DOH Medicaid Update February 2003 Vol.18, No.2

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All Medicaid fee-for-service transportation must be prior approved by the Onondaga County Department of Social Services. If your patient requires taxi, wheelchair, van, or ambulance transportation to travel to your office or facility, prior approval must be obtained by calling, faxing or e-mailing to the numbers or address below.

Telephone: (315) 701-7500, Fax: (315) 475-8123, or e-mail: RMMAS@twcny.rr.com

If your patient is enrolled in a Medicaid managed care plan, please contact the managed care plan to arrange for necessary transportation services.

Questions? Please contact Kathleen Hart of the Onondaga County Department of Social Services at (315) 435-2813.

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"Get With The Guidelines"
"Get with the Guidelines" is a new guideline-based hospital program which provides tools and resources to assist medical professionals in building systems to translate what is known about vascular disease secondary prevention into what is done in clinical practice.

Studies have demonstrated significant improvement among patients when secondary prevention interventions are implemented while the patient is still in the hospital. For more information about the American Heart Association or "Get with the Guidelines", visit the American Heart website at:

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The New York State Department of Health, Office of Medicaid Management, in conjunction with the Island Peer Review Organization (IPRO), will present seven teleconferences on clinical issues in asthma and diabetes. The sessions will each last for sixty minutes.

The teleconferences are free of charge, fulfill criteria for continuing medical education credit and will include a question and answer session with clinical experts. There will be a recording of each teleconference topic (via digital replay) made available for 24 hour per day access via telephone for those clinicians who cannot make any of the teleconference times. The teleconferences include materials that will be sent to registered participants and will also be made available on the IPRO website.

Topics, Times and Speakers:

"An Update in the Management of Adult Asthma" - Dr. Jill Karpel, North Shore-Long Island Jewish Health System

"An Update in the Management of Pediatric Asthma" - Dr. Sujatha Ramesh, Children's Hospital of Buffalo

"Issues and Practical Approaches to Cardiovascular Disease Prevention and Management in Patients with Diabetes" - Dr. Daniel Lorber, New York Hospital Medical Center of Queens/Diabetes Control Foundation, or Dr. Ruth Weinstock, SUNY Syracuse/Joslin Clinic

You may register online on the IPRO website at: www.ipro.org by phone: 516-326-7767, extension 410.

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Black and Hispanic children with asthma are more likely to be hospitalized or utilize emergency department services due to poorly controlled asthma far more frequently than white children with asthma. A recent study conducted by the Asthma Care Quality Assessment (ACQA) Project has demonstrated that this disparity in asthma status may simply reflect a difference in the use of preventive medications for asthma.

The ACQA Project is an ongoing quality of care initiative for Medicaid-insured children in five managed care organizations in California, Washington, and Massachusetts. ACQA recently conducted a cross-sectional study utilizing both a telephonic parent survey and computerized medical records and claims data of children (aged 5-16 years) with asthma. Of the 1,658 children in the respondent group, 38 percent were black, 19 percent were Hispanic, and 31 percent were white. Black children had worse asthma status than white children on the basis of the American Academy of Pediatrics (AAP) asthma physical and emotional health scores, symptom-days, and school days missed in the past two weeks. Hispanic children had equivalent AAP asthma physical health score to the black children.

Despite having worse asthma than white children, black and Hispanic children with similar insurance and social demographic characteristics were 31 percent and 42 percent, respectively, less likely to be using inhaled anti-inflammatory medication (including inhaled steroids) to prevent the beginning or worsening of an asthma episode. Other asthma care processes, including rating of providers and asthma care, use of written management plans, use of preventive visits and specialists, having no pets or smokers at home, were equal or better for minority children compared with white children.

These study findings suggest that nonfinancial barriers, such as differences in health beliefs, and concepts of disease, fears about steroids, or communication barriers (including language) between doctors and patients may play an important role in sub optimal medication use. Increasing the use of preventive medications should be a focus for improving quality of care for minority children with asthma.

According to the National Asthma Education and Prevention Program, Guidelines for the Diagnosis and Management of Asthma-Update on Selected Topics 2002, use of inhaled corticosteroids are preferred for controlling and preventing asthma symptoms, and for improving lung function and quality of life. In addition, the Update reflects new data that provides reassuring evidence on the safety of inhaled steroid use at appropriate doses in children. The Update also concludes that combination therapy, adding long-acting beta 2-agonists to inhaled steroids, is more effective than simply increasing the dose of inhaled steroids for patients over age five who have moderate or severe persistent asthma.

Source: Pediatrics, May 2002, 109 (5), pp. 857-865.

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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According to the American Diabetes Association (ADA), people with diabetes are 25-30 times more likely than the general population to lose their sight from retinopathy, cataracts or glaucoma. Diabetic retinopathy is a highly specific vascular complication that affects individuals with either type 1 or type 2 diabetes. The prevalence of retinopathy is strongly related to the duration of diabetes. Early detection and treatment can substantially reduce severe vision loss or blindness.

Patients with type 1 diabetes should visit an eye care professional annually* for a dilated eye exam beginning five years after the onset of diabetes.
Women with type 1 diabetes who are pregnant should have a comprehensive eye exam in the first trimester and close follow-up throughout pregnancy.
Patients with type 2 diabetes should visit an eye care professional shortly after diagnosis of diabetes and annually* thereafter.

*Providers must bill the appropriate evaluation and management code for the annual eye exam.

Additionally, people with diabetes should visit their eye care professional if they experience any of the following symptoms between their routinely recommended eye examinations.

For more information about diabetes and vision, the following websites are available:

The Medicaid Program reimburses for medically necessary care, services and supplies for the diagnosis and treatment of diabetes. More information regarding Medicaid coverage of services related to diabetes may be found on the NYSDOH website at:

Or contact the Bureau of Program Guidance at (518) 474-9219.

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Each year the Bureau of Health Economics of the New York State Department of Health determines the 20 most frequently billed Diagnosis Related Groups (DRG's). When payment for one of these DRG's is indicated, the remittance statement will list rate code 2996 rather than 2946.

Effective discharge date January 1, 2003, the Top 20 DRG's are:

Questions should be directed to the Bureau of Medical Review and Payment, Rate Based Provider Unit, (518) 474-8161.

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• Effective October 1, 2002, HIV genotypic and phenotypic drug resistance tests will no longer be included in the benefit package provided by managed care plans.
  • HIV drug resistance tests performed on or after October 1, 2002 should be billed to MMIS, rather than the managed care plan.
  • Medicaid managed care enrollees will obtain these services through the Medicaid fee-for-service program when ordered by an HIV specialist. As required for other Medicaid covered services excluded from the Medicaid managed care benefit package, enrollees will use their Medicaid card to obtain services from qualified Medicaid providers.
• 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 should use MMIS procedure code 87901 when billing for the HIV genotypic assay. The maximum reimbursable amount for code 87901 is $350. Laboratories should use MMIS procedure code 87903 when billing for HIV phenotypic assay. The maximum reimbursement amount for code 87903 is $675.29. Laboratories should use MMIS procedure code 87904 for each additional 1 through 5 drugs tested (list separately in addition to code for primary procedure). Payment for HIV virtual phenotype testing will be effective December 1, 2002. Local code "Y8709" should be used for payment @ a price of $80.00
  • HIV drug resistance testing is a covered service when clinically indicated, up to a maximum of 3 tests (any combination of genotypic and phenotypic) per recipient per patient treatment year.
  • Laboratories may not bill on a fee-for-service basis for a test performed while a patient is in hospital inpatient status. Medicaid payment to the hospital includes all necessary laboratory services.
  • All ordered HIV drug resistance tests are reimbursable fee-for-service directly to the testing laboratory. This includes tests ordered for:
    • Outpatients and 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); and
  • Medicaid-enrolled clinical laboratories with Department of Health approval to perform HIV drug resistance testing are entitled to reimbursement.

If you have questions about the Medicaid managed care benefit package, please contact Elizabeth Macfarlane at (518) 473-0122.

If you have questions on coverage for HIV resistance tests, please contact the Bureau of Policy Development and Agency Relations at (518) 473-2160.

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For Medicaid patients, the basis of payment for most clinic services provided in hospital outpatient departments and diagnostic and treatment centers certified under Article 28 of the Public Health Law is the threshold visit. A threshold visit occurs each time a patient crosses the threshold of a facility to receive medical care without regard to the number of services provided during that visit. Thus, a threshold visit is counted each time a patient crosses the threshold at any of a facility's authorized sites to receive medical care. The visit is all-inclusive, i.e., it includes all of the services medically necessary and rendered on that date.

A threshold visit occurs each time a patient crosses the threshold of a facility to receive medical care without regard to the number of services provided during that visit.

To be billable under Medicaid, a clinic visit must include an identifiable medical service clearly and accurately identified in the medical record. When a Medicaid patient receives treatment during a threshold clinic visit that cannot be completed due to administrative or scheduling problems, the Article 28 facility may NOT bill additional clinic visits for the completion of the service. For example, the completion of clinical laboratory tests, blood draws or x-rays, that are scheduled subsequent to the initial clinic visit do not qualify for reimbursement, unless the patient is also seen for purposes of discussing the findings and for definitive treatment planning.

Further, the administration or dispensing of a prescription or non-prescription drug is likewise not billable under Medicaid because it does not constitute a unit of medical service. A clinic visit solely for the purpose of having medication dispensed by a medical professional does not qualify as a threshold visit in a clinic certified under Article 28 of the Public Health Law, even when the patient cannot self-medicate due either to a physical or mental disability. Visits for the sole purpose of medication administration that is not given in concert with a clinical service, or related clinical service, are NOT claimable.

In addition, Department regulations prohibit reimbursement as a threshold visit for pharmacy, nutrition, medical social services, respiratory and recreation therapy services in the absence of other medical services being rendered to the patient.

To see an explanation on this issue for Article 16 clinics certified by the Office of Mental Retardation and Developmental Disabilities, please see the December 1995 Medicaid Update article"Attention: OMRDD Day Treatment and Clinic Providers."

Questions about this article, or requests for copies of the December 1995 Medicaid Update article, can be directed to the Bureau of Policy Development and Agency Relations at (518) 473-2160.

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In April 2003, the Office of Medicaid Management will be activating edits that require identification of the servicing provider. These edits verify that the servicing MMIS provider identification numbers reported on the claims are accurate and legitimate. The servicing provider identification field on the claim will be matched against the Department of Health's MMIS identification number file.

Optical providers that employ other licensed opticians and/or optometrists (enrolled with categories of service 0401, 0402 or 0423) MUST complete the servicing provider identification number field.

• On paper claims, the service provider identification number field is 22C. Field 22A must also be completed with the service provider name. Field 22B is left blank.
• For electronic submission, the service provider identification number field is on the D2 record, positions 58-65.

