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New York State

August 2007  
Volume 23, Number 8  

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News for All Providers

Important Information about Available Electronic Tools
The Medicaid Program has three electronic tools available for providers to interact with the Medicaid Program.

eMedNY Website Highlights: HIPAA Claim Denials
Did you ever get a claim denied but can't figure out why? Read this article to learn about HIPAA-compliant denials and what they mean!

Your Provider Manual is Online!...
Stay up to date with Medicaid policy by reading your provider manual.

Policy and Billing Guidance

Prior Approval Process for Enrollees Eligible for Both Medicare and Medicaid
Durable Medical Equipment, Prosthetic, Orthotic and Supply Item Providers are urged to review this change to Medicaid policy.

Dispensing Validation System Cancellations
This article provides information on how and when Pharmacy and Durable Medical Equipment Providers can cancel a request.

Preferred Drug Program News
Changes are coming effective August 28, 2007.

Preferred Drug List
Print this seven page guide to New York's list of preferred drugs.

Claim Requirements When an Ambulette Vehicle is Used
Ambulette providers are reminded of claim requirements.

Clinical Psychologists: Reimbursement of New Procedure Codes
Three new procedure codes reimbursable effective September 1, 2007.

Traumatic Brain Injury Providers: New Billing Procedure for Services Without Established Fees
A new billing procedure takes effect October 1, 2007. Find out how this affects your program.

Inpatient Hospital Billing Guidelines
Guidelines were recently updated online.

Medicaid Payment for Undocumented Immigrants or Temporary Non-Immigrants
New Medicaid policy regarding the treatment of an emergency medical condition for this special population.

Sterilization and Hysterectomy Consent Forms Available Online
Now, nurse practitioners, midwives and physicians can obtain certain forms online.

General Information

Tools for the Evaluation, Ordering and Provision of Manual and Powered Wheeled Mobility Equipment
A template and guidelines for those involved with evaluating, ordering and providing this equipment to Medicaid enrollees.

Individual Provider Training is Available
Do you need help understanding the claims process? This article explains how to request assistance.

Seminar Schedule and Registration
If you have questions about billing the Medicaid Program, read this article and learn how to make a request for training.

Computer Sciences Corporation Call Center Contact Information
Learn how to navigate Computer Sciences Call Center with this article.

Provider Resources

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News for All Providers....

ePACES - Electronic Provider Assisted Claim Entry System

WHY ePACES? It's Free, Fast, Easy-to-use and Accurate!

• Secure web-based application.
• Free-of-charge to enrolled Medicaid providers.
• HIPAA compliant transactions:
  • Claims (Professional, Dental and Institutional),
  • Claim status requests,
  • Eligibility requests,
  • Utilization Threshold (UT)/Service Authorization (SA) requests,
  • Dispensing Validation System (DVS) requests, and
  • Prior approval requests.
• Professional "real-time" claims are processed instantly, therefore claim status and the amount paid are available immediately after submission (within seconds).
• ePACES will speed up claims processing time.
• ePACES can be accessed anywhere you have internet access.
• The status of all claims, regardless of the mode of submission, is available via ePACES.

HOW DO I SIGN UP?

• To start the enrollment process call the CSC Call Center at (800) 343-9000

Electronic Funds Transfer (EFT)

WHY EFT? No more waiting for your check to arrive in the mail!

• Your Medicaid payments are directly deposited into the checking or savings account that you designate.

HOW DO I SIGN UP? It's Easy!

• Complete the EFT Provider Enrollment Form, available online at: http://www.emedny.org/info/ProviderEnrollment/index.html
• Multiple provider identification numbers? No problem, simply submit a separate EFT enrollment form for each provider identification number.
• Provider Groups receiving payments under a Group identification number need only to complete a single enrollment form for the Group identification number.
• Individual members of Provider Groups who bill individually may also enroll their individual Provider identification number.

Electronic Remittance Advice

WHY Electronic Remittance Advice? No more waiting for your paper remittance statement to arrive in the mail!

• You'll receive your electronic remittance advice two-and-a-half weeks sooner than paper remittance statements.
• Fast, secure delivery to your eMedNY eXchange or FTP (File Transfer Protocol) account.
• HIPAA-compliant 835 (or 820 for Managed Care Plans) format.
• A supplementary file provides the New York Medicaid edit error codes for denied and pended claims.
• Dual remittance statements (paper and electronic) are available for up to four weeks while you transition.

HOW DO I SIGN UP? It's Easy!

• Complete the Electronic Remittance Request Form found at: http://www.emedny.org/info/ProviderEnrollment/index.html. Select Electronic Remittance Request Form.

Software is needed to process and interpret the electronic remittance statement.

Contact your software vendor, or for a list of software vendors, refer to http://www.emedny.org/hipaa/vendors/index.html

Questions about ePACES, Electronic Fund Transfer or Electronic Remittances?
Contact the CSC Call Center at:
(800) 343-9000.

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The eMedNY website contains an enormous amount of information for providers:

• Provider Manuals,
• documents that can assist providers with claim and other transaction submissions,
• information to clarify messages and claim denials that are returned via the Medicaid Eligibility Verification System (MEVS) or the provider's remittances (electronic or paper).

Try This Search!

Go to: http://www.emedny.org/hipaa/

• From the menu on the left choose Edit/Error Knowledgebase.
• Then choose Edit Map for 835 in Order of Reason Code.

With the implementation of HIPAA standardized claim error reasons, in some cases, it can be difficult to pinpoint the specific reason for claim denial. HIPAA requires that denied claims be assigned a Claim Adjustment Reason Code. In some instances, to further define the denial reason, a HIPAA Remittance Remark Code may also be assigned to the denied claim.

The Edit Map referenced above will assist providers in pinpointing the specific eMedNY denial reason associated with the reported HIPAA reasons on the electronic 835 remittance or via ePACES. The last two columns in the mapping document will identify the specific eMedNY edit number and reason associated with the reported HIPAA denial codes.

Once the eMedNY edit number has been identified, additional information about the error causes and solutions can be found by accessing the Edit Drilldown Presented in Numeric Ranges document, on the same website page. This document will allow you to search by the eMedNY edit number for the cause(s) and possible resolution(s) to the denial.

For example: Your claim is denied for the following HIPAA codes:

• Claim Adjustment Reason Code 16 - Claim Lacks Information That Is Needed for Adjudication.
• Remittance Remark Code N259 - Missing/Incomplete/Invalid Billing Provider Secondary ID.

Access the document Edit Map for 835 in Order of Reason Code and search on Remittance Remark Code N259.

• There are two possible eMedNY edit numbers associated with N259, but only one is mapped to Claim Adjustment Reason Code 16. The eMedNY Edit is Code 00098 - Locater Code Invalid.

If further instruction is required, access the document Edit Drilldown Presented in Numeric Ranges on the same website page. Select the edit range that includes 00098. Then click on the Edit Number link for 00098. There you will be given the potential causes and solutions for the denial.

If you are receiving HIPAA denial codes on your electronic remittance (835) or via ePACES, please take the time to visit http://www.emedny.org/ and become familiar with the Edit/Error Knowledgebase available to you.

Questions about the information on the website should be directed to the eMedNY Call Center at: (800) 343-9000.

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As a provider, it is your responsibility to check and update your provider manual and review the Medicaid Update on a monthly basis to ensure you are current with the latest policy information.

Provider manuals are available online at

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

To receive a hard copy of your Manual, if you do not have access to the internet, you must contact Computer Sciences Corporation at:

(800) 343-9000.

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Policy and Billing Guidance.....

Effective August 1, 2007, this article will serve as a revision to the policy and procedures outlined in the May 2000 Medicaid Update on this subject.

A. POLICY

Medicaid law and regulation require that when an enrollee is eligible for both Medicare and Medicaid benefits (i.e., dually eligible), the provider must bill Medicare first for covered services prior to submitting a claim to Medicaid for coinsurance and deductible. Prior approval from Medicaid is not required when billing Medicare coinsurance and deductible for services otherwise requiring prior approval for Medicaid-only enrollees.

B. EXCEPTIONS

When a Durable Medical Equipment, Prosthetic, Orthotic, and Supply (DMEPOS) item requires prior approval for Medicaid-only enrollees, a medical prior approval determination for a dually-eligible enrollee may be requested under the situations listed below. When required, the provider must furnish conclusive documentation with a Medicaid prior approval request that an appeal for reconsideration of a Medicare claims denial has been submitted to and denied by the Durable Medical Equipment Medicare Administrative Contractor (DME MAC).

