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New York State

January 2008  
Volume 24, Number 1  

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Reminder: Information Required from Ambulette Providers

Annual Ambulette Survey for 2008
Providers are required to submit information to the Office of the Medicaid Inspector General.

Medicare Part D News

Medicare Part D Beneficiary Cost Sharing
How to assure that low income enrollees are assigned appropriate co-payment and deductible levels.

Information for All Providers

New Medicaid POS Terminal Now Available
A new POS terminal replaces the discontinued Omni 3750. Get yours today!

Internal Revenue Service 1099 Forms for Calendar Year 2007
1099 forms will be released soon, read this article for clarification on which claims are included!

New Recipient Restriction Program Codes Effective January 1, 2008
Announcing four new provider types to expand the provider network for this program.

Submitters of Paper Claims: Benefits of Electronic Billing
If you need more justification to bill electronically, read this article!

Policy and Billing Guidance

Coverage of Herpes Zoster Vaccine
Billing information for Medicaid coverage of the Shingles vaccine.

Personal Care Services Providers: Inappropriate Billing for "Show-Up Time"
A policy reminder to personal care providers.

Payment Changes for Bone Growth Stimulators
Changes have been made to the pricing and payment mechanism for bone growth stimulators.

Group Practice Providers: Requirements and Responsibilities in the Medicaid Program
A policy reminder for group practice providers.

Prescribers: Prior Authorization Requirements of the Mandatory Generic Drug Program
This article clarifies the Mandatory Generic Drug Program requirements and provides information on available prescriber outreach programs.

Use the Correct Provider Identification Number on Claims
Claims with certain categories of service identified as the prescribing provider will be denied.

Mandatory Managed Care for SSI and SSI-Related Medicaid Enrollees
Enrollment expands to additional counties.

Physician Case Management Provider Number No Longer Acceptable as the Referring Provider.
Changes are coming April 1, 2008 for enrollees of physician case management plans.

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Reminder: Required Information from Ambulette Providers............

Providers of ambulette services are required to submit vehicle information on an annual basis in accordance with Title 18 of New York Codes, Rules and Regulations (NYCRR) 502.6(b):

• Each provider of ambulette services must, during the month of January of each year, disclose to the Department in writing information concerning those vehicles currently owned or leased by the provider.
  
  
• The information to be disclosed must include at a minimum the name and address of the provider, each vehicle's license number and Department of Transportation identification number and a statement regarding whether the vehicle is owned or leased.
  
  
• If a provider of ambulette services fails to disclose this information, it will constitute an unacceptable practice as defined under 18 NYCRR §515.1 and will result in the imposition of administrative sanctions which may include termination of enrollment as a Medicaid provider.
  
  

The Annual Ambulette Survey form was made available in the December 2007 Medicaid Update, and is available below or online at:

http://www.omig.state.ny.us/data/content/view/81/65/

The Annual Ambulette Survey form must be returned by March 17, 2008 to:

Certified/Return Receipt mail is suggested. A copy of the form and proof of mailing should be retained for your records. In the event of non-receipt of the form by the Office of the Medicaid Inspector General, this proof will be used to validate compliance.

Questions? Please call the Office of the Medicaid Inspector General at (518) 408-0692.

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DAYS OPEN AND HOURS OF OPERATION

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

			Check One
DMV Plate Number	Vehicle Identification Number (VIN)	Passenger Capacity	Owned	Leased	Leased From

NYS DOT OPERATING CERTIFICATE #_________________________________________

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Medicare Part D News............

What if it appears a fully dual eligible beneficiary is being charged an incorrect deductible or high co-payment?

The Centers for Medicare and Medicaid Services requires Medicare Part D plans to rely on best available evidence and considers it best practice for the Part D plans to work with pharmacies to resolve these issues at the point of sale when beneficiaries present the pharmacist with appropriate evidence of correct low income status.

What is Appropriate Evidence?

Part D plans must accept any one of the following forms of evidence from enrollees or pharmacists to make a change to an enrollee's low income status:

• Medicaid Client Identification Card;
• Copy of a state document that confirms Medicaid eligibility;
• Medicare Identification Card; or
• Low Income Subsidy notice from Medicare or Social Security Administration.