Self-employed optometrists (enrolled with category of service 0422) and self-employed opticians (enrolled with category of service 0404) SHOULD NOT complete the servicing provider identification number field since the servicing provider and the billing provider are the same.

If you have any questions, please contact the Bureau of Policy Development and Agency Relations at (518) 473-2160.

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Effective February 1, 2003, the Suffolk County Medical Services Bureau will no longer review or process prior approval requests for Private Duty Nursing services.

All administrative functions related to prior approval requests for Suffolk County private duty nursing recipients will be transferred to the State Health Department's Bureau of Medical Review and Payment in Albany.

Starting on February 1, 2003, please submit prior approval requests and required documentation to the following address:

Questions should be directed to the Suffolk County Medical Services Bureau at (631) 854-9835 or to the NYSDOH, Bureau of Medical Review and Payment at (518) 474-8161.

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Effective January 1, 2003, all claims over two years old MUST INITIALLY be submitted directly to Computer Sciences Corporation within 90 days of the date control was passed to you. As part of the process your claim will be denied. A denial message (Edit 01292 - DOS Two Yrs Prior to Dte Recvd) will appear on your remittance statement. Requests for waiver of the regulation regarding submission of claims greater than two years from the date of service must then be submitted to the address below within 90 days of the Edit 01292 denial as noted on the remittance statement. Supporting documentation (cover letter of explanation, remittance statements, and notice of eligibility, fair hearing decision, evidence of agency error, etc.) must accompany your written request.

Any waiver requests received without a copy of the remittance statement documenting an Edit 01292 denial will be returned without further processing.

If you have any questions on the processing, review or disposition of claims over two years old, please call (800) 562-0856.

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Medicaid regulations require that claims for payment of medical care, services, or supplies to eligible recipients be initially submitted within 90 days of the date of service to be valid and enforceable, unless the claim is delayed due to circumstances outside the control of the provider. Acceptable reasons for a claim to be submitted beyond 90 days are:

• Litigation;
• Medicare and other insurance processing delays;
• Delay in Medicaid eligibility determinations;
• Rejection or denial of the original claim for reason(s) other than the 90-days rule;
• Administrative delay in the prior approval process;
• Interrupted maternity care; and
• IPRO denial/reversal.

Please note that if a claim is denied or returned for correction, it must be corrected and resubmitted within 60 days of the date of notification to the provider. Claim not correctly resubmitted within 60 days, or those continuing to not be payable after the second resubmission, are neither valid nor enforceable. In addition, all claims must be finally submitted to the Fiscal Agent and be payable within two years from the date the care, services or supplies were furnished in order to be valid and enforceable as against the Department or a social service district.

All claims initially delayed over 90 days must be submitted within 30 days from the time submission came within control of the provider. For paper claims, a cover letter must be attached which specifies one or more of the acceptable reasons noted above.

Resubmitted paper claim forms should be typed or printed legibly in order to reduce delays in processing. Claim forms including attachment(s) or required documentation may be submitted in batches (50 forms or less) and enclosed in a single envelope or package. The invoice number of each claim form in the batch must be specified on the cover letter.

Please send all paper claims less than two years old directly to:

Be sure to send the original claim form and retain a xerox copy for your files.

• Claims submitted via tape, diskette or modem must specify the appropriate late submission reason code. Refer to the MMIS electronic billing instructions issued by the Fiscal Agent for valid coding.

Claims submitted to CSC over two years old will be automatically denied. A denial message (Edit 01292 - DOS Two Yrs Prior to Dte Recvd) will appear on providers' remittance statements. The Department will consider claims over two years old for payment if the provider can produce documentation verifying that the cause of the delay was the result of one or more of the following:

• Errors by the Department, a local social services district, or another agent of the Department;
• Court ordered payments.

Initially, claims should be submitted to CSC for payment within 90 days of the date control was passed to the provider. Requests must then be submitted within 90 days of the Edit 01292 denial as noted on the remittance statement with all supporting documentation (cover letter of explanation, remittance statements, notice of eligibility, fair hearing decision, etc.) to:

Please note: Claims submitted for review without the appropriate documentation, or those not submitted within the 90-day time period for review, will NOT be considered for payment.

If you have any questions on the processing, review or disposition of claims over two years old, please call (800) 562-0856.

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The New York State Department of Health (NYSDOH) implemented the Family Planning Benefit Program (FPBP) effective October 1, 2002. This program provides Medicaid coverage for family planning services to all persons of childbearing age with incomes at or below 200% of the federal poverty level. This population will have access to all enrolled Medicaid family planning providers and family planning services currently available under Medicaid. The local social services districts are accepting applications from potentially eligible recipients for the FPBP. Entities (such as family planning and Prenatal Care Assistance Program providers) that have agreements (memoranda of understanding) with the local social services districts, will soon be assisting with applications for this program. Potentially eligible individuals will be screened for eligibility for Medicaid and Family Health Plus, unless they specifically request to be screened only for FPBP eligibility.

Family planning services under this program can be provided by all Medicaid enrolled family planning providers including hospital-based and free-standing clinics, federally qualified health centers or rural health centers, obstetricians/gynecologists, physicians, nurse practitioners, licensed midwives, pharmacies and laboratories that provide family planning related services.

Family planning services include:

• All FDA approved birth control methods, devices, pharmaceuticals, and supplies
• Emergency contraceptive services and follow-up
• Male and female sterilization in accordance with 18 NYCRR Section 505.13(e)
• Preconception counseling and preventive screening and family planning options

The following additional services are considered family planning only when provided during a family planning visit and when the service provided is directly related to family planning:

• Pregnancy testing and counseling
• Counseling services related to pregnancy and informed consent, and STD/HIV risk counseling
• Comprehensive reproductive health history and physical examination, including clinical breast exam - excludes mammography
• Screening for STDs, cervical cancer, and genito-urinary infections
• Screening and related diagnostic testing for conditions impacting contraceptive choice, i.e. glycosuria, proteinuria, hypertension, etc.
• HIV counseling and testing
• Laboratory tests to determine eligibility for contraceptive of choice
• Referral for primary care services as indicated

A recipient may require follow-up treatment for a condition identified during the family planning visit. However, Medicaid payment will not be available for that follow-up treatment. NYSDOH funded family planning providers must (consistent with Title X requirements) provide follow-up treatment for any STD or genito-urinary infections diagnosed during a family planning visit as part of their clinic visit rate. If an additional visit is required for the FPBP-enrolled client, Family Planning grant funds should be utilized. Treatment should be provided to the client at no cost. For providers who do not receive grant funds from the NYSDOH for family planning, treatment should either be provided, or, if necessary, clients should be referred appropriately, such as to the County Health Department, as in any other situation involving treatment of the uninsured.

Requirement for Payment:

• To insure Medicaid payment, the family planning field on the claim form must be completed to indicate a family planning service has been provided. This applies to all providers billing for family planning services, e.g., physicians, laboratories, clinics, and nurse practitioners. If this field is not accurately completed, the service being claimed is not reimbursable. If the service provided is not related to family planning, it cannot be billed under this program.
• Appropriate family planning diagnosis codes in the V25 series must be used when required on the claim form.
• Providers can begin rendering services to recipients eligible for this program. Payment for services may be retroactive to October 1, 2002 for eligible recipients under normal retroactive coverage rules. Providers submitting claims after 90 days from the date of service should use one of the following acceptable 90 day reasons:
  • Delay in Medicaid Client Eligibility Determination
  • Administrative Delay (System was available for claim payment on November 18, 2002)
• Family planning providers who order laboratory tests related to family planning must indicate on the laboratory requisition form or the written order for the laboratory test that the test is related to family planning

Systems Information:

When verifying a recipient's eligibility via the Medicaid Eligibility Verification System (MEVS):

• eMedNY MEVS System will return the following responses for FPBP eligible recipients:
  • ARU: ELIGIBLE ONLY FAMILY PLANNING SERVICES
  • POS: ELIGIBLE ONLY
    FAMILY PLANNING SRVC
  • Alternate access methods (PC, CPU, Batch) will return Table 1 Response Code 018
  • On-line NCPDP Pharmacy transactions will be rejected for Table 7 Denial Response Code 719 (MA Only Covers Family Planning), unless the submitted Drug is a Family Planning Drug. When a Family Planning Drug is submitted, the transaction will be accepted if all other edits are passed and Response Code 018 is returned.
• Systems support is available for payment of claims.

Frequently Asked Questions and Answers--Family Planning Benefit Program:

• Q. Are prescriptions for reproductive health, such as antibiotics for STDs and genito-urinary infections, paid for through FPBP?
  • A. Typically these prescriptions are not covered on a fee-for-service basis. However, if pharmaceuticals were included in an all-inclusive clinic rate, these prescriptions would be covered as part of the clinic rate. If a non-grant funded provider of family planning services identifies an infection in need of treatment, and cannot provide the treatment at no cost to the client, the client should be referred to the County Health Department or other referral resources, as appropriate.

• Q. How is a lab test, such as a pap smear, paid for?
  • A. In order for the pap smear to be covered as part of the FPBP, it must be ordered during a family planning visit. The provider must indicate on the lab requisition form or the written order that the lab test is related to family planning. The lab must place an "X" in the box following "YES" in field 22I, Family Planning, to indicate that the claim is related to a family planning service in order to receive payment for the family planning services rendered.

• Q. What if a woman who was previously sterilized goes to a family planning provider for a gynecological exam?
  • A. The gynecological exam would not be covered because it would not be related to family planning since the woman was sterilized.

• Q. Is emergency contraception covered?
  • A. Emergency contraception and follow-up visits are covered.

• Q. Are RU 486, surgical abortions, or abortion-related services covered?
  • A. No. These services are not covered.

• Q. Is a colposcopy, cryosurgery, or LEEP covered?
  • A. No, these procedures are not covered. According to the federal guidelines, these procedures are not considered services performed primarily for family planning purposes but rather procedures performed to identify and treat a medical condition, regardless of whether or not a woman is seeking to limit or expand the size of her family. If these procedures are needed to diagnose or treat suspected cervical cancer, the FPBP-enrolled woman should be referred to the regional Healthy Women Partnership for services. The list of Partnerships can be found on the DOH website:

• Q. Can a private practicing physician in the context of a family planning visit order a lab test for STD screening or a pregnancy test?
  • A. Yes. If the physician, during a family planning visit, determines the need for a STD screening or a pregnancy test, the physician can order these lab tests. The physician must indicate on the laboratory requisition form or the written order that the ordered tests are related to family planning. The lab must indicate family planning on the claim form for payment.

• Q. Is the treatment for breast or cervical cancer covered?
  • A. Treatment for breast or cervical cancer is not covered by the FPBP. Individuals with suspected breast or cervical cancer should be referred to the local Healthy Women Partnerships for screening and further diagnosis. Persons who are screened through the Healthy Women Partnerships and diagnosed as needing treatment for breast or cervical cancer may be eligible for the Breast and Cervical Cancer Treatment Program if they have no other coverage. The list of Partnerships can be found on the DOH website:

    Heatlhy Women Partnerships

• Q. Do all family planning providers need to indicate that services rendered are related to family planning?
  • A. Yes, providers must indicate that the claim is related to a family planning service in order to receive payment for the family planning services rendered.

• Q. Are infertility services covered?
  • A. Infertility services are not covered.

If you have any questions, you may contact the Office of Medicaid Management at medicaid@health.state.ny.usor by calling (518) 473-2160.

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Persons with mental illness returning to the community have need of multiple Medicaid funded services (mental health and substance abuse treatment, health and rehabilitation services, case management etc.). Medicaid providers of these services who are sensitive to the needs of this population can greatly enhance their potential for successful re-integration into the community.

It has become widely recognized that many people in jail or prison have a mental illness. Every day a few of these people re-enter their communities after their incarceration. In accordance with Kendra's Law, a new program called the Medication Grant Program will assist people with mental illness in applying for Medicaid prior to or immediately after their release from jail or prison. This new program is operating in 37 counties in New York State and in New York City. For people with mental illness, the return to the community from incarceration, especially from prison, presents some unique challenges for both the consumer and the provider who attempts to serve them. Thus, the need and importance of the Transitions Training program for providers.

Transitions Training is for administrators and supervisors of human service agencies that provide services to persons who are returning to the community from State prison and who may also have a mental illness.

The one-day program explores the effects of incarceration on an individual, both while incarcerated and after release from prison. The staff competencies and services needed to effectively serve this population are also reviewed. The training team consists of a mental health professional and men with mental illness who have experienced incarceration.

Anticipated outcomes for Medicaid providers who take Transitions Training includes an increased understanding of individuals in need of treatment upon release from prison, and a decrease in apprehension about working with an often-avoided population. The training is applicable to most Medicaid providers. Each training session may have a maximum of 25 participants. More than 40 mental health agencies in New York State have received Transitions Training and have given it high marks.

A September 10, 2002 interview about this program is archived on the Internet at http://www.corrections.com/news/livetalk/clips/media_20020910.asf. An 18-minute promotional videotape about the program is also available.

For more information about the program, or to arrange for a training session for administrators and supervisors of a Medicaid funded program, contact Terence McCormick, Director of Community Forensic Services at the New York State Office of Mental Health, (518) 402-6376 or TMcCormick@omh.state.ny.us.

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When calling to obtain a prior authorization for Serostim, remember to enter the patient's weight in pounds, their height in inches and the patient's current Body Mass Index (BMI) . The following BMI chart is provided for your assistance.

Body Mass Index Table

BODY MASS INDEX TABLE

BMI	19	20	21	22	23	24	25	26	27	28	29	30	31	32	33	34	35
Height (inches)	Body Weight (pounds)
58	91	96	100	105	110	115	119	124	129	134	138	143	148	153	158	162	167
59	94	99	104	109	114	119	124	128	133	138	143	148	153	158	163	168	173
60	97	102	107	112	118	123	128	133	138	143	148	153	158	163	168	174	179
61	100	106	111	116	122	127	132	137	143	148	153	158	164	169	174	180	185
62	104	109	115	120	126	131	136	142	147	153	158	164	169	175	180	186	191
63	107	113	118	124	130	135	141	146	152	158	163	169	175	180	186	191	197
64	110	116	122	128	134	140	145	151	157	163	169	174	180	186	192	197	204
65	114	120	126	132	138	144	150	156	162	168	174	180	186	192	198	204	210
66	118	124	130	136	142	148	155	161	167	173	179	186	192	198	204	210	216
67	121	127	134	140	146	153	159	166	172	178	185	191	198	204	211	217	223
68	125	131	138	144	151	158	164	171	177	184	190	197	203	210	216	223	230
69	128	135	142	149	155	162	169	176	182	189	196	203	209	216	223	230	236
70	132	139	146	153	160	167	174	181	188	195	202	209	216	222	229	236	243
71	136	143	150	157	165	172	179	186	193	200	208	215	222	229	236	243	250
72	140	147	154	162	169	177	184	191	199	206	213	221	228	235	242	250	258
73	144	151	159	166	174	182	189	197	204	212	219	227	235	242	250	257	265
74	148	155	163	171	179	186	194	202	210	218	225	233	241	249	256	264	272
75	152	160	168	176	184	192	200	208	216	224	232	240	248	256	264	272	279
76	156	164	172	180	189	197	205	213	221	230	238	246	254	263	271	279	287

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Please Read and Save for Future Reference

Beginning April 1, 2003, enteral formula will require a prior authorization initiated by an authorized prescriber, in order to be covered by the Medicaid program.

Medicaid is initiating this program to ensure that only medically necessary enteral formulas are ordered, dispensed and reimbursed. Enteral formula is 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. Enteral nutritional therapy is not covered for supplementation of daily protein-caloric intake where there is not a documented medical necessity or as a convenient food substitute.

When writing a fiscal order for an enteral formula, the prescriber will need to call the toll free voice interactive Enteral Prior Authorization Call Line at (866) 211-1736. If approval is given, an authorization number will be provided that must be written on the fiscal order. Then, the fiscal order is presented to the dispenser who calls the voice interactive Enteral Prior Authorization Call Line to complete the prior authorization process.

