New York State Medicaid Update - September 2023 Volume 39 - Number 14

In this issue …

Reminder: Unlicensed Interns, Residents and Foreign Physicians in Training Programs as Prescribers

Unlicensed interns, residents and foreign physicians in training programs are eligible to prescribe for New York State (NYS) Medicaid members in NYRx, the Medicaid Pharmacy program, without enrollment as a NYS Medicaid provider. In accordance with NYS Education Law, unlicensed interns, residents, and foreign physicians participating in training programs, are authorized to prescribe. NYS Medicaid recognizes the authority under which these unlicensed providers may prescribe; however, per federal requirements these physicians are not eligible for enrollment into the NYS Medicaid program without a license.

Pharmacies billing for prescriptions written by unlicensed interns, residents and foreign physicians in training programs will need to utilize point of service (POS) overrides for claim submission. NYRx has billing guidance exceptions in place to be utilized at the pharmacy POS for the enrollment requirement. These overrides will allow prescriptions written by unlicensed interns, residents and foreign physicians participating in training programs to bypass enrollment editing.

Providers should update their information on the National Plan and Provider Enumeration System (NPPES) website, since this website can be used to validate a providers taxonomy code and license information. It is specifically important that students in teaching hospitals register and select taxonomy 390200000X - Student in an Organized Health Care Education/Training Program. It is also important to change their status once they become licensed providers and enroll in the NYS Medicaid program.

Pharmacy Billing Guidance Exceptions for Non-Enrolled Prescribers in Medicaid
The NYS Medicaid program requires enrollment of all licensed prescribers who serve Medicaid and Medicaid Managed Care (MMC) members, including prescribing practitioners, as identified on pharmacy prescriptions, per the Centers for Medicare and Medicaid Services (CMS) and federal regulations.

There are two exceptions to the provider enrollment requirement:

  1. Unlicensed interns, residents, and foreign physicians in training programs.
  2. Out-of-state (OOS) licensed prescribers that are treating NYS Medicaid members for a single instance of emergency care within 180 days. These prescribers must be either enrolled in Medicare with an "approved" status or enrolled in a Medicaid plan in their own state.

Pharmacies will receive a reject code/POS rejection message for prescriptions written by a non-enrolled prescriber. Pharmacies will then utilize the override guidance provided below for the above exceptions.

Documentation

As previously stated in the Pharmacy Billing Guidance Exceptions for Non-Enrolled Prescribers article published in the March 2021 issue of the Medicaid Update, and the Reminder: Pharmacy Billing Guidance Exceptions for Non-Enrolled Prescribers article published in the June 2022 issue of the Medicaid Update, with regard to any prescriptions issued to a NYS Medicaid member by any unlicensed prescriber, records should be contemporaneously created and maintained supporting the issuance of such prescription. This requirement applies to all residents, interns and foreign physicians who participate in any medical training program. The documentation must include the National Provider Identifier (NPI) of the prescriber and NYS Medicaid provider who is responsible for supervising the prescribing unlicensed resident, intern or foreign physician in a training program.

All records related to the issuance of a prescription by non-enrolled prescribers are subject to production upon request by NYS, including but not limited to, the NYS Department of Health (DOH), Office of the Medicaid Inspector General (OMIG), Office of the State Comptroller (OSC) and the NYS Office of the Attorney General.

Pharmacy claims will initially reject for National Council for Prescription Drug Programs (NCPDP) Reject code "889" - Prescriber Not Enrolled in State Medicaid Program.

  • to override above rejection for the unlicensed resident, intern or foreign physician in a training program or OOS prescription situations described above:
    • In Field 439-E4 (Reason for Service Code): enter "PN" (Prescriber Consultation)
    • In Field 441-E6 (Result of Service Code): enter applicable value ("1A", "1B", "1C", "1D", "1E", "1F", "1G", "1H", "1J", "1K", "2A", "2B", "3A", "3B", "3C", "3D", "3E", "3F", "3G", "3H", "3J", "3K", "3M", "3N", "4A")
    • In Field 420-DK (Submission Clarification Code): enter "02" (Other Override)

Questions and Additional Information:

  • NYRx claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • NYRx Pharmacy policy questions should be directed to the NYS Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.
  • Providers should refer to the Medicaid Provider Enrollment Compendium (MPEC) document for regulatory guidance and clarifications regarding how state Medicaid agencies are expected to comply with the federal regulations.

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Identification of Hospice Recipients to Eliminate Duplicative Payment for Services Included Under the Hospice Benefit

New York State (NYS) Medicaid requires documentation of hospice participation of the recipient to prevent duplication of services that are included in the hospice rates. When a NYS Medicaid member is in receipt of hospice services, local Department of Social Services' (LDSS'), Medicaid Managed Care Organizations (MMCOs) [including mainstream MMC Plans, Human Immunodeficiency Virus-Special Needs Plans (HIV-SNPs), Health and Recovery Plans (HARPs), Managed Long Term Care Partial Capitation (MLTCP) and Medicaid Advantage Plus (MAP) Plans] and their providers, are responsible for coordinating services and financial obligations with the hospice provider. Particular attention should be paid to personal care services/consumer directed personal assistance services (PCS/CDPAS) and durable medical equipment (DME) and supplies.

The three mechanisms shown below have been established to ensure the proper coordination of services: for NYS Medicaid members receiving hospice services:

  • Hospice providers must complete the Entity/Facility Notification of Hospice Non-Covered Items, Services, and Drugs form (DOH-5778), located in the November 2022, 2022 Home Care Agency Dear Administrator Letter (DAL) titled DHCBS 22-15;
  • LDSS', MMCO or hospice providers must use the Recipient Restriction/Exception (RR/E) code C2, located in the Electronic Provider Assisted Claim Entry System (ePACES) section of eMedNY, to identify recipients who are enrolled in the hospice program; and
  • the NYS Medicaid fee-for-service (FFS) program added a billing edit incorporating the RR/E code C2 to prevent the payment of certain services that should not occur while a NYS Medicaid member is under hospice care.

Purpose of the DOH-5778 Form

To assist in the coordination of services, NYS Department of Health (DOH) issued the DHCBS 22-15, instructing hospice providers to complete the DOH-5778 form and to share it with other healthcare providers, LDSS', and MMCOs from which the hospice recipient may seek items, services, or drugs. When a non-hospice provider offers services to a recipient in hospice, the non-hospice provider should request and consult the DOH-5778 form to ascertain if non-allowable duplication of services would occur or if the service or supply is for a condition other than the hospice diagnosis. For additional information regarding hospice services, providers should refer to the eMedNY "Hospice Manual" web page.

Purpose of RR/E Code C2

Verification of eligibility through the ePACES section of eMedNY will indicate a RR/E code, C2-HOSPICE-MM, that identifies NYS Medicaid members who have opted to enroll in the hospice program.

For dual-eligible members (in receipt of both Medicare and NYS Medicaid) who have enrolled in the hospice program, NYS DOH will use a file supplied by Medicare to load the RR/E code C2 in eMedNY on the members NYS Medicaid record.

For non-dual NYS Medicaid members, RR/E code C2 will be manually added to the record of the NYS Medicaid member by NYS DOH upon receipt of the hospicebilling@health.ny.gov, from an LDSS, MMCO, or hospice provider. If a NYS Medicaid member in receipt of hospice services elects to discontinue hospice services, RR/E code C2 must be manually closed by NYS DOH.

Due to limitations of data received from Medicare, NYS Medicaid members no longer in receipt of hospice care will need to have RR/E code C2 manually closed with a manually entered end-date. Changes to a members RR/E code C2 status can be made by emailing the completed Hospice Care Recipient Restriction/Exception (RR/E) Code Update Form to hospicebilling@health.ny.gov.

Billing Edit for Rate Codes Not Covered in Conjunction with Hospice

A new edit ("02328") has been implemented in the eMedNY system for NYS Medicaid fee-for-service (FFS) claims to recognize RR/E code C2 and prevent payment for the services/programs shown below, which are not covered while enrolled in hospice.

The following codes are not payable with RR/E code C2 present on the record of the NYS Medicaid member. If a NYS Medicaid member has RR/E code C2 on any service date submitted during the active hospice enrollment and one of these rate codes is billed, the claim will be denied for the "02328" edit.

Service/Program Rate Code
Adult Day Care 2800 through 2808 and 3800 through 3809.
Certified Home Health Agency 1604, 2499 through 2500, 2552 through 2563, 2610, 2617 through 2620, 2640, 2650, 2662, 2666 through 2669, 2677 through 2679, 2687, 2841 through 2842, 2844 through 2845, 2847, 2878, 3876 through 3880, and 3967.