Part D plans must accept any one of the following forms of evidence from enrollees or pharmacists to establish that an enrollee is institutionalized and is not subject to Medicare Part D co-pays.

• Copy of a state document that confirms Medicaid payment to the facility for a full calendar month on behalf of the individual; or
• Copy of a state document showing the individual's institutional status based on at least a full calendar month stay for Medicaid purposes.

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Information for All Providers...........

A new POS terminal is now available from Computer Sciences Corporation that has all of the features of the discontinued Omni 3750 POS terminals.

Providers can obtain information about the new VeriFone VX570 Terminal online at:

Medicaid eligibility can be verified via touch-tone telephone or through the electronic Provider Assisted Claim Entry System (ePACES); a secure web-based program offered free of charge to enrolled providers. To enroll in ePACES, please call the eMedNY Call Center.

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Computer Sciences Corporation (CSC) issues Internal Revenue Service 1099 forms to providers at the beginning of each calendar year for the previous calendar year's Medicaid payments.

1099 forms for calendar year 2007 will be mailed to providers by January 31, 2008.

Due to the two-week lag between the date of the check and the date the check is issued, the amount on the 1099 form will not correspond to the sum of all checks issued for your provider identification number during the calendar year.

The 1099 forms issued for the calendar year 2007 will include the following:

• Check dated 12/18/06 (Cycle 1530) released on 01/03/2007 through and including
• Check dated 12/10/07 (Cycle 1581) released 12/26/2007.

Group Practice Providers

In order for group practice providers to direct Medicaid payments to a group identification number and corresponding 1099 form, providers must submit the group identification number in the appropriate field on the claim (paper or electronic). Claims that do not have the group identification number entered will cause payment to go to the individual provider and his/her 1099 form.

Questions? Please call the eMedNY Call Center at (800) 343-9000.

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Four new primary care provider restriction codes are being added to the Recipient Restriction Program (RRP) for use by local districts.

These new codes offer local districts more flexibility in assigning primary providers within the global "medical" and "dental" categories of restriction and will expand the RRP primary care provider network available for Medicaid enrollees and local districts.

New Provider Restriction Codes

The new codes and provider types are:

• 10 Dental Clinic;
• 11 Physician Group;
• 12 Nurse Practitioner; and
• 13 Alternative Pharmacy (specialty drug or infusion therapy).

Dental Clinic (10) has been added as an alternative to the existing Dental restriction code.

Physician Group (11) and Nurse Practitioner (12) have been added as alternatives to the existing Physician (06) and Clinic (08) restriction codes.

Alternative Pharmacy (13) has been added to exist with and support the existing Pharmacy (05) code.

Claims Submissions

Dental Clinic, Physician Group and Nurse Practitioners must follow the RRP guidelines for primary provider claims submission. These are the same guidelines that now exist for physicians and clinics.

If service is provided to a restricted enrollee by a non-primary provider, the primary provider must be contacted to inform them of the service being rendered and to obtain the primary provider's Medicaid provider identification number for billing purposes.

Alternative Pharmacies must follow the RRP guidelines for pharmacy claims submission. The primary provider's Medicaid provider identification number must be obtained for all claims submitted including those written by non-primary providers.

Questions? Please call the Office of Medicaid Inspector General at (518) 474-6866.

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If you haven't already switched to electronic claim submissions, consider the following benefits of switching to electronic billing:

• Electronic claims process much quicker than paper claim.
• You can check the status of the submitted claims within 48 hours of submission, instead of 2 weeks for paper claims.
• Electronic billing software provides editing that helps you identify certain submission errors.
• Electronic filing saves space and retrieval time.
• Electronic filing reduces paperwork, freeing your staff to handle other important tasks.

You may already be using a computerized practice management system that has electronic claim submission capability from the existing patient database. Ask your Software Vendor for more information.

Questions? Call the eMedNY Call Center at (800) 343-9000 or email emednyproviderservices@csc.com

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Policy and Billing Guidance............