General Information for Prescribers:
Physicians, Nurse Practitioners, Midwives, Dentists

1. The prescriber must call the toll free voice interactive Enteral Prior Authorization Call Line at (866) 211-1736 to initiate the prior authorization process.
2. Once approval has been given and a prior authorization number is obtained, the prior authorization number must be written on the order and documented on the Prior Authorization Prescriber Worksheet. A prescription pad may be used for an order.
3. The patient's medical record must include documentation of the patient's medical need for enteral formula. In addition, the completed prior authorization worksheet must be included in the patient's medical chart.
4. Prior authorization is required for each generic category of enteral formula. It is effective for up to six months, or the initial fill and five refills.
5. Each time a new order is written for an enteral formula, a new prior authorization must be obtained, and the new prior authorization number written on the order.
6. An agent of the prescriber (an employee such as a medical assistant) may complete the prior authorization call and write the prior authorization number on the order.
7. Prescribers do not have to initiate the enteral prior authorization process for orders written prior to April 1, 2003.
8. If a prior authorization number is not on an order for an enteral formula, the dispenser will be prohibited from filling the order. The dispenser or patient will need to contact the prescriber to ask that the prior authorization process be completed, or if completed to ask for the necessary prior authorization number.

NYS Medicaid Program Enteral Formula Prior Authorization Prescriber Worksheet and Instructions

The NYS Medicaid Program Enteral Formula Prior Authorization Prescriber Worksheet is available only as a portable document format (PDF) file. Requests for the NYS Medicaid Program Enteral Formula Prior Authorization Prescriber Worksheet in an alternate format should be made by sending an e-mail note to: MedicaidUpdate@health.state.ny.us.

General Information for Dispensers:
Pharmacy and Durable Medical Equipment Providers

1. The prescriber initiates the prior authorization process and obtains the prior authorization number.
2. The prescriber must write the prior authorization number on the order before the dispenser can fill the order and bill Medicaid.
3. When a new order for an enteral formula is presented to the dispenser, it must include a prior authorization number. The dispenser must contact the toll free voice interactive Enteral Prior Authorization Call Line at (866) 211-1736 to validate the prior authorization number prior to dispensing. Failure to validate the prior authorization number will result in claims being denied.
4. Multiple prior authorizations for multiple patients may be validated in a single phone call.
5. Initial dispensing must occur on or after the date the prior authorization number is issued and within 60 days of the order date (subject to other State laws and Medicaid restrictions).
6. A prior authorization is effective for the original dispensing and up to five refills within six months (subject to other State laws and Medicaid restrictions).
7. The dispenser must include the prior authorization number on the submitted electronic or paper claim before the claim can be paid. This prior authorization number must also be included on claims for refills.
8. eMedNY DVS authorization will continue to be required for all dates of service prior to April 1, 2003.Voice interactive prior authorization is not required for orders written prior to April 1, 2003, but dispensed on or after April 1, 2003. However, when these orders expire, a new prior authorization will be required for the enteral formula.
9. Prior authorization does not guarantee payment Payment is subject to patient eligibility and other Medicaid guidelines.

NYS Medicaid Program Enteral Formula Prior Authorization Dispenser Worksheet and Instructions

The NYS Medicaid Program Enteral Formula Prior Authorization Dispenser Worksheet is available only as a portable document format (PDF) file. Requests for the NYS Medicaid Program Enteral Formula Prior Authorization Prescriber Worksheet in an alternate format should be made by sending an e-mail note to: MedicaidUpdate@health.state.ny.us.

Recipient-Specific

• Q: Can categories of patients be exempted from the prior authorization process?
  • A: No. However, the prior authorization process should be relatively quick for orders for tube-fed individuals.

• Q: How will patients know about this program?
  • A: Prescribers and dispensers may copy information in this article for distribution and discussion with patients. In addition, we have asked for assistance from advocacy groups and associations to help distribute information.

• Q: What recipients are affected by enteral prior authorizations?
  • A: All orders for recipients who are covered under the Medicaid fee-for-service program are subject to this new requirement. Payment for enteral formula is included in the Medicaid rate paid to skilled nursing facilities, developmental centers and inpatient hospitals, and thus is not reimbursable on a fee-for-service basis.

• Q: Does the Medicaid enteral formula prior authorization program apply to orders for Medicaid managed care enrollees?
  • A: Yes, because enrollees in Medicaid managed care plans are covered under the fee-for-service for enteral formula. Prescribers who are part of Medicaid managed care networks will need to get prior authorization when prescribing an enteral formula.

• Q: Does the Medicaid enteral formula prior authorization apply to Family Health Plus, EPIC, ADAP or Child Health Plus B enrollees?
  • A: No

• Q: Will I be able to obtain a prior authorization for a patient with temporary Medicaid authorization?
  • A: Yes, however, the dispenser will not be able to adjudicate the claim on-line until the patient's eligibility is posted on the Medicaid eligibility file.

• Q: What if the patient wants to get a brand-name enteral product for which there are generic equivalents?
  • A: The conversation with the patient may be a good opportunity for the prescriber or dispenser to explain what generic products are, and why they might appear different but meet the medical need for enteral formula.

Provider-Specific

• Q: How long will it take for a prescriber to do a prior authorization?
  • A: About four minutes.

• Q: Can the prescriber ask for more than one prior authorization at the same time or do they have to call back for each order?
  • A: Multiple authorizations can be received with one phone call. You can get more than one prior authorization for the same patient, or authorizations for more than one patient during the same call. You will be asked at the end of each transaction if you want additional authorizations. Follow the instructions at the end of the call.

• Q: How will you assure that providers can get through and not get busy signals?
  • A: We have greatly expanded our telephone capacity to address anticipated increased volume.

