New York State Medicaid Update - April 2025 Volume 41 - Number 4

In this issue …


Topical Fluoride Varnish Application: Expansion of Provider Types

New York State (NYS) Medicaid reimburses for topical fluoride treatment when professionally administered in accordance with appropriate standards in both dental and non-dental settings. Effective immediately, an amendment to the Education Law permits registered dental assistants (RDAs) and licensed practical nurses (LPNs) to apply topical fluoride varnish.

In the Dental Setting, Current Dental Terminology (CDT) code "D1206" Topical application of Fluoride Varnish is permitted by RDAs, provided that such function is performed under the direct personal supervision of a licensed dentist in the course of the performance of dental services. When billing NYS Medicaid, CPT code "D1206" should be billed by the supervising dentist.

In non-dental settings, topical application of fluoride varnish is reimbursable to physicians and nurse practitioners (NPs) with CPT code "99188". Fluoride varnish can be applied by LPNs, registered nurses, and physician assistants to optimize treatment. When billing NYS Medicaid, CPT code "99188", provided by a LPN, should be billed by the supervising physician.

Providers should be trained and competent in fluoride varnish application. Training resources can be accessed through the New York State Department of Health "Improving the Oral Health of Young Children: Fluoride Varnish Training Materials and Oral Health Information for Child Health Care Providers" web page.

Providers should refer to the Dental Policy and Procedure Code Manual - New York State Medicaid, 2025 Dental Policy and Procedures, for additional information on coverage of fluoride varnish application.

CDT Code Billed By Description NYS Medicaid Rate
CDT code D1206 Dentists Topical application of fluoride varnish
Reimbursable once per three-month period for NYS Medicaid members, from eruption of first tooth through 20 years of age (inclusive). For individuals 21 years of age and older, CDT code "D1206" is only approvable for those individuals identified with a Restriction Exception code of RE "81" (Traumatic Brain Injury Eligible) or RE "95" [Office of Persons With Developmental Disabilities (OPWDD)/Managed Care Exemption)], or in cases where salivary gland function has been compromised through surgery, radiation, or disease.		 $30.30
99188 Physicians and NPs Topical application of fluoride varnish
Reimbursable once per three-month period for NYS Medicaid members, from eruption of first tooth through five years of age (inclusive).		 $30.30

Questions and Additional Information:

  • NYS Medicaid fee-for-service (FFS) coverage and policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Management by telephone at (518) 473-2160 or by email at dentalpolicy@health.ny.gov.
  • Medicaid Managed Care (MMC) reimbursement, billing, and/or documentation requirement questions should be directed to the specific MMC Plan of the enrollee. MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.
  • NYS Medicaid FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.

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Reminder: Coverage of Licensed Clinical Social Workers, Licensed Master Social Workers, Licensed Mental Health Counselors, Licensed Marriage and Family Therapists Services Provided in Article 28 Outpatient Hospital Clinics and Free-Standing Diagnostic and Treatment Centers

This article is intended to remind providers on rate codes that Article 28 hospital outpatient departments (OPDs), free-standing diagnostic and treatment centers (D&TCs) and School-Based Health Centers (SBHCs), should use to request reimbursement from New York State (NYS) Medicaid fee-for-service (FFS) for mental health counseling when provided by licensed clinical social workers (LCSWs), licensed master social workers (LMSWs), licensed mental health counselors (LMHCs), and licensed marriage and family therapists (LMFTs), within their scope of practice, as defined by the NYS Education Department.

Reimbursement for LCSW, LMSW, LMHC, and LMFT services are based on flat rates established by the NYS Department of Health (DOH) and provided via the rate codes below. These services will not be reimbursed through non-Ambulatory Patient Group (APG) payment methodology, nor priced via 3M/Solventum Grouper Pricer software.

Article 28 Clinics

Hospital OPDs and free-standing D&TCs should use the following rate codes:

Rate Code Rate Description
4222 Individual LMHC/LMFT services 20 to 30 minutes with patient.
4223 Individual LMHC/LMFT services 45 to 50 minutes with patient.
4224 Family services LMHC/LMFT with or without patient present.
4257 LCSW/LMSW services 20 to 30 minutes with patient.
4258 LCSW/LMSW services 45 to 50 minutes with patient.
4259 Family services LCSW/LMSW with or without patient present.

