New York State Medicaid Update - August 2022 Volume 38 - Number 9

In this issue …

Compound Coverage Clarification

The New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) programs cover an extensive drug benefit providing access to necessary drugs. Additionally, both programs provide coverage for compounded products that meet the requirements described in the Compound Policy: A Reminder and Clarification article published in the December 2020 issue of the Medicaid Update.

Compounding kits, which are packaged for convenience with pre-measured ingredients, are not covered when billed as an outpatient drug using "01-Not-a-Compound" in field 406-D6. These kits are not approved drugs and are excluded from the program pursuant to the Social Security Acts §1927(k)(2)(A)(i) and §1902(a)(54). When submitting a claim for ingredients in a compound, including those in a kit, pharmacies must:

  • submit a compound code of "02-Compound" in field 406-D6 (Compound Code), and
  • submit a minimum of two National Drug Codes (NDCs) in the Compound Segment, field 489-TE (Compound Product ID).

Payment will only be issued for drugs found on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page.

Providers are encouraged to refer to the Update on Pharmacy Billing for Compound Prescriptions article published in the March 2022 issue of the Medicaid Update for compounded product billing instructions. Reminder: Compounds must be made in accordance with all NYS and federal laws as well as NYS Medicaid policies.

Questions and Additional Information:

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Copayments Waived for Monkeypox Diagnostic Evaluations, Vaccine Administration, and Testing

Effective August 28, 2022, and in accordance with New York State (NYS) Governor Kathy Hochul’s Executive Order No. 20.1 titled Continuing the Declaration of a Statewide Disaster Emergency due to the Ongoing Spread of the Monkeypox Virus in the State of New York, NYS Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans Medicaid Managed Care (MMC) Plans will cover monkeypox vaccine administration, lab testing, and initial diagnostic evaluations without any cost sharing, coinsurance, or copayment liability to Medicaid FFS members or MMC enrollees for the duration of the NYS Monkeypox Disaster Emergency. NYS Medicaid providers are prohibited from collecting cost sharing, coinsurance, or copayments from Medicaid FFS members or MMC enrollees for monkeypox vaccine administration, lab testing, and initial diagnostic evaluations.

NYS Medicaid FFS Billing

Professional claims submitted for monkeypox related testing, evaluation, and vaccine administration should be identified as emergencies by reporting with Emergency Indicator = "Y". Institutional providers [Emergency Departments (EDs), hospital outpatient/Diagnostic and Treatment Centers (D&TCs), and Federally Qualified Health Centers (FQHCs)] should report Type of Admission Code = "1" to indicate an emergency when the purpose of the encounter is related to monkeypox testing, evaluation, and vaccine administration.

Pharmacy claims submitted for monkeypox vaccine administration that do not adjudicate with a zero copayment can be systematically adjusted by utilizing National Council for Prescription Drug Programs (NCPDP) field 461-EU (Prior Authorization Type Code) using a value of "04" = exempt copay. This instruction can be found in the NCPDP D.0 Companion Guide located on the eMedNY "5010/D.0 Transaction Instructions" web page.

Additional NYS Medicaid FFS policy and billing guidance regarding specimen collection, testing, vaccine administration, and treatment for suspected cases of orthopoxvirus/monkeypox virus can be found in the Updated Identification, Specimen Collection, Testing, Vaccine Administration, and Treatment for Suspected Cases of Orthopoxvirus/Monkeypox article published in the July 2022 issue of the Medicaid Update.

Questions and Additional Information:

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Reminder: Pre-Diagnostic Dental Procedure Codes in Dental Clinics Payable Under Ambulatory Patient Groups

As a reminder, the following pre-diagnostic dental procedure codes are payable in dental clinics under the Ambulatory Patient Groups (APGs) payment methodology:

In accordance with §10.27 (Dental Services Provided by Article 28 Clinics Operated by Academic Dental Centers Not Participating in Contractor's Network - Applies to MMC Program Only) of the Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan/Health and Recovery Plan Model Contract, MMC Plans are also required to pay for these services:

  • Consistent with Chapter 697 of Laws of 2003 amending Section 364-j of the Social Services Law, dental services provided by Article 28 clinics operated by academic dental centers may be accessed directly by MMC Enrollees without prior approval and without regard to network participation. The Contractor may require prior approval for orthodontic treatment by academic dental centers.
  • The Contractor will reimburse non-participating Article 28 clinics operated by academic dental centers for covered dental services, including orthodontic services, provided to MMC Enrollees at approved Article 28 Medicaid clinic rates in accordance with the protocols issued by the DOH.

Questions and Additional Information:

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Practitioner Administered Drug Update: New York State Medicaid Fee-for-Service Policy Guidance for SPRAVATO® (Esketamine) Nasal Spray

On May 12, 2022, the New York State (NYS) Medicaid Drug Utilization Review (DUR) Board recommended the below criteria for Spravato® (esketamine) nasal spray under both the Pharmacy and Medical Benefit. Mary T. Bassett, M.D., M.P.H., Commissioner of the NYS Department of Health (DOH), has reviewed and approved the DUR Board recommendations.

Effective August 11, 2022, criteria for Spravato® (esketamine) nasal spray will be as follows:

  • Before initiating Spravato® (esketamine) nasal spray, prescribers must attest that they have obtained a baseline score using a validated clinical assessment tool for depression [e.g., Hamilton Depression Rating Scale (HAMD-17), Quick Inventory of Depressive Symptomatology (QIDS-C16C), Montgomery-Asberg Depression Rating Scale (MADRS)].
  • Trial of at least two oral antidepressants prior to Spravato® (esketamine) nasal spray when used for Treatment Resistant Depression.

After the initiation of Spravato® (esketamine) nasal spray therapy, every six months prescribers must attest that Spravato® (esketamine) nasal spray has resulted in an improvement of depressive symptoms (from baseline) using the same baseline clinical assessment tool for depression (e.g., HAMD17, QIDS-C16C, MADRS).

Fee-for-Service Billing

For NYS Medicaid fee-for-service (FFS), Healthcare Common Procedure Coding Systems (HCPCS) code "S0013" should be used to bill for Spravato® (esketamine) nasal spray. The associated National Drug Code (NDC) must be included on the claim. Detailed Spravato® (esketamine) nasal spray billing guidance can be found in the Pharmacy and Medical Billing Guidance for SPRAVATO® (esketamine) article published in the March 2022 issue of the Medicaid Update.

Practitioners

Practitioners should bill Spravato® (esketamine) nasal spray as a "By Report" item. Documentation of medical necessity that includes the criteria listed above must accompany the claim as well as manufacturer invoice documenting the cost of the drug.

Clinics

Clinics must bill an ordered ambulatory claim for Spravato® (esketamine) nasal spray. The ordered ambulatory claim should be submitted on paper using the Medical Assistance Health Insurance Claim Form (eMedNY 150003 form) and should include the hospital's actual acquisition cost by invoice. Documentation of medical necessity that includes the criteria listed above must accompany the claim. Ordered ambulatory billing guidelines can be found in the eMedNY New York State 150003 Billing Guidelines - Free Standing of Hospital Based Ordered Ambulatory. Clinics should bill a separate Ambulatory Patient Group (APG) claim for patient observation following administration of Spravato® (esketamine) nasal spray.

Medicaid Managed Care

Providers participating in NYS Medicaid Managed Care (MMC) should check with the individual's health plans for billing instructions.

Questions and Additional Information:

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New York State Fee-for-Service and Medicaid Managed Care Coverage of Abortion Services

Abortion has been legal under New York State (NYS) law since 1970. NYS Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans continue to provide coverage for medically necessary abortion services - abortion services both a pregnant person and provider agree are needed - to pregnant people statewide. Additionally, the City of New York has chosen to cover elective abortions for New York City (NYC) Medicaid recipients using only City funds.