1. ITEM IS STATUTORILY NON-COVERED BY MEDICARE
   When a DMEPOS item is statutorily never covered by Medicare (e.g., bathing equipment) and is covered by Medicaid, a prior approval request may be submitted to Medicaid along with documentation of medical necessity. It is not necessary to submit claims to Medicare before requesting Medicaid prior approval in this situation.
2. SAME OR SIMILAR EQUIPMENT
   When the DME MAC issues a claim denial because the Medicare beneficiary has received a product within the last five years which has the same or similar therapeutic benefit for the same medical condition, the provider must include documentation of the DME MAC denial with any Medicaid prior approval request. The prior approval request must include any information available to the provider about the item or items that caused the current Medicare claim to be rejected. Based upon this information Medicaid will make an independent determination of current medical necessity and appropriateness with respect to the requested item.
3. PRODUCTS USED OUTSIDE THE HOME
   When the DME MAC issues a claim denial because a requested item is not being used "in the home", the provider must submit documentation of the DME MAC claim rejection with any Medicaid prior approval request. The prior approval request must also contain any information available to the provider about products supplied under Medicare reimbursement for the beneficiary's use in the home.
4. PRODUCTS IN EXCESS OF THE ALLOWED MAXIMUM
   When the DME MAC issues a claim denial because the physician's order for a Medicare covered item requests quantities that exceed Medicare payment screens, the provider must submit documentation of the denial with any Medicaid prior approval. The provider must then proceed to appeal that denial to the DME MAC and maintain a copy of the DME MAC's determination on the appeal in the provider's records for any Medicaid post-audit purposes.
5. ADVANCE DETERMINATION OF MEDICARE COVERAGE (ADMC)
   Unlike most services, certain customized or specialized wheeled mobility bases are eligible for a Medicare ADMC review prior to provision of service. When a negative ADMC decision communicates to the Medicare supplier and beneficiary that the beneficiary does not meet Medicare coverage criteria established for the base equipment, prior approval from Medicaid may be requested. The provider must submit with the prior approval request a copy of the ADMC and all the supporting documentation required by and submitted to Medicare*. This process is not to be utilized when the ADMC states that documentation submitted was not sufficient for a determination to be made. When a particular item is eligible for ADMC, all options and accessories ordered by the physician for that patient, along with the base HCPCS code, are eligible for ADMC. The current list of codes available for ADMC is:
   • Manual wheelchairs described by codes: E1161, E1231-E1234, K0005, and K0009.
   • Group 2, 3, 4 or 5 Single Power Option or Multiple Power Options wheelchair (K0835-K0843, K0856-K0864, K0877-K0891) - whether or not a power seating system will be provided at the time of initial issue.
   • Group 3 or 4 No Power Option wheelchair (K0848-K0855, K0868-K0871) that will be provided with an alternative drive control interface at the time of initial issue.
   • *Refer to the DME MAC medical policies and specific documentation requirements at the following websites:
     http://www.tricenturion.com/content/lcd_current_dyn.cfm; and
     http://www.medicarenhic.com/dme/dmemaca_sm_ch09-rev2007-01.pdf.

C. PAYMENT

• If requests for major items of DMEPOS, such as powered mobility are approved, Medicaid will issue a prior approval in the amount of $1.00 pending resolution of the appeal of the adverse Medicare coverage determination to the DME MAC. Once a DME MAC denial is received in prior approval, Medicaid payment will be made according to the applicable Medicaid pricing policy.
• If the DME MAC approves the major item of medical equipment on appeal, a bill may be submitted directly to Medicaid indicating the Medicare Approved and Medicare Paid amounts. When the DME MAC approves such a request on appeal, DO NOT enter the Medicaid prior approval number issued to you on your Medicaid claim.
• If New York State Medicaid issues a prior approval and a subsequent decision by Medicare results in a Medicare payment to the provider, the provider is required to adjust any Medicaid paid claims to reflect the Medicare Approved and Medicare Paid amounts received in conformity with Department of Health Regulation at Title 18 of the New York Code of Rules and Regulations Section 540.6.

Questions? Please contact the Pre-Payment Review Group at: (518) 474-8161.

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Pharmacy and durable medical equipment providers may cancel a Dispensing Validation System (DVS) request for supplies within 24 hours of approval. Approvals for prescription footwear, orthotics, and prosthetics must be cancelled within 90 days.

Problems Cancelling a DVS Request?

Occasionally, providers may experience difficulty cancelling a DVS number using the OMNI 3750 Terminal or ePACES. In this situation, to obtain a copy of the cancellation request form, contact Computer Sciences Corporation's (CSC) Fax on Demand Line at: (800) 370-5809, and order document number 3018 to be faxed to you.

Once the completed form is returned to CSC, you will be notified via telephone within 24 hours that your DVS has been cancelled.

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Review of PDP Drug Classes

Effective August 28, 2007, the following drugs will be added to the list of "preferred" agents and will no longer require prior authorization:

• Avalide®
• Avapro®
• Coreg®
• Duetact®
• fenofibrate
• Pataday®
• pravastatin
• Relpax®
• Tricor®
• zolpidem

Also effective August 28, 2007, the following brand name drugs have been changed to "non-preferred" status. Generics for these medications remain preferred. Prescriptions written on or after August 28, 2007 for these drugs will require prior authorization:

• Mavik®
• Norvasc®
• Uniretic®
• Zocor®

To obtain prior authorization for a non-preferred drug, contact the clinical call center at (877) 309-9493 and follow the appropriate prompts. Requests for prior authorization of non-preferred drugs may also be faxed to (800) 268-2990. Faxed requests may take up to 24 hours to process.

