New York State Medicaid Update - December 2014 Volume 30 - Number 12

In this issue.....

All Providers

NY Medicaid EHR Incentive Program Update

The NY Medicaid Electronic Health Records (EHR) Incentive Program provides financial incentives to eligible practitioners and hospitals to promote the transition to EHRs. Providers who practice using EHRs are in the forefront of improving quality, reducing costs and addressing health disparities. Since December 2011 over $619.9 million in incentive funds have been distributed within 15,808 payments to New York State Medicaid providers.

The NY Medicaid EHR Incentive Program Support Team takes great pride in offering providers free high quality program support and services. Don't take our word for it, call us at 1-888-646-5410 to speak with a program analyst for one-on-one support or navigate to the NY Medicaid EHR Incentive Program Website to view our online services.

15,808+
Payments.
NY Medicaid EHR

$619.9
Million Paid.
Incentive Program

Are you
eligible?
emedny.org/meipass

Taking a closer look: NEW NY Medicaid EHR Incentive Program Pre-validation Services.

The NY Medicaid EHR Incentive Program is pleased to announce Pre-validation Services for eligible professionals (EP) preparing to attest for the NY Medicaid EHR Incentive Program. The purpose of the new service is to potentially expedite EP attestation review, resulting in a shorter duration between attestation submission and receipt of the incentive payment.

The service is open to all EPs using individual or group Patient Volume Methods. In order to take advantage of these useful services please send an email to hit@health.ny.gov. In your email, please indicate the Patient Volume Method the EP(s) will be using to demonstrate their Medicaid Eligibility.

Upon receipt of the EP's email, the NY Medicaid EHR Incentive Program Support team will follow up with a form specific to the EP's initial request. Complete and return this form to start the Pre-Validation.

Have Questions? Contact hit@health.ny.gov for program clarifications and details.

The Medicaid Update Moves to Electronic Distribution

In an effort to reduce costs and be more environmentally minded, beginning April 1, 2015 the Office of Health Insurance Programs will no longer produce a printed version of the Medicaid Update.

The Medicaid Update will ONLY be available electronically. This delivery system allows our providers to receive policy sensitive bulletins faster. The newsletter will be delivered monthly to your designated e-mail address in a Portable Document Format (PDF).

If you do not presently receive the Medicaid Update electronically, please send your request to the following e-mail: MedicaidUpdate@health.ny.gov.

Providers who are unsure about receiving an electronic-only version of the newsletter should bear in mind that the PDF newsletter can always be printed and read in hard copy. Additionally, the current and archived newsletters are posted on the DOH Website at the following address: http://www.nyhealth.gov/health_care/medicaid/program/update/main.htm

Medicaid Partners Urged to Join eMedNY LISTSERV®

The eMedNY LISTSERV®) email system has become the primary method for dissemination of eMedNY related information and notifications to providers, vendors and other Medicaid partners. Reaching out to over 54,000 subscribers, the LISTSERV® enables our Medicaid partners to instantly receive:

  • Alerts for upcoming changes to claims and other transactions editing
  • Announcements about provider training, seminars, webinars and special web meetings being offered
  • Provider type specific changes in policy and claim submission requirements
  • ePACES changes and enhancements

The LISTSERV® email system runs on an open platform and is available free of charge to all our Medicaid partners. Also, there is no limitation on the number of individuals who may subscribe from a practice or organization and no limitation on the number of categories one may subscribe to. To ensure they receive all eMedNY communications that may impact their practice and business process, Medicaid partners who are not yet enrolled are urged to do so at their earliest convenience.

Subscribing to the eMedNY ListSERV® is quick and easy. Simply visit www.emedny.org, click on the LISTSERV® button on the right side of the home page, enter an email address and check the categories desired. All eMedNY LISTSERV® communications are archived for anyone to view at a later time.

Please contact the eMedNY Call Center at (800) 343-9000 with any questions related to the eMedNY LISTSERV®.

Mandatory Compliance Program Certification Requirement under 18 NYCRR §521.3(b)

THIS IS A REMINDER FROM THE NEW YORK STATE OFFICE OF THE MEDICAID INSPECTOR GENERAL (OMIG) FOR ALL MEDICAID REQUIRED PROVIDERS WHO ARE SUBJECT TO THE NYS SOCIAL SERVICES LAW SECTION 363-d MANDATORY COMPLIANCE PROGRAM REQUIREMENT.

Medicaid providers are required to implement and maintain a compliance program as described in NYS Social Services Law Section 363-d and 18 NYCRR Part 521. Any required provider must also certify annually that its compliance program meets the statutory and regulatory requirements. The certification must occur in December of each year.

At the time of certification, it is the responsibility of required providers to determine if:
a. it has a compliance plan that meets the requirements of SSL § 363-d and 18 NYCRR § 521.3 (c);
- and -
b. its compliance program is effective.

OMIG reminds all those who are required to have a compliance program that they must complete the certification on OMIG's website (www.omig.ny.gov) by December 31, 2014.

On December 1, 2014, OMIG made the NYS Social Service Law Compliance Program Certification Form (Certification Form) for 2014 available on its website.

A webinar, entitled "OMIG Webinar # 23 - OMIG's Compliance Certification Process: December Annual and Enrolling Providers" is available on OMIG's website at the following link http://www.omig.ny.gov/resources/webinars. Webinar #23 explains: who is required to adopt, implement and maintain an effective compliance program; what is required of mandatory compliance programs; what the certification obligation requires; and the form that must be used to certify starting on December 1, 2014.

In addition to the Webinar, the Compliance tab on OMIG's website provides tools and resources to help Medicaid providers determine if they are required to adopt, implement and maintain a compliance program under NYS Social Services Law Section 363-d and 18 NYCRR Part 521. The Compliance tab also provides resources that explain what is required of compliance programs.

Medicaid providers have an independent obligation to be aware of existing statutory and regulatory requirements of the Medicaid program. Additionally, OMIG recommends regular visits to its website to review the information and resources that are published under the Compliance Tab on OMIG's home page. The Compliance Library under the Compliance Tab provides copies of current forms, publications and other resources that could prove helpful in conducting a self- assessment and completing the certification form in December.

OMIG also recommends that required providers sign up for e-mail notices from OMIG by subscribing to OMIG's listserv. Anyone can become a subscriber at no cost by signing up on OMIG's home page. The listserv is a great way to keep informed of the introduction of new compliance tools and information on compliance. As additional compliance-related resources are posted by OMIG, those on OMIG's listserv will receive notices of their publication.

If you have any questions regarding New York State's mandatory compliance obligation for Medicaid providers, please contact the OMIG's Bureau of Compliance at (518) 408-0401 or by using the Bureau of Compliance's dedicated e-mail address compliance@omig.ny.gov.

Certification of Compliance with Section 6032 of the Deficit Reduction Act of 2005, Section 1902 of the Social Security Act, and Title 42 of the United States Code Section 1396a(a)(68)

THIS IS A REMINDER FROM THE NEW YORK STATE OFFICE OF THE MEDICAID INSPECTOR GENERAL (OMIG) FOR ALL PROVIDERS WHO ARE SUBJECT TO THE REQUIREMENTS UNDER TITLE 42 OF THE UNITED STATES CODE SECTION 1396A(68), [42 USC §1396A(68)].

On December 1, 2014, OMIG posted the Federal Deficit Reduction Act of 2005 (DRA) Certification Form for 2014 (Certification Form). The Certification Form can be accessed on OMIG's website through the following link http://www.omig.ny.gov/compliance/certification.

A webinar, entitled "OMIG Webinar #23 - OMIG's Compliance Certification Process: December Annual and Enrolling Providers" is available on OMIG's website at the following link http://www.omig.ny.gov/resources/webinars. Among other things, webinar #23 provides a "high- level" explanation of the DRA requirement and demonstrates how providers can complete the Certification Form.

When a Medicaid provider is certifying on the Certification form, it is certifying that it is meeting the requirements of 42 USC §1396a(a)(68) which provides that: (a) A State plan for medical assistance must-

"(68) provide that any entity that receives or makes annual payments under the State plan of at least $5,000,000, as a condition of receiving such payments, shall:

(A) establish written policies for all employees of the entity (including management), and of any contractor or agent of the entity, that provide detailed information about the False Claims Act established under sections 3729 through 3733 of title 31, United States Code, administrative remedies for false claims and statements established under chapter 38 of title 31, United States Code, any State laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws, with respect to the role of such laws in preventing and detecting fraud, waste, and abuse in Federal health care programs(as defined in section 1128B(f));

(B) include as part of such written policies, detailed provisions regarding the entity"s policies and procedures for detecting and preventing fraud, waste, and abuse; and

(C) include in any employee handbook for the entity, a specific discussion of the laws described in subparagraph (A), the rights of employees to be protected as whistleblowers, and the entity's policies and procedures for detecting and preventing fraud, waste, and abuse; ..."

OMIG addresses this mandate by monitoring a provider's certification of compliance status and conducting compliance program reviews of required providers. The Certification Form and frequently asked questions (FAQs) are available on the OMIG website, at the above link. If you have any questions, please contact the OMIG's Bureau of Compliance at (518) 408-0401 or by using the Bureau of Compliance's dedicated e-mail address at: compliance@omig.ny.gov.

OMIG recommends regular visits to its website to review the information and resources that are published under the Compliance Tab on OMIG's home page. The Compliance Library under the Compliance Tab provides copies of current forms, publications and other resources that could prove helpful in conducting a self-assessment and completing the certification form in December.

OMIG also recommends that required providers sign up for e-mail notices from OMIG by subscribing to OMIG's listserv. Anyone can become a subscriber at no cost by signing up on OMIG's home page. The listserv is a great way to keep informed of the introduction of new compliance tools and information on compliance. As additional compliance-related resources are posted by OMIG, those on OMIG's listserv will receive notices of their publication.

Medicaid Primary Care Rate Increase Ends December 31, 2014

The Affordable Care Act established a Medicaid Primary Care Rate Increase (PCRI) for specific primary care services furnished by certain qualified primary care providers. As stated in the December 2012 issue of the Medicaid Update, the period for the increased rate is January 1, 2013 through December 31, 2014.

For those providers already approved for the increased rate, no action is necessary. Medicaid payments systems are being updated to process claims without the rate increase for services provided on and after January 1, 2015. Eligible providers who have not signed up for PCRI may still apply. PCRI Attestations must be postmarked by January 31, 2015 to be considered. Click here for the PCRI Attestation form. Click here for the PCRI Frequently Asked Questions.

Update on the Fully Integrated Duals Advantage (FIDA) Demonstration

The Fully Integrated Duals Advantage Demonstration (FIDA) program will begin on January 1, 2015. The three-year demonstration project is a partnership between the New York State Department of Health (NYSDOH) and the federal Centers for Medicare and Medicaid Services (CMS). Through FIDA, participants can get all of their Medicaid and Medicare benefits through one managed care plan.

As of December 1, 2014:
  • 22 plans have fully executed contracts with NYSDOH Division of Long Term Care and CMS.
  • FIDA Program Announcement Letters were mailed to eligible individuals in Region I (which consists of the Bronx, Kings, New York, Queens, Richmond, and Nassau counties).
  • Marketing began in Region I.
  • The Participant Ombudsman program is operational in New York City and Nassau County. The Community Service Society of New York (CSS) is responsible for the Ombudsman program. CSS will provide enrollees in FIDA and Managed Long Term Care plans and enrollees receiving Long Term Services and Supports (LTSS) through Mainstream Managed Care plans with direct assistance in navigating their coverage and in understanding and exercising their rights and responsibilities. The Ombudsman will be known as the Independent Consumer Advocacy Network (ICAN) and can be reached by phone at 1-844-614-8800 or online at icannys.org.

Opt-in enrollment effective date for Region I starts January 1, 2015, and passive enrollment starts April 1, 2015. In Region II, which consists of Suffolk and Westchester counties, marketing can begin on March 1, 2015, opt-in enrollment effective date is April 1, 2015, and passive enrollment starts July 1, 2015.

Key features of the FIDA program:
  • An expanded package of covered items and services, which includes original Medicaid and Medicare benefits including prescription drug coverage, as well as behavioral health, home and community based waiver services and community and facility long term care services.
  • Participants will not have to pay plan premiums, copayments, or deductibles.
  • Patient-centered service planning through an interdisciplinary team (IDT) approach. FIDA members can choose family members, doctors, nurses or personal attendants to join their IDTs to help make care decisions.
  • An integrated appeals process, through which the most consumer-favorable elements of the Medicare and Medicaid grievance and appeals systems are incorporated into a consolidated, integrated grievance and appeals system for FIDA Participants.
  • Access to services provided by ICAN.

The goal of FIDA is to provide fully integrated care to improve health outcomes for dual eligible individuals. For more details about the FIDA program please see: http://www.health.ny.gov/health_care/medicaid/redesign/mrt_101.htm

Pharmacy Update

Billing Medicaid for Compounds that Contain Non-Covered Ingredients

If a provider submits a claim for a compound prescription containing a non-Medicaid covered ingredient, the entire claim will be denied.

To override this denial, the provider may send a value of "08"- 'Process Compound for Approved Ingredients' in field 420-DK - Submission Clarification Code. The "08" will by- pass any ingredient not payable by NYS Medicaid, and allows the individual Medicaid covered ingredients to be paid without denying the entire claim. By submitting the "08" value, the provider is indicating that they accept this action and will only be reimbursed for those covered ingredients (this will not override other editing, such as Pro DUR, eligibility etc.).

For more information on billing instructions please go to the following website: https://www.emedny.org/, and select EMedNY HIPAA Support -> Transaction Instructions -> NCPDP D.O Companion Guide.

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

For more information on compound prescription policy, please see the February Medicaid Update article: http://www.health.ny.gov/health_care/medicaid/program/update/2014/feb14_mu.pdf

Policy & Billing Guidance

Providers Urged to Submit Correct Coordination of Benefits (COB) Information to Medicaid for Medicare Advantage (Part C) Recipients

A recent review of claims has uncovered persistent misreporting of patient responsibility when the patient is enrolled in both Medicare Advantage Plan (Part C) and Medicaid. The following practices were uncovered:

  • A Medicare Advantage Plan made an adjustment to a claim after the claim was billed to Medicaid, and the billing provider did not make an adjustment to the Medicaid claim, resulting in an overpayment
  • Overpayments resulted because excessive Medicare Advantage Plan coinsurance, deductible and/or co-payments were reported on COB claims to Medicaid
  • Reporting Cost Avoidance (formerly known as ZERO FILL) on a service that was in fact covered by a Medicare Advantage Plan

1.1.1 Provider Responsibilities

It is the responsibility of a provider who renders services to a Medicaid Recipient to verify their eligibility before treatment. All payers reported in the eligibility response must be accounted for in the COB reporting on the claim to Medicaid.

The misreporting of information on COB claims may at times result in inappropriate payments to a provider. Providers are reminded that both federal and state laws specify that providers participating in the Medicaid program must not retain any inappropriate payments. Knowingly retaining inappropriate payments violates the Fraud Enforcement and Recovery Act (FERA), which amended the federal False Claims Act.

In addition, effective May 22, 2010 the Affordable Care Act (ACA) amended the Social Security Act (SSA) to include a variety of Medicare and Medicaid program integrity provisions. A new section under SSA, §1128J(d), requires providers of Medicare or Medicaid services or supplies to notify the program and return any inappropriate payments to the program(s) within sixty (60) days of identifying the overpayment.

It is imperative that COB claims submitted to Medicaid after Medicare or other Third Party adjudication contain all information as provided in the Remittance Advice, in accordance with Section 1.4.1.1 (COB Models) of the HIPAA 837 Claims Implementation Specifications or Technical Reports. The information is to include the Claim Adjustment Group Codes (CAGCs) and Claim Adjustment Reason Codes (CARCs) received from the previous payer(s).

1.1.2 Billing Remedies

Medicare Advantage Plan adjusts a previously adjudicated claim that has been billed to Medicaid:

The provider must send an adjusted claim with the corrected information - the Medicaid claim must be adjusted to accurately reflect Medicare's reprocessing of the claim.

Provider billed an incorrect coinsurance, deductible, or co-payment: The Medicaid claim must be adjusted. In order to correctly bill the patient responsibility to Medicaid, the adjustments on the remit from Medicare Advantage Plan must be crosswalked, without any modification, to the Medicaid Claim.

Reporting Cost Avoidance on a claim covered by the Medicare Advantage Plan:

The Primary insurance, a Medicare Advantage Plan, must be billed. Upon receiving the Medicare Advantage Plan remit, the submitter must adjust the Medicaid claim. The adjusted claim must report all adjustments from the remit, without modification, in the Coordination of Benefits 837 claim to Medicaid.

Providers who may need technical assistance complying with COB claims submission requirements should contact eMedNYHIPAASupport@csc.com

eMedNY Net Available Monthly Income (NAMI) and Patient Responsibility Editing

On June 21, 2013, Medicaid implemented new claims editing to ensure patient responsibility amounts are deducted from the appropriate inpatient hospital or nursing home claim, and that claims for nursing home services (excluding leave of absence stays) are not reimbursed when the Medicaid beneficiary is in an inpatient hospital setting. The information presented below reiterates the editing requirements detailed previously in the April 2013 edition of the Medicaid Update. It is being reprinted to assist providers who may still be experiencing claim denials related to patient responsibility amounts.

Duplicate Claims

Edit 02224 - "Inpatient/Nursing Home Duplicate" will deny inpatient hospital or nursing home claims with overlapping dates of service unless the nursing home claim contains one of the following revenue codes:

  • 0183 - Therapeutic Leave
  • 0185 - Hospital Leave
  • 0189 - Therapeutic Leave Authorized by a Medical Professional

A nursing home resident should not be in a hospital inpatient setting unless the nursing home resident is on a leave of absence. Please refer to the Edit Error Knowledge Base (EEKB) to see the Claim Adjustment Reason Code eMedNY will provide for this Edit. EEKB information is posted on eMedNY.org at: https://www.emedny.org/hipaa/5010/edit_error/index.aspx

Note: The conflicting claim will be reported on the provider's remittance statement.

Claims Involving Patient Responsibility Amounts (NAMI and Inpatient Hospital Patient Liability)

Also effective June 21, 2013, there were changes to claim reductions for Net Available Monthly Income (NAMI) amounts and Inpatient Hospital Patient Liability amounts as follows:

NAMI

NAMI reductions will be assessed to the entity in which the client "resides" on the first day of the month:

  • When an inpatient claim is received for a client responsible for NAMI, the NAMI amount will be deducted from the hospital inpatient claim.
  • When a nursing home claim is received that includes the first day of the month, the nursing home will be assessed the reduction.

The one exception to this rule is the hospital will not be assessed the NAMI when a nursing home claim for a bed reservation spans the same first day of the month.

When a paid hospital inpatient claim:
  • includes the first day of the month;
  • is reduced by the NAMI, and

a subsequent nursing home claim indicating leave of absence is processed, the nursing home claim will have the NAMI deducted and eMedNY will automatically process an adjustment to the hospital inpatient claim to reverse the NAMI deduction.

Inpatient Hospital Patient Liability
  • If an entry of an Inpatient Hospital Patient Liability amount is delayed by the responsible local agency enabling the applicable Inpatient Hospital claim to be paid prior to the eMedNY system being aware of the liability, eMedNY will automatically recognize and adjust the paid claim(s) to deduct the Patient Liability amount(s).
NAMI and Inpatient Hospital Patient Liability Amounts
  • For Medicaid beneficiaries who have an Inpatient Hospital Patient Liability on file, the amount will be returned in the Eligibility Response along with the corresponding Begin and End Dates.
  • For Medicaid Beneficiaries who have a NAMI Amount on file, the amount will be returned in the Eligibility Response along with the NAMI Begin Date.

Questions should be directed to eMedNYHIPAASupport@csc.com.

PROVIDER DIRECTORY

Office of the Medicaid Inspector General:
For suspected fraud complaints/allegations, call 1-877-87FRAUD, (877) 873-7283, or visit www.omig.ny.gov.

Provider Manuals/Companion Guides, Enrollment Information/Forms/Training Schedules:
Please visit the eMedNY website at: www.emedny.org.

Providers wishing to listen to the current week's check/EFT amounts:
Please call (866) 307-5549 (available Thursday PM for one week for the current week's amount).

Do you have questions about billing and performing MEVS transactions?
Please call the 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 e-mail: emednyproviderrelations@csc.com.

Enrollee Eligibility:
Call the Touchtone Telephone Verification System at (800) 997-1111.

Medicaid Prescriber Education Program:
For current information on best practices in pharmacotherapy, please visit the following websites: http://www.health.ny.gov/health_care/medicaid/program/prescriber_education/presc-educationproghttp://nypep.nysdoh.suny.edu/home

Need to change your address? Does your enrollment file need to be updated because you've experienced a change in ownership? Do you want to enroll another NPI? Did you receive a letter advising you to revalidate your enrollment?
Visit www.emedny.org/info/ProviderEnrollment/index.aspx and choose the link appropriate for you (e.g., physician, nursing home, dental group, etc.)

Medicaid Electronic Health Record Incentive Program questions?
Contact the New York Medicaid EHR Call Center at (877) 646-5410 for assistance.

Do you have comments and/or suggestions regarding this publication? Please contact Amy Siegfried via e-mail at: MedicaidUpdate@health.ny.gov.