DOH Medicaid Update October 2002 Vol. 17, No. 10

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In conjunction with "Breast Cancer Awareness Month," Governor Pataki has approved a fee increase for mammography services to assure access to essential breast cancer screening services.

Please refer to pages 7-459 through 7-463 of the Physician MMIS Provider Manual and pages 4-2 through 4-5 of both the Hospital-Based and Free-Standing Ordered Ambulatory MMIS Provider Manual for specific instructions on billing professional and technical components of radiology procedures.

Claims with a date of service on or after October 1, 2002 that were paid at the lower Medicaid fee may be re-submitted for an adjustment. Please refer to the instructions in the billing section of the MMIS Provider Manual for submitting an adjustment to a previously paid claim.

Questions regarding this article may be directed to the Office of Medicaid Management at (518) 473-2160.

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In an effort to respond to the increasing numbers of New Yorkers with diabetes, the Department of Health, with the assistance of the Center of Disease Control and Prevention, has funded a number of community coalitions. These coalitions provide a variety of services including:

• public education on diabetes awareness and prevention;
• practitioner education, patient self-management education programs;
• sponsorship of community functions for patients with diabetes; and,
• patient screening for diabetes.

These services, along with diabetes educational materials and other diabetes referrals and services, may be obtained by contacting the Diabetes Coalitions listed below:

Western NY Coalition for Diabetes Prevention/ Erie County Department of Health Counties served: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming (716) 858-7695	Diabetes Coalition of the Southern Tier Healthy Living Partnership/Broome County Health Department Counties served: Broome, Otsego, Tioga (607)778-2802	Diabetes Action Program/Via Health (Rochester General) Counties served: Chemung, Livingston, Monroe, Ontario, Seneca, Wayne, Yates (585) 922-4093 or (585) 922-4140
C-DROP Community Diabetes Recognition & Outreach Program/ Mohawk Valley Network Counties served: Oneida, Herkimer, Jefferson, Lewis, Oswego (315) 624-6005	Healthy Living Partnership of Tompkins, Cortland, Cayuga & Madison/Cortland County. Health Departments (607) 756-3416	Greater Capital Region Community Coalition for Diabetes Prevention Northeast Health Counties served: Albany, Columbia, Greene, Rensselaer, Schenectady (518) 447-3501
Seven Counties Diabetes Network, Glens Falls Hospital Counties served: Clinton, Essex, Franklin, Hamilton, Saratoga, Warren, Washington (518) 926-5920	Community Coalition for Diabetes Prevention/Schoharie County Department of Health Counties served: Schoharie, Fulton, Montgomery (518) 295-8474	Mid-Hudson/Catskill Community Coalition for Diabetes Prevention/Community General Hospital of Sullivan County Counties served: Dutchess, Orange, Sullivan, Ulster (845) 794-3300 ext. 2135
Diabetes Resources Coalition of Long Island Counties served: Nassau, Suffolk (631) 727-7850	Southwest Brooklyn Diabetes Coalition (718) 630-6726 __________________________________________ Pinnacle Healthcare Counties served: Westchester, Putnam, Rockland (914) 964-4558	Community Advances in Nutrition for Diabetes Through Education and Empowerment (CANDEE) Mt. Sinai School of Medicine (212) 659-9567

The NYS Medicaid Program reimburses for medically necessary care, services, and supplies for the diagnosis and treatment of diabetes. For more information, contact the Bureau of Program Guidance at (518) 474-9219.

For more information on diabetes, go the New York State Department of Health website at
http://www.health.state.ny.us/diseases/conditions/diabetes/, or call the Diabetes Control Program at (518) 474-1222.

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Under Commissioner Novello's leadership, the Department of Health has made a commitment to assist Medicaid recipients in smoking prevention and cessation. Medicaid provides reimbursement for prescription and non-prescription smoking cessation drugs. A toll-free smoker's Quitline (888-609-6292) is available to all New Yorkers, including Medicaid recipients.

