New York State Medicaid Update - July 2024 Volume 40 - Number 7

In this issue …

Update and Reminder: Medicaid Policy Loss of Records Due to Unforeseen Event

As stated in Title 18 of the New York Codes Rules and Regulations (NYCRR) §504.3, "by enrolling in the Medicaid program, the provider agrees: (a) to prepare and to maintain contemporaneous records demonstrating its right to receive payment under the medical assistance program and to keep for a period of six years from the date the care, services or supplies were furnished, all records necessary to disclose the nature and extent of services furnished and all information regarding claims for payment submitted by, or on behalf of, the provider and to furnish such records and information, upon request, to the department, the Secretary of the United States Department of Health and Human Services, the Deputy Attorney General for Medicaid Fraud Control and the New York State Department of Health; …(i) to comply with the rules, regulations and official directives of the department."

Providers whose records have been damaged, lost, or destroyed are required to report that information as soon as practicable, but no later than thirty calendar days after discovery, to the New York State (NYS) Office of the Medicaid Inspector General (OMIG) Self-Disclosure Unit. Failure to report such incidents may result in a determination of overpayment, penalties, and/or sanctions. Please note: Loss/destruction/corruption/inaccessibility of electronic records due to data corruption, theft, change in data vendor or other issues must also be included in this reporting requirement to ensure compliance with regulatory standards.

Providers are required to maintain reasonable and appropriate administrative, technical, and physical safeguards for protecting electronic health records, and should have a secure backup system in place to allow recovery of documentation destroyed or lost due to such events or any other cause. This guidance supersedes communication shared in the Update and Reminder: Medicaid Policy Loss of Records Due to Unforeseen Event article published in the November 2023 issue of the Medicaid Update.

How to Self-Report Damaged, Lost or Destroyed Records

To self-report, providers must complete the Statement of Damaged, Lost or Destroyed Records form, located on the NYS OMIG Self-Disclosure "Lost, Damaged or Destroyed Records Reporting" web page. The NYS OMIG Self-Disclosure "Lost, Damaged or Destroyed Records Reporting" web page, additionally offers the NYS OMIG Hightail Secure Uplink website, for form submission and all required supporting documentation.

When self-reporting, providers must include the following information:

  • their provider NYS Medicaid enrollment information including their Medicaid Management Information System (MMIS) number and National Provider Identifier (NPI) number;
  • their provider contact information; and
  • a statement fully explaining the loss, damage or destruction of records including:
    • a complete and full description of the loss/destruction that occurred including when it occurred, and how and when it was discovered;
    • a listing of the documents affected including document type, relevant recipients, and dates of service;
    • names and titles of individuals who discovered and documented the loss/destruction;
    • a description of all actions taken to prevent recurrence of the event that caused the loss/destruction; and
    • a complete listing and copies of any reports of the loss/destruction to insurance companies, police agencies, state agencies, or federal organizations including contact information for those entities.

Providers must also notify any other State or local agencies of their loss, damage or destruction as required by those agencies. Please note: In the event of a NYS Medicaid audit or investigation where records are requested and were not maintained as required by Title 18 of the NYCRR §504.3, NYS OMIG will review if the Statement of Damaged, Lost or Destroyed Records form was submitted and in those situations where it was, determine on a case-by-case basis whether there are mitigating circumstances for missing or damaged documents.

Additional Information:

  • For assistance with submitting the Statement of Damaged, Lost or Destroyed Records form, providers should contact the NYS OMIG Self Disclosure Unit by email at selfdisclosures@omig.ny.gov.
  • Please note: In addition to Title 18 of the NYCRR §504.3(a), providers may be subject to other record retention requirements [e.g., contractual requirements under the Medicaid Managed Care (MMC) program].

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Dental Panoramic and Periapical Radiographs Reimbursement Update for Medicaid Fee-for-Service Members and Medicaid Managed Care Enrollees

New York State (NYS) Medicaid currently reimburses for panoramic radiographs every three years if clinically indicated under Current Dental Terminology (CDT) code "D0330". This benefit is for use in routine caries determination, diagnosis of periapical or periodontal pathology only when supplemented by other necessary radiographic intraoral images (bitewing and/or periapical), completely edentulous cases, diagnosis of impacted teeth, oral surgery treatment planning or diagnosis of children with mixed dentition. Postoperative panoramic images are reimbursable for post-surgical evaluation of fractures, dislocations, orthognathic surgery, osteomyelitis, or removal of unusually large and/or complex cysts or neoplasms.

Effective August 1, 2024, for Medicaid fee-for-service (FFS) members, and October 1, 2024, for Medicaid Managed Care (MMC) enrollees, the treating dental specialist can be reimbursed for a panoramic radiograph (panorex) even if one has been taken within three years, to render the necessary dental care when the panorex provided from the referring dentist is not diagnostic or cannot be obtained. Claims for payment should be accompanied by a narrative explaining the patient-specific medical necessity.

NYS Medicaid policy currently restricts reimbursement for CDT code "D0220": "Intraoral periapical first radiographic image when taken with other types of images on the same date of service."

Effective August 1, 2024, for Medicaid FFS members, and effective October 1, 2024, for MMC enrollees:

  • CDT code "D0220" to be billed for the first periapical image and may be used in conjunction with other types of intraoral radiographs taken on the same date of service.
  • CDT code "D0230" to be billed for each additional radiographic image.
  • The total fee for all intraoral radiographic images, including the first periapical image, may not exceed the total fee allowed for a complete intraoral series.
  • The frequency limit for periapical x-rays will be updated from three times in six months to six times in 12 months.

Questions and Additional Information:

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New York State Medicaid Evidence Based Benefit Review Advisory Committee Update

On July 25, 2024, the New York State (NYS) Medicaid Evidence Based Benefit Review Advisory Committee (EBBRAC) reconvened after being on hiatus for several years. EBBRAC was established in 2015 pursuant to Chapter 57, Part B, §46-a of the Laws of 2015, as Social Services (SOS) Law §365-d, to make recommendations to the NYS Department of Health (DOH) regarding NYS Medicaid coverage of health technologies and services. During the July meeting, EBBRAC reviewed NYS Medicaid coverage of epithelium off collagen cross-linking (CXL) for patients diagnosed with progressive keratoconus and who are 14 years of age and older.

EBBRAC is chaired by Dr. Douglas Fish, Deputy Commissioner of Office of Primary Care and Health Systems Management and Chief Medical Officer of the Office of Health Insurance Programs, and Dr. Nathan Graber, Pediatric Medical Director, as his designee. Committee membership and vacancy information is available on the NYS DOH Medicaid "Evidence Based Benefit Review Advisory Committee (EBBRAC)" web page. EBBRAC will convene two to three times per year and will review evidence on selected topics as presented by the NYSDOH contractor, the Center for Evidence-based Policy (CEbP) at the Oregon Health and Science University (OHSU). Meeting agendas, notes and archived webcasts are available on the NYS DOH Medicaid "Evidence Based Benefit Review Advisory Committee (EBBRAC)" web page. The next meeting is planned for Fall 2024. At least 45 days prior to each meeting, a meeting agenda and call for public comments will be posted to the NYS DOH Medicaid "Evidence Based Benefit Review Advisory Committee (EBBRAC)" web page.

For further information on EBBRAC composition and recommendations, providers should visit the NYS DOH Medicaid "Evidence Based Benefit Review Advisory Committee (EBBRAC)" web page, or email EBBRAC@health.ny.gov.

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NYRx, the New York State Medicaid Pharmacy Prior Authorization Programs Update

On May 16, 2024, the New York State (NYS) Medicaid Drug Utilization Review Board (DURB) recommended changes to NYRx, the Medicaid Pharmacy Prior Authorization (PA) programs. The Commissioner of Health (COH) has reviewed the DURB recommendations and has approved changes to the NYRx Preferred Drug Program (PDP).

Effective August 1, 2024, PA requirements will change for some drugs in the following PDP classes:

  • Movement Disorder Agents
  • Multiple Sclerosis Agents
  • Antifungals - Topical
  • Immunomodulators - Topical
  • Anabolic Steroids - Topical
  • Growth Hormones
  • Proton Pump Inhibitors (PPIs)
  • Hemophilia Agents - Factor VIII
  • Immunomodulators - Systemic
  • Anti-inflammatory/Immunomodulators - Ophthalmic
  • Non-Steroidal Anti-inflammatory Drugs (NSAIDs) - Ophthalmic
  • Phosphate Binders/Regulators
  • Rosacea Agents - Topical

For detailed DURB information, prescribers should refer to the NYS Department of Health (DOH) Drug Utilization Review (DUR) web page. For the most up-to-date information on NYRx, the Medicaid Pharmacy PA programs, prescribers should refer to the NYRx, the Medicaid Pharmacy Program Preferred Drug List, This document contains a full listing of drugs subject to the NYRx, NYS Medicaid Pharmacy programs.

To obtain a PA, prescribers or their authorized agent should contact the clinical call center by telephone at (877) 309-9493. The clinical call center is available 24 hours per day, seven days per week, and staffed with pharmacy technicians and pharmacists who will work with you or your agent to quickly obtain a PA. Pharmacy staff are not authorized to submit for a PA nor enter into an agreement with a prescriber to effectuate PA's and appeals on the prescriber's behalf (except for a 72-hour emergency supply). Additional information can be found in the Pharmacy Program Integrity Spotlight article published in the July 2023 issue of the Medicaid Update.

NYS Medicaid-enrolled prescribers can also initiate PA requests using the web-based pharmacy PA request/response application, PAXpress®. PAXpress® is accessible via the eMedNY website, by selecting the PAXpress® button.

Resources:

Additional resources are available at the following websites and web pages:

Contact Information:

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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