DOH Medicaid Update July 2004 Vol.19, No.7

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Having closely monitored the progress of trading partner testing and claims submission for the past several months, the Department has arrived at a final deadline for accepting only HIPAA (Health Insurance Portability and Accountability Act) compliant claims.

After October 6, 2004, ONLY HIPAA-compliant electronic claims will be processed. Electronic claims submitted in a non-HIPAA-compliant format will be rejected.

The Department and Computer Sciences Corporation (CSC) staff will continue to work with providers, vendors and provider organizations, offering technical assistance and support for testing and other efforts related to achieving HIPAA compliance. Recently a new tool was introduced to help our trading partners identify edits/errors and the probable corrective action necessary. It allows claim submitters to see edit/error results of the prior week's claim cycle, and connects them to a web page describing the error, the potential cause and the solution. This new tool is available at www.nyhipaadesk.com under the News and Resources Tab, Edit/Error Knowledge Base.

Unfortunately, many of our trading partners still have not registered to test their transactions on the www.nyhipaadesk.com website and/or with CSC. If you are not yet testing, we urge you to expedite your compliance efforts, and begin the testing process as soon as possible. Any further delay may jeopardize your ability to successfully complete testing prior to October 6, 2004, which would result in an inability to submit HIPAA claims and receive payment. Information on the Medicaid HIPAA testing process is available at www.nyhipaadesk.com.

Providers utilizing clearinghouses or service bureaus to submit their Medicaid claims should be in constant contact with them to ensure they are proceeding aggressively with their HIPAA compliance program. Providers should not assume that these vendors will achieve timely HIPAA compliance, but should proactively monitor their progress. With the impending final deadline date for the rejection of non-compliant claims now set at October 6, 2004, less than three months away, providers must take all necessary steps to become HIPAA compliant as soon as possible to avoid any disruption in claims processing and payment flow.

On a related note, providers still using the old Tranz 330 Point-of-Service (POS) devices have been notified that effective August 1, 2004, these devices will no longer be supported by the Medicaid system (eMedNY). After that date, the only POS devices that will be supported will be the Verifone Omni 3750s . Ordering information may be found on the website, www.emedny.org, or by calling the Provider Services POS Inquiry Line at 800-343-9000 (Option 4), available Monday through Friday between 9:00 AM and 5:00 PM. If you intend to order a new device and have not already done so, please place your order immediately so that you will meet the deadline.

Questions regarding HIPAA Medicaid compliance and this article should be directed to CSC Provider Services at (800) 522-5518.

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Medicaid Trading Partners Urged to Test

A significant percentage of Medicaid's trading partners have still not registered to test HIPAA transactions through www.nyhipaadesk.com. This is a major concern with the final deadline date for HIPAA compliance having been set for October 6, 2004 (see above). It is essential that our partners successfully complete their Medicaid HIPAA testing as quickly as possible to avoid possible financial risks that may result from non-compliance. Providers that use the services of a clearinghouse or service bureau, or purchase HIPAA-compliant software from vendors, do not need to test directly with Medicaid. However, these providers need to be in constant contact with their clearinghouse, service bureau or software vendor to assure the entity they do business with is proceeding aggressively with its testing/compliance plan.

Edit Help Tool Now Available

Medicaid has developed, and posted at www.nyhipaadesk.com, an edit help tool for submitters of HIPAA Test and Production claims. This tool, the Edit/Error Knowledge Base, presents users individual spreadsheets for their Test and Production Deny and Pend errors for each cycle.

The spreadsheets may be downloaded or opened and submitters will be able to find their respective Electronic Transmitter Identification Number (ETIN) (formerly known as TSN) and see the MMIS edits they failed for that particular cycle. In addition, edits displayed in blue (as a hyperlink) can be clicked and a page will be displayed describing the edit, the causes for the edit failing, and a solution for correcting the problem.

To use this valuable tool just click the News & Resources tab at the top of the www.nyhipaadesk.com home page. On the left side of the News & Resources page click the little box with the plus sign next to the "Edit/Error Knowledge Base" topic. This will expand the topic. Expand the Cycle Spreadsheets topic. Next, just click the cycle spreadsheets you wish to view and get the help you need to correct your Test or Production HIPAA claims. Cycle spreadsheets are posted at www.nyhipaadesk.com every Tuesday. New edit pages are being added based on the frequency of the edit failure, so be sure to check this facility every week.

ePACES Software is Upgraded

Computer Sciences Corporation (CSC), the Medicaid fiscal contractor, has enhanced and upgraded the popular ePACES software. ePACES is the HIPAA-compliant software developed exclusively for Medicaid that may be used to submit a variety of HIPAA transactions and eligibility inquiries. ePACES is available, free of charge, to any Medicaid-enrolled provider that may be searching for a HIPAA-compliant, simple-to-use software application. Smaller volume trading partners especially are encouraged to consider ePACES as an alternative to expensive practice management billing systems. Trading partners that are still submitting paper claims should seriously consider ePACES as the application of choice for converting to HIPAA-compliant electronic claiming. Extensive information on ePACES enrollment and user requirements may be found at www.emedny.org, just click on the 'HIPAA' topic.

Parallel Proprietary and 835/820 Remittances

Currently, submitters of HIPAA 837 Test claim files, who now receive the NY Medicaid proprietary tape remittance, will receive the X12 835 or 820 tape remittances for all of their test claims (paid, pend, deny), but will only receive the status of the first 25 test claims on the accompanying proprietary paper test remittance advice.

Medicaid and CSC have developed a process that allows submitters of Production claims (HIPAA or proprietary) to receive, for a designated cycle, both their current remittance type (proprietary tape or paper) and the X12 835 or 820 tape remittance. This new parallel process allows submitters to receive the status of their entire production submission in both formats. This allows critical comparative analyses of their claims, and enhances the current HIPAA testing process. Please check the www.nyhipaadesk.com web site for the latest developments and HIPAA-related announcements. An application requesting the parallel remittances must be completed and submitted to CSC. Submitters may obtain an application at www.nyhipaadesk.com and further instructions by calling CSC's EMC Control at (518) 447-9256.

Medicaid HIPAA on the Web

A reminder that two websites maintained by Medicaid and CSC, www.nyhipaadesk.com and www.emedny.org, are the primary source for Medicaid HIPAA information and technical/systems requirements.

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Services provided by physicians/clinics, pharmacies, labs, mental health clinics, dental clinics, and other practitioners that are subject to utilization thresholds (UT) require a service authorization.

It is important to obtain a service authorization prior to the filing of a claim to expedite processing.

• If a service authorization is not obtained, claims will pend for "No UT Service Authorization On File" and will be recycled for 60 days (from the date of the remittance where the first pend appeared).
  • If a service authorization is obtained during this period, the claim will continue processing.
  • If a service authorization is not obtained in this period, the claim will be denied. You must then obtain a service authorization and resubmit the claim.
• Service authorizations remain on file for 120 days. If a claim is not paid during that period, a new service authorization must be obtained prior to submitting the claim.

Pharmacists

If you receive a claim reject because a recipient is at their utilization threshold limit and you intend to dispense the prescription, you will need to override the UT limit. To submit a UT override, you must resubmit the original transaction with an entry in the Submission Clarification Code (5.1 format) or the Denial Clarification Code (3.2 format).

Also, please inform the patient to go to their primary care provider and ask the primary care provider to submit a threshold override application form to increase the UT limits.

For detailed information about utilization thresholds and obtaining authorization, please consult the MMIS Provider Manual and the eMedNY Manual.

Laboratories

If a laboratory needs to submit a claim for a service for which a UT override application is pending (the laboratory has asked the ordering provider to submit the Threshold Override Application (TOA)), the laboratory should follow the instructions on page 3-57 of the Laboratory Provider Manual. The laboratory must be able to document that they asked the ordering provider to submit the TOA.

Providers seeking additional information on UTs or requesting UT override application forms should contact CSC Provider Services at (800) 522-5518 or (518) 447-9860. Please, have your Medicaid Provider ID number available.

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The Recipient Restriction Program (RRP) is an administrative program whereby selected recipients with a demonstrated pattern of abuse or misuse of Medicaid services may be restricted to one primary medical provider (physician or a medical clinic), one inpatient hospital, pharmacy, and/or to one dental provider and one DME provider.

This program has two major objectives:

1. To provide recipients with coordinated medical services which in turn improve the quality of their care; and
2. To reduce the cost of health care through the elimination of inappropriate utilization behavior by Medicaid recipients.

There are medical and non-medical reasons for a recipient to be placed into the restriction program.

The medical reasons include the receipt of health care services or supplies that are:

• duplicative,
• excessive,
• contraindicated, or
• conflicting.

The non-medical reasons include:

• forged prescriptions or fiscal orders,
• the possession of multiple Medicaid cards,
• card loaning and/or sharing, and
• the selling of drugs or other supplies obtained from Medicaid.

It is important to remember that the primary provider, whether a physician or clinic, is responsible for the provision of most health care services for the recipient. A referral will be needed from these primary care providers for any non-emergency medical services rendered by similar providers, including the ordering of transportation. If a client does not identify oneself as a restricted recipient, you will receive notification when you access eMedNY or other eligibility verification checks.

The primary provider's Medicaid identification (ID) number must accompany all referrals to allow for appropriate eligibility review and claims submission. Claims submitted for a restricted recipient will be denied if the primary provider's ID number in not included in the claim.

If you have any questions regarding the submission of claims for the RRP, please contact CSC Provider Services at (800) 343-9000.

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On an increasing basis, recipients who are restricted are being admitted into a nursing home, adult home, or a rehabilitation service facility on a temporary or permanent basis.

When the admission takes place, it is the responsibility of the facility where the recipient is being admitted to inform the local district Recipient Restriction Program (RRP) Coordinator and the recipient's primary care provider of the admission.

After being notified of the admission, the RRP Coordinator will review the recipient's case and make a determination if it is necessary to change the recipient's primary care provider (MD or clinic), and/or pharmacy services.

Notification is especially important for pharmacy services, since many facilities contract with local pharmacies or pharmacy benefit managers who will not know the recipient is restricted and thus will be denied payments.

Upstate New York and Long Island facilities should contact their respective local district RRP Coordinators. New York City facilities must contact the NYC MAP RRP coordinator, Mr. Floyd Martin at (212) 630-1089.

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Version 1.1 of the 2004 Products of Ambulatory Care/Products of Ambulatory Surgery (PAC/PAS) grouper has been completed and was accessible for Medicaid billing effective July 1, 2004. This replaces Version 1.0 installed in February. It will process all PAC/PAS claims with dates of service on and after February 1, 2004.

The PAC portion of the grouper has been updated to incorporate new ICD-9-CM diagnosis codes for 2004. The PAS program has been updated by replacing CPT-4 dental codes in PAS 43 with the "D" dental codes. Based upon continued provider input and ongoing systems review, additional CPT-4 procedure codes have also been incorporated into PAS groups 1, 16, and 40.

Please contact Mr. John Franklin in the Division of Health Care Financing at (518) 473-8822 if there are any questions about the grouper update or the PAC/PAS programs in general.

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Beginning in mid-July, transportation providers billing for ambulette services (category of service 0602) will be required to:

• Include the driver license number of the individual driving the vehicle on their claim.
• Include the license plate number of the vehicle used to transport the Medicaid client on their claim.

Billing instructions for paper/proprietary electronic submissions (Claim Form A):

• The first eight digits of the individual's driver license number should be entered in the other referring/ordering provider ID/license number field (Field 37).
  • The remaining digit(s) of the driver license number should be entered in the other referring/ordering provider type field (Field 38) beginning in the first position of this two-digit field.

• The vehicle license plate number should be entered in the service provider ID/license number field (FIELD 31).

• The service provider type field (Field 32) should be left blank.

Billing instructions for HIPAA 837P transactions:

• Enter the individual driver's license number in the other referring/ordering provider ID/license field (Loop 2310A, Referring Provider Name Segment, Qualifier P3 in NM101).
• The vehicle plate number should be entered as described above in (Loop 2310B, Rendering Provider Secondary Identification Segment, REF02).

Note: Under eMedNY Phase II, the billing instructions for the 837P transaction will apply to all transportation claims.

Questions regarding these instructions can be addressed to CSC's Provider Services staff by calling (800) 522-5518 or (518) 447-9860.

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Xolair® (omalizumab) is an injectable drug used in the treatment of asthma. It is FDA approved for use in:

• adults and adolescents (12 years of age and above);
• with moderate to severe persistent asthma; and
• who are inadequately controlled with inhaled corticosteroids.

In order to start treatment, patients must have an IgE level between 30 and 700 and have a positive skin test to a perennial allergen (dust, mold, pets, etc.).

Xolair® is available as a lyophilized powder that must be reconstituted using a seven-step process. The lyophilized product takes 15 to 20 minutes to dissolve and should be used within eight hours following reconstitution when stored in the vial at 2-8°C (36-45°F), or within four hours when stored at room temperature.

It is administered by SQ injection every two to four weeks. Because the solution is slightly viscous, it may take five to ten seconds to administer. Patients should be observed by a health care professional after administration, as anaphylaxis within two hours of the first or subsequent doses has been reported.

Safe and effective use of Xolair® depends upon proper reconstitution and storage requirements. Because the skills of a health care professional are needed to prepare and administer Xolair, this drug is not included on Medicaid's out-patient list of reimbursable drugs and, therefore, is not available to patients through their pharmacy.

Medicaid's policy is to ensure medication is prepared and administered in the most clinically appropriate setting.

Xolair® is reimbursable when billed from the physician's office using the appropriate procedure code, J3590, and attaching a copy of the acquisition cost invoice to the claim. Genentech, the makers of Xolair®, offers up to 120 days of dating when purchased by physicians.

For questions regarding the billing of Xolair, you may call the Bureau of Program Guidance at (518) 474-9219.

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Beginning August 23, 2004, Medicaid providers will start to see Medicaid Eligibility Verification Messages (MEVS) messages associated with new coverage codes for applicants who are not seeking coverage of long-term care services:

• Individuals will be allowed to attest to the amount of their resources, rather than provide proof.
• Individuals may also attest to the amount of their resources and qualify for short-term rehabilitation services.

To implement this new policy, the following six new Medicaid Coverage Codes have been created. The new codes will be valid for payment retroactive to April 1, 2003.

1. Coverage Code 19: "Community Coverage With Community-Based Long-Term Care"

For individuals who document their current resources.

Included: Recipient is eligible to receive most Medicaid services.

Excluded: Recipient is ineligible for nursing home services in a skilled nursing facility (SNF) or inpatient setting, managed long-term care in a SNF, hospice in a SNF, intermediate care facility services and waiver services provided under the Long-Term Home Health Care Program, Traumatic Brain Injury Program, Care at Home Waiver Program and the Office of Mental Retardation and Developmental Disabilities Home and Community-Based Waiver Program.

Client is eligible for one admission in a 12-month period of up to 29 consecutive days of short-term rehabilitation nursing home care in a SNF. Local social services districts will determine eligibility for short-term rehabilitation nursing home care. For recipients determined to be eligible, a "Notice of Intent to Establish a Liability Toward the Cost of Care - Short Term Rehabilitation" will be issued to both the recipient and facility.

2. Coverage Code 20: "Community Coverage Without Long-Term Care"

For individuals who attest to the amount of their resources, rather than provide proof.

Included: Recipient is eligible for acute inpatient care, care in a psychiatric center, some ambulatory care, including prosthetics, and short-term rehabilitation services. Short-term rehabilitation services include one admission in a 12-month period of up to 29 consecutive days of short-term rehabilitation nursing home care in a SNF, and one commencement of service in a 12-month period of up to 29 consecutive days of certified home health agency (CHHA) services.

Local social services districts will determine eligibility for short-term rehabilitation nursing home care. For recipients determined to be eligible, a "Notice of Intent to Establish a Liability Toward the Cost of Care - Short Term Rehabilitation" will be issued to both the recipient and facility. CHHA providers cannot bill Medicaid for services provided beyond 29 days, if the recipient has Community Coverage without Long-Term Care.

Excluded: Recipient is ineligible for adult day health care, Assisted Living Program, CHHA services other than short-term rehabilitation, hospice, managed long-term care, personal care, consumer directed personal assistance program, limited licensed home care, personal emergency response services, private duty nursing, nursing home services in a SNF other than short-term rehabilitation, nursing home services in an inpatient setting, intermediate care facility services, residential treatment facility services and services provided under the Long-Term Home Health Care Program, Traumatic Brain Injury Program, Care at Home Waiver Program and the Office of Mental Retardation and Developmental Disabilities Home and Community-Based Waiver Program.

The next three Medicaid Coverage Codes are for individuals who meet a spenddown requirement.

3. Coverage Code 21: "Outpatient Coverage With Community-Based Long-Term Care"

For individuals who document their current resources.

Included: Recipient is eligible for most ambulatory care, including prosthetics, and one admission in a 12-month period of up to 29 consecutive days of short-term rehabilitation nursing home care in a SNF.

Excluded: Recipient is ineligible for inpatient coverage other than short-term rehabilitation nursing home care in a SNF. Recipient is not eligible for waiver services provided under the Long Term Home Health Care Program, Traumatic Brain Injury Program, Care at Home Waiver Program and the Office of Mental Retardation and Developmental Disabilities Home and Community-Based Waiver Program.

Local social services districts will determine eligibility for short-term rehabilitation nursing home care. For recipients determined to be eligible, a "Notice of Intent to Establish a Liability Toward the Cost of Care - Short Term Rehabilitation" will be issued to both the recipient and facility.

4. Coverage Code 22: "Outpatient Coverage Without Long-Term Care"

For individuals who attest to the amount of their resources, rather than provide proof.

Included: Recipient is eligible for some ambulatory care, including prosthetics, and short-term rehabilitation services. Short-term rehabilitation services include one admission in a 12-month period of up to 29 consecutive days of short-term rehabilitation nursing home care in a SNF, and one commencement of service in a 12-month period of up to 29 consecutive days of CHHA services.

Excluded: Recipient is ineligible for inpatient coverage other than short-term rehabilitation nursing home care in a SNF. Recipient is not eligible for adult day health care, Assisted Living Program, CHHA services except short-term rehabilitation, hospice, managed long-term care, personal care, consumer directed personal assistance program, limited licensed home care, personal emergency response services, private duty nursing and services provided under the Long-Term Home Health Care Program, Traumatic Brain Injury Program, Care at Home Waiver Program and the Office of Mental Retardation and Developmental Disabilities Home and Community-Based Waiver Program.

Local social services districts will determine eligibility for short-term rehabilitation nursing home care. For recipients determined to be eligible, a "Notice of Intent to Establish a Liability Toward the Cost of Care - Short Term Rehabilitation" will be issued to both the recipient and facility. CHHA providers cannot bill Medicaid for services provided beyond 29 days, if the recipient has Outpatient Coverage without Long-Term Care.

5. Coverage Code 23: "Outpatient Coverage With No Nursing Facility Services"

For individuals who provided resource documentation for the past 36 months (60 months for trusts) and have made a prohibited transfer of assets.

Included: Recipient is eligible for all ambulatory care, including prosthetics.

Excluded: Recipient is ineligible for inpatient coverage and waiver services provided under the Long-Term Home Health Care Program, Traumatic Brain Injury Program, Care at Home Waiver Program and the Office of Mental Retardation and Developmental Disabilities Home and Community-Based Waiver Program.

6. Coverage Code 24: "Community Coverage Without Long Term Care"

Same coverage as Coverage Code 20.

Additional Information

The ARU response message for coverage "Eligible Except Long Term Care" will be changed to "Eligible Except Nursing Facility Services," to better describe the recipient's coverage.

Recipients with "Community Coverage With Community-Based Long-Term Care" and "Community Coverage Without Long-Term Care" will be eligible to enroll in managed care. In addition, recipients with "Outpatient Coverage With Community-Based Long-Term Care" and "Outpatient Coverage With No Nursing Facility Services" will be eligible to enroll in managed long-term care.

If a recipient requires a long-term care service for which s/he does not have coverage, the recipient will be required to contact his/her social services district immediately for assistance in obtaining the appropriate Medicaid coverage.

Short-term rehabilitation nursing home care in a SNF will require an entry (by the local social services district) on the Principal Provider Subsystem in order for payment to be made to the facility. Recipients in permanent absence status in a nursing home are not eligible for payment of SNF-based short-term rehabilitation. Recipients, who are eligible for Outpatient Only Care (Coverage Code 02), may qualify for temporary stays in a SNF.

If you have any questions concerning pharmacy claims and/or MEVS in general, contact (800) 343-9000.
If you have any questions concerning any other claim type, contact Computer Sciences Corporation staff at (800) 522-5518.

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Medicaid support staff receive a large volume of pharmacy related telephone calls from recipients, pharmacies and prescribers. Callers may be transferred many times before finally reaching the correct department. The following information has been provided to assist pharmacists and prescribers in contacting the right department, thereby saving everyone valuable time.

DOH Pharmacy Policy & Operations Unit 518-486-3209 Available Mon-Fri, 8:45am-5:00pm	Computer Sciences Corporation (CSC) 800-343-9000 Available Mon-Fri, 8:15am-10:00pm	DOH Bureau of Medical Review & Payment 800-342-3005 Available Mon-Fri, 8:45am-5:00pm
Policy questions related to drugs covered by Medicaid and billed by pharmacies; and To report any operational problems with the Voice Interactive Prior Authorization Call Line for prior authorization of drugs; and Questions concerning policy for the NYS Medicaid Mandatory Generic Drug Program, second generation antihistamines, Zyvox and Serostim.	Billing questions for all claims including pharmacy related claims; and Billing questions including non-payment of a claim, claim reversal and adjustments; Obtaining a provider manual; Drugs covered by the NYS Medicaid Program (see also list of reimbursable drugs www.emedny.org); Verify pharmacy point of service edits, including gender, age limitations, or quantity limitations; Verify if a drug requires prior authorization; and Questions concerning the Dispensing Validation System (DVS).	Policy questions related to medical/surgical supplies, durable medical equipment and enteral formula billed by HCPCS; and To report any operational problems with the Voice Interactive Prior Authorization Call Line for prior authorization of Enteral Formula; and Prior Approval of Medical-Surgical Supplies and Durable Medical Equipment.

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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