SBHCs

SBHCs should use the following rate codes:

Rate Code Rate Description
3257 SBHC-LCSW/LMSW services 20 to 30 minutes with patient.
3258 SBHC-LCSW/LMSW services 45 to 50 minutes with patient.
3259 SBHC-family services LCSW/LMSW with or without patient present.
3260 SBHC-individual LMHC/LMFT services 20 to 30 minutes with patient.
3261 SBHC-individual LMHC/LMFT services 45 to 50 minutes with patient.
3262 SBHC-family services LMHC/LMFT with or without patient present.

Reimbursement for the hospital OPD, D&TC and SBHC rate codes, referenced in the tables above, can be found on the NYS DOH "Alternative Payment Fee Schedule" web page.

Federally Qualified Health Centers and Rural Health Clinics

Federally Qualified Health Centers and Rural Health Clinics not opted in to receive payment via the APG reimbursement methodology should bill the Prospective Payment System rate for services rendered by the above-referenced behavioral health practitioners.

Questions:

  • NYS Medicaid FFS coverage and policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Managementby telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
  • Medicaid Managed Care (MMC) reimbursement, billing, and/or documentation requirement questions should be directed to the MMC Plan of the enrollee. MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.
  • NYS Medicaid FFS claims questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • NYS Medicaid FFS provider enrollment questions should be directed to eMedNY Provider Enrollment at (800) 343-9000.

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NYRx Pharmacy Drug Coverage: Claims Processing Enhancements and Reminders

This communication serves as a reminder to all pharmacies of their responsibility to adhere to the policies and procedures of the New York State (NYS) Medicaid program for continued enrollment enrollment as well as NYS and federal laws, rules and regulations..

NYRx Drug Coverage Criteria

NYRx, the NYS Medicaid pharmacy program, covers most medically necessary Food and Drug Administration (FDA)-approved drugs when used for NYS Medicaid-covered FDA-approved or compendia-supported indications.

The New York State Department of Health List of Medicaid Reimbursable Drugs, historically located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page, is established by the NYS Commissioner of Health (COH). The New York State Department of Health List of Medicaid Reimbursable Drugs, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page, can also be searched and sorted by National Drug Code (NDC), as well as description, drug type, labeler, cost, prior authorization (PA) code, or over-the-counter (OTC) indicator.

Only those prescription and non-prescription drugs, which appear on the New York State Department of Health List of Medicaid Reimbursable Drugs, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page, with 11-digit NDCs are reimbursable under NYRx. The list also contains non-prescription therapeutic categories, which the NYS COH has specified as essential in meeting the medical needs of NYS Medicaid members.

Drug Coverage Limitations

NYS Medicaid only provides reimbursement for drugs included in the New York State Department of Health List of Medicaid Reimbursable Drugs, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page (unless provided by a facility which includes the cost of drugs in their all-inclusive rate). The following are examples of drugs/drug uses which are not reimbursable by NYS Medicaid, in accordance with policy and/or state or federal legislation:

  • Drugs used for the treatment of anorexia, weight loss or weight gain pursuant to Social Security Act (SSA) §1927(d)(2);
  • Drugs for the treatment of sexual dysfunction pursuant to SSA §1927(d)(2) and Social Services Law (SOS) §365-a(4)(f).
  • Drugs without a federal rebate agreement or a rebate agreement with a State authorized by the Secretary pursuant to SSA §1927(a).
  • Drugs indicated for cosmetic use or hair growth pursuant to SSA §1927(d)(2).
  • Any contrast agents, used for radiological testing (these are included in the fee of the radiologist).
  • Drugs packaged in unit doses for which bulk product exists.

Compounding Drugs

Pharmacies are further reminded of their obligations to comply with previously issued Medicaid Update articles, including the Reminder Compounding Policy article published in the April 2024 issue of the Medicaid Update.