Effective for dates of service on or after October 19, 2007, Medicaid fee-for-service, Medicaid managed care plans, and Family Health Plus (FHPlus) plans cover herpes zoster vaccine (marketed under the name Zostavax ) for the prevention of shingles.

Recommendations

A single dose of zoster vaccine is recommended for adults aged 60 years and older, regardless of whether they report a prior episode of herpes zoster.

The vaccine is recommended for all indications except:

• pregnancy;
• immunocompromising conditions; and
• HIV infection with a CD4+ T lymphocyte count of ‹200 cells/µL. ›

Billing Information

The procedure code for the zoster vaccine is:

90736 - Zoster (shingles) vaccine, live, for subcutaneous injection.

Reimbursement for the vaccine when provided to Medicaid fee-for-service enrollees aged 60 years and older is the provider's actual acquisition cost plus $2.00 for administration.

Medicaid Managed Care and FHPlus plans are responsible for covering the zoster vaccine consistent with their provider contracts.

Questions? Please call the Bureau of Policy Development and Coverage at (518) 473-2160.

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The Department of Health's report card on 2007 Managed Care Plan Performance is available on the Department's website.

To access the report for commercial, Medicaid and Child Health Plus plan performance, go to:

http://www.health.state.ny.us/health_care/managed_care/reports/index.htm

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A recent pre-audit survey of the Personal Care Services Program (PCSP) conducted by the Department of Health and Human Services Office of Inspector General has identified that some PCSP provider agencies were inappropriately billing for instances where a personal care aide arrived at the enrollee's residence but was unable to provide authorized services because, for example, the individual is not at home (referred to as "show-up" time).

Department regulation at 18 NYCRR 505.14(h)(1) prohibits such payment stating:

• "no payment to the provider shall be made for authorized services unless such claim is supported by documentation of the time spent in provision of services for each individual patient."

Additionally, the General Policy section of the PCSP Provider Manual, available online at http://www.emedny.org/ProviderManuals/PersonalCare/index.html advises providers that making a claim for an improper amount or unfurnished service or supplies can be treated as a fraudulent claim.

Questions? Please call Personal Care Services policy staff at (518) 474-5271.

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Effective for dates of service on and after January 1, 2008, the purchase price and payment mechanism for bone growth stimulators, codes E0747, E0748 and E0760, will change:

• The total purchase price for these codes will be $3300.00, which will be split into two payments.
  • The first payment of $1650.00 is payable upon dispensing of the equipment with a valid fiscal order under the coverage criteria listed in the DME Provider Manual Procedure Code Section, page 56, located at:
    http://www.emedny.org/ProviderManuals/DME/index.html
  • The second payment of $1650.00 is payable upon re-evaluation of the patient's treatment plan by the ordering practitioner after the first 90 days of treatment. A new fiscal order must be written for the second payment to be covered.
• A separate Dispensing Validation System (DVS) Prior Authorization is required in order for each payment to be made.

Questions? Please call the Pre-Payment Review Group at (800) 342-3005.

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Physicians, dentists, and other practitioners may be in individual practices or practice with others in a group. When a group practice submits claims for services rendered by individual members of the group, the group is certifying that the individual member has followed Medicaid rules.

If services are provided in a group setting, the group must be a definable and legitimate entity which is enrolled in the Medicaid Program as a group provider.

All providers that submit claims to the Medicaid Program for group reimbursement must identify:

• the Medicaid provider number of the individual who provided the services; and
• the group Medicaid provider number (where services are provided in a legitimate group setting).

In this case, payment will be made to the group provider number. Use of any other provider number is prohibited.

Requirements of Individuals in the Group

• All individual practitioners in the group must be enrolled as individual Medicaid providers. No individual in the group may be a sanctioned provider.

• The group must immediately notify the Office of Health Insurance Programs (OHIP), Bureau of Enrollment, in writing, of the following:
  1. Addition or deletion of group members.
  2. Change in ownership of the group.
  3. Change/addition in address or service location.
• Any individual practitioner leaving a group must also notify OHIP, in writing, with the effective departure date.

• Upon leaving the group, a practitioner may no longer use the group provider number. Likewise, a group may not use the provider number of an individual who has left the group.

Group Compensation

Members of the group will either be principals (associates), employees, independent contractors or a combination of the above.

• The compensation agreement between group members must be in writing, and must be made available to the Department upon request.
• Federal and State anti-kickback provisions provide for administrative and criminal penalties for improper compensation arrangements. Improper arrangements usually involve compensation paid on a percentage basis. (Since not all such arrangements are illegal, providers may wish to seek the advice of counsel regarding these issues.)

Liability

Any individual practitioner in the group, or their designated agent (including billing agents), may certify a Medicaid claim for payment where the group number is used on the Medicaid claim. An individual's Medicaid provider number may not be used to bill for services performed by other group members. Where a group provider number is used on the Medicaid claim, the individual provider of care must be identified.

When a group provider number is used in Medicaid claiming, regardless of who certifies the claim:

• all members in the group are liable for overpayments;
• all members are subject to administrative sanctions (termination from Medicaid) and could be subject to criminal penalties for such violations as filing a false claim;
• the unauthorized use of any individual's Medicaid provider number without their knowledge and consent is prohibited and is subject to administrative sanctions or prosecution; and,
• where an individual leaves the group and fails to notify the Department in writing, liability for group submission of claims continues until such time as the Department receives written notification of the departure.

Submission of Claims to the Medicaid Program

When billing for any type of group practice (group of associates, or group employing other physicians or dentists):

• the group Medicaid identification number (assigned by the Department at the time of enrollment as a group) must be entered in the "Medicaid Group Identification Number" field of the claim form; and
• The physician, dentist, or other practitioner who actually provided the service must be identified by entering his/her Medicaid identification number in the "Provider Identification Number" field of the claim form.

Where group services are provided at multiple locations, the place of actual service provided by the individual must be entered into the appropriate field on the claim form.

If a provider is submitting claims to the Medicaid Program as an individual, the provider is required to have rendered the service, certify as such, and utilize his or her own individual provider number, unless either of the following two circumstances exists:

• The provider is a physician supervising a qualified practitioner. In this situation, the non-billing qualified practitioner must be identified in the "Service Provider" field.
• A locum tenens agreement is in effect. The Department's policy regarding locum tenens is outlined in the Physician Provider Manual, Policy Guidelines Section, page 39.

If the group is affiliated with a hospital or other Article 28 entity, but is a separate and definable entity (that is the members of the group are not employees of the hospital), the group may not utilize the provider number of the hospital. The entity is required to enroll as a group and utilize the group Medicaid provider number for billing.

Sanctions

Administrative sanctions such as exclusions and terminations, and the recovery of overpayments by the Department may result from improper claiming and from the failure to comply with group notification requirements as stated in this article. Additionally, the State Attorney General's Office will investigate egregious behavior.

Questions regarding this article and from individual practitioners who are contemplating forming or joining a group practice can be directed to the Medicaid Provider Enrollment Unit at:

(518) 402-7032.

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Prior authorization requirements under the Mandatory Generic Drug Program only affect drugs not included on the Preferred Drug List. Once a drug class has been identified for inclusion in the Preferred Drug Program (PDP) and appears on the Preferred Drug List, it is subject only to the prior authorization requirements of the PDP, if any.

• Brand name drugs identified as preferred on the PDL do not require prior authorization.
• Generic drugs identified as non-preferred on the PDL do require prior authorization.

Prescriber Outreach Programs

The Office of Health Insurance Programs sponsors education and outreach initiatives to assist providers in understanding the different pharmacy prior authorization programs.

Outreach interactions offered include group presentations, individual office presentations, written assistance and telephone conferences.

For information or to schedule an outreach session, contact the PDP Education Specialist by telephone at (518) 951-2046 or online at https://newyork.fhsc.com/contactus.asp

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Would you like to learn more about the New York State Medicaid Program? Visit any of the websites below for more information.

Medicaid Program	http://www.nyhealth.gov/health_care/medicaid/
eMedNY	http://www.emedny.org/
Formulary File	http://www.emedny.org/info/formfile.html
Local Departments of Social Services	http://www.ocfs.state.ny.us/main/localdss.asp#r
Medicaid Managed Care	http://www.nyhealth.gov/health_care/managed_care/index.htm
Medicaid Update	http://www.nyhealth.gov/health_care/medicaid/program/update/main.htm
Medicaid Statistics	http://www.nyhealth.gov/nysdoh/medstat/medicaid.htm
Provider Enrollment	http://www.emedny.org/info/ProviderEnrollment/index.html
Provider Manuals	http://www.emedny.org/ProviderManuals/index.html

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It is inappropriate to use a facility's Medicaid identification number in the ordering/referring/prescribing provider identification field on Medicaid claims. Therefore, claims which are submitted with the identification number of a facility, health/medical group or business entity using the following Categories of Service (COS) will be denied, effective on or about dates of service February 15, 2008.

COS	Provider Type	COS	Provider Type
0046	Physician Group	0050	Podiatrist Group
0160	D&TCs: Diagnostic & Treatment Center Svcs	0180	Dental School Clinic Services
0220	Capitation Provider	0285	Inpatient
0286	Skilled Nursing Facility	0287	Hospital Based Outpatient Services
0381	Skilled Nursing Facility	0382	Health Related Facility
0401	Optical Establishment w/Salaried Optometrist	0402	Optical Est. w/o Salaried Optometrist
0423	Optical Establishment Owned By An Optometrist

Pharmacy Claims and Restricted Recipients

When submitting claims for enrollees of the Restricted Recipient Program, the primary provider numbers should be input on the claims form as follows:

• The primary pharmacy must include the primary physician/clinic provider's Medicaid provider identification number in the Referring Provider field (NCPDP 421-DL) for all pharmacy claim submissions written by specialty providers.
• If the prescription is written by a physician in a clinic setting, the physician's license number or Medicaid provider identification number must be entered in the Ordering Provider field (NCPDP 411-DB).

For more information, please consult the June 2007 Medicaid Update article entitled "Recipient Restriction Program Information."

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What has changed for SSI and SSI-Related Medicaid enrollees?

Enrollment into Managed Care for SSI and SSI-related Medicaid enrollees has been mandatory in New York City for nearly two years. Effective March 2007, Medicaid enrollees with serious mental illness and SSI were no longer exempt and were required to enroll.

Mandatory enrollment of SSI and SSI-related Medicaid enrollees, including those with serious mental illness, is being phased in geographically throughout the State, and has recently been initiated in the following counties:

• Oswego
• Nassau
• Onondaga
• Suffolk
• Westchester

How will SSI and SSI-Related Medicaid enrollees enroll in managed care?

SSI beneficiaries in mandatory areas must choose a plan within 90 days of receiving a mailing that includes information about the Medicaid managed care program. Those who do not choose a health plan within the 90 day period will automatically be assigned to one.

Help is available to enroll, or to request an exemption for enrollees in New York City, Nassau, Suffolk and Westchester Counties by calling:

(800) 505-5678.

Enrollees in Onondaga and Oswego Counties should call their local department of social services.

How will this change the way enrollees with SSI get their Medicaid benefits?

Once enrolled in a health plan, SSI enrollees will keep their Medicaid benefits but get most of their care from the health plan's network of hospitals, physicians, and clinics.

Enrollees with SSI will continue to receive their Medicaid pharmacy benefits and most of their behavioral health benefits (mental health and substance abuse services) from the providers they currently see on a fee-for-service basis. Plan enrollees will receive a health plan identification card but will access carved out benefits including behavioral health services using their regular Medicaid card.

What services are included in the managed care benefit package for SSI and SSI-related Medicaid enrollees?

The benefit package for SSI enrollees is a "health only" package and includes:

• All medically necessary physical health care, including primary care physician visits associated with a behavioral health diagnosis;
• All laboratory services, emergency room visits and transportation, including those associated with behavioral health services or diagnoses;
• Inpatient hospital admissions when the stay covers medical services or a combination of medical and behavioral health services but the DRG or rate code is not classified as behavioral health;
• Drugs obtained and administered by a medical practitioner or facility, except for Risperdal Consta (J2794) which is reimbursed under Medicaid fee-for-service for all managed care enrollees; and
• Chemical dependence detoxification services, including medically managed detoxification and medically supervised inpatient and outpatient withdrawal.

