DOH Medicaid Update July 2005 Vol. 20, No. 8

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When billing eMedNY for services provided by a hospital-based or freestanding clinic:

• appropriate HCPCS procedure code(s) that identify the service(s) rendered to a recipient must be used in addition to the rate code;
• the procedure code entered on the claim must reflect the actual service rendered to the patient;
• appropriate procedure codes should be used when multiple services are rendered in the same clinic visit:
  • for HIPAA 837 (Institutional) claims, the procedure code must be reported in Loop 2400, SV Segment; and
  • the rate code should not be entered in the procedure code field.

Note

Dental clinics should enter the five-character CDT-4 dental procedure code. Dental clinics cannot use ICD-9-CM.

A hospital-based or freestanding clinic that is the sponsoring provider for a school-based health center(s) must use the appropriate rate code(s) in the rate code field.

Questions can be directed to the Bureau of Policy Development and Agency Relations at (518) 473-2160.

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The Department has approved a rate increase for livery (category of service 0605) transportation providers, who serve New York City recipients.

The new rates, effective for dates of service on or after May 15, 2005, are as follows:

Description	Procedure Code	Rate
One Way - inside common medical marketing area (trip up to 5 miles)	NY200	$10.10
One Way - outside common medical marketing area (trip over 5 miles)	NY202	$16.80

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An informational link titled "Provider Communications" will be created on each Provider Manual page! The intent of this link is to list recent letters that have been mailed to you.

Currently, this link is available on the Durable Medical Equipment Dealer page, and links will be established for other manuals as provider specific letters are generated.

Go to:

http://www.emedny.org/ProviderManuals/DME/index.html

then click the icon for "Provider Communications" listed under featured links.

Please check the Provider Communications link often for new information, provider notices, policy changes, and more!

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The New York State Medicaid Mandatory Generic Drug Program requires prior authorization for brand-name prescriptions with an A-rated generic equivalent.

When the FDA approves new generic drugs, Medicaid allows the equivalent brand-name drug to be dispensed for a period of six months, without prior authorization, to assure that there is an adequate supply of the new generic readily available. The Medicaid program will begin posting brand name drugs and the effective date of the prior authorization requirement that meet this standard in the Medicaid Update and on the Department's web.

The following lists of drugs have had generic equivalents available for six months or more, and require prior authorization, effective June 1, 2005. Remaining refills of current prescriptions which were written prior to this date, but were filled on or after June 1, 2005, will not require prior authorization. However, when a current prescription expires, a prior authorization will be required for the patient to continue to receive the brand-name drug.

Brand Name Drugs Requiring Prior Authorization
Effective June 1, 2005

ACLOVATE 0.05% OINTMENT

AMICAR 25% SYRUP

AMICAR 250 MG/ML VIAL

AMICAR 500 MG TABLET

ATROVENT 0.03% SPRAY

BACTROBAN 2% OINTMENT

CARDIZEM 120 MG TABLET

CILOXAN 0.3% EYE DROPS

CIPRO 250 MG TABLET

CIPRO 500 MG TABLET

CIPRO 750 MG TABLET

CORTISPORIN EAR SOLUTION

CORTISPORIN EAR SUSPENSION

CORTISPORIN EYE DROPS

CORTISPORIN EYE OINTMENT

CUTIVATE 0.005% OINTMENT

CUTIVATE 0.05% CREAM

CYCLESSA 28 DAY TABLET

CYCLOCORT 0.1% CREAM

DEPO-TESTOSTERONE 200 MG/ML

DIALYTE LM W/4.25% DEXTROSE

DIFLUCAN10MG/ML SUSPENSION

DIFLUCAN 100 MG TABLET

DIFLUCAN 150 MG TABLET

DIFLUCAN 200 MG TABLET

DIFLUCAN 40MG/ML SUSPENSION

DIFLUCAN 50 MG TABLET

DIFLUCAN/DEXTRSE 200 MG/100

DIFLUCAN/DEXTRSE 400 MG/200

DIFLUCAN/SALINE 200 MG/100

DIFLUCAN/SALINE 400 MG/200

DIPROLENE AF 0.05% CREAM

DURICEF 500 MG CAPSULE

DYNACIN 75 MG CAPSULE

ELOCON 0.1% OINTMENT

EMLA CREAM

GLUCOPHAGE XR 500 MG TAB SA

GLUCOPHAGE XR 750 MGTAB SA

GLUCOTROL XL 10 MG TABLET SA

GLUCOVANCE 1.25/250 MG TAB

GLUCOVANCE 2.5/500 MG TAB

GLUCOVANCE 5/500 MG TAB

INPERSOL W/1.5% DEXTROSE

KEFUROX 1.5 GM VIAL

KEFUROX 750 MG VIAL

LEUSTATIN 1 MG/ML VIAL

LOESTRIN 21 1/20 TABLET

LOESTRIN FE 1/20 TABLET

LOPRESSOR HCT 100/25 TABLET

LOPRESSOR HCT 100/50 TABLET

LOPRESSOR HCT 50/25 TABLET

LOPROX 0.77% TOPICAL SUSP

LOTENSIN 10 MG TABLET

LOTENSIN 20 MG TABLET

LOTENSIN 40 MG TABLET

LOTENSIN 5 MG TABLET

LOTENSIN HCT 10/12.5 TABLET

LOTENSIN HCT 20/12.5 TABLET

LOTENSIN HCT 20/25 TABLET

LOTENSIN HCT 5/6.25 TABLET

LOTRISONE CREAM

LOTRISONE LOTION

MACROBID 100 MG CAPSULE

MEFOXIN 10 GM VIAL

MEGACE 40 MG/ML ORAL SUSP

METROCREAM 0.75% CREAM

MIRALAX POWDER

MONODOX 100 MG CAPSULE

MONOPRIL 10 MG TABLET

MONOPRIL 20 MG TABLET

MONOPRIL 40 MG TABLET

MUCOMYST 20% VIAL

MUCOMYST-10 VIAL

MYAMBUTOL 400 MG TABLET

MYCELEX 10 MG TROCHE

NAPRELAN 500 TABLET SA

NAVELBINE 10 MG/ML VIAL

NEOSPORIN EYE OINTMENT

NEURONTIN 100 MG CAPSULE

NEURONTIN 300 MG CAPSULE

NEURONTIN 400 MG CAPSULE

OCUFLOX 0.3% EYE DROPS

PERCOCET 10/325 MG TABLET

PERMAX 0.05 MG TABLET

PERMAX 0.25 MG TABLET

PERMAX 1 MG TABLET

PHENERGAN 25 MG TABLET

PHENERGAN 50 MG TABLET

PLENDIL 2.5 MG TABLET SA

PROAMATINE 10 MG TABLET

PROAMATINE 2.5 MG TABLET

PROAMATINE 5 MG TABLET

PROCARDIA XL 90 MG TABLET

PURINETHOL 50 MG TABLET

REBETOL 200 MG CAPSULE

ROWASA 4 GM/60 ML ENEMA

ROXICODONE 15 MG TABLET

ROXICODONE 30 MG TABLET

SERZONE 100 MG TABLET

SERZONE 150 MG TABLET

SPECTAZOLE 1% CREAM

TAPAZOLE 10 MG TABLET

TAPAZOLE 5 MG TABLET

TERAZOL 3 CREAM

TIAZAC 360 MG CAPSULE SA

TIGAN 300 MG CAPSULE

TORADOL 30 MG/ML VIAL

UNIPHYL 400 MG TABLET

UNIPHYL 400 MG TABLET SA

UNIPHYL 600 MG TABLET

UNIPHYL 600 MG TABLET SA

VANTIN 100 MG TABLET

VANTIN 200 MG TABLET

WELLBUTRIN SR 100 MG TAB SA

WELLBUTRIN SR 150 MG TAB SA

ZANAFLEX 2 MG TABLET

ZAROXOLYN 10 MG TABLET

ZAROXOLYN 2.5 MG TABLET

ZAROXOLYN 5 MG TABLET

ZYBAN 150 MG TABLET SA

Exemptions

A limited number of brand-name drugs with generic equivalents are exempt from this requirement and are listed below.

Current Drugs Exempt From the Prior Authorization Process

Clozaril®	Gengraf®	Sandimmune®
Coumadin®	Lanoxin®	Tegretol®
Dilantin®	Neoral®	Zarontin®

These exemptions:

• do not preclude the prescribing of their generic equivalents; and
• should not be considered an opinion on the bio-equivalency of the generic versions.

Prior Authorization Process

For complete information on the prior authorization process, including the process to request a drug exemption, please visit the Department of Health's website at:

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To remain up-to-date with changes related to paper and electronic Medicaid transaction processing, please visit the eMedNY website at http://www.emedny.org. This website contains the most current information related to the New York State Medicaid program; you will be able to download or print forms and publications necessary to conduct business with New York State Medicaid.

Below is a list of some of the information available to you via the website Main Page:

What's New:

• Letters and announcements about recent changes to the Medicaid program.

Information:

• Provider enrollment and update information forms.
• Past and present Medicaid Updates.
• Frequently asked questions.
• Online license verification website - NYS Education Department's Office of the Professions.

Provider Manuals:

• Online Provider Manuals (includes policy guidelines, billing instructions, procedure codes and fee schedules, prior approval instructions), MEVS manuals, and much more.

Specifications:

• Quick reference guides for completing claims and Threshold Override Applications.

Training:

• Online information and registration for Medicaid seminars in your area.

Contacts:

• Contact information for CSC, DOH and other health related information resources.

NYHIPAADESK:

• Electronic HIPAA transaction specifications (Companion Documents).
• Registration information and forms for electronic submissions.
• Vendor information.

Please visit this website often and stay current with the latest information.

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With the new eMedNY system in place, here are a few helpful reminders to streamline the process:

Label Your X-rays and Other Attachments

• Please label incoming X-rays or any other hard attachments with:
  • requesting dentist's name;
  • provider identification number;
  • client name; and
  • client identification number.

Keep Your Mailing Address Current

• Prior Approval result rosters are mailed to the addresses associated with your locator codes (the code given to your place(s) of business) contained in the Department's Medicaid provider enrollment files.
  
  If your service address(es) has changed, please notify provider enrollment at (800) 343-9000, option #5, so that your prior approval rosters are mailed to the correct address. You must indicate the locator code on your prior approval form which reflects your current address.

Return Missing Information Routing Sheet

• When answering a Missing Information Letter, send the "Return Information Routing Sheet" to the address printed on the bottom half of the sheet along with any x-rays, and your response (which can be on the original letter or a separate 8.5 x 11 inch piece of paper). Do not send the response to the Department of Health.

Use Correct Quadrant Designations

• Quadrant designations used for billing dental procedure codes are as follows:
  • UR Teeth 1-8;
  • UL Teeth 9-16;
  • LL Teeth 17-24, and
  • LR Teeth 25-32.

Questions? Please call CSC Provider Relations at (800) 343-9000.

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As determined by legislation, the New York State Medicaid program will make an annual payment to ambulance providers, supplemental to reimbursements for medical assistance services, in four installations throughout the State fiscal year.

• If the State can secure federal financial participation, the aggregate amount will be up to $4 million annually statewide.
• If the State cannot secure federal financial participation, the aggregate amount will be up to $2 million annually statewide.

How Much Should I Expect?

For each quarter of the fiscal year (ending June 30, September 30, December 31 and March 31), for each ambulance provider, the Department will:

• Determine the ratio of each individual ambulance provider's reimbursements to the total reimbursements made to ambulance providers during the quarter of the calendar year;
• Express the ratio as a percentage; and
• Multiply the percentage of medical assistance payments made to each ambulance provider by one-quarter the aggregate amount.

Payment Cap

The Department will maintain a cumulative total of the supplemental payments made to ambulance providers within their respective districts. Once payments reach one-quarter (25%) of the aggregate total in a social services district, no additional payments will be made during that fiscal year.

For example:

• District A reached 25% of the aggregate in the 2nd quarter.
• No further supplemental payments to providers in District A will be made in the last two quarters of the fiscal year.
• Funds otherwise attributed to District A in the 3rd and 4th quarters will not be distributed.

When Will the First Payment Be Made?

The first payment will be made in the summer of 2005 and will be based upon medical assistance reimbursements made to ambulance providers throughout the first quarter of the 2005-06 State Fiscal Year. The State Fiscal Year ends June 30, 2005.

Questions? Please contact the Provider Resource Unit at 518-474-9219.

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Chapter 58 of the Laws of 2005 has increased pharmacy co-payments, beginning August 1, 2005.

For all Medicaid recipients, including Medicaid managed care enrollees, the increased co-payments are:

ITEM	CO-PAYMENT AMOUNT	DETAILS ABOUT CO-PAYMENT
Brand-Name Prescription Drugs	$3.00	One co-payment charge for each new prescription and for each refill NO CO-PAY FOR: Drugs to treat mental illness (psychotropic), tuberculosis, and birth control.
Generic Prescription Drugs	$1.00	One co-payment charge for each new prescription and for each refill NO CO-PAY FOR: Drugs to treat mental illness (psychotropic), tuberculosis, and birth control.

In addition, the annual co-payment maximum per recipient per year has been increased to $200.

1. Medicaid recipients who cannot afford to pay and tell the pharmacist that they are unable to pay must be provided with the ordered pharmacy items.
2. The pharmacy cannot refuse to provide pharmacy items because of a recipient's inability to pay. (Recipients still owe the unpaid co-pay amounts to the pharmacy and may be asked/billed.)

In addition, the following are exempt from co-payments:

• Recipients younger than 21 years old.
• Recipients who are pregnant.
  Pregnant women are exempt during pregnancy and for the two months after the month in which the pregnancy ends.
• Family planning (birth control) services. This includes family planning drugs or supplies like birth control pills and condoms.
• Residents of an adult care facility licensed by the New York State Department of Health (for pharmacy services only).
• Residents of a nursing home.
• Residents of an Intermediate Care Facility for the Developmentally Disabled (ICF/DD).
• Residents of an Office of Mental Health (OMH) or Office of Mental Retardation and Developmental Disabilities (OMRDD) certified Community Residence.
• Enrollees in a Comprehensive Medicaid Case Management (CMCM) or Service Coordination Program.
• Enrollees in an OMH or OMRDD Home and Community Based Services (HCBS) Waiver Program.
• Enrollees in a Department of Health HCBS Waiver Program for Persons with Traumatic Brain Injury (TBI).

NOTE: Recipients who are eligible for both Medicare and Medicaid and/or receive Supplemental Security Income (SSI) payments are not exempt from Medicaid co-payments, unless they also fall into one of the groups listed above.

Questions regarding the New York State Medicaid Recipient Co-Payment Program?
Call the Helpline at 1-800-541-2831.

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Providers, you now have the opportunity to receive the Medicaid Update in your own electronic mailboxes! Effective immediately, you can request all future Medicaid Updates to be emailed directly to you.

The benefits are numerous:

• You will receive the electronic version about 3 weeks earlier than the mailed hardcopy.
• You will be able to disseminate internally via your own email system, and forward to staff articles that are pertinent to your practice.
• You will have the flexibility to copy, cut and paste, highlight and print articles as needed.

Receive the Medicaid Update electronically and see what a difference it makes! To request the electronic version, just send an email to the Medicaid Update mailbox at:

MedicaidUpdate@health.state.ny.us

Please provide the following information:

• Name
• Medicaid Provider Identification Number (Your 8 digit provider identification number is located directly above the name on the address label)
• Email address (or multiple addresses, if desired)

If you are enrolled in more than one category of service, you are receiving more than one Medicaid Update. We can eliminate this duplicate mailing.

Please mail to us the address page of the duplicate copies of the Medicaid Update to:

Or email the list of duplicate numbers to: MedicaidUpdate@health.state.ny.us

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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 CSC Provider Services at (800) 343-9000.

Address Change?
A change of address form is available at: http://www.emedny.org/info/ProviderEnrollment/Provider%20Maintenance%20Forms/6101-Address%20Change%20Form.pdf.

Provider Enrollment questions should be directed to CSC at (800) 343-900, option 5.

Billing Question? Call Computer Sciences Corporation:
Provider Services (800) 343-9000.

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