For clinical concerns or preferred drug program questions, contact (877) 309-9493.
For billing questions, contact (800) 343-9000.
For Medicaid pharmacy policy and operations questions, call (518) 486-3209

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ANALGESICS
Narcotics - Long Acting	Narcotics - Long Acting
PREFERRED AGENTS	NON-PREFERRED AGENTS
Duragesic® fentanyl patch Kadian® morphine sulfate SR Oramorph SR®	Avinza® MS Contin® Opana ER® oxycodone HCL CR Oxycontin®
ANTI-INFECTIVES
Anti-Fungals	Anti-Fungals
PREFERRED AGENTS	NON-PREFERRED AGENTS
Fulvicin U/F® Grifulvin V® (tablet) Gris-PEG® griseofulvin (suspension) Lamisil®	Grifulvin V® (suspension) itraconazole (capsule) Penlac® Sporanox® (capsule, solution)
Anti-Virals	Anti-Virals
PREFERRED AGENTS	NON-PREFERRED AGENTS
acyclovir (tablet, capsule, suspension) Famvir® Valtrex®	Zovirax® (tablet, capsule, suspension)
Cephalosporins - Third Generation	Cephalosporins - Third Generation
PREFERRED AGENTS	NON-PREFERRED AGENTS
Cedax®(capsule, suspension) cefpodoxime proxetil (tablet) Omnicaf® (capsule, suspension) Suprax®	Spectracef® Vantin® (tablet, suspension)
Fluoroquinolones	Fluoroquinolones
PREFERRED AGENTS	NON-PREFERRED AGENTS
Avelox® Avelox ABC Pack® Cipro®1(suspension) ciprofloxacin (tablet, suspension) ofloxacin	Cipro® (tablet) Cipro XR® ciprofloxacin ER Factive® Floxin® Levaquin® (tablet, solution) Maxaquin® Noroxin® Proquin XR® Tequin®
Hepatitis C Agents	Hepatitis C Agents
PREFERRED AGENTS	NON-PREFERRED AGENTS
PEG-Intron® PEG-Intron Redipen® Pegasys® Pegasys Convenience Pack®	None
CARDIOVASCULAR
Angiotensin Converting Enzyme Inhibitors (ACEIs)	Angiotensin Converting Enzyme Inhibitors (ACEIs)
PREFERRED AGENTS	NON-PREFERRED AGENTS
Altace® benazepril captopril enalapril maleate lisinopril moexipril trandolapril	Accupril® Aceon® Capoten® fosinopril sodium Lotensin® Mavik®2 Monopril® Prinvil® quinapril Univasc® Vasotec® Zestril®
ACEIs + Calcium Channel Blockers	ACEIs + Calcium Channel Blockers
PREFERRED AGENTS	NON-PREFERRED AGENTS
Lotrel® Tarka®	Lexxel®
ACE Inhibitors + Diuretic	Ace Inhibitors + Diuretic
PREFERRED AGENTS	NON-PREFERRED AGENTS
benazepril/HCTZ captopril/HCTZ enalapril maleate/HCTZ lisinopril/HCTZ moexipril/HCTZ	Accuretic® Capozide® fosinopril HCTZ Lotensin HCT® Monopril HCT® Prinzide® quinapril/HCTZ Quinaretic® Uniretic®2 Vaseretic® Zestoretic®
Angiotensin Receptor Blockers (ARBs)	Angiotensin Receptor Blockers (ARBs)
PREFERRED AGENTS	NON-PREFERRED AGENTS
Avapro®1 Benicar® Cozaar® Diovan® Micardis®	Atacand® Teveten®
ARBs + Diuretic	ARBs + Diuretic
PREFERRED AGENTS	NON-PREFERRED AGENTS
Avalide®1 Benicar HCT® Diovan HCT® Hyzaar® Micardis HCT®	Atacand HCT® Teveten HCT®
Beta Blockers	Beta Blockers
PREFERRED AGENTS	NON-PREFERRED AGENTS
acebutolol atenolol betaxolol bisoprolol fumerate Coreg®1 labetalol metoprolol tartrate nadolol pindolol propranolol (tablet, solution) propranolol ER (capsule) timolol maleate	Coreg CR® Corgard® Inderal® Inderal LA® InnoPran XL® Kerlone® Levatol® Lopressor® metoprolol succinate Sectral® Tenormin® Toprol XL® Trandate® Zebeta®
Beta Blockers + Diuretic	Beta Blockers + Diuretic
PREFERRED AGENTS	NON-PREFERRED AGENTS
atenolol/chlorthalidone bisoprolol fumerate/HCTZ metoprolol tartrate/HCTZ propranolol/HCTZ	Corzide® Inderide® Lopressor HCT® Tenoretic® Ziac®
Calcium Channel Blockers (Dihydropyridine)	Calcium Channel Blockers (Dihydropyridine)
PREFERRED AGENTS	NON-PREFERRED AGENTS
Afeditab CR® amolodipine DynaCirc ® DynaCirc CR® felodipine ER isradipine nicardipine HCL Nifediac CC® Nifedical XL® nifedipine nifedipine ER nifedipine SA Sular®	Adalat CC® Cardene® Cardene SR® Norvasc®2 Plendil® Procardia® Procardia XL®
Cholesterol Absorbtion Inhibitors	Cholestrol Absorption Inhibitors
PREFERRED AGENTS	NON-PREFERRED AGENTS
Zetia®	None
HMG-CoA Reductase Inhibitors (Statins)	HMG-CoA Reductase Inhibitors (Statins)
PREFERRED AGENTS	NON-PREFERRED AGENTS
Advicor® Altoprev® Crestor® Lescol® Lescol XL Lipitor® pravastatin1 simvastatin Vytorin®	Caduet® lovastatin Mevacor® Pravachol® Zocor®2
Triglyceride Lowering Agents	Triglyceride Lowering Agents
PREFERRED AGENTS	NON-PREFERRED AGENTS
fenofibrate1 gemfibrozil Lofirba® Tricor®1	Antara® Lopid® Omacor® Triglide
CENTRAL NERVOUS SYSTEM
Sedative Hypnotics/Sleep Agents	Sedative Hypnotics/Sleep Agents
PREFERRED AGENTS	NON-PREFERRED AGENTS
Ambien CR® chloral hydrate estazolam flurazepam temazepam triazolam zolpidem	Ambien® Dalmane® Doral® Halcion® Lunesta® Prosom® Restoril® Rozerem® Somnote® Sonata®
Serotonin Receptor Agonists (Triptans)	Serotonin Receptor Agonists (Triptans)
PREFERRED AGENTS	NON-PREFERRED AGENTS
Imitrex® (tablet, nasal, injection) Maxalt® (tablet, MLT) Relpax®1	Amerge® Axert® Frova® Zomig® (tablet, nasal, ZMT)
ENDOCRINE AND METABOLIC AGENTS
Bisphosphonates	Bisphosphonates
PREFERRED AGENTS	NON-PREFERRED AGENTS
Fosamax® (tablet, solution) Fosamax® Plus D	Actonel® Actonel® with Calcium Boniva®
Calcitonins - Intranasal	Calcitonins - Intranasal
PREFERRED AGENTS	NON-PREFERRED AGENTS
Miacalcin®	Fortical®
Thiazolidinediones (TZDs)	Thiazolidinediones (TZDs)
PREFERRED AGENTS	NON-PREFERRED AGENTS
Actos® Actoplus Met® Avandia® Avandamet® Avandaryl Duetact®1	none
GASTROINTESTINAL
Anti-Emetics	Anti-Emetics
PREFERRED AGENTS	NON-PREFERRED AGENTS
Kytril® (tablet, solution) Zofran® (tablet, solution, ODT)	Anzemet®
Proton Pump Inhibitors	Proton Pump Inhibitors
PREFERRED AGENTS	NON-PREFERRED AGENTS
Nexium® Prevacid® (capsule) Prilosec OTC®	Aciphex® Nexium Packet® omeprazole Prevacid® (solutab, packet) Prevacid NapraPAC® Prilosec® Protonix® Zegerid® (capsule, packet)
IMMUNOLOGIC AGENTS
Immunomodulators -Injectable	Immunomodulators -Injectible
PREFERRED AGENTS	NON-PREFERRED AGENTS
Enbrel® Humira®	Kineret®
Immunomodulators -Topical	Immunomodulators -Topical
PREFERRED AGENTS	NON-PREFERRED AGENTS
Elidel® Protopic®	None
OPHTHALMICS
Antihistamines - Ophthalmic	Antihistamines - Ophthalmic
PREFERRED AGENTS	NON-PREFERRED AGENTS
Patanol® Pataday®1	Elestat® Emadine® ketotifen RX Optivar®
Fluoroquinolones - Ophthalmic	Fluoroquinolones - Ophthalmic
PREFERRED AGENTS	NON-PREFERRED AGENTS
ciprofloxacin ofloxacin Vigamox®	Ciloxan® (solution, ointment) Ocuflox® Quixin® Zymar®
OTICS
Fluoroquinolones - Otic	Fluoroquinolones - Otic
PREFERRED AGENTS	NON-PREFERRED AGENTS
Ciprodex® Floxin®	Cipro HC®
RENAL AND GENITOURINARY
Phosphate Binders/Regulators	Phosphate Binders/Regulators
PREFERRED AGENTS	NON-PREFERRED AGENTS
Fosrenol® Phoslo Renagel®	None
RESPIRATORY
Anticholinergics - Inhaled	Anticholinergics - Inhaled
PREFERRED AGENTS	NON-PREFERRED AGENTS
Atrovent® Atrovent HFA® Combivent® ipratropium Spiriva®	Duoneb®
Antihistamines - Second Generation	Antihistamines - Second Generation CC
PREFERRED AGENTS	NON-PREFERRED AGENTS
OTC loratadine OTC loratadine-D	Allegra® (tablet, capsule, suspension) Allegra-D® Clarinex® Clarinex-D® fexofenadine Semprex-D® Zyrtec®CC Zyrtec-D®
Beta2Adrenergic Agents - Inhaled Long Acting	Beta2Adrenergic Agents - Inhaled Long Acting
PREFERRED AGENTS	NON-PREFERRED AGENTS
Foradil® Serevent Diskus®	Brovana®
Beta2Adrenergic Agents - Inhaled Short Acting	Beta2Adrenergic Agents - Inhaled Short Acting
PREFERRED AGENTS	NON-PREFERRED AGENTS
albuterol Maxair Autohaler® Proventil HFA® Ventolin HFA® Xopenex® Xopenex HFA®	Accuneb® Alupent® metaproterenol ProAir HFA® Proventil®
Corticosteroids - Inhaled	Corticosteroids - InhaledCC
PREFERRED AGENTS	NON-PREFERRED AGENTS
Advair Diskus® Advair HFA® Asmanex® Azmacort® Flovent HFA® Qvar®	Aerobid® Aerobid-M® Pulmicort ® (Flexhaler, Turbuhaler)CC Symbicort®
Corticosteroids - Intranasal	Corticosteroids - Intranasal
PREFERRED AGENTS	NON-PREFERRED AGENTS
Nasacort AQ® Nasonex®	Beconase AQ® Flonase® flunisolide® fluticasone® Nasarel® Rhinacort Aqua® Vermyst®
Leukotriene Modifiers	Leukotriene Modifiers
PREFERRED AGENTS	NON-PREFERRED AGENTS
Accolate® Singular®	None

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At times, an ambulette vehicle is used to transport Medicaid enrollees in need of livery service (category of service 0605) or in day treatment group ride situations (category of service 0606). Since personal assistance is not required nor provided for the enrollee, the ambulette provider bills the livery/day treatment transportation fee and/or appropriate livery/day treatment procedure codes.

Claim Requirements

In the November 2005 Medicaid Update, ambulette providers were reminded that the driver's license number and vehicle license plate number must be submitted on claims for ambulette service.

Ambulette providers must follow the guidelines established for the ambulette category of service whenever an ambulette vehicle is used to transport Medicaid enrollees. The subsequent claim should include:

• the driver's license number; and
• the vehicle license plate number.

If a different driver and/or vehicle returns the enrollee from the medical appointment, the license number of the driver and vehicle used for the origination of the trip should be reported on the claim.

The Office of the Medicaid Inspector General will monitor claims for this as well as other appropriate claim information and documentation.

Questions? Call the Transportation Unit at (518) 474-5187 or email medtrans@health.state.ny.us

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Effective dates of service on or after September 1, 2007, three new procedure codes will be reimbursable to clinical psychologists.

To bill for these procedures, you must provide documentation of board certification or eligibility to participate in the board examination in Clinical Neuropsychology.

The new codes are:

• 96111    Developmental testing; extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments) with interpretation and report.
• 96116    Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report.
• 96118    Neuropsychological testing (e.g., Halstead-Reitan neuropsychological battery, Wechsler memory scales and Wisconsin card sorting test), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report.

The fee for each of these procedures is $150.

Acceptable documentation includes proof that you:

• are board certified in Clinical Neuropsychology by the American Board of Professional Psychology (ABPP)/American Board of Clinical Psychology (ABCN);
  
  or
  
  
• have been deemed eligible to participate in the board examination in Clinical Neuropsychology by the American Board of Professional Psychology (ABPP)/American Board of Clinical Psychology (ABCN).

Submit this documentation, with your Medicaid provider identification number, to:

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A new billing procedure for claiming charges for services without established fees will be established for providers in the Traumatic Brain Injury (TBI) program. This new process will take effect on October 1, 2007.

• Payments for such services were previously processed using a series of multiple rate codes with specific dollar amounts (i.e., $1, $10, $100, etc.).
• One such service that was billed with a series of rate codes is Community Transitional Services. These services used the rate code series 9864 thru 9867. System changes will allow providers to bill their total charges under one rate code for the specific service rendered.

The new total charges rate codes for each noted service will be:

• 9857 TBI Special Equipment/Supplies;
• 9867 TBI Community Transitional Services; and,
• 9874 TBI Environmental Modifications.

The fields to be completed on your claim form all remain the same. Payment will be made based on the amount recorded in the "Total Charges" field.

Questions pertaining to this new billing policy may be addressed to the Rate Based Provider Unit of the Pre-Payment Review Group at: (518) 474-8161.

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Billing personnel and billing agents for inpatient hospital providers are advised that billing guidelines were recently posted to: http://www.emedny.org.

Although the Inpatient Hospital Billing Guidelines document does not change any previously issued billing instructions, it organizes the instructions into one document to make it easier for billers to reference and locate billing procedures.

The guidelines information covers such topics as:

• General Inpatient Billing Procedures
  • Calculating and submitting the appropriate number of days.
• Diagnosis Related Groups (DRGs)
  • DRG payment calculations and "split-billing" situations.
• Non-DRG (DRG-exempt) Claims
  • DRG-exempt "split-billing" situations.
• Medicaid - Payer of Last Resort
  • Billing after Medicare and other insurance payments.
• Special Instructions for Other Inpatient Claims
  • Alternate level of care claims, graduate medical education (GME) claims, "pass-days" claims, and cost outlier claims.
• Supplemental Inpatient Billing Information
  • Inpatient services paid "offline", replacement/void of previously paid claims; Medicaid managed care clients, hospital responsibility for outside care.

Please take the opportunity to become familiar with these instructions, available at:

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The purpose of this article is to inform providers of new Medicaid policy when submitting claims for treating undocumented (illegal) immigrants or temporary non-immigrants (i.e., foreign students, visitors, workers) for an emergency medical condition.

Recent Audit Findings

An audit of claims billed for care and services to treat emergency medical conditions was conducted by the Centers for Medicare and Medicaid Services (CMS). The audit identified provider claims for emergent care and services provided to undocumented immigrants and/or temporary non-immigrants which were not true medical emergencies.

These claims were billed with the emergency indicator set to "Yes". This billing error resulted in inappropriate payments to the provider and in the State inappropriately claiming federal funds. This has also resulted in services being paid for by Medicaid for this enrollee population, which are not true medical emergencies, as defined under federal law.

The Office of Health Insurance Programs is developing payment edits to correct the claiming errors.

New Payment Edits

The CMS audit concluded that certain services do not fall under the definition of treatment of an emergency medical condition. Therefore, Medicaid will no longer cover the costs for the following services or transportation to these services:

• rehabilitation services, (including physical therapy, occupational and speech therapies), and
• encounters for chemotherapy.

Additionally, encounters for:

• radiation therapy, and
• most durable medical equipment/supplies and services,

do not fall under the definition of treatment of an emergency medical condition.

CMS told New York to cease claiming federal expenditures for these non-emergency services. Edits are being developed to deny the above mentioned services when billed as emergency services.

Not all services that are medically necessary meet the federal definition of an emergency medical condition.

• Emergency medical conditions do not include debilitating conditions resulting from an initial event, which later requires ongoing regimented care.
  
  
• Certain types of care provided to chronically ill persons are beyond the intent of the federal laws and implementing State laws, and are not considered "emergency services" for the purpose of Medicaid payment. Such care includes:
  
  
  • › alternate level of care in a hospital,
  • › nursing facility services, home care (including private duty nursing), and
  • › personal care.
    
    
• Also, care and services related to an organ transplant procedure are not included in the federal definition of treatment for an emergency medical condition.

Certification of Treatment of Emergency Medical Condition Forms: The DSS-3955 (Upstate) or MAP-2151 (NYC)

The treating physician must complete, date, sign and submit the DSS-3955 or MAP-2151 form for any undocumented or temporary non-immigrant who has received and is applying for Medicaid coverage for the treatment of an emergency medical condition.

A new DSS-3955 or MAP-2151 must be obtained from the treating physician for each new episode requiring treatment of an emergency medical condition. An individual may reapply whenever he or she needs treatment of an acute emergency medical condition and the treating physician provides a new DSS-3955 or MAP-2151.

If you have provided medical treatment to an individual who appears to meet the above criteria and who indicates he/she has no means of paying for the services, he/she may be referred to a local department of social services for a determination of Medicaid eligibility.

The local department of social services will notify you of the acceptance/denial of the application, the period of coverage and the individual's Client Identification Number (CIN) when appropriate. If the immigrant is found eligible for Medicaid, you can receive reimbursement for the emergency services by billing eMedNY.

Billing instructions, provider manuals and sample paper claim forms are available at:

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The following forms will no longer be available via written request:

FORM NUMBER	FORM TITLE
LDSS-3113	Acknowledgement of Receipt of Hysterectomy Information (English)
LDSS-3113S	Acknowledgement of Receipt of Hysterectomy Information (Spanish)
LDSS-3134	Sterilization Consent Form (English)
LDSS-3134S	Sterilization Consent Form (Spanish)

These forms may be obtained online at:

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General Information.....

