screening Material (September 2002) - The Lower Extremity Amputation Prevention (LEAP) program was designed to educate primary care providers and their patients about the importance of frequent and thorough foot inspections.

US Dept of Health & Human Services  (888) 275-4772
Health Resources & Services Administration   Fax#: 703-821-2098
Information Center   e-mail - ask@hrsa.gov
PO Box 2910
Merrifield, VA 22116

NYS Asthma Action Plan (October 2002) - Designed for the primary care provider to use with families who need a simple asthma management regimen. It should be used as an education and communication tool between the provider, the patient and his or her family. The Action Plan can be ordered by writing or calling:

NYS Dept of Health  (518) 465-0432
Distribution Center
11 Fourth Avenue
Rensselaer, NY 12144-2415

Viral Prescription (October 2002) - Designed as a tool for practitioners to simplify and expedite the correct management of viral upper respiratory infections and to educate patients about their viral infections, an infection that requires proper management but not an antibiotic. The Viral Prescription Pad can be viewed via the web at:

Forms can be ordered by indicating the quantity requested (1, 5, 10, 25), in writing, to the address below, or by using the order form provided in the October 2002 Medicaid Update*:

Viral Prescription
Box 2000
Albany, NY 12220

*All Medicaid Update editions can be requested by calling the Provider Resource Unit at (518) 474-9219, or by e-mailing your request to MedicaidUpdate@health.state.ny.us. Copies are available as hardcopy, or in an electronic version.

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The Medicaid Program covers the ordering of enteral formula under certain conditions:

• Must be an integral component of a documented medical treatment plan and ordered in writing by an authorized prescriber.
• Covered for tube feeding or for oral liquid administration when there is a documented diagnostic condition where caloric and dietary nutrients from food cannot be absorbed or metabolized.
• Must be medically necessary and be substantiated in the patient's medical record by documented physical findings or laboratory data (e.g., changes in skin or bones, significant loss of lean body mass, abnormal serum/urine albumin, protein, iron or calcium levels, or physiological disorders resulting from surgery, etc.). Nutritional depletion can occur in a wide variety of medical conditions, particularly where the disease affects the gastrointestinal system. This depletion may result from the pathological processes of inadequate food intake, impaired digestion or absorption of nutrients, defective nutrient utilization or enhanced nutrient requirements. Documentation must include one or more of the following:
• Clinical findings related to the malnutrition such as recent involuntary weight loss (adults less than 85% of ideal body weight or less than 90% of normal lean body mass; or a child with no weight or height increase for six months);
• Laboratory evidence of low serum proteins (i.e., serum albumin less than 3 gms/dl; anemia or lymphopenia less than 1200/cmm);
• Failure to increase or maintain body weight with usual solid or oral liquid food intake.

Questions regarding this article may be referred to the Bureau of Medical Review and Payment at (518) 474-8161.

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Reminder! Pharmacists or pharmacy staff must call the prior authorization call line (877) 309-9493, to validate the prior authorization number.

The first step in obtaining prior authorization requires the prescriber to initiate the prior authorization process when writing for a brand drug. The second step requires the pharmacist or pharmacy staff to validate the prior authorization number before submitting the claim. If this step is omitted, the claim will not be paid.

All other requirements for prescribing brand drugs where a generic is available must also be met including: the indication of "DAW" and "Brand (Medically) Necessary" on the prescription in the prescriber's own handwriting.

All brand drugs prescribed in the Medicaid program, where an A-rated generic equivalent is available, are subject to prior authorization unless they are listed below.

Coumadin®	Gengraf®	Sandimmune®
Clozaril®	Lanoxin®	Tegretol®
Dilantin®	Neoral®	Zarontin®

The New York State Medicaid Program appreciates your support of the Mandatory Generic Initiative!

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Here are some hints to help speed up pharmacy prior authorization requests when you use the Voice Interactive Phone System (VIPS) for Pharmacy Prior Authorizations!

• Have your prior authorization worksheet complete before calling. Use the sample provided in the October Medicaid Update Supplement.
• Once you become familiar with the system, you can immediately select your numeric choice without listening to the full question.
  • For example, at the beginning of the menu, you can select "1" for Zyvox, "2" for Serostim, or "3" for Brand Medically Necessary prescriptions without listening to all choices.
• When entering telephone numbers, MMIS numbers, and other numeric values, you can move quickly to the next question by pressing the "#" key after entering the full number.

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Dental procedures that vary in difficulty or complexity from case to case are difficult to assign a fixed fee within the fee schedule. Therefore, they are designated "BR" (By Report) and are priced on a case-by-case basis through the pended claims process.

To ensure payment of an appropriate amount in the context of current Medicaid fees, please bill your usual and customary charge on all dental "BR" procedure codes.

Questions may be referred to the Bureau of Medical Review and Payment, Dental Prior Approval/Pend Unit at (800) 342-3005, option 3.

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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

The scheduled seminar will be held:

February 13, 2002 - - 10:00 AM
Westchester Department of Social Services
Basement Conference Room A
143 GrandStreet
White Plains, NY

Additional seminars may be scheduled as new programs are implemented or changes to existing billing procedures are announced.

The seminar will last approximately two hours. 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

Pharmacies contact:
eMedNY Provider Services at (800) 343-9000

Please complete the registration information using the link to the form below:

To register, please mail the completed page to:

Computer Sciences Corporation
Attn.: Provider Outreach
800 North Pearl Street
Albany, NY 12204

Or, fax a copy of the completed page to: 518-447-9240

Note: Please keep a copy of your seminar choice for your records. No written confirmations will be sent.

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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