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Policy and Billing Guidance

New York City Ambulette and Livery Providers: Bridge and Tunnel Toll Change
Medicaid payment information for the recent toll increase.

New York City Practitioners and Facilities: Transportation Service Complaints
Register your complaint online!

Preferred Drug Program Update Options
Obtain information in a number of ways!

Mandatory Generic Drug Program Update
Additional drugs now require prior authorization.

Pharmacy Benefits for Family Planning Benefit Program Enrollees
Certain medications are covered under this Program.

Update on Mandatory Managed Care for SSI and SSI-Related Enrollees
Contains new and clarified information.

Chemical Dependence Providers: Comprehensive Treatment Plan May Now Include Compulsive Gambling Counseling
Specific information regarding recent policy change.

National Provider Identifier Implementation September 2008
Continue to supply proprietary information during interim.

Provider Services

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

The tolls charged by the New York City Metropolitan Transit Authority (MTA) to cross the bridges and tunnels that connect the City were changed effective March 16, 2008.

Therefore, for dates of service on or after March 16, 2008, procedure codes NY117 (ambulette) and NY227 (livery) allow a maximum of $8.30 per unit. You should bill only the amount of toll incurred.

Please note:

• Providers may seek Medicaid reimbursement for the appropriate E-Z Pass toll amount (as indicated in the table below) only if a toll was incurred while transporting a Medicaid enrollee in the vehicle across an affected bridge or tunnel. Only the E-Z Pass toll charge should be claimed.
• If a vehicle is transporting more than one rider on the same trip, the provider may bill one unit per round trip crossing, not one unit per passenger.
• Providers should enroll in the E-Z Pass program by calling (800) 333-TOLL, or online at:

http://www.e-zpassny.com

Below is the new toll schedule for MTA-operated bridges and tunnels:

Crossing	Toll Amount
Verrazano-Narrows Bridge	$8.30
Bronx-Whitestone Bridge Brooklyn-Battery Tunnel Queens Midtown Tunnel Throgs Neck Bridge Triborough Bridge	$4.15
Henry Hudson Bridge	$1.90
Marine Parkway-Gil Hodges Memorial Bridge Cross Bay Veterans Memorial Bridge	$1.55

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Transportation providers operating in New York City are licensed by the Taxi and Limousine Commission (TLC). Complaints regarding ambulette or livery service concerning poor driving habits, inappropriate passenger care, long transports or untimely pickup or discharge can be filed online at:

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Visit our Web site!

Go to http://newyork.fhsc.com to access the following information:

• The current Preferred Drug List and Quicklist.
• Forms and worksheets for all pharmacy prior authorization programs.
• Copies of provider letters sent whenever changes are made.

Schedule an outreach presentation!

• Education specialists are available to present Preferred Drug Program information to your staff. Send a request to NYPDPnotices@firsthealth.com or call (518) 951-2046.

Let us do the work for you!

• We can automatically send you the Preferred Drug List via e-mail whenever there are updates. Send a request to NYPDPnotices@firsthealth.com

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

Effective May 1, 2008, new prescriptions for the brand-name drugs below will require prior authorization:

• ADOXA PAK 1/150 MG TABLET
• COLESTID GRANULES
• COMBUNOX TABLET
• WELLBUTRIN XL 300 MG TABLET
• ZOFRAN 32 MG/50 ML BAG

Prescriptions written prior to May 1, 2008, but filled on or after May 1, 2008, including refills, will not require prior authorization. However, when the prescription expires, a prior authorization is required for the patient to continue to receive the brand-name drug.

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Effective March 27, 2008, pharmacies may bill Medicaid for the following medications when prescribed for Family Planning Benefit Program enrollees for the treatment of sexually transmitted infections.

• antibacterial
• antibiotics
• antifungal
• antiviral
• wart treatment
• antimitotic
• immune Response Modifier
• pediculicide/scabicide
• topical steroids.

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

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Mandatory enrollment of SSI and SSI-related Medicaid enrollees, including those with serious mental illness has been implemented and is being phased in geographically throughout the State. Mandatory enrollment of SSI individuals has already begun in New York City, Nassau, Onondaga, Oswego, Suffolk and Westchester counties.

Effective March 2008	Effective May/June 2008
Cattaraugus	Livingston
Chautauqua	Monroe
Erie	Ontario
Genesee	Seneca
Niagara	Yates
Orleans
Allegany
Rockland

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 a health plan.

Medicaid enrollees located in New York City, Nassau, Suffolk and Westchester counties can request an exemption by calling:

(800) 505-5678.

Enrollees in all other counties listed 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, the individual will keep his/her Medicaid benefits but will get most of his/her care from the health plan's network of providers, 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 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.
• All benefit package services must be provided by network providers or by referral and may require prior authorization.

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?

A complete description of the Medicaid Managed Care benefit package and all services billable directly to Medicaid fee-for-service is available at:

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

Providers with questions regarding Medicaid Managed Care for the SSI population, or to obtain a list of Medicaid rate and fee codes payable for Medicaid Managed Care SSI enrollees, should be referred to (518) 473-0122.

Medicaid Eligibility Information

Providers should check the Medicaid Eligibility Verification System (MEVS) at each visit, or at a minimum on the first and tenth of every month to determine Medicaid eligibility and managed care enrollment status.

Identification of SSI or SSI-related Medicaid Enrollees

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

• MEVS will show an "S" in the category of assistance field.
• On the VeriFone terminal, the category of assistance response will be returned after the anniversary date in the following format:
  
  ANNIV DT: MM/DD/YYYY
  MSG: COA=S
  MSG: RECERT MONTH=MM
  
  
• 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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Click on the link to your Provider Manual at http://www.emedny.org/ProviderManuals/index.html and you will find the archived versions and other important information regarding recent changes made to your Provider Manual.

Providers without internet access may contact the eMedNY Call Center at the number below to request a paper copy:

(800) 343-9000.

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Changes to Office of Alcoholism and Substance Abuse Services (OASAS) regulations (14 NYCRR Part 822, Chemical Dependence Outpatient Services) now authorize counseling for compulsive gambling as part of a comprehensive treatment plan. Please note:

• Gambling counseling may not be provided on a stand-alone basis. It must be provided simultaneously with delivery of a chemical dependency service.
• This service is for those patients who meet the admission criteria for chemical dependency services.
• Individuals with only a compulsive gambling diagnosis or significant others effected by another individual's compulsive gambling actions do not meet Part 822 admission criteria and this service is not reimbursed by Medicaid.
• Compulsive gambling treatment can only be administered by a compulsive gambling counselor authorized by OASAS to provide compulsive gambling treatment as a co-occurring disorder with chemical dependency.
• Individual and group counseling for compulsive gambling should be addressed specifically as to how the patient's gambling behaviors and consequences relate to and impact their chemical dependency. The service must be identified and delivered in accordance with the patient's specific individualized treatment plan.

Compulsive Gambling and Medicaid Billing

OASAS certified Part 822 chemical dependency outpatient clinic programs may receive Medicaid reimbursement for individual or group compulsive gambling services, only if the following conditions have been met:

• The patient meets Part 822.3 admission criteria. Specifically, Part 822.3(a)(1) admission procedures require that: the individual is in need of a chemical dependence service; or, is a significant other who manifests emotional effects from another individual's chemical abuse or dependence as stated in Part 822.3 (g)(2).
• Individuals with a compulsive gambling only diagnosis, or significant others effected by another individual's compulsive gambling only actions do not meet Part 822 admission criteria.
• The patient receives a comprehensive evaluation within two weeks from admission per Part 822.4(a)(4).

Operating Regulations Part 822.10(b)(ii) and (iii) provide that:

• ii) Individual Sessions should be conducted to address the patient's gambling behaviors and consequences and how they relate to their chemical dependency.
• iii) Group Sessions should be conducted to address the patient's gambling behaviors and consequences as well as how it impacts their chemical dependency.

• Part 822.10(c) requires that the compulsive gambling session (with the required relation to chemical dependency) must be conducted by an OASAS credentialed compulsive gambling counselor.
• The service must be identified and delivered in accordance with the patient's specific individualized treatment plan.
• The service must meet other applicable Part 822 Program Operating regulations.
• If the above conditions have been met, the OASAS certified Part 822 Outpatient Chemical Dependence Program must use the appropriate existing Part 822 Chemical Dependence Medicaid Billing rate codes and reimbursement amounts.
• Providers use their usual and customary Part 822 Billing Medicaid rate codes. There are no separate Medicaid billing individual group session rate codes or reimbursement amounts for compulsive gambling services delivered in an OASAS certified Part 822 Outpatient Clinic.

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Implementation of the National Provider Identifier (NPI) requirement will be September 1, 2008. As a result, New York State Medicaid provider identification numbers, or license numbers, will continue to be required for processing until the NPI system release is installed.

The Office of Health Insurance Programs recommends that you and your information systems staff confirm that your vendor will be capable of processing HIPAA transactions using proprietary identifiers until September 1, 2008.

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

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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/health_care/medicaid/program/update/main.htm

Hard copies can be obtained upon request by emailing: medicaidupdate@health.state.ny.us

Office of the Medicaid Inspector General: http://www.omig.state.ny.us (518) 473-3782

Questions about an Article?
Each article contains a contact number for further information, questions or comments.

Questions about billing and performing EMEVS transactions?
Please contact eMedNY Call Center at: (800) 343-9000.

Provider Training
To sign up for a provider seminar in your area, please enroll online at:

http://www.emedny.org/training/index.aspx

For individual training requests, call (800) 343-9000 or email:

emednyproviderrelations@csc.com

Enrollee Eligibility
Call the Touchtone Telephone Verification System at any of the numbers below:

(800) 997-1111    (800) 225-3040      (800) 394-1234.

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

• Fee-for-Service Providers
  A change of address form is available at:        http://www.emedny.org/info/ProviderEnrollment/index.html
• Rate-Based/Institutional Providers
  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, Kelli Kudlack, 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.