DOH Medicaid Update December 2004 Vol.19, No.12

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The HIPAA compliance deadline is approaching very quickly and, with that, the end of our HIPAA exception process.

• After December 29, 2004, Medicaid will accept and process only HIPAA-compliant claims and other transactions.
• Electronic transactions not submitted in a HIPAA format will be rejected.

Providers not yet converted to the HIPAA format are placing their Medicaid payments at great risk.

The HIPAA Exception Process instituted on October 6 has been very successful. The provider community has been extremely responsive and Computer Sciences Corporation (CSC) has received HIPAA Exception Process Applications from all but a few providers not able to comply with the October 6 deadline.

There has been a steady upward spiral of providers moving their Medicaid billings to the HIPAA format. The trend is expected to accelerate as the December 29 date nears.

If you have not yet started testing with CSC, you are urged to submit compliant test files immediately to allow the turnaround process sufficient time for you to achieve compliance by December 29.

If a claims test file is submitted by noon on Wednesday, they are available at the www.nyhipaadesk.com website by noon of the following Tuesday.

• Providers should look under "Edit/Error Knowledge Base" and use their TSN (Transaction Supplier Number) to identify the status of their claims-paid, pend, deny. Providers will be able to quickly find the edit reasons denying their claims and a possible resolution.

Providers needing additional assistance should contact the CSC HIPAA Helpline at (800) 522-5518.

Do Not Jeopardize Your Medicaid Payments. Comply Today!

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If you are making the transition to HIPAA and are concerned that your claims were not accepted due to the new format changes, you can now get early results.

• Call the Check Line at (518) 472-1550 after noon on Monday to verify that your payment is normal for the claims you submitted last cycle that ended the prior Wednesday at noon.
• If you suspect that you had an exceptional number of claims denied due to changing to the new format, you can request a list of denied HIPAA claims for the prior week. To do so, call the HIPAA Support Help Line at (800) 522-5518 and ask for the HIPAA Denial Report. Requests can only be made for the most recent payment cycle, and will not be accepted before noon on Monday.
• The HIPAA Denial Report will be mailed to you and will list all of the claims you submitted in HIPAA format that denied in the past weekly cycle. Please be aware that it lists only HIPAA submissions, and those that were denied.
• We hope that the availability of this new report will give you the confidence to move forward with your changes to HIPAA compliance at the earliest possible date. Even if you have an approved application for HIPAA Exception Processing, your electronic submissions must be HIPAA-compliant by December 29, 2004.

CSC and the Department have developed extensive resources to expedite your HIPAA compliance efforts, which are available at the www.nyhipaadesk.com and www.emedny.org websites.

If you have any questions relative to Medicaid's HIPAA requirements or need technical clarification, please contact the CSC HIPAA Support Help Line at (800) 522-5518.

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Upon implementation of Phase II in March 2005:

• eMedNY will not produce remittance advices on round reel tape or cartridge.
• eMedNY remittance advices (835 and 820 transactions) will be delivered as electronic response files through the eMedNY eXchange.

Providers will still have the alternate choice of receiving paper remittance advices; however, if you choose the electronic transactions 835 or 820, you will not receive paper remittance advices.

Even if you submit certain claims on paper forms, these will be included in the electronic 835/820.

Providers who submit claims under multiple Electronic Transmitter Identification Numbers (ETIN) will receive multiple 835/820 transactions (or paper remittance advices) and multiple checks; i.e., one advice and one check for will be issued to the provider for each ETIN that submitted claims.

Providers who submit claims under multiple ETINs, and receive the 835 or the 820, must choose a primary ETIN for the purpose of receiving retroactive adjustment advices (rate-based providers) and claims submitted on paper forms (any provider).

For questions regarding this matter, please call CSC at (800) 522-5518 or (518) 447-9860.

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You will receive the Update about 3 weeks before the mailed copy!

Email your request, along with your provider identification number (found on the mailing address label of this update) to: MedicaidUpdate@health.state.ny.us.

Let us know if you want to continue receiving the hard copy in the mail, in addition to the emailed copy.

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In the October 2004 Medicaid Update, we introduced and described eMedNY eXchange as a new communication method. The eMedNY eXchange is now available for submitting the following HIPAA-compliant electronic requests to Medicaid:

• 270/271 - Eligibility Benefit Inquiry and Response
• 278 - Service Authorization Request and Response

The eMedNY eXchange works like email:

• users are assigned an "inbox" and are able to send and receive transaction files in an email-like fashion.
• Transaction files are "attached" and sent to eMedNY for processing.
• Responses are delivered to the user's inbox, and can be "detached" and saved on the user's computer.
• For security reasons, the eMedNY eXchange will be accessible only through the eMedNY website (www.emedny.org).