The benefit package for SSI enrollees does not include the following behavioral health services, which are billable directly to Medicaid fee-for-service:

• Mental health inpatient and outpatient services;
• Mental health services certified by the New York State Office of Mental Health for individuals with serious mental illness;
• Chemical dependence inpatient rehabilitation services; and,
• All chemical dependence outpatient services, including methadone maintenance treatment programs.

Where can a provider get additional information about the managed care benefit package?

See the complete description of the Medicaid Managed Care benefit and services billable directly to Medicaid fee-for-service online at:

http://www.nyhealth.gov/health_care/managed_care/providers/

For questions regarding Medicaid managed care for the SSI population or a list of Medicaid rate and fee codes payable for Medicaid managed care SSI enrollees, providers may call:

(518) 473-0122.

Identification of an SSI or SSI-Related Managed Care Enrollee

Providers are urged to check eMedNY at each visit, or at a minimum on the first and tenth of every month, to determine Medicaid eligibility and managed care enrollment status.

Depending upon the method a provider uses to verify an enrollee's Medicaid eligibility, the following responses identify SSI or SSI-related enrollees:

The Medicaid Eligibility Verification System (MEVS)

MEVS will show an "S" in the category of assistance field.

VeriFone Terminal

On the VeriFone terminal, the category of assistance response will be returned after the anniversary date in the following format:

Telephone Verifications

For telephone verifications, an SSI or SSI-related enrollee will be identified by "Category of Assistance S" after the anniversary month in the stated response. For enrollees with any other category of assistance, it will not be returned via the terminal or telephone.

This information is then followed by managed care plan eligibility and covered services if applicable.

NCPDP DUR Response Formats

Variable Eligibility and Claim Capture (5.1): Field 504 (message), position 21 will be "S" or space filled.

ePACES Response Details

Eligibility, Service Authorization, and DVS - the COA "S" will be displayed in the Medicaid Message section.

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Do you want to receive your copy of the Medicaid Update up to 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!

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Effective April 1, 2008, when providing services to patients enrolled in the physician case management plans listed below, you will need a referral from the enrollee's primary care provider.

The primary care provider's Medicaid identification number must be used on your claim form instead of the physician case management plan identification number. Claims indicating the physician case management plan identification number as the referring provider will be denied.

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Location of Referring Provider Field

The referring provider identification number field is located as follows:

Claim Form Identifier	Location
UB04	Form Locator 78
NYS 150001	Field 19C
NYS Form A	Field 23
837D	Loop 2310A
837I	Loop 2310C
837P	Loop 2310A

Primary Care Provider Contact Information

	Ins Code	Physician Case Management Plan Name & Contact	After Hours
Broome County
1		Broome MAX - Ins Codes. Office hrs Monday - Friday 8:30 am - 5 pm Broome County DSS - (607) 778-2702	Call the PCP.
	G3 DD AT VG DY AR WR SL M4 DC FO	Broome MAX - Gauri Bhard-Waj, MD Broome MAX - Dan Driscoll Broome MAX - Stephen Dygert Broome MAX - Vincent Giordano Broome MAX - Lourdes Primary Care Broome MAX - Arjun Patel Broome MAX - R. A. Ramanujan Broome MAX - Azmat Saeed Broome MAX - Samuel Addo Broome MAX - United Medical Associates Broome MAX - United Health Services
Erie County
2	E4	Erie County PCMP 2A - Rosenthal (Gold Choice) Monday - Friday 8:30am - 4:30pm (716) 898-5971, or (716) 898-5966 (option 3) (888) 419-1722	Call the PCP.
Chemung, Schuyler and Steuben Counties
4	PH	Southern Tier Priority Healthcare - Twin Tiers (607) 795-5215, (607) 795-5216, or (888) 447-8528	Call the PCP.
5	SY	Southern Tier Pediatrics (607) 734-2264, (607) 937-5317, or, (866) 787-5437 24 hours/day 7 day/week	Call the number at left.