New York State Medicaid Update - January 2026 Volume 42 - Number 1
In this issue …
- Pharmacy
- All Providers
- Policy and Billing
Reminder: NYRx Allows 90-day Prescribing for Most Maintenance Medications and OTC Drugs including Vitamin D and Folic Acid Preparations
NYRx, the New York State (NYS) Medicaid Pharmacy program would like to remind stakeholders including prescribers, pharmacies, NYS Medicaid members, and other caregivers that 90-day supplies of most maintenance medications and over the counter (OTC) drugs, are covered by NYRx. This benefit applies, but is not limited to, NYRx-covered OTC and prescription vitamins and minerals, including vitamin D and folic acid. A complete list of medications covered by NYRx can be found on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page. 90-day supplies offer numerous benefits:
- For patients – Cost savings with less copays, convenience of less trips to the pharmacy, improved medication adherence, and reduced risk of missing refills.
- For prescribers – Increased patient adherence equals easier monitoring, reduced administrative burden, increased patient satisfaction, and a more streamlined process for chronic disease management.
- For pharmacies – Increased patient adherence, improved operational efficiency leading to more time for additional services such as immunizations and medication therapy management, and enhanced customer satisfaction resulting in a stronger patient-pharmacy relationship.
Prescribers should consider writing for a 90-day supply and pharmacies should work with prescribers to switch to a 90-day supply, once it is determined appropriate and the patient is on a stable dose of a maintenance medication.
Questions
Questions regarding this policy should be directed to NYRx by email at NYRx@health.ny.gov or by telephone at (518) 486-3209.
Important Pharmacy Update: Vaccine Billing Guidance
NYRx, the New York State (NYS) Medicaid Pharmacy program, will be making some changes to its billing guidance for vaccine claims, billed by National Drug Codes (NDCs). Due to the changes, the NYS Department of Health has provided the following updated billing guidance until further notice.
Effective immediately, all vaccine claims billed by NDCs should be submitted with the pharmacies usual and customary price (U&C), in National Council for Prescription Drug Programs (NCPDP) field 426-DQ.This is a change to previous communications on this topic:
- Correction: NYRx, Medicaid Pharmacy Program Vaccine Billing Guidance
- NYRx, Medicaid Pharmacy Program: Pharmacists as Immunizers Fact Sheet
Please note: The total reimbursement amount returned in NCPDP field 509-F9 (Total Amount Paid) will include the administration fee in addition to reimbursement of the vaccine (when billed via NDC). A separate claim for administration should not be transmitted for vaccines billed with an NDC. This guidance does not apply to claim vaccine submissions for the Vaccines for Children program.
NYS Department of Health will notify providers of any further updates as necessary.
Questions
- Pharmacy policy questions should be directed to NYRx at NYRx@health.ny.gov.
- Billing questions should be directed to eMedNY at (800) 343-9000.
Reminder: Compounded Prescriptions Policy
Effective February 5, 2026, NYRx, the New York State (NYS) Medicaid Pharmacy program, will be implementing system changes to enforce compound policy for certain compound claims. The policy explicitly states that compounded products will only be reimbursed when the final compounded product is produced to meet the specific clinical needs of an individual patient that cannot be met by a commercially available FDA-approved drug and when the ingredients are compendia-supported for the intended route of administration and indication. The following ingredients, when used in topical compounds, are excluded from formulary coverage:
| Baclofen | Ketoprofen | Lidocaine |
| Cyclobenzaprine | Diclofenac | Fluconazole |
| Clonidine | Amitriptyline | Itraconazole |
Please note: The above products lack compendia-support or are available in commercial products, when used topically.
Topical compounded prescription claims which contain the affected drugs will deny for eMedNY edit #00551, Item Not Eligible for Payment on Fill Date. The National Council for Prescription Drug Programs (NCPDP) reject code is "MR", Product not on Formulary.
NYRx acknowledges the need for traditional extemporaneous compounding to customize a drug to meet the needs of a NYS Medicaid member. NYRx will only reimburse for ingredients with compendia-support and where the final compounded product is produced to meet the specific clinical needs of an individual patient that cannot be met by a commercially available Food and Drug Administration (FDA)-approved drug.
Compounded products may be prescribed to replace commercially available products when there is a documented sensitivity or contraindication to dyes, preservatives or fillers or lack of availability. Sensitivities or contraindications must be documented on the prescription and in the medical chart of the NYS Medicaid member. Pharmacies that submit compound prescription claims for reimbursement must follow the policy as previously communicated in the:
- NYRx, Medicaid Pharmacy Program - Pharmacy Manual Policy Guidelines (section "4.0 Basis of Payment," "Compounded Prescriptions"); and
- Medicaid Update articles regarding compounding and other topics can be found on the Medicaid Update homepage, by searching topics in the "Search All Medicaid Update Issues" box found near the top of the web page.
Alternative commercially available FDA-approved products should be leveraged whenever possible. The Non-opioid alternatives for selected pain indications in adults document, can assist providers in selecting treatment options based on the indications of the patient.
If a prescriber has determined that an ingredient excluded for topical coverage is the only treatment appropriate for a NYS Medicaid member, the prescriber may submit a letter of medical necessity and supporting documentation to NYRx@health.ny.gov for a review of coverage. Supporting documentation must include published clinical guidelines and/or peer reviewed literature and chart notes that justify why the prescribed ingredient is effective in topical formulations and medically necessary. The NYS Department of Health will continue to monitor and will make updates as necessary.
The NYS Department of Health will continue to monitor compounded prescriptions and will make system updates as necessary.
Questions and Additional Information:
- Pharmacies should refer to the NYRx, Medicaid Pharmacy Program - Pharmacy Manual Policy Guidelines.
- Practitioner and pharmacy 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".
- For a list of preferred drugs in NYRx, providers should refer to the NYRx, the Medicaid Pharmacy Program Preferred Drug List.
- Questions regarding compound billing should be directed to the eMedNY Call Center at (800) 343-9000.
- Questions regarding this policy should be directed to NYRx@health.ny.gov.
- Medicaid Managed Care (MMC) enrollee medical claims are also subject to the requirements above. Questions regarding MMC reimbursement, billing, and/or documentation requirements should be directed to the MMC Plan of the enrollee.
Self-Disclosure Obligation Reminder
Pursuant to Social Services Law §363-d and Title 18 of the New York Codes, Rules and Regulations (NYCRR) 521-3, any person who has received an overpayment under the NYS Medicaid program is required to report, return, and explain the overpayment through the New York State (NYS) Office of the Medicaid Inspector General (OMIG) Self-Disclosure program, or to their contracted Medicaid Managed Care (MMC) Organizations for NYS Medicaid managed care overpayments. MMC Organizations should report recoveries received from network provider self-disclosures to NYS OMIG on their Provider Investigative Report. Additionally, MMC Organizations are required to report, return and explain any self-identified capitation payment overpayments to NYS OMIG within sixty days of identification.
Providers should regularly review their billings to ensure accuracy. Additionally, although providers cannot submit self-disclosures for overpayments currently subject to audit, if a provider is audited, the provider should exercise reasonable diligence to identify overpayments in other time periods for similar issues.
As a result of the review of the provider, if the provider determines the individual is in receipt of an overpayment, they are required to self-disclose the overpayment to NYS OMIG or their MMC Organization within 60 days of identification or by the date any corresponding cost report is due, if applicable, pursuant to 18 NYCRR 521-3.3. Failure to exercise reasonable diligence to identify any overpayments, and subsequently retaining those overpayments, may result in monetary penalties and/or sanctions, in addition to the recoupment of the overpayment in a future audit or review.
It is recommended that providers document any internal audit or review conducted, and the results of such audit or review. If after their review a provider determines that no overpayment is due, no further action is required. Such documentation may be requested in a future NYS OMIG audit or review, or a compliance program review pursuant to 18 NYCRR 521-1.
To obtain additional information and resources regarding the NYS OMIG Self-Disclosure program, providers can visit the NYS OMIG "Self-Disclosure" website.
Questions
Questions regarding the NYS OMIG Self-Disclosure program should be directed to the NYS OMIG Bureau of Self-Disclosure by email at selfdisclosures@omig.ny.gov or by telephone at (518) 402-7030.
Reminder: Sign Up for eMedNY Training Webinars
eMedNY offers various types of training webinars for providers and their billing staff, which can be accessed via computer and telephone (no travel is necessary). Valuable provider webinars offered include:
- New! Provider Services Portal - Practitioner
- ePACES for: Dental, Durable Medical Equipment (DME), Doula, Free-Standing and Hospital-Based Clinics, Institutional, Physician, Private Duty Nursing, Professional Real-Time, Transportation and Vision Care.
- ePACES Dispensing Validation System (DVS) for DME
- eMedNY Website Review
- Medicaid Eligibility Verification System (MEVS)
- Medicaid Revalidation for Practitioners
- 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
Questions regarding training webinars should be directed to the eMedNY Call Center at (800) 343-9000.
Project TEACH: On-Site and Virtual Training by Request, Child/Adolescent Mental Health Toolkit
Project TEACH is pleased to announce its upcoming offerings, designed to equip maternal and pediatric health care providers with essential mental health knowledge and tools. This year, Project TEACH is expanding its reach with on-site training requests, a new Child/Adolescent Mental Health Toolkit, and a robust Webinar Wednesday series.
On-Site and Virtual Training Opportunities
Project TEACH is now accepting requests for trainings in maternal and pediatric mental health. These one-hour sessions, available virtually or in-person, provide practical, evidence-based education for professionals caring for pediatric and perinatal patients. Each training offers 1.25 Continuing Medical Education (CME) credits.
- Maternal Mental Health (MMH) topics: Led by Project TEACH reproductive psychiatrists or perinatal psychologists, these trainings are available to any New York State (NYS) agency supporting perinatal patients. Topics include:
- "Recognizing and assessing mental health concerns: Next steps in care"
- "Suicide risk assessment and management"
- "A non-prescriber's guide to psychiatric medications"
- "Treating depression and anxiety: Psychopharmacological approaches"
- "Treating bipolar disorder: Psychopharmacological approaches"
- "Trauma-informed care for perinatal patients"
- Child/Adolescent Mental Health topics: Led by Project TEACH child and adolescent psychiatrists and/or primary care clinicians; these trainings are offered to pediatric and family medicine practices in NYS. They focus on assessment and management of:
- ADHD
- Depression
- Anxiety
- Aggression
- Suicide risk and safety planning
- Trauma-informed care
- School refusal
- Eating disorders
- Non-suicidal self-injury
- Autism Spectrum Disorder and Intellectual/Developmental Disabilities (IDD)
To request a core training, providers should refer to the Project TEACH "Request A Service" web page or call (855) 227-7272.
Child/Adolescent Mental Health Toolkit for Primary Care Clinicians
Project TEACH has launched the Child/Adolescent Mental Health Toolkit, a valuable resource created by child and adolescent psychiatrists and inspired by the Primary Care Champions team. The Child/Adolescent Mental Health Toolkit offers evidence-based "Quick Check" guides designed for real-time, point-of-care reference, assisting clinicians in assessing and managing mental health concerns in pediatric patients within a primary care setting.
Webinar Wednesday Series 2026
Join Project TEACH for its Webinar Wednesday series, featuring both Child/Adolescent and MMH topics. Webinar details are listed below.
| Topic/CME Credit | Date/Time | Registration Details |
|---|---|---|
| "Problematic (or Excessive) Screen Use in Children and Teens" 1.0 CME credit |
Wednesday, March 18, 2026 Noon to 1 p.m. |
Project TEACH "Problematic (or Excessive) Screen Use in Children and Teens" web page |
| "PRACTICE Makes Perfect: Managing Trauma and Attachment Challenges in Primary Care" 1.0 CME credit |
Wednesday, May 27, 2026 Noon to 1 p.m. |
Project TEACH "PRACTICE Makes Perfect: Managing Trauma and Attachment Challenges in Primary Care" web page |
| "Preventive Mental Health in Primary Care Practice" 1.0 CME credit |
Wednesday, July 15, 2026 Noon to 1 p.m. |
Project TEACH "Preventive Mental Health in Primary Care Practice" web page |
| "IDD and Dev Disability: Assessment and Treatment in Primary Care" 1.0 CME credit |
Wednesday, September 16, 2026 Noon to 1 p.m. |
Project TEACH "IDD and Dev Disability: Assessment and Treatment in Primary Care" web page |
| "Working with Families in Primary Care: Round Table Discussion" 1.0 CME credit |
Wednesday, November 19, 2025 Noon to 1 p.m. |
Project TEACH "Working with Families in Primary Care: Round Table Discussion" web page |
| Topic/CME Credit | Date/Time | Registration Details |
|---|---|---|
| "Fertility and Mental Health" 1.0 CME credit |
Wednesday, April 15, 2026 Noon to 1 p.m. |
Project TEACH "Fertility and Mental Health" web page |
| "Opioid Use Disorder in the Perinatal Period: Screening and Treatment" 1.0 CME credit |
Wednesday, June 17, 2026 Noon to 1 p.m. |
Project TEACH "Opioid Use Disorder in the Perinatal Period: Screening and Treatment" web page |
| "Identifying and Responding to Intimate Partner Violence Among Perinatal Individuals" 1.0 CME credit |
Wednesday, October 14, 2026 Noon to 1 p.m. |
Project TEACH "Identifying and Responding to Intimate Partner Violence Among Perinatal Individuals" web page |
| "Substance Use Disorders in the Perinatal Period: Your Role in Screening, Support and Treatment" 1.0 CME credit |
Wednesday, December 16, 2026 Noon to 1 p.m. |
Project TEACH "Substance Use Disorders in the Perinatal Period: Your Role in Screening, Support and Treatment" web page |
Intensive Training: Child & Adolescent Mental Health for Primary Care Clinicians
Project TEACH will host an in-person, two-day intensive training for primary care clinicians this spring, from Sunday, April 19, 2026, to Monday, April 20, 2026, at the Woodcliff Hotel located at 199 Woodcliff Drive, Fairpoint, NY. Additional details and registration information will be available soon on the Project TEACH "Intensive Training: Child & Adolescent Mental Health for Primary Care Clinician" web page website..
NYS Office of Mental Health Launches Digital Wellness Resources
The NYS Office of Mental Health has introduced digital wellness tools on the NYS BeWell "Digital Wellness" web page, to help youth, parents, caregivers and educators foster healthier relationships with technology. These free resources offer guidance on managing screen time, navigating social media safely, protecting privacy and addressing cyberbullying.
About Project TEACH
Project TEACH is the NYS psychiatry access program for child, adolescent and perinatal mental health. In addition to training and webinar opportunities, Project TEACH offers referral support to healthcare clinicians and allied health professionals. Telephone consultations with child/adolescent or perinatal psychiatrists are available to primary care, OBGYN, pediatric and psychiatric clinicians in NYS. Consultations are billable as a NYS Medicaid fee-for-service using Current Procedural Terminology code "99452".
Questions and Additional Information:
- Questions regarding Project TEACH trainings and webinars should be directed to the Project TEACH Clinical Services Warmline at (855) 227-7272, between Monday through Friday, from 9 a.m. to 5 p.m.
- For information on Project TEACH services, past webinars and trainings, and clinical and family resources, providers should visit the Project TEACH website.
Brain Injury Grand Rounds Webinar Series
The New York State (NYS) Department of Health, the NYS Office of Mental Health, and the NYS Office of Addiction Services and Supports are excited to announce the upcoming Brain Injury Grand Rounds webinar series. This webinar series is designed to enhance the understanding, treatment, and engagement for individuals with brain injuries and co-occurring mental health and substance use disorders.
Each session is crafted to provide actionable insights and practical tools for a wide range of stakeholders, including health care professionals, social workers, counselors, case managers, and anyone involved in the care and support of individuals with brain injuries. Interested participants can refer to the session information below, as well as scan the QR codes for easy sign-up, per session, using your mobile device.
Brain Injury 101: Understanding & Identifying Brain Injury webinar via WebEx
Tuesday, March 31, 2026
10 a.m. to 11 a.m.
This session offers a practical foundation in Acquired Brain Injury, including concussions, other Traumatic Brain Injuries (TBI), and hypoxic events. Learn how these often-underrecognized injuries can shape behavior, cognition, and recovery, particularly with behavioral health or substance use challenges. Through real-world case examples, participants will learn to identify possible indicators of brain injury even without a formal diagnosis. They will also gain insight into how brain injuries are assessed and confirmed in clinical practice.
Presenters:
- Brian Im, MD, Director, Brain Injury Rehabilitation at NYU Rusk Rehabilitation; Co-Director, TBI Model Systems Project at Rusk Rehabilitation and Bellevue Hospital, Co-Director of the NYU Concussion Center; Fellowship Director, NYU Rusk Rehabilitation Brain Injury Medicine Fellowship
- Jessica Rivetz, MD, Staff Brain Injury Physiatrist at Sunnyview Rehabilitation Hospital
To sign-up for this session, visit the WebEx "Brain Injury 101: Understanding & Identifying Brain Injury" web page, or scan the QR code below.
Brain Injury Treatment: Psychopharmacology & Medical Interventions webinar via WebEx
Tuesday, April 21, 2026
10 a.m. to 11 a.m.
This session explores the neurobehavioral and psychiatric symptoms that often complicate brain injury recovery. These include cognitive changes, impulse control issues, emotional dysregulation, post-traumatic stress, suicidality, and new or worsening substance use. Learn about medication considerations specific to brain injury, including agents to avoid, which may support stabilization, and how brain injury can alter an individual's response to psychiatric and addiction treatments.
Presenters:
- Brian Im, MD, Director, Brain Injury Rehabilitation at NYU Rusk Rehabilitation; Co-Director, TBI Model Systems Project at Rusk Rehabilitation and Bellevue Hospital, Co-Director of the NYU Concussion Center; Fellowship Director, NYU Rusk Rehabilitation Brain Injury Medicine Fellowship
- Jessica Rivetz, MD, Staff Brain Injury Physiatrist at Sunnyview Rehabilitation Hospital
To sign-up for this session, visit the WebEx "Brain Injury Treatment: Psychopharmacology & Medical Interventions" web page, or scan the QR code below.
Brain Injury: Practical Strategies for Engagement webinar via WebEx
Tuesday, May 19, 2026
10 a.m. to 11 a.m.
This session examines barriers often preventing individuals with brain injury from fully engaging in behavioral health and addiction services. Practical strategies to improve access and participation will be provided, including communication techniques supporting clients with cognitive challenges. Learn approaches to reduce confusion and overwhelm by shaping environments, as well as ways to adapt therapy, groups, and case management so that care is genuinely informed by the needs of people living with brain injury.
Presenters:
- Karen Thomas, CBIST, Senior Director of Programs, Brain Injury Association of New York State
- Lottie Dunbar, MS, CCC-SLP, Assistant Director, Brain Injury Services at Living Resources Corporation
To sign-up for this session, visit the WebEx "Brain Injury Treatment: Psychopharmacology & Medical Interventions" web page, or scan the QR code below.
All clinicians are welcome! Continuing medical education and continuing education credits will be available for physicians, nurses, social workers, psychologists, credentialed alcoholism and substance abuse counselors, and licensed mental health counselors. Interested participants should check the details, per webinar, for specific information by visiting the NYS Department of Health "Traumatic Brain Injury" web page, located at: https://www.health.ny.gov/prevention/injury_prevention/traumatic_brain_injury/.
Questions and Additional Information:
- Questions should be directed to BIgrandrounds@health.ny.gov.
- For more information regarding the Brain Injury Grand Rounds webinar series, practitioners should visit the NYS Department of Health "Traumatic Brain Injury" web page, located at: https://www.health.ny.gov/prevention/injury_prevention/traumatic_brain_injury/.
- Practitioners are encouraged to print and distribute the official Brain Injury Grand Rounds Flyer, located at: https://www.health.ny.gov/prevention/injury_prevention/traumatic_brain_injury/docs/grand_rds_flyer1.pdf, with colleagues.
Updates to Wheelchair Policies
In accordance with the fiscal year 2026 enacted state budget, the New York State (NYS) Department of Health will be introducing three wheelchair initiatives, effective January 1, 2026, for fee-for-service (FFS) and March 1, 2026, for Medicaid Managed Care (MMC).
Reimbursement for Wheelchair Evaluations
NYS Medicaid FFS reimbursement for wheelchair evaluations using Current Procedural Terminology (CPT) code "97542" will be increased for clinicians billing outside of Article 28 clinic-based settings (all Article 28 hospital outpatient departments and diagnostic and treatment centers). Reimbursement for clinicians billing within Article 28 clinics will remain unchanged. Updated information is available in the eMedNY Rehabilitation Services Procedure Codes & Fee Schedule Manual.
| CPT Code | Description | Previous Fee | New Fee |
|---|---|---|---|
| 97542 | Evaluation for Wheelchair, each for 15 minutes. | $28.02 | $44.58 |
Wheelchair Preventative Maintenance
Preventative maintenance will be covered for all primary power wheelchairs (PWCs) that are less than five years old.
| CPT Code and Description | Modifier and Description | Method of Authorization | Frequency | MRA |
|---|---|---|---|---|
| A9900 Miscellaneous Durable Medical Equipment (DME) supply, accessory, and/or service component of another Healthcare Common Procedure Coding System (HCPCS) code. |
MS The MS modifier must be included with the A9900 HCPCS code. Code six-month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty. |
Direct Bill No prior approval necessary. Providers can file a claim and bill NYS Medicaid directly. |
F16 Once every six months. |
$175.00 90-minute service. |
Preventative maintenance is covered for all PWCs that are less than five years old. Backup PWCs are not eligible for preventative maintenance. An order by the physician is not required.
The service is for up to 90 minutes and permitted once every six months. This includes, but is not limited to, the following examples:
- evaluation, diagnostics, assessment;
- tightening of bolts and screws;
- checking tires for wear and inflate, if needed;
- general cleaning;
- necessary lubrication/oiling;
- checking integrity of wires and connections;
- checking all positioning components for wear and cover integrity; and
- simple repairs or replacement of minor parts (i.e. nuts, bolts, screws) are included in the fee.
Preventative maintenance must be performed by a qualified technician who is an employee of an enrolled DME provider and must be performed according to the guidelines of the manufacturer. Replacement parts other than basic minor parts that do not require prior approval (i.e. armrests, cushions) and are not covered by the warranty of the manufacturer, may be billed separately at the time of the preventative maintenance service.
The authorized PWC supplier must document and maintain all records of preventative maintenance services performed including claims, payment, work orders, checklists, etc. All documentation must be maintained for a minimum of six years and should be available when requested by the NYS Department of Health. Providers should refer to Title 18 of the New York Codes Rules and Regulations (NYCRR) §504.3(a). The labor/HCPCS code "K0739" should not be billed simultaneously with CPT code "A9900".
Repair of Backup PWCs
In limited instances, Group 2, Group 3, Group 4, Group 5, and Group 6 PWCs with or without power options, will be eligible for use as a backup PWC when the user has been provided with a new, primary PWC. This backup PWC will allow the NYS Medicaid member to maintain independent mobility when the primary PWC is being repaired or when a backup manual wheelchair, or suitable loaner wheelchair that would meet the medical needs of the NYS Medicaid member medical needs cannot be provided. For additional information, providers should refer to the eMedNY DME Procedure Codes & Coverage Guidelines.
| Eligible Wheelchairs |
HCPCS Code for Repair |
Modifier and Description |
Method of Authorization |
|---|---|---|---|
| Group 2 and up PWC that had been previously used as the primary source of mobility for the NYS Medicaid member. | K0899 Repair of any backup PWC regardless of group or code at purchase. |
TW ("Back-up equipment") Indication that a PWC is a backup device is signified by using HCPCS code K0899 and adding the TW modifier. |
Direct Bill Limited to $5000 over a period of five years (prior authorization required for total amounts exceeding $5000 or wheelchairs greater than 10 years old). |
Please note: During repairs of Group 1 primary PWCs, users should obtain a backup manual wheelchair, a temporary rental, or a loaner PWC from the DME provider.
When making repairs to a backup PWC, providers should advise the following:
- Repairs should be indicated by using HCPCS code "K0899" and the TW modifier.
- Repairs can be directly billed up to a limit of $5000 over a period of five years.
- Additional repairs, or repairs to a PWC that has been used as a backup for more than five years would be reviewed on a case-by-case basis via prior approval. Only one backup PWC will be covered.
- Preventative maintenance is not applicable to backup PWCs.
- Labor costs would also fall under HCPCS code "K0899" with modifier. "K0739" should not be billed for backup PWC repairs.
Requirements:
- The backup PWC should accommodate the seating and positioning components from the primary PWC to be used interchangeably. Providers should refer to the eMedNY DME Procedure Codes & Coverage Guidelines (pages 37 and 38).
- New PWCs should not be requested if the intended use is as a backup PWC.
- Lack of a backup PWC would cause undue hardship when the primary PWC of the NYS Medicaid member is being repaired.
- The NYS Medicaid member must have adequate storage space for both PWCs to be kept inside and away from the elements.
- Backup PWCs should not be used as a primary chair unless there is documented failure of the primary chair.
- The backup PWC must be used by only one person and cannot be transferred to someone else.
Repairs to features that were not approved at initial issue and/or not included in the original configuration of the PWC will not be considered medically necessary. New features on the primary PWC will not be retro-fit to the backup.
Documentation
The authorized PWC supplier must document and maintain all records of repairs to the current primary and backup PWC. All documentation must be maintained for a minimum of six years and should be available when requested by the NYS Department of Health. Providers should refer to Title 18 of the NYCRR §504.3(a), or upon audit.
Documentation should confirm that, given the requested repair, the retired primary PWC would be a safe and suitable backup PWC when the new primary PWC is being serviced. Additionally, documentation for all repairs must include the serial number of the wheelchair, funding source and date of purchase. The provider must document that the repairs are necessary for the backup PWC to be safe and effectively used.
Questions and Additional Information:
- Policy and coverage guideline questions should be directed to the Bureau of Medical Review by telephone at (800) 342-3005 or by email at OHIPMedPA@health.ny.gov.
- 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 FFSMedicaidPolicy@health.ny.gov.
- Billing questions should be directed to General Dynamics Information Technology at (800) 343-9000.
- MMC enrollment, reimbursement, billing, and/or documentation requirement questions should be directed to the specific MMC Plan of the enrollee.
- MMC Plan contact information and plan directory can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.
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
