DOH Medicaid Update October 2004 Vol.19, No.10

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With the implementation of eMedNY Phase II in March 2005, claims will not be accepted in the 80-byte blocked format. Your HIPAA-compliant EDI X12 and NCPDP electronic claims must be submitted as Streamed Data.

You were previously notified that following eMedNY Phase II, physical media such as tape, diskette, and cartridge would no longer be accepted.

At the time you change to an electronic method of sending claims, you should also begin sending Streamed Data.

If you are using a vendor, service bureau or clearinghouse, please contact them to verify that you will meet these requirements for eMedNY Phase II.

If you have any questions visit www.eMedNY.org or call CSC Provider Services at 800-522-5518 or (518) 447-9860.

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The August 2004 Medicaid Update stated:

The "tilde" character (~) will no longer be allowed as a segment terminator within the messages.

Since that article, several providers have voiced a concern that this will impact their efforts in preparing for eMedNY Phase II.

We are pleased to announce that CSC has developed a method to continue supporting the use of the "tilde" as a segment terminator in eMedNY Phase II, so changes will not be required to your systems.

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HIPAA remittance advices (835 and 820 transactions) will be delivered as electronic response files through the eMedNY Exchange.

You will have the alternate choice of receiving paper remittance advices. However, those who choose the electronic transactions 835 or 820 will not receive paper remittance advices. This means that, 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--one advice and one check for each ETIN. This will eliminate the current requirement of a separate check remittance.

Additionally, remittance advices (electronic or paper) will contain a maximum of 10,000 claim lines. Any excess will be carried over to additional remittance advices. Each remittance advice will have a corresponding check.

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).

Providers who do not choose a primary ETIN will not be able to receive information regarding retroactive adjustments or claims submitted on paper since eMedNY will not be able to link this information to any specific ETIN.

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

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The implementation of eMedNY Phase II in March of 2005 will introduce a new electronic file submission method:

eMedNY Exchange

The eMedNY Exchange works like email:

• Users are assigned an "inbox."
• Through this inbox, the user is able to send and receive transaction files in an email-like fashion.
• Transaction files are "attached" by the user and sent to eMedNY for processing.
• Responses are delivered to the user's inbox. They can be "detached" and saved on the user's computer.

Users will be able to send and receive the following HIPAA compliant transaction files:

• 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/Service Authorization Request and Response (except for DVS requests)
• NCPDP Version 5.1 - National Council for Prescription Drug Programs

Access to the eMedNY Exchange will be obtained through an enrollment process.

Providers who are not enrolled in ePACES will need to follow an eMedNY Exchange enrollment process during which they will be issued a user ID and an initial password. Procedures and instructions regarding how to enroll into the eMedNY Exchange will be made available at a later time.

Magnetic Media Submitters

Providers have been previously notified (in the September 2004 Medicaid Update, and Computer Sciences Corporation's letter of August 9, 2004) that magnetic media (tape, diskette, and cartridge) will not be supported by eMedNY. Providers who currently use these media must migrate to the eMedNY Exchange by March 2005. Information regarding the availability of the eMedNY Exchange for enrollment will be announced at a future date.

Dial-up

Although the eMedNY Electronic Gateway will remain as an access option after the eMedNY Phase II implementation, this method will be discontinued sometime in the future. Therefore, these submitters are strongly encouraged to consider enrolling in the eMedNY Exchange as soon as it is available.

The MMIS Electronic Gateway will be shut off when Phase II is implemented. Providers who currently use this connection only are encouraged to migrate to the eMedNY Exchange as it becomes available. Otherwise, they may use the eMedNY electronic gateway, while it is available, with a new ID and password (your MMIS Electronic Gateway ID and password will not be accepted by eMedNY).

More details regarding these matters will be provided at a later time. Please visit the eMedNY website (www.eMedNY.org) frequently and look for mailings from CSC and the Department.

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Claims

Transportation providers are advised that with the implementation of eMedNY Phase II in March 2005, the current legacy electronic Claim Form A format will no longer be supported. All non-emergency transportation services billed electronically will be required to be submitted on the HIPAA 837 Professional transaction (837P).

This change impacts transportation companies who provide only non-emergency transportation services and are not currently using the HIPAA 837P transaction. In order to continue submitting their claims electronically, these providers need to take action to convert to the 837P format by March 2005.

Information regarding the 837P HIPAA Transactions can be found in the HIPAA Implementation Guides as well as the New York State Companion Guides at www.hippadesk.com.

Procedure Codes

Procedure codes will change with the implementation of eMedNY Phase II. Non-emergency transportation procedure codes will change from the current format, CCNNN (where CC = County Code and N = numeric character) to the format, NYNNN (NY is a fixed value and N = numeric character).

You and local district staff will be notified of these new codes in advance of implementation.

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Need a quick reference for Medicaid or HIPAA information, but don't have access to the Internet? Try the new Provider Services Fax-On-Demand System, faxable information available to you 24 hours a day, seven days a week.

It's easy! All you need is a touch-tone telephone, a fax machine to receive the document, and a telephone or extension number that will identify you as the recipient of the requested document(s).

Just dial 800-370-5809 to obtain quick reference documents for HIPAA and Medicaid-related topics. A series of voice prompts will take you through the process of requesting documents. You may request up to five documents at a time.

Request a list of documents (option 2) when you call the Fax-On-Demand System for the first time. Request the document list periodically to ensure that you have the most current update of a document and to see if any new documents of interest have been added.

Documents are currently available for the following topics:

• General HIPAA Information
• DOH Letters
• Trading Partner Agreements
• ePACES & ePACES Enrollment
• HIPAA Transaction Codes & Definitions
• HIPAA Testing - nyhipaadesk.com Website
• Supplementary Medicaid Documents
• NCPDP PC to Host Testing

If you do not receive a document that you've requested from the Fax-On-Demand system, please verify that you are entering the correct number for your fax machine during the request process and that your fax machine is operational.

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Effective for dates of service on and after November 1, 2004, Medicaid will no longer accept claims for the following drugs when billed under an unlisted code.

Please add these new codes to your respective provider manual (Rev. 7/03).

Code	Drug	Unit Description
J0215	Amevive	Injection, Alefacept, 0.5mg
J1595	Copaxone	Injection, Glatiramer Acetate, 20mg
J1652	Arixtra	Injection, Fondaparinux Sodium, 0.5mg
J1655	Innohep	Injection, Tinzaparin Sodium, 1000 IU
J2353	Sandostatin LAR	Injection, Octreotide, Depot Form For Intramuscular Injection, 1mg
J2783	Elitek	Injection, Rasburicase, 0.5mg
J9263	Eloxatin	Injection, Oxaliplatin, 0.5mg
J9395	Faslodex	Injection, Fulvestrant, 25mg
Q20051	Acthrel	Injection, Corticorelin Ovine Triflutate, per dose
Q2012	Adagen	Injection, Pegademase Bovine, 25 IU
Q2017	Vumon	Injection, Teniposide, 50mg

¹1Q2005 is limited to Ordered Ambulatory only.

In addition, the following code is now available for billing dates of service on and after January 1, 2004.

Code	Drug	Unit Description
J2505	Neulasta	Injection, Pegfilgrastim, 6mg

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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.

• What Is One of The Most Important Causes Of High Blood Cholesterol?
  • Fat is one of the most important causes of high blood cholesterol.
• Are All Fats Bad For My Cholesterol?
  • No. Some types of fats are clearly good for blood cholesterol and others are clearly bad. Cholesterol in food does affect blood cholesterol levels but not as much as eating a diet high in "bad fats." Saturated and Trans fats are examples of "bad fats."
• Where Does Fat Come From?
  • Fats are found in both animal and plant foods. As a rule, more saturated or "bad fat" is found in animal foods, while more polyunsaturated and monounsaturated or "good fat" is found in vegetable foods.
• Why Are "Bad Fats" Bad, And "Good Fats" Good?
  • There are "good fats" and "bad fats." The "bad fats" increase the risk for certain diseases while the "good fats" lower the risk. It is important to substitute "good fats" for "bad fats!"

• What Are Saturated Fats And Why Are They "Bad"?
  • High blood cholesterol levels greatly increase the risk for heart disease. When you have a lot of saturated fats in your diet, your liver responds by making more cholesterol. This raises your blood cholesterol level. It is the most harmful fat you can eat!
• What Does Saturated Fat Look Like And Where Does It Come From?
  • Saturated fat is found mainly in animal foods and is solid at room temperature. Some examples of saturated fat are: meat, bacon, cheese, butter, whole (not skim) milk, and ice cream.
• What Are Trans Fats?
  • Trans fatty acids are made by heating vegetable oils in the presence of hydrogen. This process is called hydrogenation. They are changed from a liquid to a solid form. Trans fats prolong the shelf life of packaged foods.
• How Can I Tell If Packaged Foods Have Trans Fats In Them?
  • Check the food label for the words trans fats. Not all foods have trans fats listed. The Food and Drug Administration is requiring that all trans fats be listed on the Nutrition Label by 2006.
  • Check the ingredient list for the words hydrogenated oils. The higher up on the ingredient list, the more trans fat the food contains.
• How Can I Avoid Or Lower The Amount Of Trans Fat I Eat?
  • Choose liquid vegetable oils or a soft tub margarine that has little or no trans fat.
  • Eat less packaged, baked and snack foods including fast foods. When buying snack and packaged items, choose the brand without trans fats or hydrogenated oils as an ingredient. (Ex.: There are brands of potato and tortilla chips, pancake mixes, etc. without hydrogenated oils).
  • When foods without hydrogenated oils can't be avoided, choose products that list hydrogenated oils near the end of the ingredient list.

Remember: there is no safe level of trans fats in the diet!

• What Are The "Good Fats?"
  • Polyunsaturated and monounsaturated fats are the "good fats." They come mainly from plants and are liquid at room temperature. They help lower blood cholesterol levels.

 

TYPES OF FAT	MAIN SOURCE	APPEARANCE AT ROOM TEMPERATURE
MONOUNSATURATED (Good fat) Lowers LDL (bad cholesterol) and raises HDL (good cholesterol)	Olives, olive oil, canola oil, peanut oil, cashews, almonds, peanuts and most other nuts, avocados, etc.	Liquid
POLYUNSATURATED (Good Fat) Lowers LDL, raises HDL	Corn, soybean, safflower, sesame, sunflower and cottonseed oils, fish, sesame and sunflower seeds, walnuts, etc.	Liquid
SATURATED (Bad Fat) Raises both LDL and HDL	Whole milk, butter, cheese, ice cream, red meat, chocolate, coconuts, coconut milk, coconut and palm oil, brazil and macadamia nuts, pistachios, poultry, etc.	Solid
TRANS (Bad Fat) Raises LDL	Most margarines, vegetable shortening, partially hydrogenated vegetable oil, deep fried chips, most fast foods, most commercial baked goods, most dry packaged foods and instant mixes, etc.	Solid or semi-solid

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Effective for order dates on or after October 1, 2004, the maximum quantities will be changed for insulin infusion and drug infusion supplies.

Please note these changes below (in BOLD) and insert them in your Pharmacy or Durable Medical Equipment Provider Manual (Rev. 4/04)

CODE	PRODUCT	QUANTITY/SIZE	REFILLS	PRICE
A4221	#Supplies for maintenance of drug infusion catheter, per week (list drug separately), (bill monthly)	Each unit (up to 100 units per month)	5	$1.00
A4230	#Infusion set for external insulin pump, non-needle cannula type.	Each (up to 30) (two month supply)	5	$13.54
A4232	#Syringe with needle for external insulin pump, 3 cc's.	Each (up to 30) (two-month supply)	5	$4.63

When the description is preceded by a "#", Medicaid Eligibility Verification System (MEVS)/ Dispensing Validation System (DVS) authorization is required.

Questions regarding this article may be referred to the Medical Prior Approval Unit at (800) 342-3005.

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When obtaining a prior authorization for a second generation antihistamine, select Option 9 from the Voice Interactive Phone System (VIPS) when you begin the process. Option 9 requests pertinent clinical information needed to receive a valid prior authorization number. Many providers have selected Option 3 instead, the option for requesting a brand-name drug when a generic is available. Using the appropriate option will reduce manual reviews and resubmissions from your staff, as well as aid in the timely reimbursement to the dispensing pharmacy.

Option Tips for Medicaid VIPS

Request	VIPS Telephone Number	Option to Select
Brand-name drugs	877-309-9493	#3
Antihistamines	877-309-9493	#9
Zyvox	877-309-9493	#1
Serostim	877-309-9493	#2
Enteral Formula	866-211-1736	#1 Physician or Physician Assistant #2 Nurse Practitioner or Midwife #3 Dentist

Reminders

1. Prior Authorizations can only be obtained using the Prior Authorization VIPS.
2. The VIPS is voice sensitive, thus is also sensitive to certain levels of background sound. Even if using the touchtone phone pad, please keep in mind background noise may result in difficulty obtaining a prior authorization.
3. The dispensing pharmacist must call the VIPS to validate the prior authorization number before dispensing. Failure to validate the prior authorization number will result in the claim not being paid.

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Effective for order and prescriptions dated on or after October 1, 2004, prior approval requirements for the specific codes listed below will be removed.

All coverage criteria remains the same and documentation of medical necessity must be maintained in the ordering physician or optometrist clinical files.

Contact Lenses - Physician and Ophthalmic Services

Code	Description
92310	Prescription of optical and physical characteristics of and fitting of contact lens, (includes materials) with medical supervision of adaptation (for ocular pathology); corneal lens, both eyes, except for aphakia.
92311	Corneal lens for aphakia, one eye
92312	Corneal lens for aphakia, both eyes
92313	Corneoscleral lens, one eye
92326	Replacement of corneal contact lens

(See pages 2-74 and 7-126 (Rev. 7/03) of your Physician Services Provider Manual, and pages 2-41, 2-53 and 4-17 (Rev. 7/03) of your Ophthalmic Services Provider Manual.)

Polycarbonate Lenses - Ophthalmic Services

The following new procedure code has been added to the Ophthalmic Fee Schedule, effective for dates of service on or after October 1, 2004, and should be used in addition to the basic code for each lens, when medically necessary.

Code	Description	Maximum Fee - NYS
S0580	Polycarbonate lens (list this code in addition to the basic code for the lens) (ages 21 and over require prior approval)	$10.00

(Refer to the policy guidelines on page 2-51 (Rev. 7/03) of your Ophthalmic Services Provider Manual for additional information.)

Sleep Testing - Physician Services

Orders for sleep testing are limited to physician specialists in pulmonology, otolaryngology and neurology. Documentation to support the medical necessity of sleep testing must be maintained in the ordering physician's clinical file.

Code	Description
95805	Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness.
95807	Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate and oxygen saturation, attended by a technologist.
95808	Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist.
95810	Sleep staging with 4 or more additional parameters of sleep, attended by a technologist.
95811	Sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist.

Orders for sleep testing are limited to physician specialists in pulmonology, otolaryngology and neurology. Documentation to support the medical necessity of sleep testing must be maintained in the ordering physician's clinical file.

(See pages 7-20 for instructions on billing the professional component and 7-149 (Rev. 7/03) of your Physician Services Provider Manual for additional information.)

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You may encounter seniors who have pharmacy coverage from Medicare, Medicaid and/or EPIC.

Seniors enrolled with full Medicaid coverage ARE NOT eligible for Elderly Pharmaceutical Insurance Coverage (EPIC). However, seniors with spend-down or surplus Medicaid coverage ARE eligible to join EPIC for coverage of claims not covered while in Medicaid spend-down status.

When seniors have prescription drug coverage with both EPIC and Medicaid spend-down, pharmacies should always bill Medicaid before billing EPIC. Claims not covered by Medicaid (because the senior is in spend-down status) should then be billed to EPIC.

When seniors have a Medicare drug discount card with $600 Transitional Assistance credit, Medicare is the primary coverage.

The following billing hierarchy applies:

1. Medicare ($600 credit).
2. Medicaid (spend-down).
3. EPIC, which is always the payer of last resort

If you have additional questions regarding EPIC claims processing procedures and policies, please call the EPIC Provider Helpline at 1-800-634-1340.

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As a condition of enrollment in the New York State Medicaid program, a current pharmacy license is required (out-of-state and/or New York State).

If the license that you provided with your original Medicaid application has expired or is close to expiring, you are required to submit a copy of your new license to:

If the ownership or the name of your pharmacy has changed, it is your responsibility to submit an updated license and Medicaid enrollment application to the Department.

Failure to maintain a valid license or to notify the Department of a change in name or ownership may result in termination from the Medicaid program. If your provider number is terminated, you may be subject to any enrollment requirements or policies currently in effect.

Effective March 19, 2003, the New York State Education Department requires certain pharmacies located outside of New York State to register with the New York State Board of Pharmacy. State Education Law 6808-b requires that out-of-state pharmacies that ship, mail or deliver prescription drugs and/or devices to other registered establishments, authorized prescribers, and/or patients within the State must be registered in New York State. This includes mail order and delivery services, including delivery of medications, to nursing homes located within New York State. You must adhere to this requirement to be a Medicaid provider. The New York State Education Department may grant exceptions to this requirement to pharmacies that deliver 600 or fewer prescriptions per year into New York State.

If this requirement applies to your pharmacy, please call the New York State Board of Pharmacy at: (518) 474-3817, ext. 130.

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• Claims for Medicare covered items must always be billed to Medicare prior to submission for payment by New York State Medicaid program.
• If the patient has other insurance, claims must be submitted to the third party insurance prior to submission for payment to the New York State Medicaid program.
• If the patient has other insurance or is on Medicare, brand drugs with a generic equivalent will still require prior approval.

If you have questions regarding this article, please contact the Pharmacy Policy and Operations staff at (518) 486-3209, or e-mail: ppno@health.state.ny.us

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• Q. Can pharmacies still use the facility MMIS (Medicaid Management Information System) ID (identification) number for billing when a prescription is written by an intern or resident?
  • A: For orders originating in a hospital, clinic, or other healthcare facility, the facility's Provider ID number may be entered only when the prescriber's Provider ID or State license number is unavailable and cannot be obtained.
    When a prescription is written by an unlicensed intern or resident, the supervising physician's Provider ID number should be entered. If the supervising physician is not enrolled in the New York State Medicaid program, his/her State license number may be entered. When these numbers are unavailable and cannot be obtained, enter the facility's Provider ID number.
    Please be aware, Medicaid has instituted a license verification edit to verify the prescriber's license or Provider ID number on pharmacy claims is accurate and legitimate. Medicaid is reviewing the use of facility Provider IDs. A facility's Provider ID number should only be used as a last resort.
    Reminder: A facility's Provider ID number cannot be used for any product that requires prior authorization.
• Q: I am trying to transmit a prior authorization for brand-name Valium. Is this covered?
  • A: Prescribers, Please Note! Medicaid will only reimburse for diazepam, the generic of Valium®. Valium® will not be covered, even if a prior authorization is obtained. The labeler of this drug does not participate in the Medicaid Federal Drug Rebate Program, therefore making Valium® ineligible for reimbursement. The prior authorization system is likely to assign a number at the request of the doctor, but claims for Valium® are not reimbursable and the pharmacist will be notified when attempting to transmit the claim.

Pharmacists & Prescribers! Do you have questions concerning Drug Coverage?

A recent review of Pharmacy Policy telephone statistics indicates 30% of incoming calls are inquiries concerning whether or not a drug or a particular NDC is covered by New York State Medicaid. This information can be directly accessed by viewing the list of Medicaid reimbursable drugs at:

http://www.eMedNY.org/info/formfile.html

Utilizing this website will prevent you from having to call our Albany office and will allow our Pharmacy Policy staff to be more readily available to answer policy-specific questions.

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This article reiterates Medicaid policy to pay specific inpatient services outside the electronic claims payment system, and explains how this existing process impacts Medicare Buy-In situations (see item #2 below).

The Medicaid payment system cannot process electronic claims when certain conditions apply. In these situations, the hospital can receive payment by submitting a paper claim form (currently UB-92), Medicare and/or other third party benefit statements, and a cover letter to the Medicaid program for processing. If approved, a separate check will be mailed to the hospital.

Following are situations where an "off-line" payment will be processed for care provided to eligible clients. The two-year billing rules apply to these cases.

1. Patient is granted Medicaid eligibility during the inpatient stay, and the case will be paid on a DRG (diagnosis-related group) basis.
   In this case, a pro-rated (partial) DRG payment will be made.
2. Patient is Medicaid eligible at admission and becomes Medicare eligible during the stay.
   In this case, Medicare will make a DRG payment based on services rendered from the first day of Medicare entitlement.
   • Medicaid will compare the Medicare-paid DRG to the Medicaid DRG (which is based on the entire stay).
   • If the DRGs differ, and the Medicaid-only payment exceeds the Medicare payment, Medicaid will pay the difference plus any Part A deductibles, coinsurance and LTR days that may be appropriate (please note: it may be appropriate to bill a portion of the stay electronically. You will be advised at the time your case is reviewed.).
3. Partial Part A payment is denied because another partial Part A payment was made for the same spell of illness (remittance denial message 01129).
4. Patient is covered by a Medicare managed care plan, and the plan leaves a patient responsibility that is greater than traditional Medicare deductibles or coinsurance amounts.

The documentation noted above should be mailed to:

Questions regarding this article can be addressed to the Rate-Based Provider Unit at 518-474-8161.

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Medicaid recipients in New York City have the option to enroll in the following service areas 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, Queens
NYPS Select Health SN	OG	NYPSSEL SN	Bronx, Brooklyn, Manhattan
VidaCare Inc. SN	OD	VIDACARE SN	Bronx, Manhattan
MetroPlus Partnership in Care Plan SN	OM	METROPLUS SN	Bronx, Brooklyn, Queens, Manhattan

Providers note: These codes in your 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.

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Most individuals who are eligible for Medicare Part B are also eligible for premium free Part A coverage. However, there are some individuals who do not have enough work quarters to qualify for free Medicare Part A.

For those individuals who have Medicare Part B, and meet the income and resource requirements of the Qualified Medicare Beneficiary Program (QMB) (i.e., income below 100% of the Federal Poverty Level and resources less than $4000 for an individual and $6000 for a couple), states may purchase Part A coverage on their behalf.

On July 1, 2004, New York State began enrolling individuals in the Medicare Part A Buy-in system who are:

• SSI cash recipients age 65 or over; and,
• on the Part B Buy-in, but not eligible for premium free Part A coverage.

The State initially enrolled approximately 85,000 individuals. As new individuals meet the criteria for this program, the State will purchase Part A coverage on their behalf. The State will pay the Medicare Part A premiums, deductibles, and coinsurance amounts for these individuals.

For these individuals enrolled in Medicare Part A by the State, providers of Medicaid services will be required to bill Medicare for Part A claims that would otherwise have been paid by Medicaid.

The Social Security Administration will send notices to these individuals informing them of their new benefit.

Information available through the Medicaid Eligibility Verification System (MEVS) will provide you with the Medicare coverage that the client has for the date of service.

Questions regarding this article can be directed to the Department at (518) 474-9138.

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Effective for order dates on or after October 1, 2004, prior approval requirements, short-term rental without prior approval ('-RR') and fees will be changed for the items listed below. Please insert the changes in BOLD type in your MMIS Durable Medical Equipment Provider Manual (Rev. 4/04).

All coverage criteria remain the same and documentation of medical necessity must be maintained in the ordering provider's clinical files.

CODE	PRODUCT	PRICE
E0140	# Walker, with trunk support, adjustable or fixed height, any type	$1664.24
E0168	# Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each	131.53
E0265 '-RR'	Hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress	1019.20
E0303 '-RR'	Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress	2361.67
E0439	#Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or per unit (LPM) mask, and tubing (one unit = one liter per minute) (up to six units)	72.50

Reimbursement for oxygen systems is an all-inclusive monthly rate. E0439, E0424 (Stationary gaseous oxygen system) and E1390 (Oxygen concentrator) may NOT be billed in combination. Liquid oxygen is only covered if the standards on page 2-56 and 2-57 of your MMIS Durable Medical Equipment Provider Manual (Rev. 4/99) are met.

CODE	PRODUCT	PRICE
E0776 '-RR'	I.V. pole	59.62
E2500	#Speech generating device, digitized speech, using pre-recorded messages, less than or equal to 8 minutes recording time	391.06
K0004 '-RR'	#High strength, lightweight wheelchair (see page 4-37 of your MMIS DME Provider Manual (Rev. 4/04) for coverage and product parameters)	810.86
K0006 '-RR'	#Heavy-duty wheelchair (see page 4-38 of your MMIS DME Provider Manual (Rev. 4/04) for coverage and product parameters)	737.03
K0108	Other accessories (repair/replacement of wheeled mobility parts not listed and less than $100.00 including parts, requires prior approval if more than one per year)	99.99
T5001	#Positioning seat for persons with special orthopedic needs, for use in vehicles	513.75

• When the description is preceded by" #", Medicaid Eligibility Verification System (MEVS)/Dispensing Validation System (DVS) authorization is required.
• Underlined "______" code numbers indicate that prior approval is required.
• When '-RR' is noted under the code, four months rental at 10% of price is allowed without prior approval.

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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