Policy

• Smoking cessation therapy consists of prescription and non-prescription agents. Covered agents include nicotine patches, inhalers, nasal sprays, gum, and Zyban (bupropion).
• Two courses of smoking cessation therapy per recipient, per year are allowed. A course of therapy is defined as no more than a 90-day supply (an original prescription and two refills, even if less than a 30-day supply is dispensed in any fill).
• If a course of smoking cessation therapy is interrupted, it will be considered one complete course of therapy. Any subsequent prescriptions would then be considered the second course of therapy.
• Multiple smoking cessation therapies, using different routes of administration, are allowed (e.g., Zyban and nicotine patches may be used concomitantly if warranted). Professional judgment should be exercised when dispensing multiple smoking cessation products.
• Duplicative use of any one agent is not allowed (i.e., same drug/same dosage form/same strength).
• Pharmacists--The Dispensing Validation System (DVS) must be used when dispensing smoking cessation products (see below).

DVS Guidelines for Pharmacists

• Approval must be obtained through DVS by using the National Drug Code (NDC) number for the drug prescribed. The claim will go through all DVS editing.
• Claims with a DVS approval will also be subject to on-line Drug Utilization Review (DUR). Issuance of a DVS prior approval number does not guarantee payment. Be sure to monitor all DUR messages appropriately.
• A Prior Approval number will not be issued manually to override or circumvent the DVS.
• Upon receiving the DVS approval number, the pharmacist should record the number. This number is necessary for all adjustments and claim resubmissions.
• The DVS claim date must match the date of dispensing.

Smoking Cessation Agents Claim Submission Instructions for DVS/DUR

• These transactions can be submitted through both the DUR NCPDP 3.2 variable format and RTDS "3A" fixed formats.
• Only one DVS transaction can be submitted at a time. Use NCPDP Field 103 (Transaction Code),Value 01 only. If other DUR NDC codes are submitted in the same transaction (Values 02-04), the first claim must be the smoking cessation product's DVS claim.
• The pharmacy's category of service must be entered in the last four positions (29-32) of the NCPDP Field 201 (Pharmacy Number). Valid categories of service are 0441 (Freestanding Pharmacy), 0161 (Clinic Pharmacy), and 0288 (Hospital Pharmacy).
• NCPDP Field 406 (Compound Code) must contain a Value of 1.
• The corresponding NDC of the smoking cessation product must be entered in NCPDP Field 407 (NDC Number).
• The Date of Service must be the Current Date for a DVS transaction.
• Each smoking cessation refill requires a new DVS number. For example, a prescription written for an original and two refills would require THREE UNIQUE DVS NUMBERS. Pharmacies should make sure that the previously issued DVS number for that script is cleared from their software prior to transmitting each script's refill. Depending on your software, failure to clear the number would transmit the previous DVS number on the claim. This would prevent a new DVS number from being issued, causing the claim to be denied by the fiscal agent's DVS approval processing edits.
• If approved, a DVS approval number will be returned in field 526. If rejected, a reason code will be returned.
• DVS Reason Codes are returned in the response in NCPDP Field 504 (Message), position 89-91 (variable 3.2 format) and positions 100-102 (fixed RTDS 3A format). A list of these reason codes can be found in Table 9, page 64 of the DUR Provider Manual.
• The eight-digit DVS number is returned in NCPDP Field 526 (Additional Message) positions 68-75 (variable 3.2 format) and positions 345-352 (fixed RTDS 3A format).
• FOR FUTURE REFERENCE, ALWAYS RECORD THE DVS NUMBER WHEN RETURNED.
• DVS instructions can be found in your DUR Provider Manual on pages 10 and 11.

For further information on the policy regarding smoking cessation, please call the Pharmacy Policy Unit at (518) 486-3209.
For questions regarding the actual on-line transmission of a smoking cessation claim, call (800) 343-9000.

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In the recently released Executive Summary of The National Asthma Education and Prevention Program, Expert Panel Report-2 Guidelines for the Diagnosis and Management of Asthma- Update on Selected Topics 2002, the recommendation to develop an asthma action plan for patient self-management < remains unchanged

The use of written asthma action plans, as part of an overall effort to educate patients in self-management, is recommended, especially for patients with moderate or severe persistent asthma and patients with a history of severe exacerbations

The Department of Health, together with the healthcare community, has developed an Asthma Action Plan. The purpose of New York's Asthma Action Plan is to help families become proactive and anticipatory with respect to asthma exacerbations and their control. The Asthma Action Plan should be used as an education and communication tool between the provider, the patient and his or her family. The patient/family should be able to demonstrate an understanding of the plan and the appropriate use of medicines.

The Asthma Action Plan has been designed for the primary care provider to use with families who need a relatively simple asthma management regimen. Practitioners should also provide additional educational material about asthma, peak flow monitoring, and environmental control.

The Asthma Action Plan's three page carbonless paper format allows the practitioner to keep one copy for the medical record, one copy for the patient/family to keep for their information, and one copy for school, daycare or work.

The NYS Asthma Action Plan is available in English (Publication # 4850) and Spanish (Publication # 4851) at no cost to practitioners within New York. To order the Asthma Action Plan, call (518) 465-0432 or write to :

A complete order form and a listing of other asthma educational materials available may be found on the NYSDOH website at: http://www.health.state.ny.us/diseases/asthma/brochures.htm

The Medicaid Program reimburses for medically necessary care services, and supplies needed in the diagnosis and treatment of asthma. For information regarding Medicaid payment of these services, contact the Bureau of Program Guidance at (518) 474-9219.

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In 2000, the New York State Department of Health joined with the health care community to form the New York State Upper Respiratory Infection Project Committee. The committee sponsored the First Statewide Conference on Antibiotic Resistance at Hudson Valley Community College in Troy in April 2002. At that conference, a "Viral Prescription" pad developed by the committee was introduced.

The "Viral Prescription"

• provides practitioners with a tool that simplifies and expedites the correct management of viral upper respiratory infections;
• allows practitioners to rapidly and consistently educate patients about their viral infection, an infection that requires proper management but not an antibiotic; and,
• has been piloted by clinicians statewide and appears to be highly effective in dealing with the inappropriate demand for an antibiotic by some patients or their parents.

Committee members recommend that the "Viral Prescription" be used as a management aid and introduced to the patient after examining the individual and determining that the patient has a viral upper respiratory infection. Please take time with the patient to review the areas of the Prescription you feel are the most appropriate in managing his/her particular symptoms. The "Viral Prescription" includes general instructions for managing the symptoms of a viral upper respiratory illness, possible over-the-counter medications that may be helpful, and a section for follow-up monitoring.

The Upper Respiratory Infection Project Committee seeks your help in addressing this important public and personal health issue. Please use the "Viral Prescription" in your practices.< Please feel free to reproduce copies for your use or see the order form below.

Please send any comments or suggestions to: abxuse@health.state.ny.us .

YES! I want to use the Viral Prescription in my practice.

Please send:

_____ Viral Prescription Pad (50 sheets per pad)_____1_____5_____10_____25

Name:________________________________________________________________________

Street Address:_________________________________________________________________

City_____________________________________________ State __________ Zip ___________

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As previously announced, the Department of Health will soon be implementing eMedNY, a new Medicaid system that will consolidate the Medicaid Management Information System (MMIS) and the Electronic Medicaid Eligibility Verification System (EMEVS). eMedNY is being developed by, and will be operated by, Computer Sciences Corporation.

Phase I of eMedNY, Medicaid Eligibility Verification Systems (MEVS), will replace the functionality currently provided by EMEVS. The turnover of EMEVS processing to eMedNY is scheduled to take place during the weekend of November 16, 2002.

The consolidation and modernization of operations under eMedNY is designed to offer enhanced features for providers interacting with the Medicaid program while ensuring a seamless transition with minimal impact on providers.