Following the implementation of eMedNY Phase II in March 2005, eMedNY eXchange will accept or return additional types of transactions, including the following:

• 837 - Dental, Professional and Institutional Claims
• 835 - Claim Remittance Advice
• 820 - Claim Remittance Advice (Managed Care Plans only)
• 270/271 - Eligibility Benefit Inquiry and Response
• 276/277 - Claim Status Request and Response
• 278 - Prior Approval/Prior Authorization (except for DVS requests)
• NCPDP Version 5.1 - National Council for Prescription Drug Programs
• MEDS - Medicaid Managed Care Encounter Data

After the implementation of Phase II, eMedNY eXchange will be a convenient method submission for providers who are now submitting claims on magnetic media (tape, diskette, cartridge), since these media will not be supported by eMedNY. It will also be an effective way to receive your remittance advices (835 and 820).

For more information about eMedNY eXchange, visit www.emedny.org or call Provider Services at (800) 343-9000.

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Transportation providers should be advised, with the implementation of eMedNY Phase II in March 2005, the current Legacy electronic Claim Form A format will no longer be supported!

This change is of particular interest to transportation providers who deliver only non-emergency transportation services and may not be currently using the HIPAA 837P transaction.

Medicaid has a free internet-based billing program called ePACES through which providers can submit HIPAA-compliant electronic claims. Information about enrolling in ePACES and the minimum PC configuration requirements can be found at www.emedny.org.

For questions regarding this matter, please call CSC at (800) 522-5518 or (518) 448-9860.

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Beginning as early as January 2005, Medicaid providers will begin to see a change in the graphics of the Common Benefit Identification Card (CBIC). This card is used by Medicaid recipients to access Medicaid covered products and services, as well as public assistance and food stamps.

The new card will contain the following changes:

• The overlay hologram of the State seal, currently covering the front of the card, will be removed and replaced with a background image of the State seal of the same size.
• The State seal located in the upper right hand corner will be vividly colorized.

The current text and the recipient photo and signature will remain unchanged, and will be printed in the same locations. The card numbering mechanism will also remain unchanged.

The newly designed cards will not affect any processes relating to the access of Medicaid benefits.

There will not be a massive replacement of all existing cards. Existing cards will remain valid, and will continue to be used to receive Medicaid benefits.

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Paper forms will undergo significant changes with the implementation of Phase II in March 2005. The new forms are required to accommodate systems changes, and to comply with the Centers for Medicare and Medicaid Services (CMS) regulations.

• NYS Form A, HCFA-1500, and Pharmacy forms will be accepted with modifications in format and provider-type users.
• NYS Form B and Form C will be discontinued.
• The standard CMS UB-92 Form will be adopted for rate-based providers.
• The current Prior Authorization/Prior Approval forms will be modified.
• The current Threshold Override Application (TOA) form will be modified.

Samples of the new paper forms for Phase II are available at www.emedny.org in the "Phase II Paper Forms" section.

Claim Form A
This form will be required, with modifications, only for dental billing (categories of service 0180, 0200, and (0287 or 0160 with specialty 912) and transportation billing (categories of service 0601, 0602, 0603, 0605, 0606).

HCFA-1500
The modified version of this form will be required for the current users and for the fee-for-service provider types currently using Form A and Form C.

Provider categories of service that are expected to use the modified NYS HCFA-1500 under eMedNY Phase II

Service Category Code	Service Category Name	Current Form	eMedNY Form (modified)
0140	QMB Chiropractor & Portable X-ray	NYS-HCFA 1500	NYS-HCFA 1500
0162	Clinic-based Ordered Ambulatory	Claim Form A	NYS-HCFA 1500
0163, 0389	Ordered Ambulatory Part A & B (other than Lab)	Claim Form A	NYS-HCFA 1500
0164, 0261, 0262, 0283, 0321-0325, 0386, 0387, 0442, 0443, 0604	DME and Hearing Aid	Claim Form C	NYS-HCFA 1500
0281	Hospital-based Ordered Ambulatory Lab	NYS-HCFA 1500	NYS-HCFA 1500
0282	Hospital-based Ordered Ambulatory (Other than Lab)	NYS-HCFA 1500	NYS-HCFA 1500
0401, 0402, 0404, 0405, 0407, 0408, 0422, 0423	Vision Care	NYS-HCFA 1500	NYS-HCFA 1500
0460	Physician	NYS-HCFA 1500	NYS-HCFA 1500
0469	Nurse Practitioner	NYS-HCFA 1500	NYS-HCFA 1500
0500	Podiatrist	NYS-HCFA 1500	NYS-HCFA 1500
0521	Nurse LPN	Claim Form A	NYS-HCFA 1500
0522	Nurse RN	Claim Form A	NYS-HCFA 1500
0523	Hospital Registry LPN	Claim Form A	NYS-HCFA 1500
0524	Hospital Registry RN	Claim Form A	NYS-HCFA 1500
0525	Midwife	Claim Form A	NYS-HCFA 1500
0560	Clinical Social Worker	NYS-HCFA 1500	NYS-HCFA 1500
0580	Clinical Psychologist	Claim Form A	NYS-HCFA 1500
0621	Occupational Therapist	Claim Form A	NYS-HCFA 1500
0622	Physical Therapist	Claim Form A	NYS-HCFA 1500
0623	Speech Pathologist/Speech Therapist	Claim Form A	NYS-HCFA 1500
1000	Free Standing Laboratory	NYS-HCFA 1500	NYS-HCFA 1500

NYS Pharmacy Claim
The modified Pharmacy form will be accepted for categories of service 0161, 0288, and 0441.

UB-92
All rate-based providers that currently bill on Form A or on Form B will be required to use the Centers for Medicare and Medicaid Services (CMS) standard UB-92 form.

Provider categories that are expected to use the UB-92

Service Category Code	Service Category Name	Current Form	eMedNY Form (modified)
0121	Child Care	Claim Form B	UB-92
0123	Residential Treatment Facility	Claim Form A	UB-92
0160	Diagnostic and Treatment Center	Claim Form B	UB-92
0164	School Supportive Health Services	Claim Form A	UB-92
0165	Hospice	Claim Form B	UB-92
0220	Managed Care Capitation	Claim Form A	UB-92
0260, 0260 with specialty 798	Free-standing Home Health Care and Long Term Home Health Care	Claim Form A	UB-92
0263	TBI Waiver	Claim Form A	UB-92
0264	Personal Care Agency; Limited Licensed Home Care	Claim Form A	UB-92
0265	Case Management Services	Claim Form A	UB-92
0266	Personal Emergency Response System	Claim Form A	UB-92
0267	Assisted Living Program (ALP)	Claim Form B	UB-92
0268	OMH Rehabilitative Services	Claim Form A	UB-92
0269	OMRDD HCBS Waiver	Claim Form A	UB-92
0284, 0284 with specialty 798	Hospital-based Home Health Care and Long Term Home Health Care	Claim Form A	UB-92
0286	Skilled Nursing Facility (Inpatient)	Claim Form B	UB-92
0287	Hospital-based Day Treatment Center	Claim Form B	UB-92
0381	Long Term Care (LTC) Skilled Nursing Facility	Claim Form B	UB-92
0383	LTC Day Care	Claim Form B	UB-92
0384	Intermediate Care Facility (ICF-DD)	Claim Form B	UB-92
0385	OMRDD State Operated Clinic and Day Treatment	Claim Form B	UB-92
0386	NH-based Home Health Care	Claim Form A	UB-92
0388 w/specialty 798	NH-based Long Term Home Health Care	Claim Form A	UB-92

Computer Sciences Corporation (CSC) will schedule seminars to train providers in the new billing requirements.

Providers that create paper claims using a software program will need to modify their software to accommodate the changes.

If you have any questions about the contents of this article, please call CSC Provider Services at (800) 522-5518 or (518) 447-9860.

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The Department's Office of Managed Care (OMC) will change managed care plan encounter data reporting requirements with the implementation of eMedNY Phase II in March 2005.

The current Medicaid Encounter Data System (MEDS) was redesigned in an effort to:

• enhance specificity;
• take advantage of and be consistent with national health care transaction standards; and,
• support financial analysis and rate setting.

Encounter data elements will be submitted to the department for:

• professional services;
• institutional services (hospital and clinic);
• pharmacy services; and,
• dental services.

A MEDS II Data Element Dictionary has been developed by OMC, and has been shared with managed care plans that submit encounter data.

For more information on encounter data or new MEDS II requirements, please call Mary Beth Conroy in OMC's Bureau of Quality Management and Outcomes Research at (518) 486-9012.

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The use of mobile vans to provide the operatories for the provision of dental services has become more prevalent than in the past.

In recognition of this trend, additional information about the use of such vans or other movable vehicles is requested of dentists seeking to enroll into the Medicaid program for the first time.

As an enrolled dental provider, if you have obtained a van, or other movable vehicle, for the provision of dental services subsequent to your enrollment, you should contact the Enrollment Unit to update your enrollment information at:

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The Department of Health wants health care providers to remain up to date regarding the most recent influenza-related information.

Influenza antiviral medications are an important adjunct to influenza vaccine in the prevention and treatment of influenza. In the setting of the current vaccine shortage, the Centers for Disease Control and Prevention (CDC) has developed interim recommendations on the use of antiviral medications for the 2004-05 influenza season. Please refer to:

www.cdc.gov/flu

and,

www.health.state.ny.us/diseases/communicable/influenza/

The recommendations are not intended to guide use of these medications for any other situations, such as an outbreak of avian influenza. The recommendations may be updated as more information on the supply of influenza vaccine and antiviral medications becomes available.

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Pharmacies submitting applications for enrollment in the Medicaid program are required to furnish written evidence of application to enroll in the Medicare program when submitting their Medicaid application to the Department of Health.

Failure to submit evidence of Medicare application or an actual Medicare Award Letter will cause a delay in the Medicaid enrollment process.

Currently enrolled pharmacies are encouraged to enroll in Medicare now to avoid any delays in Medicaid payments.

Medicare enrollment information is available at: www.cms.gov/providers/enrollment

Questions regarding this article? Please call the Provider Enrollment Unit at (518) 486-9440

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The Department is beginning to migrate provider manuals to the internet at:

http://www.emedny.org/providermanuals/index.html

Currently Available:

• Information For All Providers
• Vision Care
• Transportation
• Home and Community Based Waiver Services(OMRDD)
• Midwife

More information in next month's Medicaid Update!

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Same Policy-New Edit

For a recipient with both Medicare and Medicaid coverage, all charges for Medicare covered drugs and supplies must be billed to Medicare first.

New Medicare Edit for Pharmacies

Effective January 3, 2005, Medicaid will be implementing a claims processing edit (Edit 152) to ensure that Medicaid is billed as a last resort when a recipient is both Medicare/Medicaid dually eligible (dual eligibles) and the drug or supply is covered by Medicare.

Billing for Medicare/Medicaid Dual Eligibles

Pharmacies must be enrolled in Medicare in order to bill Medicaid for drugs or supplies provided to dually eligible recipients. Pharmacies must indicate the Medicare paid amount on the submitted Medicaid claim or payment will be denied.

Information on Medicare enrollment can be found at:

www.cms.hhs.gov/providers/enrollment/default.asp

Questions?

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The following information needs to be submitted for a patient who is eligible for both Medicare and Medicaid on the Medicaid Client Eligibility file:

1. Enter a value of '13' in field 340-7C "Other Payer ID" to identify the payer as Medicare.
2. At a minimum, the first 4 of the following 5 qualifiers must be submitted when billing Medicaid. All of the required information is readily available on the remittance you receive from Medicare reflecting the results of their processing of the claim.

In Field 342-HC "Other Payer Amount Paid Qualifier" enter the following qualifiers	In Field 431-DV "Other Payer Amount Paid" (Medicare Dollar Amounts)
07 - Medicare Approved	Enter the amount from the Medicare remittance identified as the approved amount.
08 - Medicare Paid	Enter the amount of the payment you received from Medicare.
99 1st Occurrence - Deductible Amount	Enter the amount from the Medicare remittance identified as applying to the patient's deductible.
99 2nd Occurrence - Coinsurance Amount	Enter the amount from the Medicare remittance identified as the patient's coinsurance amount.
99 3rd Occurrence - Co-Payment Amount	Enter the amount from the Medicare remittance identified as the patient's co-pay amount.

Additional information on billing can be found in the Pro-DUR ECCA Provider Manual available on-line at http://www.emedny.org/ProviderManuals/Pharmacy/index.html

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The Medicaid program encourages practitioners to copy and distribute the following information to their patients and to share it with their colleagues.

Fruits and vegetables are rich in vitamins, minerals, fiber and carbohydrates .They have also been linked to many health benefits, including lowered risk for certain cancers, stroke, heart disease and high blood pressure.

Why are fruits and vegetables so healthy?

Fruits and vegetables are high in:

• fiber, which reduces the risk of blood clots and protects against heart disease and stroke;
• potassium, which can help control blood pressure;
• folate, which can help lower levels of an amino acid (homocysteine), that seems to be a risk factor for heart disease; and
• vitamin B6, which reduces the risk of coronary heart disease.

While it's important to eat a wide variety of fruits and vegetables, research is showing links between specific fruits and vegetables and specific diseases.

• Tomatoes and products made with tomatoes are rich in lycopene which has been found to protect against cancer particularly prostate cancer;
• Dark leafy vegetables, especially spinach and broccoli, orange juice, fortified grains, eggs, bananas, chicken, milk, fish and in vitamin supplements such as folic acid, contain folate which has been shown to decrease the risk of colon cancer;
• Five or more servings of fruits and vegetables appear to lower the risk of stroke. Dark leafy green vegetables (broccoli, spinach), citrus fruits (oranges, tangerines, grapefruit) and juices seem to provide the most benefit;
• Eight or more servings a day of fruits and vegetables appear to lower the risk of heart disease. Fruits high in Vitamin C and green leafy vegetables seem the most helpful; and
• Blood pressure appears to drop on a diet of fruits, vegetables, low-fat dairy products and low saturated fat.

Source: The Harvard School of Public Health http://www.hsph.harvard.edu/nutritionsource/fruits.html
Prepared by the NYSDOH, Office of Medicaid Management, Bureau of Program Guidance

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• What are Proteins and what do they do?
  • About 75% of your weight is protein. This chemical family is found in muscle, bone, skin, hair, and virtually every other body part of tissue. It makes up the enzymes that are responsible for the body's chemical reactions and the hemoglobin that carries oxygen in your blood. At least 10,000 different proteins make you what you are and keep you that way.
• Are there different types of protein?
  • There are two types of protein. One type is called complete protein and is found in animal sources. This kind of protein contains all the amino acids needed to make new protein. The other type is called incomplete protein and is found in fruits, vegetables, grains and nuts. They are called incomplete proteins because they do not contain amino acids.

    

• What are amino acids?
  • Amino acids have been called the building blocks because they provide the material for making all protein and are responsible for breaking down the food we eat into waste and providing energy.
• What happens if I eat too much protein?
  • When protein digests, it releases acids which are then broken down by calcium. Eating lots of protein, as is recommended in the "no carb" diets, requires a lot of calcium. Some of the calcium will be pulled from the bone. For this reason, a high protein diet over a long period of time can lead to weakened bones and fractures.
• What happens if I eat too little protein?
  • Lack of protein could lead to growth failure, loss of muscle mass, decreased immunity, weakening of the heart, respiratory system and death. Lack of protein is the leading cause of malnutrition in poorer countries, and this disease is called kwashiorkor.
• How much protein should I eat?
  • Almost any reasonable diet will provide enough protein each day. Eating a variety of foods will provide the essential amino acids needed every day. You rarely eat "straight" protein. It usually comes packaged with lots of unhealthy fat, for example, when you eat meat or drink whole milk. If you eat meat, choose the leanest cuts. If you like dairy products, pick the low fat or skim products. Beans, soy, nuts, and whole grains are examples of protein without a lot of saturated fat and with a lot of fiber and nutrients.

Source: The Harvard School of Public Health http://www.hsph.harvard.edu/nutritionsource/fruits.html

PREPARED BY THE NEW YORK STATE, DEPARTMENT OF HEALTH, OFFICE OF MEDICAID MANAGEMENT, BUREAU OF PROGRAM GUIDANCE

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Missing Issues?
The Medicaid Update, now indexed by subject area, can be accessed online at the New York State Department of Health website: http://www.health.state.ny.us/health_care/medicaid/program/main.htm
Hard copies can be obtained upon request by calling (518) 474-9219.

Would You Like Future Updates Emailed To You?
Email your request to our mailbox, MedicaidUpdate@health.state.ny.us
Let us know if you want to continue receiving the hard copy in the mail in addition to the emailed copy.

Do You Suspect Fraud?
If you suspect that a recipient or a provider has engaged in fraudulent activities, please call the fraud hotline at: 1-877-87FRAUD. Your call will remain confidential.

As a Pharmacist, Where Can I Access the List of Medicaid Reimbursable Drugs?
The list of Medicaid reimbursable drugs is available at: http://www.eMedNY.org/info/formfile.html

Questions About an Article?
For your convenience each article contains a contact number for further information, questions or comments.

Do You Want Information On Patient Educational Tools and Medicaid's Disease Management Initiatives?
Contact Department staff at (518) 474-9219.

Questions About HIPAA?
Please contact the HIPAA Support Helpline at (800) 522-5518 or (518) 447-9860.

Address Change?
Please contact the Bureau of Medical Review and Payment at:
Fee-for-Service Provider Enrollment Unit, (518) 486-9440
Rate Based Provider Unit, (518) 474-8161

Billing Question? Call Computer Sciences Corporation:
Provider Services (800) 522-5518 or (518) 447-9860.

Comments and Suggestions Regarding This Publication?
Please contact the editor, Timothy Perry-Coon at MedicaidUpdate@health.state.ny.us or via telephone at (518) 474-9219 with your concerns.

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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