March 2010    Volume 26, Number 4  

In this issue....

POLICY AND BILLING GUIDANCE

NPI submitted on claims to Medicare must be enrolled with NY Medicaid
Changes to Medicaid fee-for-service reimbursement policy
Billing for mental health clinic visits for SSI and SSI-related recipients
NY Medicaid requires facilities to register NPIs of their attending (servicing) providers

PHARMACY UDATES

Pharmacy requirement to enter dispensing pharmacist NPI on claims delayed
Pharmacies billing for immunizations are urged to enroll in VFC program
Important reminder about Medicaid pharmacy prior authorization programs
National Drug Code (NDC) billing announcement
NY Medicaid mandatory generic drug program requires PA for brand-name prescriptions with an A-rated generic equivalent
Fox Insurance Company of New York members now enrolled in Medicare LI-NET program

ALL PROVIDERS

NY Medicaid to receive federal matching funds for EHR incentives program
H1N1 Influenza Vaccine Provider Update
ePACES offers significant benefits over paper claims
Medicaid Seminars Offered
Smoking Cessation Awareness
Provider Directory

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If the National Provider Identifier (NPI) on a Medicare claim is not enrolled with New York Medicaid, the crossover claims will be rejected by eMedNY and affected providers will not receive a notice of the denial. Due to a large volume of rejections, National Government Services has suspended sending letters to providers notifying them that their claims did not crossover to Medicaid because their NPI is not enrolled with Medicaid.

If your Medicare remittance indicates that your claims were crossed over to Medicaid, please ensure the NPI on the Medicare remittance matches the NPI used for Medicaid billing. If the NPI does not match the NPI used for Medicaid billing then the NPI must be enrolled with Medicaid. Please contact the CSC Call Center at (800) 343-9000 for instructions on how to enroll your NPI. The Remittance Advice Remark code of MA07 is used to indicate that the claim was a crossover. In previous articles the indicator was given as MA18 in error. The Medicare remittance might also have the notation: Claim forwarded to the NYS Department of Health.

ADJUSTMENTS INCLUDE:

• In order to adjust a claim using the crossover process, the original claim must be paid as a crossover claim. If the original claim was submitted directly to Medicaid then an adjustment must be submitted directly to Medicaid. An adjustment submitted to Medicare for a claim that was not paid through the crossover will be denied for edit 00725 - No Matching History Record. In this instance the adjustment must be resubmitted directly to Medicaid.
• There are circumstances when a claim denied by Medicare is resubmitted to Medicare as an adjustment. In this scenario Medicare will pay the claim and the crossover will come to Medicaid as an adjustment. If the original claim was never paid, the crossover will be denied for edit 00725 - No Matching History Record. In this instance the claim must be submitted directly to Medicaid.

Questions? Please call the eMedNY Call Center at (800) 343-9000.

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PHYSICIAN SERVICES NOW CARVED-OUT OF HOSPITAL CLINIC AND INPATIENT RATES

PHYSICIAN SERVICES: Effective for dates of service on or after February 1, 2010, physicians may bill the physician fee schedule for services provided in any Article 28 hospital outpatient clinic or inpatient setting (including exempt, per-diem inpatient rates) for Medicaid fee-for-service patients.

Previously, if a physician was salaried by a hospital facility and his/her salary was included in the facility cost report, the clinic or inpatient payment to the hospital was considered payment in full for the service. The physician was prohibited from submitting a fee-for-service claim to Medicaid. This prohibition was fully eliminated effective February 1, 2010.

PHYSICIAN SERVICES ARE NOW CARVED OUT OF APG OR APR-DRG PAYMENTS FOR SERVICES PROVIDED IN:

• Ambulatory Surgery Settings - physician services were previously carved-out of the PAS facility payment and continue to be carved-out of the APG payment;
• Emergency Departments - carved-out effective January 1, 2009;
• Article 28 Hospital Outpatient Clinics - carved-out effective February 1, 2010; and
• Inpatient Settings carved-out effective February 1, 2010.

When hospital emergency department, ambulatory surgery, or hospital Article 28 outpatient rate codes for APGs or inpatient rate codes for APR-DRGs are billed, the physician may also submit a separate claim to Medicaid for their professional services. This includes physicians who are on staff and salaried by the hospital.

In order to bill physicians providing services in these settings must be enrolled in New York Medicaid. The HIPAA 837P billing format must be used. Physicians should bill Medicaid using the fee schedule published in the physician provider manual. Physicians should bill the global fee or the professional fee using the -26 modifier, when appropriate (e.g. radiology). The physician provider manual and information regarding enrolling in New York Medicaid as a provider are available online at www.emedny.org.

Changes to Medicaid fee-for-service reimbursement policy for practitioner services provided in hospital settings

LICENSED MIDWIFE SERVICES: The professional component for licensed midwife services is included in the APG payment to the hospital for services provided in emergency departments and outpatient clinics. However, licensed midwives may continue to bill the midwife services fee schedule for newborn deliveries in the inpatient setting for Medicaid fee-for-service patients. The midwife services fee schedule can be found online at www.emedny.org in the midwife provider manual.

ALL OTHER PRACTITIONER SERVICES (E.G., DENTISTS, NURSE PRACTITIONERS, PSYCHOLOGISTS, AND PHYSICIAN ASSISTANTS): The professional component for all other practitioners including dentists, nurse practitioners, psychologists, and physician assistants is included in the APG or APR-DRG payment to the hospital. These practitioners may not separately bill Medicaid for their professional services. There will be no change to current Medicaid policy, which disallows payment of interns and/or residents, yet permits payments for supervising and/or teaching physicians under certain specified conditions (see the June 2009 Medicaid Update for details).

Regardless of their past billing practices, dentists providing dental services in clinics may not bill against the dental fee schedule for any dental services other than orthodontics (D8000 - D8999). The professional component for dental services is included in the APG payment to the hospital. Orthodontists may continue to bill Medicaid fee-for-service using the dental fee schedule.

FREE-STANDING DIAGNOSTIC AND TREATMENT CENTERS (D&TCS): The above physician carve-out policy for hospital-based services does not apply to D&TCs. Physicians providing services in D&TCs may not bill Medicaid. The practitioner professional component for all D&TCs is currently included in the clinic threshold rate and will be included in the APG payment to the clinic upon implementation of APGs. This includes payment for physicians and all other practitioners - nurse practitioners, licensed midwives, physician assistants, etc. The only exceptions to this policy are orthodontics, dialysis, and the professional component for radiology services.

FREE-STANDING AMBULATORY SURGERY: Physician services continue to be carved-out of free-standing ambulatory surgery.

For more information regarding APGs, please contact the Division of Financial Planning and Policy at (518) 473-2160.

For more information regarding APR-DRGs, please contact the Division of Health Care Financing at (518) 474-3267.

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The benefit package for SSI and SSI-related Medicaid managed care enrollees does not include the following behavioral health services which are billable directly to Medicaid fee-for-service:

• Mental health inpatient and outpatient services;
• Mental health services certified by the New York State Office of Mental Health for individuals with serious mental illness (these services are also "carved-out" for non-SSI Medicaid managed care enrollees);
• Chemical dependence inpatient rehabilitation services; and
• All chemical dependence outpatient services, including methadone maintenance treatment programs.

To ensure claim reimbursement for carved-out services, Computer Sciences Corporation (CSC), suggests providers use the following revenue codes and/or bill type when billing for rate codes 1610, 2870, 1629, 2880, 1407, 4013, 1400, 1422, 1432, or 1441 in order to derive the appropriate specialty codes.

To derive specialty code 964 - Bill Type 72 or 73 and Revenue Code 0513.
To derive specialty code 924 - Revenue Code 0911.
To derive specialty code 983 - Bill Type 76 or 86.

These billing instructions are also available online in "Issues of eMedNY" at: http://www.emedny.org/HIPAA/News/csc_emedny_news/KnownIssues_Archive.pdf

Claims submitted with inappropriate coding are subject to recoupment based on audit.

A listing of the current mainstream managed care plans and other types of managed care plans inclusive of the services they cover is available for viewing at: http://www.emedny.org/ProviderManuals/AllProviders/PDFS/Information_for_All_Providers-Third_Party.pdf.

Please contact the eMedNY Call Center at (800) 343-9000 with any questions on billing procedures for services carved-out of the Medicaid managed care benefit.

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New York Medicaid requires that clinics, hospitals, and other facilities register the National Provider Identifier (NPI) and licenses for all practitioners who are affiliated with the facility and might be included as an attending (servicing) provider on claims submitted by the facility.

Recent claim submissions indicate a large number of facilities are still submitting claims where the attending provider NPI is not affiliated with the billing NPI of the facility. New York Medicaid will deny claims if the attending providers entered on the claims are not registered with Medicaid as being affiliated with the provider facility.

NEW YORK MEDICAID PROVIDES TWO METHODS FOR REGISTERING YOUR AFFILIATED PRACTITIONERS' NPIs:

• At the eMedNY Website at: https://npi.emedny.org/Facility/. or via batch by following the instructions in the Facilities Practitioner's NPI Reporting (batch reference guide) located on the NYHIPAADESK home page under NPI.
• Facilities with a large number of practitioners are encouraged to maintain a "roster" of all attending provider NPIs. As changes are made to the roster, please forward the list to New York Medicaid using the batch facilities method (above). Duplicate posting of practitioners will not create a problem.

For questions and concerns regarding Facility Affiliated Practitioner NPI Reporting, please contact the eMedNY Call Center at (800) 343-9000.

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The January 2010 Medicaid Update announced that effective April 1, 2010, all pharmacies are required to enter the Dispensing Pharmacist's National Provider Identifier (NPI) on the NCPDP claim in field 444-E9 Provider ID, with an '05' in field 465-EY Provider ID Qualifier. To allow pharmacies ample time to implement this change and to ensure access to necessary medications for recipients, the Office of the Medicaid Inspector General (OMIG) has deferred the implementation and enforcement of this requirement for sixty (60) days.

OMIG will monitor all NCPDP claims for Dispensing Pharmacist's NPI effective April 1, 2010. Any NCPDP claims submitted electronically without the Dispensing Pharmacist's NPI will be denied after June 1, 2010. This change will not impact pharmacies that bill on paper claim forms. Pharmacists who do not possess an NPI can apply for one at: http://www.cms.hhs.gov/NationalProvIdentStand/.

Questions? Please contact the eMedNY Call Center at (800) 343-9000.

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The Vaccines for Children (VFC) Program, implemented in 1994, was designed to improve vaccination coverage levels by providing vaccines at no cost to VFC-eligible children through public and private providers enrolled in the program. The VFC program allows the government to buy vaccines at a discount and distribute them to states, which then distribute them at no charge to private physicians' offices, public clinics, and pharmacies to provide to children who meet the eligibility requirements.

Categories of eligible children aged less than 19 years include:

• Medicaid recipients (both fee-for-service and managed care);
• Uninsured;
• Underinsured (their insurance doesn't cover immunizations);
• American Indians/Alaskan Natives.

For more information visit: www.cdc.gov/vaccines/programs/vfc/providers/default.htm. Please contact the NYS Vaccines for Children Program via e-mail at nyvfc@health.state.ny.us or call (800) 543-7468.

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When validating a prior authorization, providers are required to enter the 11-digit NDC of the drug being dispensed. Validating with an incorrect NDC will cause the prior authorization number to fail upon claim adjudication. Recently, an increased number of failed prior authorizations have occurred for the topical immunomodulator Protopic (tacrolimus). Please remember to provide the 11-digit NDC that corresponds to the strength of Protopic that the prescriber ordered:

• Protopic 0.03% ointment (minimum age limit of 2 years);
• Protopic 0.1% ointment (minimum age limit of 16 years).

For Medicaid pharmacy or policy questions, please call (518) 486-3209.

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The Federal Drug Rebate Program requires pharmaceutical manufacturers to sign a rebate agreement in order to have their pharmaceuticals covered by state Medicaid programs. The actual rebate amount is based on the claim information transmitted by the pharmacy provider. Therefore, it is imperative that the dispensing pharmacy provides accurate drug information.

To ensure accurate claiming:

• The National Drug Code (NDC) must correspond to the actual prescription or over-the-counter drug being dispensed. Preprogrammed NDCs do not guarantee the transmission of accurate information. It is considered a fraudulent billing practice to bill using a NDC other than that which is dispensed.
• The 11 digits of the NDC must accurately reflect what is dispensed (package size matters).
• The number of units dispensed must correspond to the correct reimbursement quantity (i.e., grams, milliliters or vials).
• Do not bill for a particular manufacturer's product and dispense another manufacturer's product.

The benefits of accurate pharmacy coding include reduced audits and timely reimbursement. Provider payments are subject to recoupment if products are billed for and not dispensed. Questions? Please call the Medicaid Pharmacy Unit at (518) 486-3209. To verify coverage of a particular NDC, please contact the eMedNY Call Center at (800) 343-9000 or visit: http://www.emedny.org/info/formfile.html.

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Effective April 15, 2010, new prescriptions for the brand-name drugs listed below will require prior authorization:
CALAN SR 120 MG, 180 MG CAPLET	REGLAN 10 MG TABLET
CASODEX 50 MG TABLET	TEMOVATE 0.05% CREAM
CONDYLOX 0.5% TOPICAL SOLUTION	TEMOVATE 0.05% OINTMENT
DEPAKOTE ER 250 MG, 500 MG TABLET	TOPAMAX 25 MG, 50 MG, 100 MG, 200 MG TABLET
PHENERGAN 25MG/ML AMPUL	URSO 250 MG TABLET

Prescriptions written prior to April 15, 2010, but filled on or after this date, including refills, will not require prior authorization. However, when the current prescription expires, a prior authorization will be required for the patient to continue to receive the brand-name drug.

NOTE: Brand-name drugs that are on the Medicaid Preferred Drug List do not require prior authorization and are not subject to the Medicaid Mandatory Generic Drug Program prior authorization requirements.

For pharmacy billing questions, please call (800) 343-9000.

For Medicaid pharmacy policy questions, please call (518) 486-3209.

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Effective March 10, 2010, the Centers for Medicare & Medicaid Services (CMS) ended its prescription drug plan contract with Fox Insurance Company of New York and enrolled all current Fox enrollees into the Limited Income NET Program (LI-NET), administered by Humana. This temporary Medicare coverage under the LI-NET program will be extended until April 30, 2010, unless the enrollee subsequently selects a different plan.

The LI-NET program is the only way for affected Fox members to receive their Medicare drug coverage during the transition period beginning March 10, 2010. As in the normal course of business, an E1 inquiry may be initiated to determine member eligibility in the LI-NET program. To make sure Part D eligible beneficiaries continue to receive Medicare drug coverage, please discontinue billing ProCare Rx (on behalf of Fox) for the affected beneficiaries and, instead, process all claims using the Limited Income NET 4Rx data below:

BIN	610649
PCN	05440000
CARDHOLDER ID	Beneficiary HICN or Medicare ID Number
GROUP ID	May be left blank

If you are unable to process a Limited Income NET claim, please contact the Limited Income NET Program pharmacy benefits manager at (800) 783-1307, and select option #1.

LI-NET resources are available online at: www.humana.com/pharmacists/resources/li_net.asp.

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OVERVIEW: Section 4201 of the American Recovery and Reinvestment Act of 2009 (Recovery Act), Pub. L. 111-5 established an incentive program for payment to providers who adopt and become meaningful users of electronic health records.

In another key step to further develop a robust U.S. health information technology (HIT) infrastructure, the Centers for Medicare & Medicaid Services (CMS) announced on December 9, 2009, that New York's Medicaid program will receive federal matching funds for state planning activities necessary to implement the electronic health record (EHR) incentive program established by the American Recovery and Reinvestment Act of 2009 (Recovery Act)

New York will initially receive approximately $5.91 million in federal matching funds for planning. The Recovery Act provides a 90 percent federal match for state planning activities to administer the incentive payments to Medicaid providers, to ensure their proper payments through audits and to participate in statewide efforts to promote interoperability and meaningful use of EHR technology statewide and, eventually, across the nation. The automated advantages afforded by EHR implementation allow physicians, nurses, hospitals and ultimately patients greater access to important medical records. EHRs will improve the quality of health care for the citizens of New York and make their care more efficient.

New York will use its federal matching funds for planning activities that include conducting a comprehensive analysis to determine the current status of HIT activities in the state. As part of that process, New York will gather information on issues such as existing barriers to its use of EHRs, provider eligibility for EHR incentive payments, and the creation of a State Medicaid HIT Plan, which along with the State HIT plan will define the state's vision for its long-term HIT use. Note: This timeline for implementation indicates that providers should not expect to receive incentive payments until 2011.

To learn more about this initiative and view supporting materials, including the NYS Department of Health (NYSDOH) Health Information Planning Document, visit: www.nyhealth.gov/regulations/arra/department_of_health_programs.htm#health_it.

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Dear New York State H1N1 Influenza Vaccine Provider (outside New York City):

The New York State Department of Health (NYSDOH):

• Requests that you continue to vaccinate patients for H1N1 influenza and retain your current stocks of vaccine in case there is a disease resurgence;
• Reminds you about the need for a second dose of H1N1 vaccine for children &10 years of age;
• Reminds you to report all vaccine doses administered.

Continue to vaccinate for H1N1 influenza and retain current vaccine stocks. January through March is the traditional influenza season. While disease activity is now low, there is a real possibility of an additional wave of pandemic H1N1 influenza disease, similar to what happened in the 1957-1958 pandemic. As a result, the New York State Department of Health (NYSDOH) encourages you to:

• Continue to offer and encourage H1N1 influenza vaccination to your patients;
• Retain your current supply of H1N1 influenza vaccine in your office, unless you do not have sufficient space to store it. Contact your county health department if you have vaccine that you are unable to store;
• Call 1-800-KID-SHOT to place a vaccine order or to cancel a remaining order;
• Instructions on what to do with unused vaccine will be provided in the future.

Reminder on second vaccine doses for children less than 10. Children less than 10 years old are recommended to get a second dose of H1N1 vaccine at least 28 days after the first dose. The state immunization registry, NYSIIS, can be used to check on which children need a second dose and can generate reminder lists and letters.

• Either nasal spray (if appropriate for the patient in question) or injectable vaccine may be used for the second dose regardless of the type of vaccine administered for the first dose.
• Pre-filled 0.25 ml syringes for children under age 3 years are no longer available. Please use vaccine from multi-dose vials for second doses of injectable vaccine.
• NYSDOH has waived the provisions of state law which usually restricts the use of thimerosal-containing influenza vaccines in pregnant women and children under the age of 3 years. There is no scientific evidence of harm caused by the low doses of thimerosal in vaccines. For more information, please visit: http://www.nyhealth.gov/diseases/communicable/influenza/h1n1/health_care_providers/frequently_asked_questions/vaccine_containing_thimerosal.htm.

Reminder to report vaccine doses administered. The federal provider agreement which you signed to receive H1N1 influenza vaccine commits you to report vaccine usage.

• Vaccine given to persons less than 19 years of age must be reported by state law to the New York State Immunization Information System (NYSIIS). For more information, please visit: http://www.health.state.ny.us/prevention/immunization/information_system/.
• Doses administered to persons age 19 years and older may be reported to NYSIIS, or aggregate doses administered must be reported to the NYSDOH telephone or Web-based systems. Please visit: http://www.nyhealth.gov/diseases/communicable/influenza/h1n1/health_care_providers/vaccine/docs/vaccine_reporting_requirements.pdf

Providers in New York City should report all H1N1 doses administered to the New York City Immunization Registry (CIR). Call the NYC Vaccine Hotline: (212) 676-2259 for more information.

Please call (800) KID-SHOT with any questions. Thank you for your continued efforts to vaccinate New Yorkers against influenza.

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If you continue to submit paper claims to eMedNY, consider the convenience of billing using ePACES. ePACES is a free, Web-based application offered by New York Medicaid that allows paper claim submitters to streamline their billing practice and achieve greater administrative efficiencies.

ePACES benefits include:

• ePACES software edits your claim information as you enter it, allowing you to correct invalid data before you submit your claims to eMedNY for processing.
• Providers who submit professional claims can take advantage of ePACES 'real-time' option. When you select the real-time option, your claim will be processed as soon as it is received. The status of your claim (including payment amount) will be available for viewing in ePACES within seconds! The actual payment will be subject to the regular Medicaid disbursement cycle.
• Providers who submit claims in batches, usually processed within 24-48 hours, will be able to view their results right on ePACES! This means that you can know the status of your claims submitted via ePACES before eMedNY could have received your paper claims.
• Electronic claims are less prone to errors and on average have a 10% higher approval rate than paper claims.
• ePACES is also a convenient way to enter your requests for prior approval. A reference number will be returned to your ePACES screen, which can be later used to check the approval status on ePACES.

To learn more about how to sign up for ePACES, please visit the eMedNY Website at www.emedny.org. Click on the NYHIPAADESK tab, then eMedNY Quick Reference at the lower left of the screen, and finally, click on FOD: ePACES Enrollment in the center of the screen or contact the eMedNY Call Center at (800) 343-9000 for assistance.

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• Do you have billing questions?
• Are you new to Medicaid billing?
• Would you like to learn more about ePACES?

If you answered YES to any of these questions, please consider registering for a Medicaid seminar. Computer Sciences Corporation (CSC) offers a variety of seminars to providers and their billing staff. Many of the seminars planned for the upcoming months offer detailed information and instruction about Medicaid's Web-based billing and transaction program - ePACES.

ePACES is the electronic Provider Assisted Claim Entry System which allows enrolled providers to submit the following type of transactions:

• Claims
• Eligibility Verifications
• Utilization Threshold Service Authorizations
• Claim Status Requests
• Prior Approval Requests

Physicians, nurse practitioners and private duty nurses can even submit claims in "REAL-TIME" via ePACES. With "real-time" the claim is processed within seconds and providers can get the status of a claim, including the paid amount without waiting for remittance advice.

Fast and easy seminar registration, locations, and dates are available on the eMedNY Website at: http://www.emedny.org/training/index.aspx.

Please review the seminar descriptions carefully to identify the seminar appropriate for your training requirements. Registration confirmation will instantly be sent to your e-mail address.

If you are unable to access the Internet to register, we can fax you a list of seminars and registration information to you through CSC's Fax on Demand at (800) 370-5809. Please request document 1000 for January - March seminar dates, 1001 for April - June seminar dates, 1002 for July - September seminar dates and 1003 for October - December seminar dates.

Note: Seminar schedule information is posted quarterly in CSC's Fax on Demand and Website at the beginning of each quarter. Please continue to check for updated information.

Questions? Please contact the eMedNY Call Center at (800) 343-9000.

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By providing counseling, pharmacotherapy, and referrals, you can double your patients' chances of successfully quitting. For more information, please visit www.talktoyourpatients.org or call the NY State Smokers' Quitline at 1-866-NY-QUITS (1-866-697-8487).

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Office of the Medicaid Inspector General:
http://www.omig.state.ny.us or call (518) 473-3782 with general inquiries or 1-877-87FRAUD with suspected fraud complaints or allegations.
This contact information can also be used for Provider Self-Disclosures.

Questions about billing and performing MEVS transactions?
Please contact eMedNY Call Center at: (800) 343-9000.

Provider Training
To sign up for a provider seminar in your area, please enroll online at:
http://www.emedny.org/training/index.aspx

For individual training requests, call (800) 343-9000 or email: emednyproviderrelations@csc.com

Enrollee Eligibility
Call the Touchtone Telephone Verification System at any of the numbers below:

(800) 997-1111    (800) 225-3040      (800) 394-1234.

Address Change?
Questions should be directed to the eMedNY Call Center at: (800) 343-9000.

Fee-for-Service Providers
A change of address form is available at: http://www.emedny.org/info/ProviderEnrollment/index.html

Rate-Based/Institutional Providers
A change of address form is available at: http://www.emedny.org/info/ProviderEnrollment/index.html

Does your enrollment file need to be updated because you've experienced a change in ownership?
Fee-for-Service Providers please call (518) 402-7032
Rate-Based/Institutional Providers please call (518) 474-3575

Comments and Suggestions Regarding This Publication?
Please contact the editor, Kelli Kudlack, at: medicaidupdate@health.state.ny.us

Medicaid Update is a monthly publication of the New York State Department of Health containing information regarding the care of those enrolled in the Medicaid Program.