New York State Medicaid Update - July 2021 Volume 37 - Number 9
In this issue …
- All Providers
- Important Reminder to Hospitals and Clinics: Affiliated Practitioner Must Record Their National Provider Identifiers with eMedNY
- Reminder: Sign Up for eMedNY Training Webinars
- Financial Hardship Application and Information
- Medicaid Consumer Fact Sheets Now Available
- NY State of Health: Higher Income New Yorkers May Now Qualify for Financial Assistance to Lower the Cost of Health Coverage
- Pharmacy Update
- Policy and Billing Guidance
Important Reminder to Hospitals and Clinics: Affiliated Practitioners Must Record Their National Provider Identifiers with eMedNY
Clinics, hospitals, and other facilities submitting Institutional Claims (837I) to New York State (NYS) Medicaid are required to record the National Provider Identifiers (NPIs) and associated License Numbers for affiliated attending providers. eMedNY will deny claims if attending providers NPIs are not affiliated with the facility submitting the claim. These claims will result in denial codes:
- Paper/Portable Document Format (PDF) remittances will have Edit 02067- Attending Provider Not Linked to Billing Provider reported and
- 835 remittance statements will return Health Insurance Portability and Accountability Act (HIPPA) X12 denial code 96/N198.
Hospitals and clinics that have not yet recorded the NPIs of all their affiliated practitioners with Medicaid must do so prior to re-submitting claims for those practitioners.
eMedNY provides two methods for recording NPIs:
- Submit files via batch process: This process allows providers to submit files through existing batch submission methods. The specification for this batch process is available through the eMedNY Facilities Practitioner's NPI Reporting Batch Reference Guide.
- Use the eMedNY "Enter Facilities Practitioner's NPIs" web site: The site was developed to allow for individual entry of these affiliations. Providers can access the site via the eMedNY home page, then select the "eMedNY Tools Center" menu option (visually located on the upper righthand side of the home page), then select the "Enter Facilities Practitioner's NPIs" option. Alternatively, providers can directly visit the eMedNY "Enter Facilities Practitioner's NPIs" option.
Facilities that have large numbers of practitioners are encouraged to maintain "rosters" of all their attending providers' NPIs. As updates are made to rosters, please forward them to NYS Medicaid using the first method listed above.
Questions
All questions should be directed to the eMedNY Call Center at (800) 343‑9000.
Reminder: Sign Up for eMedNY Training Webinars
eMedNY offers several online training webinars to providers and their billing staff, which can be accessed via computer and telephone. Valuable provider webinars offered include:
- ePACES for: Dental, Durable Medical Equipment (DME), Free-Standing and Hospital-Based Clinics, Institutional, Physician, Private Duty Nursing, Professional (Real-Time), Health Homes, Nursing Homes, and Transportation
- ePACES Dispensing Validation System (DVS) for DME
- ePACES Dispensing Validation System (DVS) for Rehabilitation Services
- eMedNY Website Review
- Medicaid Eligibility Verification System (MEVS)
- New Provider / New Biller
Webinar registration is fast and easy. To register and view the list of topics, descriptions and available session dates, providers should visit the eMedNY Provider Training web page. Providers are reminded to review the webinar descriptions carefully to identify the webinar(s) appropriate for their specific training needs.
Questions
All questions regarding training webinars should be directed to the eMedNY Call Center at (800) 343‑9000.
Financial Hardship Application and Information
The New York State (NYS) Office of the Medicaid Inspector General (OMIG) has developed and implemented a new process that affords providers the opportunity to apply for relief in the event an OMIG audit may pose a financial hardship to the organization. Providers that have received a Final Audit Report and wish to apply for financial hardship consideration may contact the OMIG Bureau of Collections Management at collections@omig.ny.gov. The Bureau of Collections Management will send providers Financial Hardship Applications and, upon receipt, OMIG will review the applications then make a determination as to appropriate re-payment plans.
Providers must complete the application in its entirety to be eligible for relief. Providers who already are in a repayment agreement with OMIG will be required to complete an application upon their one-year review by OMIG. Sample Financial Hardship Applications are posted on the NYS OMIG Financial Hardship Application Information website.
Questions and Additional Information
Providers that have questions or are seeking additional information on the Financial Hardship process are encouraged to email the Bureau of Collections Management at collections@omig.ny.gov.
Medicaid Consumer Fact Sheets Now Available
Following a recommendation from the Medicaid Redesign Team (MRT) II, the New York State (NYS) Department of Health (DOH) Office of Health Insurance Programs (OHIP) created Medicaid consumer fact sheets focused on chronic health conditions. Each fact sheet provides information regarding how a condition can be prevented or managed, as well as relevant Medicaid benefits that can be used to help members stay healthy. Topics include sickle cell disease, diabetes, high blood pressure, asthma control, HIV-PrEP (Human Immunodeficiency Virus - Pre-Exposure Prophylaxis), and smoking cessation. Fact sheets can be found on the MRT II Policies and Guidance web page and are available in English, Spanish, Traditional Chinese, Russian, Haitian Creole, Bengali, and Korean. The most recently added Sickle Cell Disease fact sheet is also available in Simplified Chinese, Polish, Yiddish, Arabic, and Italian.
NY State of Health: Higher Income New Yorkers May Now Qualify for Financial Assistance to Lower the Cost of Health Coverage
New federal financial assistance is now available through NY State of Health to qualifying, higher-income individuals for the first time. This financial assistance is being implemented as part of the American Rescue Plan Act (ARPA) signed into law on March 11, 2021.
Nearly 120,000 enrollees with income below 400 percent federal poverty level (FPL) are already receiving these enhanced tax credits and nearly 18,000 higher-income enrollees are eligible for these federal tax credits for the first time. Higher-income individuals enrolled outside of NY State of Health and uninsured individuals may also be eligible for enhanced tax credits available through NY State of Health. Before the ARPA, tax credits were not available to higher-income individuals and their families (i.e., those earning more than $51,040 and families of four earning more than $104,800). Through the ARPA, these federal tax credits are available to these individuals and their families when enrolling in a health plan through NY State of Health.
Individuals with low and moderate incomes (i.e., those earning up to $51,040 and families of four earning up to $104,800) who were previously eligible for tax credits are now eligible for higher tax credits. NY State of Health automatically applied higher tax credits without enrollees needing to take any action. Enrollees can make changes to their account by logging into their NY State of Health account, contacting an Enrollment Assistor, and/or calling NY State of Health at (855) 355‑5777.
To allow as many individuals as possible to access these enhanced tax credits, the 2021 Open Enrollment Period has been extended through December 31, 2021. Individuals and families can apply for coverage through the NY State of Health website, by phone at (855) 355‑5777, or by connecting with a free enrollment assistor via the NY State of Health Find a Broker/Navigator" search tool.
Additional Information
To read more about how NY State of Health enrollees' benefit from the ARPA, providers can visit the How NY State of Health Enrollees Benefit from the American Rescue Plan web page.
Medicaid Pharmacy Prior Authorization Programs Update
On May 13, 2021, the New York State (NYS) Medicaid Drug Utilization Review (DUR) Board recommended changes to the Medicaid Pharmacy Prior Authorization (PA) programs. The Commissioner of Health (COH) has reviewed the recommendations of the Board and has approved changes to the Preferred Drug Program (PDP) within the NYS Medicaid fee-for-service (FFS) Pharmacy program.
Effective August 26, 2021, PA requirements will change for some drugs in the following PDP classes:
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
- Antibiotics, Inhaled
- Triglyceride Lowering Agents
- Antimigraine Agents, Other
- Colony Stimulating Factors
- Anti-Inflammatories / Immunomodulators – Ophthalmic
- Fluoroquinolones – Otic
- Antihyperuricemics
- Triglyceride Lowering Agents: To be consistent with current guidelines, the step therapy requirement will be removed from omega-3 ethyl esters and icosapent products.
Additional Information:
- For more detailed information on the DUR Board, visit the NYS DUR web page.
- For up-to-date information on the Medicaid FFS Pharmacy Prior Authorization (PA) programs and for a full listing of drugs subject to the Medicaid FFS Pharmacy programs, refer to the NYS Medicaid FFS Preferred Drug List.
- To obtain a PA, contact the clinical call center at (877) 309‑9493. The clinical call center is available 24 hours per day, seven 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 the PAXpress® web-based pharmacy PA request/response application. To access the PAXpress application, providers can visit the eMedNY home page to select the "eMedNY Tools Center" drop-down tab (visually located on the upper righthand side of the home page), then select the "PAXpress" option.
- Additional information is available at the following web sites:
Change to Dental Clinic Billing Logic in Ambulatory Patient Groups
Effective January 1, 2020, the Ambulatory Patient Group (APG) crosswalk was updated to version 3.15. This update included a change to APG 367-370 Level I - IV Oral Maxillofacial Procedure from Type 23 (Dental Procedure) to Type 2 (Significant Procedure).
| APG | APG Description |
|---|---|
| "367" | Level I Oral and Maxillofacial Procedure |
| "368" | Level II Oral and Maxillofacial Procedure |
| "369" | Level III Oral and Maxillofacial Procedure |
| "370" | Level IV Oral and Maxillofacial Procedure |
Following the January 1, 2020 APG changes, if a provider billed a clinic claim for multiple extractions, only the first line would pay. To receive reimbursement for subsequent lines on the claim, the "XS" modifier must be added to subsequent lines, then the first line will pay 100 percent and the subsequent lines will pay at 75 percent.
Effective January 1, 2020, dental clinic providers are advised to place the "XS" modifier to subsequent repeat dental code lines on the same APG claim for reimbursement of APG 367-370 (Level I – IV Oral Maxillofacial Procedure). Providers may submit previously processed claims for adjustments. Claim adjustments include:
- for a claim submitted for adjustment within 60 days of the date of service:
- submit claim adjustment with Delay Reason (DR) Code "11"
- claim adjustment must be submitted within 60 days of notification of the paid claim, or
- for a claim submitted for adjustment more than 60 days after the date of service:
- submit claim adjustment with DR code "3"
- eMedNY edit 02159 - DR code "3" (authorization delays invalid) will cause the claim to pend for review
- Health Insurance Portability and Accountability Act (HIPPA) reason code "29" (Adjustment Reason Code "29" with no Remittance Remark Code) will be reported on the 835 remittances
- claim status code "718" will be reported when the claim is pended for manual review
- submit supporting documentation from New York State (NYS) Department of Health (DOH) in the form of a letter with the transaction control number (TCN) of the pended electronically submitted claims for claim adjustment past 60 days.
Steps to Submit Claim Adjustments 60 Days After the Date of Service:
- Providers compile all claim TCNs for adjustment.
- Providers contact the NYS DOH Dental Policy Team by email at dentalpolicy@health.ny.gov or by phone at (518) 473‑2160 when all the TCNs have been compiled.
- NYS DOH will review the claims, and if appropriate, forward a letter approving the use of DR code "3".
- Providers electronically submit the claims to be adjusted DR code "3".
- Providers submit the list of TCNs eligible for claim adjustments past 60 days with the letter from NYS DOH approving the use of DR code "3" within 60 days from the claims pending or being submitted to:
New York State Department of Health
Attn: Medical Pended Claims
431B Broadway
Menands, NY 12204-2836
Questions
Questions regarding Medicaid Dental Policy should be directed to the Office of Health Insurance Programs (OHIP), Division of Program Development and (DPDM) by phone at (518) 473‑2160 or by email at dentalpolicy@health.ny.gov.
Coverage of Applied Behavior Analysis
Effective August 1, 2021 for New York State (NYS) Medicaid fee-for-service (FFS) and effective October 1, 2021 for Medicaid Managed Care (MMC) Plans [including mainstream MMC Plans and HIV (Human Immunodeficiency Virus) Special Needs Plans (SNPs)], NYS Medicaid will cover Applied Behavior Analysis (ABA) services when provided by NYS Medicaid enrolled Licensed Behavior Analysts (LBAs), Certified Behavior Analyst Assistants (CBAAs), or other individuals specified under Article 167 of NYS Education Law working under the supervision of LBAs. An LBA can supervise up to six CBAAs at one time.
About ABA Services
ABA is the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior. This includes the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. ABA services, provided by LBAs, CBAAs, or other individuals specified under Article 167 of NYS education law, will be covered for NYS Medicaid FFS members and MMC enrollees under the age of 21 with diagnosies of Autism Spectrum Disorder (ASD) and/or Rett Syndrome, as defined by the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5). Medicaid members must be referred for ABA services by NYS licensed and NYS Medicaid-enrolled physicians (including psychiatrists and developmental/behavioral pediatricians), psychologists, psychiatric nurse practitioners, pediatric nurse practitioners, or physician assistants.
Additional Information:
- Referring providers should follow the criteria for diagnosing ASD found in the DSM-5 and outlined in the NYS Department of Health (DOH) Clinical Practice Guideline on Assessment and Intervention Services for Young Children with ASD.
- LBAs and CBAAs must be enrolled in the NYS Medicaid FFS program to be able to be reimbursed for ABA services rendered to NYS Medicaid FFS members.
- LBAs and CBAAs must be enrolled in the NYS Medicaid FFS program and be credentialed by enrollees' MMC Health Plans to be able to be reimbursed for ABA services rendered to NYS MMC enrollees.
- Article 28 facilities can bill for ABA services using the Ordered Ambulatory Fee Schedule for services provided by affiliated LBAs/CBAAs. LBAs/CBAAs providing ABA services in Article 28 facilities must be enrolled in the NYS Medicaid program.
- LBAs and CBAAs can find Medicaid FFS enrollment requirements on the eMedNY Provider Enrollment web page.
- LBAs and CBAAs may practice in any legally authorized setting. Examples of such settings may include private practice, settings where NYS Medicaid members reside full-time or part-time, clinics, hospitals, residences, and community settings.
- LBAs, CBAAs, and others can find information regarding NYS LBA/CBAA licensure and/or certification requirements by visiting the NYS Education Department Education Law Article 167, Applied Behavior Analysis web page.
FFS Billing Guidance
LBAs enrolled in the NYS Medicaid FFS program can bill the NYS Medicaid FFS program for ABA services rendered using the following Healthcare Common Procedure Coding System (HCPCS) codes:
| HCPCS Codes | Code Description | Fee |
|---|---|---|
| "97151" | Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face to face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan. | $7.25 ($29/hour) |
| "97155" | Adaptive behavior treatment with protocol modification, administered by a physician or other qualified health care professional, which may include simultaneous direction of a technician, face-to-face with one patient, every 15 minutes. | $7.25 ($29/hour) |
LBAs enrolled in the NYS Medicaid FFS program can bill the NYS Medicaid FFS program for ABA services rendered by enrolled CBAAs under their supervision using the following procedure codes:
| HCPCS Codes | Code Description | Fee |
|---|---|---|
| "97152" | Behavior identification-supporting assessment, administered by one technician under the direction of a physician or qualified health care professional, face-to-face with the patient, each 15 minutes. | $7.25 ($29/hour) |
| "97153" | Adaptive behavior treatment by protocol, administered by a technician under the direction of a physician or other qualified healthcare professional, face-to-face with one patient, every 15 minutes. | $7.25 ($29/hour) |
The NYS Medicaid FFS program will reimburse providers for ABA services billed for an initial 60 minutes (four units) per date of service. After the initial 60 minutes of ABA services for a date of service are met, then ABA services, in increments of 15 minutes for the same date of service, can be billed. The ABA fee schedule, ABA Provider Manual, and general Medicaid FFS billing guidance will soon be available on the eMedNY ABA web page.
Questions and Additional Information:
- Medicaid FFS coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP), Division of Program Development and Management (DPDM), by phone at (518) 473‑2160 or by email at FFSMedicaidPolicy@health.ny.gov.
- MMC enrollment, reimbursement, billing and/or documentation requirement questions should be directed to the MMC enrollee's specific MMC Plan. Contact information for each MMC Plan can be found in the eMedNY NYS Medicaid Program Information for All Providers Managed Care Information document.
- FFS billing/claims questions should be directed to the eMedNY Call Center at (800) 343‑9000.
- FFS provider enrollment questions should be directed to eMedNY Provider Enrollment at (800) 343‑9000.
Reminder: Zero-Fill for Third Party Liability Only Necessary During Third-Party Coverage Effective Dates
All Medicaid claims submissions should accurately reflect payments received from all other insurers (Medicare qand/or other available insurance) to allow for the correct calculation of Medicaid reimbursement. The Explanation of Benefits (EOB) and other documentation supporting Medicare and third-party insurance reimbursement amounts must be retained for audit or inspection by the New York State (NYS) Department of Health (DOH), Office of the Medicaid Inspector General (OMIG), the Office of the State Comptroller (OSC) or other state or federal agencies responsible for audit functions.
On June 1, 2021, a new edit (edit 02304) was set to pend for submission of documentation to support zero-fill (no payment from primary insurance) for all professional claims. Providers can refer to the following documents for more information regarding edit 02304:
- The eMedNY Edit 02304 will Pend for Manual Review for all Professional Claims document
- The eMedNY Submission Guidance Fee-for-Service (FFS) Claims with Third Party Liability (Medicare or Other Insurance) document
Third-party insurance eligibility should be checked for each date of service. If the insurance is not active for a date of service, Medicaid claims should not be submitted with zero-fill reimbursement. This may cause delays in claims processing. If during the Medicaid eligibility checking process a known third-party does not appear, please contact the third-party liability unit at TPL@health.ny.gov.
Questions and Additional Information:
- General questions regarding claims submission should be directed to the eMedNY Call Center at (800) 343‑9000.
- Questions regarding specific medical pended claims should be directed to the Bureau of Medical Review, Pended Claims Unit at (800) 342‑3005 (option 3).
- Questions regarding specific dental pended claims should be directed to the Bureau of Dental Review, Pended Claims Unit at (800) 342‑3005 (option 2).
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
Donna Frescatore
Medicaid Director
Office of Health Insurance Programs
