DOH Medicaid Update September 2005 Vol. 20, No. 10

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A number of family planning clinics have recently had their Family Planning Benefit Program (FPBP) claims denied for reason code 01314. To avoid claim denials for this reason code, clinics should be certain that the following fields are completed as follows:

• The condition code field should be completed with the code A4 (Family Planning).
• The Principal Diagnosis Code field should have the primary diagnosis code.
• The Other Diagnosis Code 1 field should have the secondary diagnosis code.

In accordance with previous billing instructions for the FPBP, (Medicaid Update May 2003 and June 2004 ), in order to secure payment for family planning services provided to eligible recipients:

• The family planning field on the claim form must be completed to indicate a family planning service has been provided; and,
• A family planning diagnosis code in the V25 series must be used on the claim form. This diagnosis may appear as either the primary or secondary diagnosis.

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Provider Services (800-343-9000) is available to assist you if you are having problems submitting claims to Medicaid. However, staff are not able to perform routine claim status checks for providers and submitters who contact the call center for this reason.

Providers who wish to receive claim status prior to receiving the check and paper remittances have the following options:

• Providers can submit an electronic 276 Claim Status Request.
• If you are signed up for ePACES, you can get the status of any of your claims by submitting a Claim Status Request over ePACES.
• ePACES submitters with Professional Claims may select the real-time feature, and get an immediate response to their claim request.
• You can sign up to receive an Electronic Remittance, which is available on the check date.
  • To sign up for Electronic Remittances, visit our website: www.emedny.org.
    Click on "Provider Enrollment Forms" under "Featured Links", then on "Electronic Remittance Request Form".
    You can even sign up to receive electronic remittances for claims submitted on paper.
• The amount of your check is available the Friday prior to the check date by calling (866) 307-5549.

Provider Services is available to assist you with all methods of claims submission and will continue to assist you with claim problems.

We appreciate your understanding and cooperation in keeping Provider Services available to providers who are having difficulties submitting claims.

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The Department maintains a list of providers who have been excluded from the Medicaid program.

These providers, by reason of their exclusion, are not permitted to order services or supplies.

The Medicaid Electronic Verification System (MEVS) claims processing system has an electronic edit in place that precludes a provider (i.e., pharmacist) from submitting a Medicaid claim for an order made by an excluded provider.

• Modifying a claim, such as substituting a valid provider number to circumvent the excluded provider edits, is an unacceptable practice which can result in sanctions and/or monetary penalties being imposed.
• Similarly, overriding DUR messages inappropriately or searching for an eligible client identification number to obtain payment are activities which will result in corrective action by the Department.

We also remind you of two other requirements that appeared in previous Medicaid Updates.

 

Gifts, Inducements and Remunerations (February 2005 Medicaid Update)

Under Department of Health (DOH) regulations and Board of Regents rules (Part 29) involving pharmacy unprofessional conduct, owners of pharmacies, pharmacists or their employees cannot offer any remuneration to a Medicaid beneficiary if the person knows or should know that the offer or transfer is likely to influence the beneficiary's selection of a provider of Medicaid items or services.

Any remuneration can include advertised waiver of co-payments/coinsurance, cash or cash equivalents, gifts such as cell phones, pagers and the transfer of items for free or for other than fair market value.

We have confirmed with the State Board of Pharmacy that there are no monetary exemptions permitted under the Board of Regents rules concerning unprofessional conduct. The only potential exception to this policy for pharmacy providers is:

• the provision of an item or device to a beneficiary which is directly related to the administration of medication for that person, or,
• waiver of Medicaid co-payments based on the recipient's inability to pay.

Prescription Writing Requirements (March 2004 Medicaid Update)

Prescribers:

Provide your State license number or your provider identification number on all prescriptions written for Medicaid recipients. This will ensure proper processing of the prescription.

When a prescription is written by an unlicensed intern or resident, the supervising physician's provider number or State license number must be provided. Please refer to the December 2003 Medicaid Update for further information on prescription requirements.

Pharmacists:

A facility provider number can only be used to process pharmacy claims under the Medicaid program as a last resort.

If the prescriber's license number or provider number has not been provided, pharmacists should attempt to contact the prescriber to obtain their license number or provider number and to verify the prescriber's identity. If a pharmacist is certain that the prescription was ordered by a legitimate prescriber and the license number or provider number is readily available in the records of the pharmacy, it is not necessary to record this number on the prescription. Pharmacies utilizing a facility's provider number in a high percentage of Medicaid claims for payment could be subject to review or audit.

Questions?

Concerning potential unprofessional conduct by pharmacies, contact:

Concerning whether an item or device provided to a Medicaid recipient is in support of the administration of medication, contact:

Concerning the prohibition of inducements and gifts in the Medicaid program, contact:

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Effective October 3, 2005, all prescription Proton Pump Inhibitors (PPI) require prior authorization. These include Prevacid, Prilosec, Nexium, Protonix, Acidphex and all generic PPIs. No prior authorization is required when ordering over the counter (OTC) proton pump inhibitors such as Prilosec OTC, or any generic or OTC gastric acid reducers. Remember that NYS Medicaid covers these over the counter medications; however a written order is required.

• For prescriptions ordered prior to October 3, 2005, no prior authorization is required. When the current prescription, including refills, expires, prior authorization will be required.
• Prior authorization is required for each new prescription and is effective for the life of the prescription (up to five refills within six months). Note that other State laws and Medicaid requirements still apply to these prescriptions.
• The prescriber, or their authorized agent, calls the Pharmacy Prior Authorization Call Line at 1-877-309-9493. After entering the identification information, and responding to three questions about the patient's medical needs, a prior authorization number is assigned. The prior authorization number must be written on the prescription and documented in the patient's medical chart.
• Multiple prior authorizations for multiple patients may be validated in a single phone call. For helpful hints when using the call line, see "Hints for Using the Pharmacy Prior Authorization System".
• The patient's medical record must include documentation of the rationale for requesting the prior authorized drug. The prior authorization worksheet must be included in the patient's medical chart.
• To complete the prior authorization process, the pharmacist must call the Pharmacy Prior Authorization Call Line at (877) 309-9493 to validate the prior authorization number prior to dispensing. Failure to validate the prior authorization number will result in the claim not being paid. Initial dispensing must occur within 60 days of the date prior authorization was obtained.
• The pharmacist must include the prior authorization number on the submitted electronic or paper claim before the claim can be paid. This prior authorization number must also be included on claims for refills. Prior authorization does not guarantee payment. Payment is subject to patient eligibility and other Medicaid guidelines.

Instructions and forms for obtaining prior authorization for prescription proton pump inhibitors:

Proton Pump Inhibitor (PPI) Prior Authorization Request - Prescriber Worksheet and Prescriber Instructions.
Proton Pump Inhibitor (PPI) Prior Authorization Request - Pharmacy Worksheet and Pharmacy Instructions.

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Here are some hints to help speed up pharmacy prior authorization requests when you use the Voice Interactive Phone System (VIPS) for Pharmacy Prior Authorizations!

• Call (866) 211-1736 if you are requesting prior authorization for enteral formula.
• Call (877) 309-9493 if you are requesting prior authorization for prescription drugs.
• An agent of the prescriber (an employee, such as a medical assistant) may complete the prior authorization.
• Have your prior authorization worksheet complete before calling. Use the sample provided in the Medicaid Update.
• Once you become familiar with the system, you can immediately select your numeric choice without listening to the full question.
  • For example, at the beginning of the menu, you can select
    • "1" for Zyvox,
    • "2" for Serostim, or
    • "3" for Brand Medically Necessary prescriptions
    • "9" for Other Drugs including
      • Second Generation Antihistamines (option 1)
      • Proton Pump Inhibitors (option 2)
• Use the keypad to enter numbers.
• When entering telephone numbers, MMIS numbers, and other numeric values, you can move quickly to the next question by pressing the "#" key after entering the full number.

Some providers have expressed difficulty in entering the client identification number (CIN) into the automated pharmacy prior authorization telephone response system.

• Please verify the correctness of the CIN before calling the system. The format of the CIN is 2 letters, 5 numbers, 1 letter - e.g. AB12345C
• Listen carefully to the voice prompt directions
  • USE THE KEYPAD TO ENTER ALL 8 VALUES AT ONCE. For letters, enter the corresponding number on the keypad. For Q, use 7 and for Z, use 9 (These letters are not visible on all keypads).
  • AFTER ALL EIGHT VALUES HAVE BEEN ENTERED, the caller must define the first, second and eighth value by entering the number that represents the letter of the CIN. For example, the voice prompt will say "The first number you pressed was 2 - If you wanted an A, press 1. If you wanted a B, press 2".
  • The CIN is repeated for verification. Please take the time to listen and verify.

Please contact us at (518) 486-3209 if you have questions after following these instructions.

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The Medicaid program now covers the over-the-counter (OTC) formulation of omeprazole called Prilosec OTC™. Prilosec OTC™ is the only proton pump inhibitor (PPI) available over-the-counter. Prescribers may use their prescription blanks to write fiscal orders for Prilosec OTC™.

Currently, the Medicaid program covers a large variety of over-the-counter products used to treat heartburn which include calcium carbonate, magnesium hydroxide and aluminum hydroxide preparations.

These traditional antacids cost the Medicaid program approximately 30 to 40 cents a day!

A cost comparison of various short term PPI therapies is outlined below. It is important that patients with gastrointestinal disorders are provided the most clinically appropriate and cost effective treatment.

OTC and Prescription Proton Pump Inhibitor Options
(please refer to product literature for indications, dosage and administration requirements)

Drug Name	Strength	Estimated Medicaid Cost per Tablet/Capsule		Estimated Medicaid Cost for 14 Days of Therapy*
Prilosec (omeprazole) OTC™	20mg	$ 0.68		$ 9.52
Omeprazole	10mg	$ 3.25		$ 45.50
Omeprazole	20mg	$ 3.65		$ 51.10
Aciphex (rabeprazole)	20mg	$ 4.13		$ 57.82
Nexium (esomeprazole)	20mg	$ 4.28		$ 59.92
Prevacid (lansoprazole)	30mg	$ 4.28		$ 59.92
Prilosec (omeprazole)	20mg	$ 4.06		$ 56.84
Prilosec (omeprazole)	40mg	$ 5.83		$ 81.62
Protonix (pantoprazole)	20mg	$ 3.37		$ 47.18

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Medicaid fee-for-service dental providers will not be reimbursed for services provided to the following Medicaid managed care enrollees:

1) Medicaid managed care enrollees whose plan provides dental benefits (unless the provider participates in the health plan's dental network or has a valid referral from the enrollee's primary care provider).

These enrollees should be referred by their health plan to a participating dentist. Eligibility status for these enrollees will appear as follows:

• Phone message: "Eligible PCP" or "Eligible capitation guarantee" "Dental" is spoken in the list of covered services
• Verifone message: "Managed care coordinator" or "Other or additional payer" A "J" is listed under "Plan code"
• ePACES message: "Managed care coordinator" or "Other or additional payer" A "J" is listed under "Carrier Code"

2) Medicaid managed care enrollees who are in their guarantee period and whose plan does not provide dental benefits.

These enrollees should be referred by their health plan to a participating dentist. Eligibility status for these enrollees will appear as follows:

• Phone message: "Eligible capitation guarantee" "Dental" is not spoken in the list of covered services
• Verifone message: "Other or additional payer" No "J" is listed under "Plan code"
• ePACES message: "Other or additional payer" No "J" is listed under "Carrier Code"

When a Medicaid beneficiary joins a Medicaid managed care plan, that individual is guaranteed eligibility in the plan for a six-month period, beginning at the date of enrollment, even if the individual loses eligibility for Medicaid benefits during that time period.

Thus, when an enrollee loses Medicaid eligibility during their first six months of enrollment in a Medicaid managed care plan, that individual is in "guarantee" status.

A person in their guarantee period is eligible for only those services provided by the Medicaid managed care plan, and is not eligible for "carved-out" services or any other services provided on a fee-for-service basis (with the exception of family planning and pharmacy services).

Therefore, an enrollee in a guarantee period whose plan does not cover dental benefits is not eligible for dental care provided on a fee-for-service basis.

Providers should check the eligibility status of each Medicaid beneficiary before providing services to ensure that claims will be paid.

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An article in the May 2005 Medicaid Update incorrectly stated that the Medicaid program will begin posting a list of brand-name drugs with A-rated generic equivalents on the Department of Health (DOH) website.

This list will not be available on the DOH website!

A list of brand-name drugs that require prior authorization can be accessed on the eMedNY Formulary File at www.emedny.org/info/formfile.html using the following "Search" criteria:

Field: PA Code

Value: 8

Sort by: NDC Code

This list is updated monthly and may not include the most recent additions.

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Commencing with dates of service on and after October 1, 2005, practitioners who participate in the Preferred Physicians and Children's (PPAC) program will receive the enhanced fees when they bill Medicaid in the following manner:

 

• For well child care services furnished in an office setting:
  use the CPT-4 Preventive Medicine Services codes 99381-99385 and 99391-99395.
• For newborn care services:
  use 99431, 99433, or 99435.
• For all other services furnished in an office setting:
  continue to use CPT-4 Evaluation and Management Codes 99201-99205 and 99211-99215.
• For services furnished in an in-patient setting:
  Use CPT-4 Evaluation and Management Codes 99221-99223, 99231-99233 and 99238-99239.

For PPAC providers billing for well-child care under the Child/Teen Health Program (C/THP) guidelines:

• add the modifier -EP; and
• complete the C/THP-EPSDT Referral Code Indicator in Field 22G of the Medicaid eMedNY 150001 Claim Form to indicate that a C/THP service is being provided.

Use of any other codes other than those identified above will result in lower Medicaid payments than you are entitled to as an enrolled PPAC provider!

Please note: Only those providers enrolled in PPAC will be eligible to receive the enhanced PPAC reimbursement for visits.

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The New York State Education Department (SED) has begun issuing professional licenses under the following new profession codes:

Code	Description
09	Medical Physicist - Diagnostic Radiology
11	Medical Physicist - Medical Health
12	Medical Physicist - Medical Nuclear
13	Medical Therapeutic Radiology
21	Pharmacy - 3 Year License
54	Contact Lens Dispenser
59	Dentistry Limited License
69	Dental Hygiene Limited License
72	Licensed Master Social Worker
73	Licensed Clinical Social Worker
84	Dental Hygiene Anesthesia
90	Psychotherapy Visits
91	Druggist

In the April 2005 Medicaid Update, providers were given special instructions on how to bill when the servicing, ordering, referring or prescribing provider is licensed with one of the above profession codes. These instructions were to be followed until eMedNY claims processing system had been updated to accept these new profession codes.

As of June 1, eMedNY claims processing is able to accept these new profession codes. Therefore, when the servicing, ordering, referring or prescribing provider is licensed with one of the profession codes listed above, enter the license number as instructed in your provider manuals.

Note: Certified Social Workers historically licensed with a profession code of 80 were converted to profession codes 72 (Licensed Master Social Worker) or 73 (Licensed Clinical Social Worker) by SED. eMedNY will no longer accept profession code 80 when entering license information for Social Worker. You may verify practitioner profession codes by accessing the NYSED website at www.op.nysed.gov/opsearches.htm.

Please note that this list reflects additions to existing profession codes as authorized by the State Education Department. The existence of a particular profession code does not mean that the code is eligible for Medicaid billing. Providers are responsible for determining that a particular professional service (and therefore corresponding profession code) is eligible for service provision based on type of clinic or other certification available at their site.

For example, individuals licensed under the Nutrition Profession Code of 48 cannot render billable services in Article 28 (Department of health certified) clinics. Clinics should contact their certifying agency for specific information related to their license.

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Effective September 1, 2005, Family Health Plus (FHPlus) enrollees will be responsible for making co-payments for certain medical care and services.

FHPlus plans will implement FHPlus co-payments.

Co-payments for FHPlus will not be processed through eMedNY and providers will not be able to use eMedNY to verify co-pay status for FHPlus enrollees.

Note: FHPlus has no annual cap on co-payments, other than for dental services (see chart below).

SERVICE	AMOUNT	DETAILS ABOUT CO-PAY	NO CO-PAY FOR THESE SERVICES
Physician Visits	$5.00	One co-payment for each visit to a physician, nurse practitioner or physician assistant.	Emergency Services Family Planning Services Maternity Care
Clinic Visits	$5.00	Outpatient clinics in hospitals or freestanding clinics such as Community Health Centers	Emergency Services Mental Health Clinics Family Planning/Prenatal Services Chemical Dependence Clinics MR/DD Clinics
Brand Name Prescription Drugs	$6.00	One co-payment for each new prescription and for each refill	Drugs to treat mental illness (psychotropics) Birth Control Drugs Tuberculosis Drugs
Generic Prescription Drugs	$3.00	One co-payment for each new prescription and for each refill	Drugs to treat mental illness (psychotropics) Birth Control Tuberculosis Drugs
Over-the-Counter Medications (OTCs)	$.50	Covered OTCs - Smoking cessation (e.g.: patches, gum) Insulin	No other OTCs are covered by FHPlus
Medical Supplies	$1.00	Covered supplies - diabetic supplies (e.g., test strips, glucose monitor, lancets, syringes), enteral formulae and hearing aid batteries.	No other supplies are covered by FHPlus
Lab Tests	$.50	One co-payment for each laboratory test	Pregnancy or prenatal tests Laboratory services related to emergencies
Radiology Services	$1.00	Radiology services, including diagnostic radiology, ultrasound, nuclear medicine and radiation oncology services Z	Radiology services related to emergencies
Inpatient Hospital	$25.00	One $25 co-payment for each hospitalization of any length involving at least one overnight stay	Hospital stays for childbirth, miscarriage, family planning services or, prenatal care.
Emergency Room	$3.00	Only for non-urgent or non-emergency services	Urgent or emergency services
Dental Visits	$5.00	Co-pay for each non-emergency visit, but only up to $25 a year	Emergency services Non-emergency visits once the $25 cap has been met

The Following People Are Exempt From Making Co-Payments

• People who state they cannot afford to pay. Health care providers have an obligation to provide services regardless of the patient's ability to pay co-payments.
• People under 21 years of age.
• Pregnant women are exempt during pregnancy and for the two months after the month in which the pregnancy ends.
• People obtaining family planning services, including prescription birth control.
• Residents of Adult Care Facilities licensed by the New York State Department of Health (DOH) are not required to make pharmacy co-payments. Other co-pay requirements still apply.
• Permanent residents of a Nursing Home or community based residential facility.
• 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.
• Residents of the Office of Mental Health (OMH); Residential Care Centers for Adults (RCAA); and Family Care homes (FC), but not adult homes.

Vision Benefit

• The Family Health Plus vision benefit is amended to include once in every twenty-four (24) month period:
• one eye exam;
• either one pair of prescription eyeglass lenses and a frame, or prescription contact lenses only when medically necessary; and,
• one pair of medically necessary occupational eyeglasses.

Coverage will no longer include the replacement of lost, damaged or destroyed eyeglasses.

• The occupational vision benefit will now cover the cost of job-related eyeglasses, if that need is determined by a participating provider through special testing done in conjunction with the regular vision examination.
  • Occupational eyeglasses can be provided in addition to regular glasses but are available only in conjunction with a regular vision benefit once in any 24-month period.

Family Health Plus enrollees may purchase an upgraded frame or lenses for occupational eyeglasses by paying the entire cost as a private customer. Sun-sensitive and polarized lens options are not available for occupational eyeglasses.

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Computer Sciences Corporation (CSC) announces a schedule of seminars to be offered to providers and their billing staff.

Seminar locations and dates are available at the eMedNY website. Registration is fast and easy.

Go to http://www.emedny.org/training/index.aspx to register for the eMedNY Training Seminar appropriate for your provider category and location.

If you are unable to access the internet to register, please contact CSC's call center at (800) 343-9000, to obtain a registration form. You may also request seminar schedule and registration information by contacting CSC's Fax on Demand at (800) 370-5809.

Please refer to these resources frequently for additional seminar offerings.

CSC representatives look forward to meeting with you at upcoming seminars!

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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?
Questions should be directed to CSC at (800) 343-900, option 5.

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

Rate-based/Institutional Provider Enrollment
A change of address form is available at: http://www.emedny.org/info/ProviderEnrollment/Provider%20Maintenance%20Forms/6106-Rate%20Based%20Change%20of%20Address%20Form.pdf

Billing Questions? 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