Private Duty Nursing Claims

If a NYS Medicaid member has a RR/E code C2 on any service date submitted during the active hospice enrollment and the claim derives Provider Category of Service (COS) "0521", "0522", "0523" and "0524", the claim will be denied for the new edit ("02328").

RR/E code C2 will also prevent enrollment into MMCO. Apart from Program of All-Inclusive Care for the Elderly (PACE) Plans, a NYS Medicaid member already enrolled in a PACE Plan may enroll in hospice and remain in their plan. PACE has an alternative end of life program, so hospice participation is not allowed.

Questions:

Questions or request for assistance should be directed to hospicebilling@health.ny.gov.

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Importance of Medical Coding on Practitioner Drug Claims

NYRx, the Medicaid Pharmacy program, utilizes a sophisticated clinical editing system that leverages pharmacy and medical claim data [from both Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC)] to auto-approve claims that meet prior authorization (PA) criteria as described in the NYRx, the Medicaid Pharmacy Program Preferred Drug List. As a result, if the correct diagnosis, drug, or procedure code is present in the claim history of the NYS Medicaid member/MMC enrollee, an approved PA can be generated without prescriber involvement. This decreases the need for the prescriber to obtain a PA.

Providers can further improve this process and decrease the need to obtain PA.

Prescribers can:
  • timely submit medical claims to Medicaid FFS and MMC Plans;
  • ensure the accuracy of the claim information being transmitted;
  • ensure code claims with all appropriate diagnosis, per the International Classification of Diseases (ICD), and procedure codes that are most closely associated with the services provided:
    • up to 12 codes on professional claims;
    • up to 25 codes on institutional claims; and
    • up to five codes on prescriptions claims.
Pharmacies can:
  • submit ICD codes to NYRx, if present on a prescription:
    • up to five codes can be submitted per the pharmacy transaction;
    • claims should be formatted without the decimal included;
    • ICD codes will be collected via the transaction and used for future claim approvals (the ICD codes cannot be leveraged on the same day of service).

Questions:

  • Policy questions should be directed to NYRx@health.ny.gov.
  • Claims processing questions should be directed to eMedNY Call Center at (800) 343-9000.

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New York State Medicaid Coverage of Respiratory Syncytial Virus Monoclonal Antibody (Nirsevimab) for Infants

New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC), including mainstream MMC Plans, and Human Immunodeficiency Virus-Special Needs Plans (HIV-SNPs), are providing coverage for the administration of nirsevimab, a monoclonal antibody preparation for the prevention of Respiratory Syncytial Virus (RSV), as recommended by the Advisory Committee on Immunization Practices (ACIP) of the Center of Disease Control and Prevention (CDC). Additional information on the ACIP recommendations can be found on the CDC aVFC-ACIP Vaccine Resolutions" web page.

Nirsevimab has also been ACIP recommended for inclusion in the Vaccines for Children (VFC) program. NYS Medicaid provides reimbursement for the administration of VFC vaccines provided at no cost to providers. As such, NYS Medicaid will not reimburse the cost of nirsevimab. Effective October 1, 2023, NYS will open ordering of nirsevimab through the VFC program. Providers can refer to the Advisory Committee on Immunization Practices - Vaccines for Children Program - Vaccines to Prevent Respiratory Syncytial Virus (RSV) document, for additional information.

Medicaid FFS Billing Instructions

Current Procedural Terminology (CPT) codes provided in the table below have been added to the Physician, Nurse Practitioner, Midwife and Ordered Ambulatory Fee Schedules for NYS Medicaid-enrolled and qualified providers, as well as outpatient clinic billing. Outpatient clinics should bill using the NYS Medicaid Ordered Ambulatory Services Fee Schedule. Providers must bill using the applicable CPT code below for the dose administered appended with modifier “SL” (indicating a VFC product supplied at no cost) and CPT code “90460” to be reimbursed $25.10 for the administration of nirsevimab.

CPT Code Code Description
90380 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use.
90381 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use.

MMC Billing Instructions

For NYS Medicaid members enrolled in an MMC Plan, providers must contact the specific MMC Plan of the enrollee for billing instructions. MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.

Questions and Additional Information:

  • FFS coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management (DPDM) by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
  • FFS billing/claim questions should be directed to the eMedNY Call Center at (800) 343-9000.

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Pharmacy Coverage Expanded to Include Over the Counter Naloxone

New York State (NYS) Medicaid now covers naloxone over-the-counter (OTC) when either prescribed by the practitioner of a NYS Medicaid member or dispensed to a NYS Medicaid member in compliance with the State-issued naloxone standing order. Information regarding the naloxone standing order can be found on the NYS Department of Health (DOH) "Standing Order for Naloxone in Pharmacies" web page. A pharmacy, in compliance with NYS law and regulations, and NYS Medicaid policy, may submit a claim and dispense naloxone OTC pursuant to a fiscal order or via a standing order. When dispensing naloxone OTC via a standing order all the following must apply:

  • a NYS Medicaid member had specifically requested the item on the date of service; or
  • a pharmacist initiated dispensing per a determination of need/risk on date of service for a NYS Medicaid member; and
  • a pharmacy submits one course of therapy (two doses) with no refills; and
  • the drug item(s) are dispensed according to:
    • Food and Drug Administration (FDA) guidelines;
    • NYS laws, rules, and regulations; and
    • NYS Medicaid Policy.

Billing a Standing Order:

  1. Enter a value of "5" in the Prescription Origin Code field 419-DJ to indicate pharmacy dispensing;
  2. Enter a value of "99999999" in the Serial Number field 454-EK;
  3. Submit the prescriber identification field 411-DB with the NPI of the authorizer of the standing order;
  4. Maintain documentation that includes:
    1. NYS Medicaid member consent, and
    2. modality of the NYS Medicaid member request (in pharmacy or by telephone), or
    3. pharmacist determination of need/risk, and
    4. date and time of either:
      1. the request of the NYS Medicaid member; or
      2. the pharmacist need/risk evaluation.

Questions and Additional Information:

  • NYRx claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • NYRx Pharmacy coverage and policy questions should be directed to the NYS Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.
  • Naloxone standing order specific questions should be directed to naloxonepharmacy@health.ny.gov.

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Community Health Worker Services for Pregnant and Postpartum People

Effective October 1, 2023, for New York State (NYS) Medicaid fee-for-service (FFS), and for NYS Medicaid Managed Care (MMC) Plans [inclusive of Mainstream MMC Plans, Human Immunodeficiency Virus-Special Needs Plans (HIV-SNPs), as well as Health and Recovery Plans (HARPs)], NYS Medicaid will reimburse Community Health Worker (CHW) services for pregnant and postpartum populations. NYS Medicaid members are eligible for CHW services during pregnancy and up to 12 months after the end of pregnancy, regardless of how the pregnancy ends.

A CHW is a public health worker, not otherwise recognized as a licensed or certified NYS Medicaid provider type, that reflects the community served through lived experience that may include, but is not limited, to pregnancy and birth, housing status, mental health conditions, substance use or other chronic conditions, shared race, ethnicity, language, and/or sexual orientation, or community of residence. The CHW functions as a liaison between healthcare systems, social services, and community-based organizations to improve overall access to services and resources and to facilitate improved health outcomes for the populations served.

Covered CHW services include health advocacy, health education, and health navigation supports aimed at improving health outcomes, overall health literacy, and preventing the development of adverse health conditions, injury, illness, or the progression thereof. Individual or group based CHW services are defined as direct interaction with the eligible NYS Medicaid member or group of members. The service must be recommended by a physician or other health care practitioner.

At this time, CHWs will not enroll in or bill NYS Medicaid directly. CHW services are billed by the supervising NYS Medicaid-enrolled:

  • Clinic
  • Hospital Outpatient Department (OPDs)
  • Physician
  • Midwife
  • Nurse Practitioner (NP)
  • Psychologist
  • Licensed Clinical Social Worker (LCSW)
  • Licensed Mental Health Counselor (LMHC)
  • Licensed Marriage Family Therapist (LMFT)

Billing NYS Medicaid FFS

  • Article 28 freestanding clinics and hospital OPDs can bill for CHW services using the codes below on Ambulatory Patient Groups (APG) claim.
  • Federally Qualified Health Centers (FQHCs) may bill for CHW services only if the FQHC has elected to be reimbursed under APGs when the CHW service is provided in conjunction with a threshold visit with a licensed health care provider.
  • When billing for CHW services, modifiers U1 and U3 must be included consecutively, in this order, on the claim line when seeking reimbursement for CPT codes "98960", "98961" or "98962".

Community Health Worker Services Common Procedure Coding System Procedure Codes

CPT Code/Modifier Code Description Annual Allowance Per NYS Medicaid Member Reimbursement Rate
98960/U1, U3 Self-management education and training face-to-face using a standardized curriculum for an individual NYS Medicaid member, each 30 minutes. 12 units total (30 minutes = 1 unit*) $35.00
98961/U1, U3 Self-management education and training face-to-face using a standardized curriculum for two to four NYS Medicaid members, each 30 minutes. $16.45
98962/U1, U3 Self-management education and training face-to-face using a standardized curriculum for five to eight NYS Medicaid members, each 30 minutes. $12.25

*One unit must be a minimum of 16 minutes with a maximum of 37 minutes.

MMC Billing Instructions

For NYS Medicaid members enrolled in MMC, providers must contact the MMC Plan of the enrollee for billing instructions. MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.

Questions and Additional Information:

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Pharmacy Program Integrity Spotlight

The Pharmacy Program Integrity Spotlight is a monthly series intended to share program integrity information with providers and reinforce pharmacy program requirements.

Pharmacy Credential Verification Review

The Office of the Medicaid Inspector General (OMIG), an independent office within the New York State (NYS) Department of Health (DOH), conducts audits and reviews NYS Medicaid providers of reimbursable services, equipment, and supplies.

One type of review is the pharmacy credential verification review (CVR). The pharmacy CVR is a comprehensive review of an enrolled pharmacy provider compliance with New York State (NYS) Medicaid pharmacy program requirements and pharmacy laws, rules, and regulations pertaining to the practice of pharmacy and operation of pharmacy establishments. Pharmacy CVRs are conducted periodically and unannounced. The pharmacy CVR consists of an interview, a pharmacy inspection, and a records review. It is the goal of OMIG to minimize disruption to pharmacy operations when conducting a pharmacy CVR. Areas of focus include, but are not limited to:

  • Pharmacy ownership - Providers must notify NYS DOH of changes in ownership within 15 days of the ownership change.
  • Pharmacy supervision - Supervising pharmacists must be enrolled as a NYS Medicaid provider and a NYS registered pharmacist must be on site at all times while the pharmacy is open.
  • Pharmacy inventory - All drugs held for sale must be from legitimate sources. Expired, misbranded, and/or adulterated drug products must be removed from active drug stock and returned through an authorized reverse distributor. 340b drugs must be stored separately from general drug stock and only used for 340b program recipients. All drugs should be stored according to storage requirements on the package label.
  • Pharmacy records - Prescription records and daily dispensing logs must be readily retrievable. The daily dispensing logs must bear the initials of the dispensing pharmacist(s). All records supporting NYS Medicaid payments must be maintained for six years.
    • Please note: Enrolled pharmacy providers continue to be subject to any additional record retention requirements outlined in their prior or current contracts with Medicaid Managed Care (MMC) or Managed Long Term Care (MLTC) or Subcontractors thereof, including retention for 10 years or more as delineated therein. Other reminders can be found in the Pharmacy Program Integrity Spotlight article published in the June 2023 issue of the Medicaid Update..
  • Prescription claiming - Auto-refilling is not allowed. Claims for prescriptions billed to NYS Medicaid that are not delivered to or picked up by the recipient within 14 days must be reversed and drug product returned to stock or returned through an authorized reverse distributor.

The best way pharmacy providers can prepare for a pharmacy CVR is by ensuring they remain knowledgeable of current and applicable NYS Medicaid program requirements, evaluating operational procedures regularly for compliance with those requirements, and correcting areas of non-compliance in a timely manner. For up-to-date pharmacy policy and billing communications or to sign up for the eMedNY LISTSERV, providers should visit the eMedNY "Pharmacy Manual" web page. eMedNY "Pharmacy Manual" web page. NYS Medicaid overpayments identified through the internal review of the provider must be reported and returned to the OMIG Self-Disclosure Program. Additional information regarding the OMIG Self-Disclosure Program can be found on the OMIG "Self-Disclosure" web page.

Questions:

Questions regarding the pharmacy CVR process should be directed to PharmacyProgramIntegrityUnit@omig.ny.gov.

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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

James McDonald, M.D., M.P.H.
Commissioner
New York State Department of Health

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs