New York State Medicaid Update - December 2015 Volume 31 - Number 13

In this issue...

ALL PROVIDERS POLICY AND BILLING GUIDANCE PHARMACY UPDATE PROVIDER DIRECTORY
ALL PROVIDERS

Mandatory Electronic Prescribing in New York State

Exceptions and Waivers

Effective March 27, 2016, practitioners are required to issue electronic prescriptions unless granted a waiver or meeting one of the limited situational exceptions defined within Public Health Law š 281, and 10 NYCRR Part 80, § 80.64.

The following is a list of exceptions from the requirement to electronically prescribe:

  • Prescriptions issued by veterinarians
  • Prescriptions issued in circumstances where electronic prescribing is not available due to temporary technological or electrical failure
  • A paper or oral prescription may be issued for a controlled substance, that does not exceed a 5 day supply, ONLY if the practitioner reasonably determines that it would be impractical for the patient to obtain substances prescribed by electronic prescription in a timely manner, AND such delay would adversely impact the patient's medical condition
  • Prescriptions issued by a practitioner to be dispensed by a pharmacy located outside the state
  • Practitioners who have received a waiver or a renewal thereof for a specified period determined by the commissioner, from the requirement to use electronic prescribing

Pursuant to Public Health Law § 281 and 10 NYCRR Part 80, § 80.64(c)(3) the Commissioner of Health may grant a practitioner a waiver, not to exceed a time period of one year, from the requirement to electronically prescribe. Waivers may be granted based upon a showing of economic hardship, technological limitations that are not reasonably within the control of the practitioner, or other exceptional circumstances demonstrated by the practitioner.

The practitioner's showing shall include a sworn statement of facts detailing the circumstances in support of a waiver, and should be accompanied by any and all other information which would be relevant to the commissioner's determination. The practitioner shall also provide any information which would tend to negate the need for a waiver.

There are three classifications of waivers which will be available online and in paper form:

♦Individual Practitioner
♦Group Practice
♦Institutional

Please monitor the Bureau's website for updated information pertaining to the waiver process and electronic prescribing.

https://www.health.ny.gov/professionals/narcotic/electronic_prescribing/

Questions concerning Electronic Prescribing in New York State?

Q: Is an electronic facsimile of a prescription considered an electronic prescription?

A: No. A definition of an electronic prescription can be found in Public Health Law § 3302 and specifically states that a prescription generated on an electronic system that is printed out or transmitted via facsimile is not considered an electronic prescription.

Q: Can an agent or employee of the prescriber create or prepare an electronic prescription?

A: Yes. Education Law § 6802 and 10 NYCRR Part 80, §§ 80.67 and 80.69 do not prohibit an agent of the practitioner from preparing an electronic prescription for his or her review and electronic signature. "Preparing" an electronic prescription is a distinct act that does not include electronically signing or transmitting the electronic prescription.

Q: Can an agent or employee of the prescriber electronically sign an electronic prescription?

A: No. Practitioners are authorized to prescribe by virtue of their licenses to practice medicine or dentistry. Therefore, only the practitioner may review and sign the prescription.

Q: Can an agent or employee of the prescriber transmit an electronic prescription to the pharmacy?

A: The signing and transmission of an electronic prescription are two distinct actions. Only the practitioner may review and electronically sign the prescription. Once signed, an agent or employee of the practitioner may transmit the prescription on behalf of the practitioner. The act of transmission must be independent of the review and signature process.

Q: Should I return all of my unused Official New York State Prescription forms to the Bureau of Narcotic Enforcement (BNE)?

A: Not necessarily. Under limited circumstances, the use of an Official NYS Prescription form will still be allowed, including events such as a power outage or technological failure. However, it is unlikely that practitioners and institutions will need to continue to keep a similarly large inventory as in the past. Please consider the amount of prescription paper you will need to keep on hand, safeguard any stored Official New York State Prescription forms, and return unneeded or unwanted forms to BNE at 150 Broadway, Albany, NY 12204. BNE will continue to supply Official New York State Prescription forms to practitioners and institutions. Additional Frequently Asked Questions may be found on the New York State Bureau of Narcotic Enforcement website at: http://www.health.ny.gov/professionals/narcotic/electronic_prescribing/docs/epcs_faqs.pdf

Webinar trainings are now available for the New York Medicaid Management Information System (NYMMIS)

In 2016, the New York State Department of Health (NYS DOH) will be transitioning to a new Medicaid System, the New York Medicaid Management Information System (NYMMIS) and a new fiscal agent, Xerox State Healthcare, LLC.

As previously advised in the October 2015 Medicaid Update, training is open. In addition, real time webinars of all instructor-led sessions currently being held at 431 B Broadway, Menands are now available. While in- person attendance for training is recommended, the new webinar option will allow for greater flexibility.

For a course listing, to register for a training session or for additional information, please go to the interim website at www.interimNYMMIS.com.

NY Medicaid EHR Incentive Program Update

The NY Medicaid Electronic Health Record (EHR) Incentive Program provides financial incentives to eligible professionals 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 $740 million in incentive funds have been distributed within 22,112 payments to New York State Medicaid providers.

22,112 Payments.

$740+ Million Paid.

Are you eligible? For more information, visit www.emedny.org/meipass

2016 Public Health Reporting Measures

For providers who have previously demonstrated meaningful use, the EHR Reporting Period for 2016 will be the full calendar year (January 1 to December 31)

Providers must formally register their intent to submit data for a given Public Health Reporting measure, before or within 60 days of the start of the EHR Reporting Period. The NY Medicaid EHR Incentive Program will be releasing a new and improved registration system on January 4, 2016. All new public health registrations for 2016 must be completed in the new system.

Please contact the support team at 1-877-646-5410 Option 3 or MUPublicHealthHELP@health.ny.gov for assistance with the public health reporting measures and registration.

2015 Attestations

NY Medicaid is not yet accepting 2015 meaningful use attestations for Modified Stage 2.

Announcements will be made on the Program website and LISTSERV when providers may attest.

2015 attestations for Adopt, Implement, or Upgrade (AIU) are still being accepted. The attestation deadline for 2015 is March 31, 2016.

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

POLICY AND BILLING GUIDANCE

Attention Transportation Providers Policy Regarding Vehicle Ownership or Leasing and Insurance

Vehicle Ownership & Insurance

Medicaid program transportation service providers are personally and directly responsible for their fleet of vehicles. A provider must own the vehicles outright or be personally responsible for the vehicles pursuant to a vehicle lease agreement. The provider may enter into a lease agreement with a motor vehicle manufacturer or with a licensed vehicle dealership. Vehicle leases are acceptable so long as the lease agreement is in the name of the Medicaid-enrolled transportation service provider and the vehicle is registered to the Medicaid- enrolled transportation service provider.

Further, vehicles must be insured and maintained by the Medicaid-enrolled transportation service provider.

It is unacceptable for a Medicaid-enrolled transportation service provider to enter into any arrangement whereby the provider uses or leases vehicles registered to, insured and/or maintained by another individual or entity. Such an arrangement has the potential of bypassing significant safety and financial controls that are fundamental to the integrity of the Medicaid Program and the safety of the Medicaid enrollees.

Providers in violation of this policy must continue to meet these standards concerning vehicle ownership, registration, maintenance, and insurance. Those providers deemed in violation of this policy are subject to penalty, including disenrollment from the Medicaid program. Note: New transportation provider applicants must adhere to these requirements at the time of application.

If you have any questions, please contact the Medicaid Transportation Unit at (518) 473-2160 or via email to MedTrans@health.ny.gov.

Attention Transportation Providers Updated Policy Regarding Subcontracting

Subcontracting Policy

Medicaid program transportation service providers are personally and directly responsible for transporting Medicaid enrollees. These responsibilities may not be assigned, delegated or subcontracted out. Such an arrangement has the potential of bypassing significant safety and financial controls that are fundamental to the integrity of the Medicaid program and the safety of Medicaid enrollees.

Due to mechanical breakdowns and other acute circumstances, transportation providers may face times when the number of available vehicles registered to the provider does not meet the need for services. Formerly, the Medicaid program allowed on a short-term basis Medicaid-enrolled Provider A to subcontract with or lease vehicles from Medicaid-enrolled Provider B or other entity in order to ensure the provision of services to the enrollee. Effective immediately, the Medicaid program no longer allows these arrangements.

If a Medicaid transportation provider encounters a circumstance when his supply of provider-registered vehicles does not meet the need for services, the provider must alert the appropriate transportation manager as soon as possible so that the transportation manager may find an available provider to perform the necessary trip or trips. Please be reminded that Medicaid transportation managers are accessible 24/7 by telephone, and can be identified using the contact list available online at http://www.emedny.org/ProviderManuals/Transportation/index.html.

If you have any questions, please contact the Medicaid Transportation Unit at (518) 473-2160 or via email to MedTrans@health.ny.gov.

Attention Ambulette and Taxi/Livery Providers Record Keeping Requirements Have Been Updated

In accordance with Title 18 NYCRR §504.3(a) and 517.3(b), transportation providers will be reimbursed only when contemporaneous, complete, acceptable, verifiable records are available upon request to the State in connection with an audit, investigation or inquiry. The documentation below is required for every leg of a trip, and must be maintained for a period of six years following the date of payment. If any of the required information is incomplete, or deemed unacceptable or false, any relevant paid reimbursement will be recouped and the provider may be subject to other statutory or regulatory liability, financial damages and sanctions.

Ambulette, Taxi/Livery Providers

Effective January 1, 2016,in addition to historically required acceptable trip verification, the Department will now require the full printed name and signature of the driver providing the transport attesting that the referenced trip was completed. The full list of required trip verification information now includes, at a minimum:

  • The Medicaid enrollee's name and Medicaid identification number;
  • The date of the transport;
  • Both the origination of the trip and time of pickup;
  • Both the destination of the trip and time of drop off;
  • The vehicle license plate number;
  • The driver's license number;
  • The full printed name and signature of the driver providing the transport; and
  • An attestation from the driver that the trip was completed.

Electronic Records

The use of electronic record-keeping methodology is becoming more prevalent. Transportation vendors using electronic methods to prepare and maintain contemporaneous documentation to support Medicaid claims must produce documentation with an accurate system-generated, unmodifiable date and time stamp for each leg of a billable trip including the pickup and drop-off, as well as driver attestation as required.

Supplemental Documentation

The following items presented as the only evidence of a trip are not considered acceptable documentation. However, these documents may be considered supplemental to additional required documentation and can be presented to supplement required documentation:

  • A driver/vehicle manifest or dispatch sheet;
  • Issuance of a prior authorization by an approved official with subsequent checkmarks;
  • A prior authorization roster; or
  • An attendance log from a day program.

Reminder - Requirements under 505.10 Transportation for Medical Care and Services

Providers must comply with 18 NYCRR§ 505.10 in its entirety.

Attention Taxi and Livery Providers Updated Taxi (Category of Service 0603) And Livery (Category of Service 0605) Claims Requirement

The Department has reached agreement with the Office of the Medicaid Inspector General and the Attorney General's Medicaid Fraud Control Unit to require that claims submitted by taxi/livery providers include both the driver license and vehicle license plate number. The Department agrees that reporting this information will aid in its intent to ensure quality services and program integrity.

Effective July 1, 2016, claims that do not include the required fields will be denied for edit 00267, "VEHICLE LICENSE PLATE / DRIVER'S LICENSE NUMBER REQUIRED."

Questions may be referred to the Medicaid Transportation Unit at (518) 473-2160 or via email to MedTrans@health.ny.gov.

PHARMACY UPDATE

Medicaid Pharmacy Prior Authorization Programs Update

On November 19, 2015, the New York State Medicaid Drug Utilization Review (DUR) Board recommended changes to the Medicaid pharmacy Prior Authorization (PA) programs. Effective January 21, 2016, the Fee-For-Service (FFS) pharmacy program will implement the following parameters:

Drugs for Opioid Induced Constipation (OIC)

  • Confirm diagnosis for the FDA-approved or compendia-supported indication(s):
  • Absence of covered diagnosis in patient's claim history will require prescriber involvemen
  • Step therapy:
  • Trial with an osmotic laxative, a stimulant laxative and a stool softener prior to use of lubiprostone (Amitiza(®)), methylnaltrexone (Relistor(®)), or naloxegol (Movantik(™))
  • Quantity limits based on FDA-approved labeling:
  • Lubiprostone (Amitiza(®)):
  • 2 capsules per day (60 capsules per 30 days)
  • Methylnaltrexone (Relistor(®)):
  • Single-use vials and syringes (8 mg and 12 mg):
  • 1 vial/syringe per day (30 vials/syringes per 30 days)
  • Kits (contains 7 pre-filled single-use syringes in 8 mg and 12 mg):
  • 4 kits per 28 days
  • Naloxegol (Movantik(tm)):
  • 1 tablet per day (30 tablets per 30 days)

Kalydeco (ivacaftor), Orkambi (ivacaftor/lumacaftor)

  • Confirm diagnosis for the FDA-approved or compendia-supported indication(s). Genetic testing required to verify appropriate mutation;
  • Absence of covered diagnosis in patient's claim history will require prescriber involvement

Erythropoietin-Stimulating Agents (ESAs)

  • Confirm diagnosis for the FDA-approved or compendia-supported indication(s):
  • Absence of covered diagnosis in patient's claim history will require prescriber involvement

Daraprim (pyrimethamine)

  • Confirm diagnosis for the FDA-approved or compendia-supported indications:
  • Absence of covered diagnosis in patient's claim history will require prescriber involvement
  • Require concurrent utilization of leucovorin

For more detailed information on the DURB, please refer to:http://www.health.ny.gov/health_care/medicaid/program/dur/index.htm

Following is a link to the most up-to-date information on the Medicaid FFS PA Programs. This document contains a full listing of drugs subject to the Medicaid FFS Pharmacy Programs: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf

To obtain a PA, please contact the clinical call center at 1-877-309-9493. The clinical call center is available 24 hours per day, 7 days per week with pharmacy technicians and pharmacists who will work with you, or your agent, to quickly obtain a PA. Medicaid enrolled prescribers can also initiate PA requests using a web-based application. PAXpress(®) is a web based pharmacy PA request/response application accessible through a new button "PAXpress" located on the home screen at eMedNY.org.

Additional information, such as the Medicaid Standardized PA form and clinical criteria are available at the following websites: http://www.nyhealth.gov or http://newyork.fhsc.com or http://www.eMedNY.org.

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-educationprog and http://nypep.nysdoh.suny.edu/home

Need to change your address? Does your enrollment file need to be updated because you have experienced a change in ownership? Do you want to enroll another NPI? Did you receive a letter advising you to revalidate your enrollment?
Visit http://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.

Comments and Suggestions Regarding This Publication?
Please contact the editor, Amy Siegfried, at medicaidupdate@health.ny.gov

The Medicaid Update is a monthly publication of the New York State Department of Health.

Andrew M. Cuomo
Governor
State of New York

Howard A. Zucker, M.D., J.D.
Commissioner
New York State Department of Health

Jason A. Helgerson
Medicaid Director
Office of Health Insurance Programs