Claims Processing

Pharmacy claims submitted for medications that are not active on the New York State Department of Health List of Medicaid Reimbursable Drugs, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page, will be rejected with targeted National Council for Prescription Drug Programs (NCPDP) messaging. Rejection messaging has recently been updated to provide additional detail regarding coverage criteria. Reject messages are returned via NCPDP Reject Code: 511-FB. Additionally, the Medicaid Eligibility Verification System (MEVS) Denial Code for a transaction is returned within the additional message information 526-FQ and indicates the MEVS error for rejected transactions.

Edit # Edit Description NCPDP Reject Message
00551 Item not eligible for payment on fill date. MR: Product not on formulary.
01600 Terminated NDC number. "825": Claim date of service is outside of the product FDA/Nonlinear Solvers and Differential Equations marketing date.
02351 NDC not federal participant. AC: Product not covered non-participating manufacturer.
02352 NDC is a Drug Efficacy Study Implementation (DESI) drug. "70": NDC not covered.
Requires additional MEVS.
Denial Code "722": NDC DESI code is invalid.
02353 NDC excluded from State Plan coverage. "70": NDC not covered.
02354 Procedure code required instead of NDC. 8J: Incorrect product/service ID for processor/payer.
Additional MEVS Denial Code "705": NDC/Advanced primary care not covered.

Frequently Rejected Drugs as of April 2025

NDC Name Coverage Limitation Resolution and Additional Information
Polyethylene Glycol 3350 Powder Product not on formulary. Pharmacy may search for an alternative NDC. NYRx provides coverage of select NDCs for OTCs. Providers should refer to the New York State Department of Health List of Medicaid Reimbursable Drugs, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page, to determine available alternative therapies.
VASCEPA® 1 GM capsule Non-participant Medicaid. Drug Rebate Program (MDRP). Pursuant to SSA §1927(a), drug manufacturers are required to participate in the MDRP for coverage.
Zepbound 2.5mg/0.5ml State Plan exclusion Indications for weight loss are not covered pursuant to SSA §1927(d)(2).
OneTouch Verio test strips Product not on formulary. NYRx provides coverage of select diabetic testing supplies. Providers should refer to the NYRx Preferred Diabetic Supply Program Resource document.
Bromphen-PSE-DM 2-30-10 mg/5 ml oral syrup State Plan exclusion Limited coverage of combination cough and cold products are reimbursable by NYRx. Providers should refer to the New York State Department of Health List of Medicaid Reimbursable Drugs, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page.
Wegovy 0.25mg/0.5ml State Plan exclusion Indications for weight loss are not covered pursuant to SSA §1927(d)(2).
Thera-M Plus tablet Product not on formulary. Pharmacy may search for an alternative NDC. NYRx provides coverage of select NDCs for OTCs. Providers should refer to the New York State Department of Health List of Medicaid Reimbursable Drugs, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page, to determine available alternative therapies.
Aspirin EC 81mg Product not on formulary Pharmacy may search for an alternative NDC. NYRx provides coverage of select NDCs for OTCs. Providers should refer to the New York State Department of Health List of Medicaid Reimbursable Drugs, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page, to determine available alternative therapies.
Benzoyl Peroxide Product not on formulary Pharmacy may search for an alternative NDC. NYRx provides coverage of select NDCs for OTCs. Providers should refer to the New York State Department of Health List of Medicaid Reimbursable Drugs, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page, to determine available alternative therapies.

Resources:

Questions:

  • Questions regarding this guidance should be directed to NYRx@health.ny.gov.
  • NYRx billing/claims questions should be directed to the eMedNY Call Center at (800) 343-9000. The eMedNY Call Center hours are Monday through Friday from 7 a.m. to 10 p.m., and Saturday through Sunday from 8:30 a.m. to 5:30 p.m.

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Pharmacy Reminder: Coordination of Benefits Processing Instruction for New York State Medicaid

New York State (NYS) Medicaid providers are required to bill applicable third parties that may be liable for a claim before billing NYS Medicaid. NYS Medicaid is always the payer of last resort. Federal regulations require that all other available resources be used before NYS Medicaid considers payment. Through coordination of benefits (COB), NYS Medicaid will pay the patient responsibility for correctly submitted NYS Medicaid coverable claims, up to the NYS Medicaid allowed amount.

Providers must exhaust all existing benefits prior to billing the NYS Medicaid. Providers should always ask a NYS Medicaid member if they have other third-party coverage to ensure the proper COB. Pharmacies are responsible for submitting claims to other coverage before submitting claims to NYS Medicaid. Pharmacies are required to coordinate with the proper primary payer. This includes submitting a claim under the appropriate coverage benefit, medical or pharmacy.

Certain services may be rejected by the primary payer, but coverage should still be pursued in situations including, but not limited to:

  • prior authorization (PA) needs to be obtained from the primary payer;
  • billing Medicare Part D for services covered by Medicare Part B, or billing Medicare Part B for services covered by Medicare Part D and getting a rejection;
  • submitting to the wrong third-party causing claims to bypass incorrectly (third-party claims that incorrectly bypass the primary plan responsibility of payment is considered inaccurate billing and may be subject to audit recoveries);
  • billing the appropriate benefit (medical versus pharmacy);
  • billing of the appropriate service code [National Drug Code (NDC) versus Healthcare Common Procedure Coding System (HCPCS) code];
  • the pharmacy is not contracted with the primary payer of the NYS Medicaid member; and
  • resolve by obtaining an override or enroll with the Third-Party Liability (TPL) or advise the NYS Medicaid member and prescriber of the need to change dispensing to a network pharmacy.

Pharmacies that have difficulty billing primary insurance for the above situations, should advise prescribers and NYS Medicaid members of potential delays as well as options for resolution. If claim issues are resolved, the pharmacies may then resubmit the claims to NYS Medicaid after the claims are properly adjudicated with the primary payer.

Reminder

Providers must maintain evidence and documentation, which are subject to audit, for a minimum of six years following the date of NYS Medicaid payment. This evidence should include, but not be limited to, denials of claims by responsible TPL plans, other applicable TPL plan responses, and payment information. Prescribers are responsible for prescribing, per plan formulary, and to pursue any claim issues such as, but not limited to:

  • necessary PAs or appeals;
  • prescription alternatives (for a non-formulary or non-preferred drug);
  • necessary changes (quantity supply, day supply, etc.); and
  • selection of an in-network pharmacy that is agreeable to the NYS Medicaid member.

If following the values are not reported correctly, the claim will fail a pre-adjudication edit in National Council for Prescription Drug Programs (NCPDP) field 340-7C with Reject Code "7C" (Missing/Invalid Other Payer ID Code). It is important to use the proper codes for both primary payer ID and qualifier to receive the correct payment.

Payer Type 339-6C
(Other Payer ID Qualifier)		 340-7C
(Other Payer ID)		 351-NP
(Other Payer-Patient Responsibility Amount Qualifier)
Commercial Third-Party Liability (TPL) 99 99 01, 04, 05, 06, 07, 09, or 12
Medicare Part B 05 Carrier # 01or 07
Medicare Part C, Medicare Advantage, Medicare Managed Care 99 13 01, 04, 05, 06, 07, 09, or 12

Other Coverage Code "2" (Field 308-C8) - Patient Has Other Coverage This Claim Covered

The following codes are valid entries to be returned for field 351-NP (Other Payer-Patient Responsibility Amount Qualifier) when the claim is submitted to primary insurance:

"01" = Deductible
"04" = Amount reported from previous payer as exceeding periodic benefit maximum
"05" = Co-pay amount
"06"* = Patient pay amount
"07" = Co-insurance amount
"09" = Health plan assistance amount
"12" = Coverage gap amount
*NYRx and NCPDP recommends the use of the component pieces; however, if the components do not sum to patient pay amount, the use of 351-NP (Other Payer-Patient Responsibility Amount Qualifier) value of "06" is allowed.

Other Coverage Code "3" (Field 308-C8) - Patient Has Other Coverage, This Claim Not Covered

NYRx will not accept a combination of Other Coverage Code of "3" in NCPDP field 308-C8 (Other Coverage Code) with reject codes in field 472-6E (Other Payer Reject Codes) indicating another third-party is responsible for payment. Only reimbursable over-the-counter (OTC) drugs may be submitted in this manner when the product is not covered as a benefit from the primary payer. The pre-adjudication edit will return NCPDP Reject Code "6E - M/I Other Payer Reject Code", for all other entries.

Other Coverage Code "4" (Field 308-C8) - Patient Has Other Coverage Payment Not Collected

If value code "4" is submitted in field 308-C8 for situations where the prior payer did not make a payment, the system will enforce that the following conditions are met:

  • NCPDP field 431-DV (Other Payer Amount Paid) is equal to zero;
  • NCPDP field 351-NP (Other Payer-Patient Responsibility Amount Qualifier) is present from the primary payer;
  • 353-NR (Other Payer-Patient Responsibility Amount Count) is present from the primary payer; and
  • 352-NQ (Other Payer-Patient Responsibility Amount) segment is included from the primary payer.

If any of the above conditions are not met, the system will deny the claim and return NCPDP Reject Code "536" (Other Payer-Patient Responsibility Value Not Supported).


The following codes are valid entries for field 351-NP (Other Payer-Patient Responsibility Amount Qualifier) when the Other Coverage Code of "4" is submitted in field 308-C8 (Other Coverage Code):

Blank = Not Specified
"01" = Deductible
"04" = Amount Reported from previous payer as Exceeding Periodic Benefit Maximum
"05" = Co-pay Amount
"06"* = Patient Pay Amount
"07" = Co-insurance Amount
"09" = Health Plan Assistance Amount
"12" = Coverage Gap Amount
*NYRx and NCPDP recommends the use of the component pieces; however, if the components do not sum to patient pay amount, the use of 351-NP (Other Payer-Patient Responsibility Amount Qualifier) value of "06" is allowed.

The following codes are invalid entries for field 351-NP (Other Payer-Patient Responsibility Amount Qualifier) when the Other Coverage Code of "4" is submitted in field 308-C8 (Other Coverage Code). The pre-adjudication edit will return the NCPDP Reject Code "536" (Other Payer-Patient Responsibility Amount Qualifier Value Not Supported).

"02" = Product/Selection/Brand Drug Amount
"03" = Sales Tax Amount
"08" = Product Selection/Non-Preferred Formulary Selection Amount
"10" = Provider Network Selection Amount
"11" = Product/Selection/Brand Non-Preferred Formulary Selection Amount
"13" = Processor Fee Amount

Additional information regarding the fields shown above can be found in the eMedNY New York State Department of Health (NYS DOH) Office of Health Insurance Programs (OHIP) Standard Companion - Transaction Information document (NCPDP D.0 Companion Guide). Billing questions should be directed to the eMedNY Call Center at (800) 343-9000.

Workers Compensation and COB

If a patient has a work-related injury, for which they have an open Workers Compensation case, Workers’ compensation coverage must be utilized prior to billing the NYRx. Claims billed to NYRx as the primary payer when another party is responsible will be rejected with the following claims edit:

Edit # Edit Description NCPDP Reject Message
01631 Client Has Other Insurance 13 - M/I Other Coverage Code and Additional MEVS Reject Code 717- Client Has Other Insurance

Please note: The following updated guidance supersedes previous instructions for billing a non-workers compensation claim as a secondary claim.

Effective immediately, if the drug claim is not related to the Workers Compensation case of the patient, such as a maintenance medication for an unrelated chronic condition, NYRx may be billed as the primary payer with an Eligibility Clarification Code. Upon verifying the drug is not related to Workers Compensation case, the pharmacy may bill NYRx as primary with the Eligibility Clarification Code of "2" in field 309-C9. Providers must ensure all other responsible payers are included on the claim, if applicable.

Billing Reminders:

  • Providers must bill accurately.
  • Providers must accept NYS Medicaid payment as payment in full.
  • Providers submit claims only for services actually furnished.
  • All inaccurate or false claim submissions resulting in NYS Medicaid payment are subject to audit and recovery and may result in NYS Medicaid enrollment termination for the provider.

Questions:

  • Questions regarding billing COB claims can be directed to eMedNY at (800) 343-9000.
  • Questions regarding this policy should be directed to NYRx@health.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.
Acting Commissioner
New York State Department of Health

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs