DOH Medicaid Update June 2005 Vol. 20, No. 7

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Following the implementation of eMedNY Phase II, the Department offered a Transition Plan to submitters and providers who needed additional time to meet the requirements of the new Medicaid system. The Transition Plan, which allowed providers to continue to send claims to MMIS in pre-Phase II formats, is ending on June 20, 2005. All providers must begin sending their claims directly to eMedNY no later than June 20, 2005.

In order to assist providers who had problems making the required changes to their internal systems for eMedNY Phase II system, the Department and CSC implemented these changes to the eMedNY system:

• Electronic claims for ordered ambulatory services, such as laboratory and radiology services (categories of service 0281, 0282, 0162, and 0163) are supported on Institutional Health Care Claim format (837I).
• eMedNY accepts the entry of an 8-digit PA number on claims, even for PAs that were issued with 11 digits. If your internal system cannot support the entry of an 11-digit PA number, simply enter the right-most eight digits, and eMedNY will match it to the 11-digit issued PA.
• eMedNY accepts two-digit locator codes, and fills a leading zero to meet the three-digit requirement for Phase II.
• eMedNY recognizes that a two-character license type code has been entered with a license number on an inbound claim, and converts it to the required three-character profession code.

Note: Two of these changes, the two-digit locator code conversion and the conversion of two-character license type codes to three-character profession codes, are temporary accommodations to assist providers in their transition to eMedNY. Providers will need to make the necessary changes to their internal systems to begin sending three-digit locator codes and three-character profession codes to eMedNY by mid-September 2005.

Providers who are still sending claims to MMIS using the Transition Plan are advised to complete the transition to eMedNY as soon as possible. There are several methods available for sending claims directly to eMedNY.

eXchange: The eMedNY eXchange works like email: users are assigned an "inbox" and are able to send and receive transaction files in an email-like fashion. Transaction files are "attached" and sent to eMedNY for processing and the responses are delivered to the user's inbox so they can be "detached" and saved on the user's computer. eMedNY eXchange requires high-speed access to the Internet.

ePACES: Also available to submitters with high-speed Internet access. Submitters can submit their claims directly to eMedNY using a standard browser on a PC. Submitters of professional claims can select a real-time option that adjudicates and provides claim determination online. Prior authorization requests can also be entered through ePACES, and when determination of the request is available, that information is available on ePACES.

FTP: Submitters without high-speed access to the Internet may want to consider the FTP option. FTP allows you to dial up the Medicaid system, and send your claims using a common File Transfer Protocol (FTP).

Users of the MMIS Electronic Gateway may want to consider the eMedNY Electronic Gateway. For information about how to sign up for this method, please call CSC Provider Services at 1-800-343-9000.

If you have any questions regarding this article, please contact CSC Provider Services at (800) 343-9000.

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The Department is beginning to make provider manuals available on the internet at:

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

Up to this time, the Medicaid program has relied on a paper provider manual.

• Upon enrollment, the new provider receives a plastic binder containing policy and billing information.
• When a change is made to the manual, replacement pages have been mailed to the affected provider group(s).

Now, the Department is updating all manuals and will migrate the material to the eMedNY website. New providers will no longer receive the binder of material, nor will changes to existing manuals be mailed to providers. Rather, all necessary information will be available online.

Manuals can be printed, and downloaded to your own computer!

Manuals are also available in hardcopy, upon request. Call Computer Sciences Corporation at (800) 343-9000

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CREDENTIALING

Medicaid providers need to ensure that they do not employ, or are affiliated with, any individual who has been excluded from either the Medicare or the Medicaid program.

• Pursuant to federal regulations and Department regulations at 18 NYCRR 515.5, an excluded person cannot be involved in any activity relating to the furnishing of medical care, services or supplies to recipients of medical assistance for which claims are submitted to Medicaid.
• The same prohibition applies to activities related to the Medicare program. Activities include both furnishing and ordering (i.e., prescribing) medical care, services or supplies.
• This prohibition extends to group affiliations and to employers (hospitals, nursing homes, pharmacies, etc.) who cannot be associated with, or employ, an excluded individual.
• Eligible Medicaid providers are prohibited from submitting claims or ordering services for excluded individuals.

Providers violating this regulation can be subject to exclusion, a demand for restitution, and/or civil penalties.

We urge providers to undertake appropriate credentialing procedures to ensure compliance. A list of all excluded Medicaid providers is contained on the Department's website at:

http://www.health.state.ny.us/health_care/medicaid/fraud/dqprvpg.htm

Click "next" after reading the text, and click "download the complete list in delimited format".

Additionally, providers should also check the Health and Human Services/Office of Inspector General website at http://www.oig.hhs.gov (click Exclusion Database) for Medicare exclusions.

If providers wish to check the New Jersey list of excluded providers, the website is:

http://www.state.nj.us/treasury/debarred/

The above lists are not indicative of a person's ability to practice their profession in this state. For credentialing on that issue, you should check with the appropriate state licensure agency.

PVR-292 LISTING

Historically, the Department has published a printed list of excluded providers (PVR-292) who, by reason of their exclusion, were not permitted to order services or supplies. This list was, in essence, a partial list of all excluded providers, since it only included providers who could cause orders to be made (e.g., physicians, dentists, optometrists, physician's assistants, podiatrists). Examples of providers, who were not listed, because they do not cause orders to be made, are pharmacies, durable medical equipment providers, registered nurses and transportation providers.

The complete list of excluded providers is now available electronically. As such, we are discontinuing mailing the printed PVR-292 listing after June 2005. For the months of April, May and June, we will mail an "add-deleted" list to supplement the paper PVR-292 issued in March 2005. As you are probably aware, there is an electronic edit in place in MEVS that precludes a filling provider (e.g., pharmacist) from submitting a Medicaid claim for an order made by an excluded provider. We believe the complete list of all excluded providers will facilitate your ability to perform proper credentialing and to accurately and quickly check a provider's Medicaid enrollment status.

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Major changes were made to the Medicaid program on March 24 with the implementation of eMedNY (Phase II).

eMedNY Phase II training seminars will be conducted by representatives of Computer Sciences Corporation's (CSC) Provider Relations at various locations statewide. The purpose of these seminars is to review and explain the specific NYS Medicaid billing requirements, for both paper and electronic transactions, related to eMedNY implementation. The agenda for the seminars includes:

• Overview of eMedNY Phase II
• Billing and remittance changes that apply to paper and electronic transactions
• Other eMedNY Phase II changes with impact on providers
• Questions and answers session

Seminar Schedule and Registration

Seminar locations and dates are available at the eMedNY website. Seminar registration is fast and easy. To register for the eMedNY Phase II Training Seminar appropriate for your provider category, please go to http://www.emedny.org/training/index.aspx.

Providers who do not have internet access may register by fax or mail. Registration materials, including locations, dates, and times can be obtained via fax by calling (800) 370-5809. This fax-back system will prompt the provider through the document order process. The seminar registration information is document number 2008.

Providers with questions should contact: (800) 343-9000. CSC representatives look forward to meeting with you at upcoming seminars.

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New York State's Home and Community Based Long Term Home Health Care Program (LTHHCP) Waiver for the aged and disabled was approved on December 30, 2003 for an additional five-year period by the Centers for Medicare and Medicaid Services (CMS).

• Waiver services are health care related services provided to Medicaid eligible individuals that are not reimbursable by Medicaid outside of participation in a Home and Community Based Waiver program.
• Eleven waiver services are approved for Medicaid reimbursement by CMS for individuals eligible for, and enrolled in, the LTHHCP waiver.
• Services include respite, personal emergency response system (PERS), moving assistance, home delivered meals, social day care and transportation to social day care, housing improvement (environmental accessibility adaptations), medical social services, nutritional counseling, respiratory therapy, and home maintenance (chore services).

Medicaid eligible individuals must be:

• assessed as medically eligible for nursing facility level of care; and
• be authorized for participation in the LTHHCP waiver by the local department of social services.

Waiver services provided to Medicaid eligible individuals, whose participation in the LTHHCP waiver has not been authorized by and are not enrolled in the LTHHCP waiver by the local department of social services, are not reimbursable by Medicaid. Medicaid expenditures for the above listed waiver services provided to non-participating LTHHCP waiver individuals are subject to recoupment.

Questions regarding the LTHHCP Medicaid waiver may be directed to the Department of Health's Bureau of Long Term Care at (518) 474-6580.

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Effective Date	Drug	Dosage	NDC#
June 1, 2005	Aranesp	100 mcg/0.5 ml syringe	55513004104
June 1, 2005	Aranesp	150 mcg/0.3 ml syringe	55513004301
June 1, 2005	Aranesp	150 mcg/0.3 ml syringe	55513004304
June 1, 2005	Aranesp	200 mcg/0.4 ml syringe	55513004401
June 1, 2005	Aranesp	300 mcg/0.6 ml syringe	55513004601
June 1, 2005	Aranesp	500 mcg/1 ml syringe	55513004801
June 1, 2005	Aranesp	150 mcg/0.75 ml via	55513005401
June 1, 2005	Aranesp	150 mcg/0.75 ml via	55513005404
June 1, 2005	Aranesp	25 mcg/0.42 ml syringe	55513005801
June 1, 2005	Aranesp	25 mcg/0.42 ml syringe	55513005804
June 1, 2005	Aranesp	25 mcg/ml vial	55513001001
June 1, 2005	Aranesp	25 mcg/ml vial	55513001004
June 1, 2005	Aranesp	40 mcg/ml vial	55513001101
June 1, 2005	Aranesp	40 mcg/ml vial	55513001104
June 1, 2005	Aranesp	60 mcg/ml vial	55513001201
June 1, 2005	Aranesp	60 mcg/ml vial	55513001204
June 1, 2005	Aranesp	100 mcg/ml vial	55513001301
June 1, 2005	Aranesp	100 mcg/ml vial	55513001304
June 1, 2005	Aranesp	200 mcg/ml vial	55513001401
June 1, 2005	Aranesp	200 mcg/ml vial	55513001404
June 1, 2005	Aranesp	300 mcg/ml vial	55513001501
June 1, 2005	Aranesp	40 mcg/0.4 ml syringe	55513003704
June 1, 2005	Aranesp	60 mcg/0.3 ml syringe	55513003901
June 1, 2005	Aranesp	60 mcg/0.3 ml syringe	55513003904
June 1, 2005	Aranesp	100 mcg/0.5 ml syringe	55513004101

Providers are reminded that effective January 1, 2006, all pharmacy products will be excluded from nursing home rates for dual eligible (Medicaid and Medicare) recipients.

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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