• Q: How should a fiscal order for an enteral formula be written?
  • A: The requirements for a fiscal order for an enteral formula are: the name, address and telephone number of the ordering practitioner, the name and CIN of the recipient, the date ordered, the original signature of the ordering practitioner, the name of the item, quantity ordered (e.g., 1500 calories per day/one month supply), directions for use, and number of refills. For enterals, the prior authorization number must also be written on the fiscal order. A prescription pad may be used for the order.

• Q: How often can enteral formula be dispensed?
  • A: A monthly supply of enteral formula is dispensed once a month. When one week or less remains on the month's supply, the order may be refilled. A new order for enteral formula will not be authorized for dispensing until ten days or less remain on the last refill of the current prescription.

• Q: Can medical residents or physician assistants use the institution or clinic MMIS number when requesting a prior authorization?
  • A: No. Medical residents and physician assistants must use the supervision prescriber's MMIS number. An institution or clinic MMIS number will not be accepted.

• Q: What happens to a patient who gets to the dispenser and it told that they need a prior authorization approval to get their order?
  • A. The dispenser may contact the prescriber who may then choose to use the prior authorization system. Recipients may also contact their prescriber to discuss their order. There is no provision to ensure payment for enteral formula without a prior authorization number.

• Q: Can the dispenser substitute generically equivalent enteral products?
  • A: Yes. The federal government classifies the most used enteral products under one category. For example, Ensure, Boost, Resource and generic store brand complete nutrition formulas are considered equivalent. For specialized formulas, there may not be equivalent formulas made by another manufacturer.

• Q: Does Medicaid pay for infant formula?
  • A: Standard milk-based infant formula is not covered by Medicaid. Special formulas for metabolic disorders or lactose intolerance are reimbursable. Families should access the WIC Program when seeking assistance in obtaining infant formulas.

• Q: When does Medicaid require paper prior approval for enteral formulas?
  • A: Paper prior approval is required when the prescriber is not able to certify via the voice interactive system that the formula is medically necessary. Other specific instances include, if a patient receiving oral supplementation has a Body Mass Index categorized as obese by the Centers for Disease Control, if a product is categorized as B9998 Miscellaneous enteral formula, or when calories prescribed exceeds normal dietary guidelines, e.g., over 2000 calories per day.

• Q: How is the paper prior approval process initiated and completed?
  • A: The prescriber should initiate the prior approval process by completing Section 1, Fields 1-26 of Form DSS-3615, "Order/Prior Approval Request". The dispenser receives this form and completes Sections 2 and 3 and mails the form for review to the appropriate Area Office indicated in the Inquiry Section of the MMIS provider manual.

Blank forms are available by calling Computer Sciences Corporation at (800) 522-5518 (within New York State) or (518) 447-9860 (out of state). The forms can also be obtained by writing to Computer Sciences Corporation, PO Box 4401, Albany, NY 12204.

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Enteral Products And Item Codes

Product	Code	Product	Code	Product	Code
80056	B4154	Isocal HN Plus	B4150	Phenex 2	B4154
Acerflex	B4154	Isocal II	B4150	PhenylAde	B4154
Accupepha	B4153	Isocal-HN	B4150	PhenylAde Amino Acid	B4155
Advera	B4154	Isofiber	B4150	Phenylfree	B4154
Alimentum	B4153	Isolan	B4150	Phenylfree 2	B4154
Alitraq	B4154	Isomil	B4150	Phenylfree 2HP	B4154
Amin-Aid	B4154	Isosource	B4150	Phlexy-10 Capsules	B4155
Analog Formulas	B4154	Isosource 1.5	B4152	Phlexy-10 Drink Mix	B4155
Apple Fiber	B9998	Isosource VHN	B4154	PKU2	B4154
Aquasol E	B9998	Isosource-HN	B4150	Polycose	B4155
ATMF	B4150	Isotein-HN	B4153	Portagen	B4150
Attain	B4150	I-Valex-1	B4154	Pregestimal	B4154
BCAD-2	B4154	I-Valex-2	B4154	ProBalance	B4150
Bio-care	B4150	Jevity	B4150	ProCel	B4155
Boost	B4150	Jevity Plus	B4150	Product 3232A	B4155
Boost Breeze	B4150	Juven	B4155	Product 80056	B4154
Boost Plus	B4152	KetoCal	B4151	Profiber	B4150
Calcilo XD	B4154	Ketonex 1	B4154	Promix	B4155
Calories Plus	B4152	Ketonex 2	B4154	ProMod	B4155
Casec	B4155	Kindercal	B4150	Promote	B4150
Choice DM	B4154	LactAid tablets	B9998	Propac	B4150
Compleat	B4151	Lactofree	B9998	Pro-Peptide	B4154
Compleat Pediatric	B4151	L-Elemental	B4153	Pro-Peptide VHN	B4154
Comply	B4152	L-Emental Hepatic	B4154	Pro-Phree	B4155
Criticare-HN	B4153	L-Emental Pediatric	B4153	Propimex 1	B4154
Crucial	B4153	Lipomul	B4155	Propimex 2	B4154
Cyclinex-1	B4154	Lipisorb	B4154	ProSobee	B4151
Cyclinex-2	B4154	Lofenelac	B4154	Pro-Stat	B4155
Deliver 2.0	B4152	Lonalac	B4150	ProSure	B4155
Diabetisource	B4154	Lorenzo Oil	B4154	Protain XL	B4154
Diabetisource AC	B4154	Magnacal Renal	B4154	Provide	B4154
Doucal	B4154	Maxamaid Formulas	B4154	ProViMin	B4155
Egg/Pro	B4155	Maxamum Formulas	B4154	Pulmocare	B4154
EleCare	B4153	MCT Oil	B4155	Reabilan	B4153
Elemental 028 Extra	B4154	Meritene	B4150	Reabilan-HN	B4154
Elementra	B4155	Microlipid	B4155	ReGain Plus	B4154
Enfamil AR	B9998	Moducal	B4155	Renalcal	B4154
Enlive	B4150	Modulen IBD	B4154	Re-Neph	B4154
Enriched Antioxident Formula	B4155	MSUD Formulas	B4154	Re-Neph Free	B4154
Ensure	B4150	Naturite	B4150	Replete	B4154
Ensure Light	B4150	Naturite Plus	B4152	Resource	B4150
Ensure Plus	B4152	Neocate	B4153	Resource Arginaid	B4155
Ensure Plus HN	B4152	Neocate One +	B4153	Resource Arginaid Extra	B4154
Entera	B4150	Neopro	B4154	Resource Diabetic	B4150
Entera Isotonic	B4150	Nestle Flavor Pkts	B9998	Resource Diabetishield	B4150
Entera OPD	B4154	Neutra-Phos	B9998	Resource For Kids	B4150
Enteralife HN	B4150	Newtrition	B4150	Resource Fruit Bev.	B4150
Enteralife HN-2	B4150	Newtrition HN	B4150	ReSource Glutasolve	B4155
Entrition HN	B4150	Newtrition Isofiber	B4150	Resource Instant Protein	B4155
Entrition 1.5	B4152	Newtrition Isotonic	B4150	Resource Plus	B4152
Epulor	B4155	Newtrition 1.5	B4152	Respalor	B4152
Essential ProPlus	B4155	Nitrolan	B4150	Restore-X	B4155
Essential Protein	B4155	NovaSource 2.0	B4152	Ross Carbohydrate Free	B4155
Fiberlan	B4150	NovaSource Pulmonary	B4154	Sandosource Peptide	B4154
Fibersource	B4150	Novasource Renal	B4154	Scandi Shake	B4152
Fibersource HN	B4150	NuBasics	B4150	Similac PM 60/40	B4154
Flavonex	B9998	NuBasics 2.0	B4152	SLD	B4154
Forta Drink	B4150	NuBasics Juice Drink	B4150	SoyPro	B4155
Forta Shake	B4150	NuBasics Plus	B4152	Stresstein	B4154
Fortison	B4150	NuBasics VHP	B4150	Subdue	B4153
Generic Complete Nutrition	B4150	Nutri-Drink	B4150	Subdue Plus	B4153
Generic Complete Nutrition Plus*	B4152	Nutramigen	B4150	Sumacal	B4155
Gevral Protein	B4155	Nutrassist-1.5	B4152	Suplena	B4154
Glucerna	B4154	Nutren Junior	B4150	Sustacal	B4150
Glucena Shake	B4154	Nutren-1	B4150	Sustagen	B4150
Gluco-Pro	B4154	Nuten-1.5	B4152	Sympt-X Glutamine	B4155
Glutamine-Plain	B4155	Nutren-2	B4152	Tolerex	B4156
Glutamine Rapid Release	B4155	Nutriforus	B4152	Traumacal	B4154
Glutapak-10	B4155	Nutrihep	B4154	Traum-Aid HBC	B4154
Glutarex-1	B4154	Nutrilan	B4150	Travasorb Hepatic	B4154
Glutarex-2	B4154	NutriRenal	B4154	Travasorb -MCT	B4154
Glutasolve	B4155	NutriVent	B4154	Travasorb Renal	B4154
Glutasorb RTU	B4153	NutriVir	B4153	Travasorb Standard	B4156
Glytrol	B4150	Optimental	B4153	Travasorb-HN	B4153
Hearty Balance	B4150	OS 1	B4154	TwoCal-HN	B4152
Hepatic-Aid	B4154	OS 2	B4154	Tyrex-1	B4154
Hominex-1	B4154	Osomolite	B4150	Tyrex-2	B4154
Hominex-2	B4154	Osomolite-HN Plus	B4150	UCD-1	B4154
HOM 1	B4155	Osmolite-HN Plus	B4150	UCD-2	B4154
HOM 2	B4155	Pediasure	B4150	Ultracal	B4150
HPF Plus	B4155	Pepdite One+	B4153	Ultracal HN Plus	B4150
Immun-Aid	B4154	Peptamen	B4154	Ultralan	B4152
Immune System Booster	B4155	Peptamen 1.5 Diet	B4153	Ultracare Kids	B4154
Immunocal	B4155	Peptmen Jr	B4154	VHC 2.25	B4152
Imu-Plus	B4155	Peptamen VHP	B4154	Vari-Flavors	B9998
Impact	B4154	Peptinex	B4153	Vital-HN	B4153
Impact 1.5	B4154	Peptinex DT	B4153	Vitaneed	B4151
Impact Glutamine	B4153	Peptical	B4153	Vivonex flavor pkts	B9998
Impact Recover	B4154	Perative	B4154	Vivonex Pediatric	B4153
IntensiCal	B4153	Periflex	B4154	Vivonex Plus	B4154
Introlite	B4150	PFD-2	B4155	Vivonex RTF	B4153
Isocal	B4150	Phenex 1	B4154	Vivonex-TEN	B4154

* Generic complete nutrition store brands include: CVS, Eckerd, Equate, Hannaford, Price Chopper, Rite Aid, Target

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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