MMC enrollees may receive services from any qualified Medicaid provider, inside or outside their health plan, for family planning and reproductive health services. These services include abortion without prior approval from the health plan or primary care provider, as long as the provider accepts NYS Medicaid and offers the needed services. MMC Plans are advised to review Utilization Management criteria to ensure alignment with this policy. Please note: NYS Medicaid will provide payment for birth control on the same day as an abortion service.

The following services, while also covered by NYS Medicaid, are not considered abortion services:

  • treatment for spontaneous abortion (miscarriage),
  • termination of ectopic pregnancy,
  • the use of drugs or devices to prevent implantation of the fertilized ovum, and
  • menstrual extraction.

Questions and Additional Information:

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New York State Medicaid Polio Vaccine Coverage

New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans provide coverage for the inactivated poliovirus vaccine (IPV) and the administration of IPV when administered to Medicaid FFS members and MMC enrollees. The NYS Department of Health (DOH) Division of Epidemiology has issued the HEALTH ADVISORY: Update #2 Regarding Poliovirus in New York State, that includes NYS-specific vaccine recommendations to alert clinical staff in Epidemiology/Infection Control, Emergency Departments (EDs), Infectious Disease, Neurology, Radiology, Nursing, Internal Medicine, Pediatrics, Family Medicine, Intensive Care, Pharmacy, Laboratory Services, and all patient care areas.

Vaccine Billing Guidance

The NYS Medicaid program provides reimbursement to NYS Medicaid providers for IPV vaccine administration and the acquisition cost (per invoice) of the IPV vaccine by submitting an ordered ambulatory claim as follows:

Code Code Description
90713 Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use

For Medicaid FFS members 19 years of age and older, providers must bill the Current Procedural Terminology (CPT) code "90471" for vaccine administration and the CPT code of the IPV vaccine administered at acquisition cost. Providers will be reimbursed their acquisition cost for the IPV vaccine and $13.23 for the administration of the vaccine. Providers should not seek reimbursement for the IPV vaccine if they have obtained the vaccine from State or other government agency at no cost. If obtained at no cost, providers should append the "FB" modifier (indicating an adult vaccine supplied at no cost) to the CPT code for the IPV vaccine.

For Medicaid FFS members under 19 years of age, providers must bill the CPT code "90460" for vaccine administration and the CPT code of the IPV vaccine administered appended with the "SL" modifier (indicating a child vaccine supplied at no cost). Providers will be reimbursed $17.85 for the administration of the IPV vaccine.

Provider Billing Instructions:

  • Article 28 clinics that administer the IPV vaccine should bill ordered ambulatory and follow the billing guidelines listed above.
  • Private practitioners who provide the IPV vaccine [i.e., physicians, nurse practitioners (NPs), and midwives (MWs)] may bill a professional claim for the vaccine and administration using the billing guidelines listed above.
  • School Based Health Centers (SBHCs) should bill for the vaccine and administration as an ordered ambulatory service using the above billing instructions and append the "HA" modifier to both the CPT code for the IPV vaccine (in addition to the appropriate "FB" or "SL" modifier) and CPT code for vaccine administration.
  • Federally Qualified Health Centers (FQHCs), including SBHCs designated as FQHCs (SBHCs/FQHCs), may submit a Prospective Payment System (PPS) threshold clinic claim if the vaccine is administered as part of an encounter in which a significant procedure and/or medical visit accompanies the vaccination. If IPV vaccine administration is provided as a stand-alone service, the FQHC should seek reimbursement for the IPV vaccine and administration as an ordered ambulatory service and follow the billing guidelines listed above.
  • SBHC/FQHCs providing IPV vaccine administration as a stand-alone service should follow the SBHC ordered ambulatory billing instructions listed above.

Vaccine Counseling

As a reminder, providers offering vaccine counseling services to members under 19 years of age should follow the coverage and reimbursement policy outlined in the Early and Periodic Screening, Diagnostic, and Treatment Program Childhood Vaccine Counseling Coverage Benefit article published in the March 2022 issue of the Medicaid Update.

Medicaid Managed Care Providers

NYS MMC providers must contact the Medicaid MMC enrollee's individual plan for specific billing instructions for vaccines, vaccine administration and vaccine counseling services.

Questions and Additional Information:

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Office of the Medicaid Inspector General to Issue Audit Reports Related to Third-Party Health Insurance Requirements for Fee-for-Service and Managed Care

The Office of the Medicaid Inspector General (OMIG) will issue draft and final audit reports to providers in the coming months where a response to the initial third-party health insurance (TPHI) review, originally issued by OMIG contractor, Gainwell Technologies, formerly known as Health Management Systems, Inc. (HMS), was not received or payment was not made in-full.

New York State (NYS) Medicaid is the payor of last resort, and all other health care coverage should be exhausted before NYS Medicaid is billed. The initial review required providers to seek reimbursement from Medicare, and all other liable third parties, for services rendered to NYS Medicaid beneficiaries. In accordance with this review and pursuant to Federal Regulation 42 Code of Federal Regulations (CFR) 433, Subpart D as well as NYS regulation, Title 18 of the New York Codes Rules and Regulation (NYCRR), Part 540, §540.6(e) and Part 542, provider cooperation in pursuing these recoveries is required.

Questions

All questions should be directed to OMIG by email at ThirdP@omig.ny.gov or by telephone at (518) 408-5791.

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Deleting Facility-Practitioner Affiliations in eMedNY

The New York State (NYS) Medicaid program requires enrolled facilities to report and maintain, in eMedNY, certain information about practitioners who are affiliated with the facility and who, therefore, would be included as a furnishing, ordering, prescribing, referring or attending (OPRA) provider on claims submitted by the facility. This includes updating records in eMedNY when a practitioner is no longer affiliated with the facility.

Effective immediately, there is no longer an option to delete an affiliated practitioner when the affiliation ends. Instead, the facility must now disaffiliate the practitioner by end-dating the affiliation. All updates to a facility's affiliations must be made on the eMedNY website.

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Attention: Renew Certification Statements Annually

The Certification Statement for Provider Billing Medicaid form (eMedNY-490601), is required in order to submit electronic and paper claims. Providers utilizing multiple Electronic/Paper Transmitter Identification Numbers (ETINs) for billing must submit a certification for each ETIN. In addition, the Certification Statement for Provider Billing Medicaid form must be renewed on an annual basis. Failure to renew will result in the inability to submit claims and receive payments from New York State (NYS) Medicaid.

For provider convenience, eMedNY will send two certification renewal notices, each with a pre-printed certification form. The first notice will be sent 45 days prior to the expiration of the provider's current certification. If the provider's renewed certification is not received within 30 days of the expiration, a second notice will be sent. It is only necessary to return one of these renewed certifications. It is recommended that providers maintain the correct correspondence address with eMedNY to receive certification renewal notices in a timely manner. The renewal forms are pre-printed with the ETIN, certification date, provider name and provider Identification Number (ID). Providers are required to sign and notarize one of the forms and return it to the address provided. Providers should not alter the pre-printed information.

Questions

All questions should be directed to the eMedNY Call Center at (800) 343-9000.

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Reminder: Sign Up for eMedNY Training Webinars

eMedNY offers various online training webinars to providers and their billing staff, which can be accessed via computer and telephone. No travel is necessary. Valuable provider webinars offered include:

  • ePACES for: Dental, Dispensing Validation System (DVS) Durable Medical Equipment (DME), Home Health, Institutional, Private Duty Nursing, Professional (Real-Time), and Transportation
  • eMedNY Website Review
  • Medicaid Eligibility Verification System (MEVS)
  • New Provider / New Biller
  • Provider Enrollment Portal - Practitioner

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.

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

Kathy Hochul
Governor
State of New York

Mary T. Bassett, M.D., M.P.H.
Commissioner
New York State Department of Health

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs