DOH Medicaid Update February 2004 Vol.19, No.2

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New edits have been developed to highlight recipient eligibility messaging. Previously, pharmacy claims for recipients, whose eligibility file designated them as residing in a residential facility, generated an "NH" warning in the message field. Effective January 3, 2004, the NH warning message was replaced with a denial message based on Edit 1493 (Pharmacy Service Included in In-State Facility Rate-Deny), Reject code 85, RX Denial 325.

If a prescription is needed by a patient discharged from a residential facility whose eligibility file still has this "NH" designation, the pharmacist has the option to fill the prescription by overriding these edits. To override the denial message, use the eligibility clarification code of 2 in field 309-C9 in the NCPDP 5.1 billing format. The claim will then pend for up to 30 days (Edit 1316, Reject code 85, RX Response code 310) awaiting the eligibility update.

Please note: If the eligibility update does not occur within the 30 days of claim submission, the claim will be denied for edit 1316 (Pharmacy Service Included in In-State Facility Rate).

It is important to be sure that the patient you are billing for has actually been discharged from a residential facility, as claims billed are subject to denial or recoupment.

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Medicaid recipients in New York City now have the option to enroll in the following expanded service area for five Special Needs Managed Care Plans.

Medicaid Provider Name	MEVS code on VeriFone	10 characters in eMedNY window	Service Area
FidelisCare Healthier Life SN	OF	FIDELIS SN	Bronx, Brooklyn, SI, Manhattan, Queens
Healthfirst PHSP Inc SN	OH	HLTHFST SN	Bronx, Brooklyn, Manhattan
NYPS Select Health SN	OG	NYPSSEL SN	Manhattan, Bronx, Brooklyn
VidaCare Inc. SN	OD	VIDACARE SN	Manhattan, Bronx
MetroPlus Partnership in Care Plan SN	OM	METROPLUS SN	Bronx, Brooklyn, Queens, Manhattan

Providers should make note of these codes in their MMIS Provider Manual under the heading "Recipient Other Insurance Codes".

Special Needs Plans: Provider Relations
NYPS SelectHealth SN Provider Relations (866) 469-7774	VidaCare Inc SN Provider Inquiry (800) 556-0674	Fidelis Care HealthierLife SN Provider Relations Call Center (888) FIDELIS (888) 343-3547
MetroPlus Plan SN Provider Relations Call Center (800) 597-3380		Healthfirst PHSP SN Provider Relations (800) 801-1660

* Please contact the health plans above for Special Needs Plans (SNP) benefit package information.

Enrollees can call the New York Medicaid CHOICE Helpline at (800) 505-5678 to find out more about SNPs.

Questions regarding this article can be directed to the Department of Health at (518) 486-1383.

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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
• IPRO denial/reversal.

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. Claims 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 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 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 photocopy 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 or the HIPAA 837 Companion Documents available at: https://www.nyhipaadesk.com, for valid coding.

PROCEDURES FOR REQUESTING A WAIVER OF THE TWO YEAR BILLING REGULATION

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 Date Received) 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.

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

If you have any questions on the processing, review or disposition of claims over two years old, please call (800) 562-0856, menu #4.

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Effective March 1, 2004, Cialis will be added to the List of Medicaid Reimbursable Drugs.

This drug will be subject to the same rules and restrictions currently applied to Viagra and Levitra (note: there is a maximum of 6 tablets every 30 days and prescriptions are limited to an original one-month supply with up to 2 refills). Refer to the November 2003 Medicaid Update (page 11) for specific dispensing instructions and limitations.

The Medicaid Update may be accessed online at the New York State Department of Health website: http://www.health.state.ny.us/health_care/medicaid/program/main.htm

If you have any question please contact the Medicaid Pharmacy Unit at 518-486-3209.

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Many Medicaid recipients may be working in environments that may expose them to harmful substances. This article is provided to assist health care providers in identifying patients whose conditions may be related to their work environment. Because occupational disease is under- recognized,¹ failing to consider the workplace factors that may contribute to a patient's condition can result in the ordering of unnecessary tests, inappropriate referrals, and of equal or greater importance, a missed opportunity to protect others who may be at risk. ^1,2,3

As time with the patient is limited, there are a few, simple questions that can assist in determining if a condition may be work-related.¹ Providers should routinely ask their patients:

• "What kind of work do you do?"
• "Are you now or have you previously been exposed to dusts, fumes, chemicals, radiation, or loud noise?"
• "Are your symptoms better or worse when you are at work?"
• "Do you think your health problems are related to your work?"

If the replies to these questions rule out the likelihood of a condition being work-related, inquiries along this line can stop. But if something is stated that arouses suspicion, a full occupational health history should be taken.

Self-administered occupational history forms can be an efficient way to obtain this information and are available online at: http://www.atsdr.cdc.gov/HEC/CSEM/exphistory/exphist_form.htm

It should be remembered that many occupational factors act in concert with non-occupational factors to cause disease, so indication of other etiologic factors, such as smoking, does not necessarily rule out a disease as also having an occupational etiologic component. ² For more information on taking an exposure history, go to: http://www.atsdr.cdc.gov/HEC/CSEM/exphistory/pdffiles/exposure_history.pdf.

If the initial evaluation raises the suspicion that the disease is related to the workplace, providers in New York State can utilize a statewide network of occupational health clinics for consultation and referral: http://www.health.state.ny.us/environmental/workplace/clinic_network.htm. Some diseases, such as occupational lung diseases, pesticide poisonings, and heavy metals poisonings are reportable to the New York State Department of Health (NYSDOH). NYSDOH's authority in statute and regulation enables it to access and obtain this information in accordance with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The NYSDOH provides information to health care providers and their patients, and with a patient's permission, will work with employers to identify and correct hazardous workplace conditions. Patients' interests are always put first and their confidentiality is maintained.

¹Newman LS. Occupational Illness. New England Journal of Medicine, 333:1126-1134, 1995.
²Rosenstock L, Cullen MR. Clinical Occupational Medicine. WB Saunders Company, Philadelphia PA, 1986.
³ US DHHS, Agency for Toxic Substances and Disease Registry. Case Studies in Environmental Medicine. Taking an Exposure History. March 2000.

For more information contact Kitty Gelberg, Ph.D., MPH at (866) 807-2130 or e-mail her at khg01@health.state.ny.us.

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The Bureau of Health Economics of the New York State Department of Health has produced a new Diagnosis Related Group (DRG) table for Medicaid payments to New York State hospitals. The new table is effective for discharges beginning January 1, 2004.

Providers may request the table by sending an e-mail request to RBU@health.state.ny.us. Please include "2004 SIW Table" on the subject line of your e-mail.

Annually the Bureau of Health Economics determines the 20 most frequently billed DRGs. When payment for one of these DRGs is indicated, the remittance statement will list rate code 2996 rather than 2946.

Effective discharge date January 1, 2004, the Top 20 DRGs are:

 14      SPECIFIC CEREBROVASC DISORD EXC TIA & INTRACRANIAL HEMORRHAGE
 88      CHRONIC OBSTRUCTIVE PULMONARY DISEASE
 89      SIMPLE PNEUMONIA & PLEURISY AGE >17 W CC
121      CIRCULATORY DISORDERS W AMI & MAJOR COMP, DISCHARGED ALIVE
127      HEART FAILURE & SHOCK
139      CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC
143      CHEST PAIN
183      ESOPHAGITIS, GASTROENT & MISC DIGEST DISORD AGE >17 W/O CC
294      DIABETES AGE >35
296      NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W CC
359      UTERINE & ADNEXA PROC FOR CA IN SITU & NONMALIG W/O CC
371      CESAREAN SECTION W/O CC
372      VAGINAL DELIVERY W COMPLICATING DIAGNOSES
373      VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES
541      RESP DISORD EXC INFECTIONS, BRONCHITIS, ASTHMA W MAJOR CC
629      NEONATE, BWT > 2499G, W/O SIGN OR PROC, W NORM NEWB DIAG
745      OPIOID ABUSE OR DEPENDENCE W/O CC
751      ALCOHOL ABUSE OR DEPENDENCE W/O CC
775      BRONCHITIS & ASTHMA AGE <18 W/O CC
852      PERCUTANEOUS CARDIOVASCULAR PROC W NON-DRUG ELUTING STENT W/O AMI

If you have any questions, please contact the Bureau of Medical Review and Payment, Rate Based Provider Unit, at (518) 474-8161.

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This month's patient educational tools features an article on "How your Doctor Diagnoses Asthma".

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

   

• Wheeze
      A wheezing sound when you breathe. Sometimes this happens only when you have a cold.
• Cough
      You may cough up mucus. The cough often comes back and may last longer than one week.
• Shortness of breath
      Difficulty breathing may happen occasionally or often. It feels like you cannot get enough air into your lungs.
• Chest tightness
      Your chest may feel tight in cold weather or during exercise. Chest tightness may be one of the signs that your asthma is getting worse.

The asthma symptoms alone are not enough to diagnosis asthma. You must see a doctor who will perform tests to make the correct diagnosis.

To Diagnose Asthma, the Doctor Will Need to See if Three Criteria Are Met:

• You have recurring episodes where your airflow becomes blocked (obstructed), resulting in at least one of the above asthma symptoms.
• The blocked airflow can be at least partially reversed.
• Other possible diagnoses are ruled out.

The Doctor Will:

Evaluate your medical history to identify:

Ask about what triggers your asthma. Asthma triggers are things that irritate your airways and make breathing difficult.

The Doctor Will:

• Conduct a physical exam that focuses on the upper respiratory tract, chest, and skin.
• Listen for wheezing during normal breathing.
• Look for increased nasal secretions and nasal polyps.
• Look at your skin for eczema and other allergic skin reactions.

Spirometry

• Spirometry is the most reliable test for diagnosing asthma.
• Spirometry measures the amount and rate of air a person breathes in order to diagnose illness or determine progress in treatment.
• A spirometer is an instrument that measures the maximum volume of air that you can exhale after breathing in as much as you can. The total volume you exhale is called "forced vital capacity", FVC.
• The spirometer also measures the volume of air you exhale in the first second. This is called "forced expiratory volume in one second", FEV1.
• In general, the more air you breath out during the first second of a full exhalation, the better.
• The doctor may take several spirometry readings to compare your FVC and FEV1. These readings will allow the doctor to determine how much obstruction is in your airways.
• The doctor may next give you a bronchodilating drug that will relax the muscles of your airways. After the drug has taken effect, spirometry testing will be performed again. If you are able to breathe out significantly more air during the first second that you could before, it indicates that your breathing obstruction is "reversible". This is a strong indication of asthma.

Your doctor may order additional tests to help rule out other possible causes for your symptoms. These additional tests may include: additional pulmonary function tests; chest x-rays; allergy testing; examination for nasal polyps or sinusitis; and evaluation for gastroesophageal reflux (heartburn).

Remember: If your doctor diagnoses you with asthma, this does not mean you have to stop living a normal life. The good news is that with the right treatment, people with asthma can live with almost no limits to their activities.

Adapted from: Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (Bethesda, MD): National Institutes of Health, National Heart, Lung, and Blood Institute: 1997.

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. 2/04

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BEFORE activating an enteral formula prior authorization, the dispenser must:

1. Have the formula in stock;
2. Notify the recipient if you plan to substitute a generically equivalent formula;
3. Agree to dispense the formula for all refills;
4. Begin to complete the Dispenser Worksheet:
   • Determine correct HCPCS ("B") code for the formula per Classification List.
   • Determine the caloric units per month per written fiscal order. (The number of calories per can divided by 100 equals the number of caloric units per can.) Further instructions on caloric unit calculation are available at: http://www.health.state.ny.us/health_care/medicaid/program/2003/jun2003.htm#enteral

WHILE activating an enteral formula prior authorization, the dispenser must:

1. Validate that the caloric unit calculation authorized through the telephone system is correct per the written fiscal order. ( NOTE: once the dispenser activates an authorization, the prescriber cannot cancel it.)
   • Do not activate a prior authorization if the telephone system is reporting an amount less than the written fiscal order. Contact the prescriber to reconcile the prior authorization and written fiscal order. Through the telephone system, the prescriber can cancel a prior authorization that has not been activated and request another with the correct calories per day. The telephone system will then convert calories per day to caloric units per month for the dispenser call.
2. Validate that the refills on the written fiscal order match the prior authorization.
   • Do not activate a prior authorization if the telephone system is reporting a different number of refills than is written on the fiscal order. Contact the prescriber to reconcile the prior authorization and written fiscal order. Through the telephone system, the prescriber can cancel a prior authorization that has not been activated and enter refills per written fiscal order on a new authorization, or a new written fiscal order can be provided by the prescriber to match the refills on the prior authorization.
3. If the authorization is correct, answer accordingly on the telephone system and complete theDispenser Worksheet.

AFTER activating an enteral formula authorization, the dispenser must:

1. Dispense all monthly refills in full as indicated on the written fiscal order for the approved period of service, until the expiration date of the prior authorization.
2. Only dispense refills requested by the recipient. Further information on refills are available at: http://www.health.state.ny.us/health_care/medicaid/program/2003/sep2003.htm
3. Bill with the same Prior Authorization Number, Recipient CIN, Provider ID, Category of Service and five or seven digit HCPCS code as entered and reported on the telephone system for the claim to be paid. Refills and caloric units (quantity) cannot exceed what has been authorized on the prior authorization record.

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Product	Code
80056 powder	B4154
Accupepha	B4153
Acerflex	B4154
Advantage 10+	B4151
Advantage 60+	B4151
Advera	B4154
Alimentum	B4153
Alitraq Powder	B4154
Amin-Aid Powder	B4154
Analog formulas	B4154
Apple Fiber	B9998
Aquasol E	B9998
ATMF	B4150
Attain	B4150
BCAD-2	B4154
Bio-care	B4150
Boost	B4150
Boost Breeze	B4150
Boost High Protein	B4150
Boost Plus	B4152
Boost Pudding	B4150
Boost w/Fiber	B4150
Calcilo XD	B4154
Calories Plus	B4152
Casec Powder	B4155
Choice DM	B4154
Compleat	B4151
Compleat Pediatric	B4151
Comply	B4152
Criticare-HN	B4153
Crucial	B4153
Cyclinex-1	B4154
Cyclinex-2	B4154
Deliver 2.0	B4152
Diabetisource	B4154
Diabetisource AC	B4154
Duocal	B4154
Egg/Pro Powder	B4155
EleCare Powder	B4153
Elemental 028 Extra	B4154
Elementra	B4155
Enfamil AR	B9998
Enlive	B4150
Enriched Antioxidant Formula	B4155
Ensure	B4150
Ensure HN	B4150
Ensure Light	B4150
Ensure Plus	B4152
Ensure Plus HN	B4152
Ensure Pudding	B4150
Ensure w/ Fiber	B4150
Entera	B4150
Entera Isotonic	B4150
Entera OPD	B4154
Enteralife HN	B4150
Enteralife HN-2	B4150
Entrition HN	B4150
Entrition 1.5	B4152
Epulor	B4155
Essential Pro Plus	B4155
Essential Protein	B4155
Fiberlan	B4150
Fibersource	B4150
Fibersource HN	B4150
Flavonex	B9998
Forta Drink	B4150
Forta Shake	B4150
Fortison	B4150
Gevral Protein	B4155
Glucerna	B4154
Glucerna Select	B4154
Gluco-Pro	B4154
Glutamine-Plain	B4155
Glutamine Rapid Release	B4155
Glutapak-10	B4155
Glutarex-1	B4154
Glutarex-2	B4154
Glutasolve	B4155
Glutasorb RTU	B4153
Glytrol	B4150
Hearty Balance	B4150
Hepatic-Aid Powder II	B4154
Hominex-1	B4154
Hominex-2	B4154
HOM 1	B4155
HOM 2	B4155
HPF Plus	B4155
Immun-Aid	B4154
Immune System Boost	B4155
Immunocal	B4155
Imu-Plus	B4155
Impact	B4154
Impact 1.5	B4154
Impact Glutamine	B4153
Impact Recover	B4154
IntensiCal	B4153
Introlite	B4150
Isocal	B4150
Isocal-HN	B4150
Isocal HN Plus	B4150
Isocal II	B4150
Isofiber	B4150
Isolan	B4150
Isomil & Isomil DF	B4150
Isosource	B4150
Isosource 1.5	B4152
Isosource VHN	B4154
Isosource-HN	B4150
I-Valex-1	B4154
I-Valex-2	B4154
Jevity 1 Cal	B4150
Jevity 1.2 Cal	B4150
Jevity 1.5 Cal	B4152
Juven	B4155
KetoCal	B4151
Ketonex 1	B4154
Ketonex 2	B4154
Kindercal	B4150
LactAid tablets	B9998
Lactofree	B9998
L-Emental	B4153
L-Emental Hepatic	B4154
L-Emental Pediatric	B4153
Lipisorb	B4154
Lipomul	B4155
Lofenelac	B4154
Lonalac	B4150
Lorenzo Oil	B4154
Magnacal Renal	B4154
Maxamaid formulas	B4154
Maxamum formulas	B4154
MCT Oil	B4155
Meritene Powder	B4150
Microlipid	B4155
Moducal Powder	B4155
Modulen IBD	B4154
MSUD Diet	B4154
MSUD-1	B4154
MSUD-2	B4154
Naturite	B4150
Naturite Plus	B4152
Neocate	B4153
Neocate Junior	B4153
Neocate One +	B4153
Nepro	B4154
Nestle Flavor Packets	B9998
Neutra-Phos	B9998
Newtrition	B4150
Newtrition HN	B4150
Newtrition Isofiber	B4150
Newtrition Isotonic	B4150
Newtrition 1.5	B4152
Nitrolan	B4150
NovaSource 2.0	B4152
NovaSource Pulmonary	B4154
Novasource Renal	B4154
NuBasics	B4150
NuBasics Juice Drink	B4150
NuBasics Plus	B4152
NuBasics VHP	B4150
Nutri-Drink	B4150
Nutramigen	B4150
Nutrassist-1.5	B4152
Nutren Junior	B4150
Nutren-1	B4150
Nutren-1.5	B4152
Nutren-2	B4152
Nutrifocus	B4152
NutriHeal	B4150
Nutrihep	B4154
Nutrilan	B4150
NutriRenal	B4154
NutriVent	B4154
NutriVir	B4153
NutriVir NSA	B4153
Optimental	B4153
OS 1	B4154
OS 2	B4154
Osmolite	B4150
Osmolite-HN	B4150
Osmolite-HN Plus	B4150
Pediatric E028	B4153
Pediasure	B4150
Pepdite One +	B4153
Peptamen	B4154
Peptamen 1.5 Diet	B4153
Peptamen Jr	B4154
Peptamen VHP	B4154
Peptinex	B4153
Peptinex DT	B4153
Peptical	B4153
Perative	B4154
Periflex	B4154
PFD-2	B4155
Phenex 1	B4154
Phenex 2	B4154
PhenylAde Amino Acid	B4155
PhenylAde Drink Mix	B4154
Phenylfree 1	B4154
Phenylfree 2	B4154
Phenylfree 2HP	B4154
Phlexy-10 Capsules	B4155
Phlexy-10 Drink Mix	B4155
PKU1	B4154
PKU2	B4154
PKU3	B4154
Polycose	B4155
Portagen	B4150
Pregestimal	B4154
ProBalance	B4150
ProCel	B4155
Product 3232A	B4155
Profiber	B4150
Promix	B4155
ProMod	B4155
Promote	B4150
Propac	B4150
Pro-Peptide	B4154
Pro-Peptide VHN	B4154
Pro-Phree	B4155
Propimex 1	B4154
Propimex 2	B4154
ProSobee	B4151
Pro-Stat	B4155
Pro-Stat 101	B4155
ProSure	B4155
Protain XL	B4154
Provide	B4154
ProViMin	B4155
Pulmocare	B4154
Reabilan	B4153
Reabilan-HN	B4154
ReGain Plus	B4154
Renalcal	B4154
Re-Neph/Re-Neph Free	B4154
Replete	B4154
Resource	B4150
Resource Arginaid	B4155
Resource Arginaid Extra	B4154
Resource Diabetic	B4150
Resource Diabetishield	B4150
Resource for Kids	B4150
Resource Fruit Beverage	B4150
Resource Glutasolve	B4155
Resource Instant Protein Powder	B4155
Resource Plus	B4152
Resource Support	B4150
Respalor	B4152
Restore-X	B4155
Resurgex	B4155
Ross Carbohydrate Free	B4155
Sandosource Peptide	B4154
Scandi Shake	B4152
Similac PM 60/40	B4154
SLD	B4154
SoyPro	B4155
Stresstein	B4154
Subdue	B4153
Subdue Plus	B4153
Sumacal	B4155
Suplena	B4154
Sustacal	B4150
Sustacal Pudding	4150
Sustagen Powder	B4150
Sympt-X Glutamine	B4155
Tarvil (paper PA required)	B4155
Tolerex	B4156
Traumacal	B4154
Traum-Aid HBC	B4154
Travasorb Hepatic	4154
Travasorb-HN	B4153
Travasorb-MCT	B4154
Travasorb Renal	B4154
Travasorb Standard	B4156
TwoCal-HN	B4152
Tyrex-1	B4154
Tyrex-2	B4154
UCD-1	B4154
UCD-2	B4154
Ultracal	B4150
Ultracal HN Plus	B4150
Ultralan	B4152
Ultracare Kids	B4154
VHC 2.25	B4152
Vari-Flavors	B9998
Vital-HN	B4153
Vitaneed	B4151
Vivonex flavor packets	B9998
Vivonex Pediatric	B4153
Vivonex Plus	B4154
Vivonex RTF	B4153
Vivonex-TEN	B4154

• Use code B4100 #Food thickener, administered orally, per ounce for products such as Thick-It, Thick-n-Easy and Thicken-Up. A Dispensing Validation System (DVS) authorization number is required, obtained through the Medicaid Eligibility Verification System (MEVS). (For questions on obtaining a DVS authorization through MEVS, call Computer Sciences Corporation at (800) 343-9000.)

• Paper prior approval is required for code B9998, when the prescriber orders greater than 2000 calories per day for any combination of formula(s), or over 1000 calories per day for code B4155.

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

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Currently, the New York State Medicaid program provides reimbursement for compound prescriptions using the NDC code for each ingredient as described in Option 1 -- Billing for Individual Components by NDC Number.

Effective February 18, 2004, a revised method of billing compound prescriptions, Option 2 -- Billing for a Compound as a Single Entity, may be used.

Note: The HCPCS code S9430 referenced on page 4-38 (Rev. 4/03) of the Pharmacy MMIS Manual for compound billing is incorrect and should be deleted from your manual.

Option 1 -- Billing for Individual Components by NDC Number using NCPDP 3.2 or 5.1

• This option must be used when billing compounded controlled substances to comply with the Bureau of Controlled Substances standards.
• Submit claims for compounded prescriptions using the NDC code for each ingredient. These claims are eligible for the Electronic Claim Capture (ECC) option when submitted through the NCPDP format.
• Each ingredient must have a unique prescription number.
• For on-line submitted claims, NCPDP Compound Code Field (406-D6) must contain a value of 1.
• Each drug ingredient payable by New York State Medicaid will be reimbursed at AWP-12% plus a dispensing fee: $3.50 (if a brand drug) or $4.50 (if a generic drug).
• Each ingredient may impact the patient's utilization threshold.
• Payment will only be made for NDCs covered on the List of Medicaid Reimbursable Drugs.

Option 2 -- Billing for a Compound as a Single Entity using NCPDP 5.1

• The entire prescription must have one unique prescription number.
• For on-line claims capture, Compound Code Field (406-D6) must contain a value of 2.
• In the Product Service ID Field (407-D7), enter NDC Code of all "9s".
• In the Product/Service ID Qualifier Field (436-E1) a value of 03 must be entered.
• A value of 1 must be entered in the Quantity Field.
• Reimbursement for each compound prescription billed using Option 2 is restricted to the usual and customary price charged to the general public for the total sum of the ingredients, up to the maximum reimbursable amount (MRA) for this option ($50.00), plus a dispensing fee of $3.50 and a compounding fee of $0.75.
• There is no co-payment assessed using this option.
• The pharmacy must retain the prescription and documentation of ingredients, amounts and costs.
• Pharmacy claims for compounds will be reviewed on a regular basis and those found non- compliant with New York State Medicaid policy will be subject to denial and/or recoupment.

Policy Reminder

  

A compound is considered reimbursable only when the following conditions have been met:

a.) A combination of any two or more legend drugs found on the List of Medicaid Reimbursable Drugs; or

 

b.) A combination of any legend drug(s) included on the List of Medicaid Reimbursable drugs and any other item(s) not commercially available as an ethical or proprietary product, or

 

c.) A combination of two or more products which are labeled: "Caution: For Manufacturing Purpose only."

For example: The combination of Aquaphor® and Hydrocortisone Cream 2.5% is NOT considered a compound.

Reconstitution of a commercially available product is not considered compounding.

If you have any questions or require further information, contact Pharmacy Policy Staff at (518) 486-3209.

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If you change your address, it is your responsibility to notify the Medicaid program in writing. Keeping your file current will ensure you receive all updates and announcements.

Your request should include your:

• provider name;
• provider identification number;
• category of service;
• new address;
• new telephone number; and,
• provider's signature.

Signature stamps, photocopies, etc., are not acceptable.

Indicate if your new address includes changes to both your correspondence address and pay to address. Mail information to:

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This live satellite videoconference (presented in collaboration with the University at Albany School of Public Health) will be broadcast free to participating hospitals and organizations.

Who should attend?

Primary care and family physicians, endocrinologists, physician assistants, nurse practitioners, nurses, dietitians, health psychologists, exercise specialists, social workers and other health care professionals who care for people with or at risk for diabetes.

As a result of viewing this satellite broadcast, participants will be able to:

• Identify three factors that put patients at high risk for developing type 2 diabetes.
• Describe three overall behavioral changes that health care providers can discuss with their patients to reduce the transition from impaired glucose tolerance to type 2 diabetes.
• Identify specific individuals and programs within and outside of your practice environment that can become part of a diabetes prevention team for your patients.
• Identify three key behavioral strategies that patients can use to get started losing weight.
• Identify available resources to assist health care providers in meeting clinical practice recommendations for people already diagnosed with diabetes.

Presenters:

• James Desemone MD, FACE -- Associate Professor of Medicine, Director, Goodman Diabetes Service - Division of Endocrinology and Metabolism, Albany Medical Center
• Elizabeth Venditti, Ph.D., Director, Lifestyle Resource Core for the Diabetes Prevention Program/Diabetes Prevention Program Outcomes Study, University of Pittsburgh Medical Center and Assistant Professor of Psychiatry, Department of Behavioral Medicine, University of Pittsburgh

Moderator:

• Benita Zahn -- Television news anchor and Health Reporter for Albany-based NewsChannel 13's Live at 5 and Live at Noon.

Questions and Answers -- Phone in questions toll-free.

Free Continuing Education Credits

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Medical Society of the State of New York (MSSNY) through the joint sponsorship of the School of Public Health, University at Albany, SUNY; Bureau of Chronic Disease Services - Diabetes Prevention and Control Program, NYS Department of Health. The School of Public Health is accredited by the MSSNY to provide continuing medical education (CME) for physicians. The School designates this educational activity for a maximum of 1.5 hours of category one credit towards the AMA/PRA. Each physician should claim only those hours of credit that he/she actually spent in the educational activity.

This Educational Activity is presented by the School of Public Health Continuing Education, which has been approved as a provider of continuing education by the New York State Nurses Associations' Council on Continuing Education, which is accredited by the American Nurses' Credentialing Center's Commission on Accreditation. It has been approved for 1.5 contact hours and has been assigned approval code 54NLRE-PRV-02-067.

• Continuing education for dietitians pending.
• CME/CEU awarded at no charge to participants at certified downlink sites.

Registration online: http://www.albany.edu/sph/coned/diabetes.html

Listing of viewing sites available: http://www.albany.edu/sph/coned/sites.pdf

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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