FULL ONLINE CLAIM ADJUDICATION

One of the enhancements of the eMedNY is its capability to provide Electronic Claim Capture and Adjudication (ECCA). In fact, during Phase I eMedNY will perform full online adjudication for pharmacy claims and return an immediate claim status response, which will allow pharmacy providers to determine if their claims were approved for final payment. eMedNY will continue to capture (approve for payment/pend) or reject pharmacy claims as appropriate.

In order to adjudicate claims online, full editing needs to be performed. Consequently, new pend and denial codes have been added to the current response tables in the NCPDP specifications. The tables and response codes can be found in the revised ProDUR/ECCA Provider Manual, which will be made available prior to implementation.

With eMedNY, pharmacies will also be able to submit online claim adjustments and reversals even for claims that were originally submitted via magnetic media or paper.

Pharmacies will continue to receive complete information regarding paid and pended claims on their weekly remittance statements as they do now. Claims that are rejected during the online processing, however, will not appear on remittance statements. (NOTE: Medicaid payments and remittance statements will continue to be lagged, as currently in accordance with State Law.)

In September 2002, a letter was sent to all pharmacies providing detailed notification of all the changes to the NCPDP specifications related to online claim adjudication. If you have not received this letter, you should request a copy by calling CSC's Provider Services at (866) 488-3717 Monday through Friday from 9:00 a.m. to 5:00 p.m.< prior to November 16, 2002.

Provider Services

CSC's Provider Services will provide telephone support for all eMedNY transactions. CSC will retain the same telephone number that is currently used for EMEVS inquiries: (800) 343-9000. After November 16, 2002, CSC's Provider Services business hours for EMEVS inquires will be Monday through Friday from 7:00 a.m. to 10:00 p.m. and Saturday, Sundays, and holidays from 8:30 a.m. to 5:30 p.m. After these hours, providers may still call Provider Services for emergency inquiries>

IMPORTANT INFORMATION-PHARMACY CLAIM CORRECTION FORMS

With eMedNY Phase I implementation, there will be no facility for processing < pharmacy

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Recently, Department of Health utilization review staff has discovered several instances where pharmacies have been billing with generic NDC numbers that the distributor has stopped using several years ago.

When filling generic prescriptions, please be sure that you transmit the NDC number of the product you are dispensing.

Frequently, the prices of generic drugs come down as competition increases. Pharmacies may get a higher reimbursement by billing with the older NDC number. Providers engaging in this practice may be subject to recoupment or exclusion from the Medicaid Program.

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Coming to you soon!

A special edition of the Medicaid Update,

Devoted to the new Medicaid Law on Mandatory Generics!

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As you are aware, the Department of Health has mailed to pharmacy providers a listing of providers who are not eligible to prescribe for Medicaid recipients. This listing is commonly referred to as the PVR-292 listing.

Effective January 2003, the New York State Department of Health is discontinuing the automatic mailing of this listing to every Pharmacy provider.

The need to continue to mail a hard copy of the list of disqualified providers (PVR-292) has been diminished through a number of activities. As claims are transmitted via the online Prospective Drug Utilization Review system, the provider is supplied the license verification. In addition, the PVR-292 is now available on the DOH website at www.health.state.ny.us/health_care/medicaid/fraud/dqprvpg.htm. This electronic version is downloadable by anyone who would like to print a copy for personal use.

In recognizing these new and improved ways of ensuring that ineligible providers do not prescribe for Medicaid recipients, the Pharmacy Advisory Committee (PAC) for the Medicaid program passed a resolution in 2002 supporting the elimination of hard copy mailings.