After an extensive collaboration with practitioners, therapists, medical equipment providers, advocates and Medicaid medical review staff, and utilizing State and national standards; guidelines for wheeled mobility equipment and a sample evaluation for wheeled mobility have been developed.

These resources are intended to assist providers in collecting and formalizing all necessary information to support Medicaid approval and/or payment for this equipment.

The documents are available at: http://www.emedny.org/ProviderManuals/DME/index.html

Questions? Please contact the Pre-Payment Review Group at: (518) 474-8161.

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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:

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Computer Sciences Corporation (CSC) has Regional Representatives available to assist individual providers in resolving a variety of Medicaid claiming difficulties they may be experiencing. This service is provided to Medicaid enrolled providers free-of-charge!

CSC Regional Representatives can help providers with issues/problems such as:

• Paper or electronic billing.
• ePACES usage.
• Prior Approval completion.
• Eligibility verification or service authorization response.
• Remittance interpretation (review solutions for pending and denied claims).

How to Make the Request

Providers may request to be contacted by a Regional Representative to schedule an individual training session by calling the Call Center at:

If using the email method to request a call from a Regional Representative, please include your provider identification number, the nature of your request, and contact information.

A CSC Regional Representative will contact you either via email or telephone to discuss your needs.

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• Do you have billing questions?
• Are you new to Medicaid billing?
• Would you like to learn more about ePACES?

If you answered YES to any of these questions, please consider registering for a Medicaid seminar. Computer Sciences Corporation (CSC) offers various types of seminars to providers and their billing staff. Many of the seminars planned for the upcoming months offer detailed information and instruction about Medicaid's web-based billing and transaction program - ePACES. ePACES seminars are designed for specific provider types.

ePACES is the Electronic Provider Assisted Claim Entry System that allows enrolled providers to submit the following type of transactions:

• Claims
• Eligibility Verifications
• Utilization Threshold Service Authorizations
• Claim Status Requests
• Prior Approval Requests

Professional providers such as physicians, nurse practitioners and private duty nurses can even submit claims in "REAL-TIME" via ePACES. Real-time means that the claim is processed within seconds and professional providers can get the status of a real-time claim, including the associated paid amount, without waiting for the remittance advice to be delivered.

Seminar locations and dates are available at the eMedNY website. Seminar registration is fast and easy. Seminars are free to enrolled Medicaid providers. Go to: http://www.emedny.org/training/index.aspx, to find and register for the eMedNY Training Seminar appropriate for your provider category and location.

Review the seminar descriptions carefully to identify the seminar appropriate to meet your training needs. Registration confirmation will be instantly sent to your email address.

If you are unable to access the Internet to register, you may also request seminar schedule and registration information by contacting CSC's Fax on Demand at:

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Hours of Operation

For provider inquiries pertaining to non-pharmacy billing or claims, or provider enrollment:

      Monday through Friday

7:30 a.m. - 6:00 p.m. Eastern Standard Time

For provider inquiries pertaining to eligibility, service authorizations, DVS, and pharmacy claims:

      Monday through Friday

7:00 a.m. - 10:00 p.m. Eastern Standard Time

     Weekends and Holidays

8:30 a.m. - 5:30 p.m. Eastern Standard Time

 

Call Center Telephone Tree

 

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Do you want to receive your copy of the Medicaid Update three weeks sooner? Sign up today for the electronic version!

Simply send an email to medicaidupdate@health.state.ny.us designating the email address or addresses you'd like the Medicaid Update sent to!

If you do not want the hard copy, please provide your Medicaid provider identification number and confirm that you do not want the hard copy.

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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.nyhealth.gov/medicaid/program/update/main.htm
Hard copies can be obtained upon request by emailing: MedicaidUpdate@health.state.ny.us

Questions About an Article?
For your convenience each article contains a contact number for further information, questions or comments.

Questions about billing and performing MEVS transactions?
Please contact CSC Provider Services at: (800) 343-9000, or via e-mail at: emednyproviderrelations@csc.com

Provider Training
To sign up for a provider seminar in your area, please enroll online at: http://www.emedny.org/training/index.aspx or call CSC at (800) 343-9000.

Patient Eligibility
Call the Touchtone Telephone Verification System (800) 997-1111, (800) 225-3040 or (800) 394-1234.

Address Change?
Questions should be directed to CSC at (800) 343-9000, option 5.

Fee-for-service Provider Enrollment
A change of address form is available at:
http://www.emedny.org/info/ProviderEnrollment/index.html

Rate-based/Institutional Provider Enrollment
A change of address form is available at:
http://www.emedny.org/info/ProviderEnrollment/index.html

Comments and Suggestions Regarding This Publication?
Please contact the editor, Timothy Perry-Coon at MedicaidUpdate@health.state.ny.us

Medicaid Update is a monthly publication of the New York State Department of Health containing information regarding the care of those enrolled in the Medicaid Program.