Hardcopies will no longer be sent automatically to pharmacies. Mailings of the PVR-292 will be discontinued effective January 2003, unless you request continuation of hard copies before December 1, 2002, by completing the form below and mailing it to the following address:

I wish to continue to be mailed a hard copy of the PVR-292.
Name_______________________________________
Provider ID#________________________________
Address____________________________________
___________________________________________
___________________________________________

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• Overview of MMIS
• Discussion of Medicaid Managed Care
• Explanation of 90-day Regulation
• Explanation of MMIS Provider Manual
• Overview of Billing Options
• Explanation of Utilization Threshold Program

Please indicate the seminar(s) you wish to attend below:

Additional seminars may be scheduled as new programs are implemented or changes to existing billing procedures are announced.
Please complete the registration information using the link to the form below:
To register, please mail the completed page to:

Direct questions about these seminars to CSC as follows:

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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Reminders To Be Compliant

• Transactions and Code Sets testing must begin by April 15, 2003. It is imperative that you conduct an assessment of your administrative and operational procedures and develop an appropriate HIPAA compliance strategy for your organization.
• The Privacy Rule was published in the Federal Register on December 28, 2002. A "paperwork glitch" delayed the rule's effective date to April 14, 2001. The compliance date is April 14, 2003. To insure that the provisions of the Privacy Final Rule provide strong privacy protection without hindering access to healthcare, the Department of Health & Human Services proposed modifications to the Rule. On August 14, 2002 these modifications were published in the Federal Register. Information on these modifications and the complete Final Rule may be accessed at http://www.hhs.gov/ocr/hipaa/privrulepd.pdf
• "The HIPAA Privacy Rule: Checklist - What Needs to be Done?" references key sections of the Privacy Rule and details actions necessary to insure compliance. The checklist may be accessed at our Medicaid HIPAA website, http://www.health.state.ny.us/health_care/medicaid/hipaa/privacy.htm

Provider Survey Results

• In April, the Department of Health's Office of Medicaid Management, HIPAA Practice Group, and Computer Sciences Corporation mailed out a HIPAA Readiness Survey to over 40,000 Medicaid providers who bill electronically. The main purpose of the survey was to assess the provider community's knowledge of the HIPAA legislation and learn more about the status of our providers² HIPAA compliance efforts. We have received over 8,000 responses to the survey. The preliminary results are not as encouraging as we had hoped. Below are some of the results:
  • 61% of the practitioners (i.e. physicians, psychologists, etc.) and 45% of the institutional providers (i.e. hospitals,nursing homes, home health agencies, etc.) who responded to the survey indicated that they had not begun a HIPAA education/awareness program.
  • 72% of the practitioners and 67% of the institutional providers who responded had not conducted an assessment of their practice/business processes to determine HIPAA impact.
  • 53% of practitioners and 37% of the institutional providers who responded indicated that they do not know what they have to do first to become HIPAA compliant.

We urge all our providers who bill electronically to undertake necessary steps to insure HIPAA compliance. Remember, Transactions and Code Sets testing must begin by April 15, 2003 and you must be compliant by October 16, 2003. We will be providing you with a Medicaid companion document well in advance of the April testing date, and we will be scheduling regional Medicaid HIPAA training in early 2003. But, you should not be waiting for Medicaid. You should assess your business processes and determine what administrative/system changes will be required for you to become HIPAA compliant. < As of October 16, 2003 Medicaid will only accept HIPAA compliant electronic transactions.

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Beginning November 17, 2002, most brand-name drugs with a generic equivalent will not be covered by the Medicaid program, unless a prior authorization is obtained. This new requirement is a result of legislation passed in January 2002.

If a generic drug is prescribed, no additional actions will be required. However, when writing a prescription for a brand-name drug that has a generic available, the prescriber will need to call the prior authorization line. The prior authorization number that is assigned must be written on the prescription or Medicaid will not reimburse the brand-name drug. The pharmacist will also need to validate the prior authorization number before submitting the claim.

A limited number of brand-name drugs with generic equivalents are exempted from these new Medicaid requirements. There is also a process to request that other brand-name drugs be exempt for all Medicaid recipients.

A Special Edition Medicaid Updatehas been released which provides detailed instructions on the new program, and answers to common questions for physicians, other prescribers, and pharmacists. The information is available on the Department of Health website.

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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