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POLICY & BILLING GUIDANCEMedicaid Managed Care now available inJefferson and St. Lawrence CountiesMost Medicaid beneficiaries residing in Jefferson and St. Lawrence counties now have the option toenroll in Medicaid Managed Care. Excellus Health Plan is now available in these counties for bothMedicaid Managed Care and Family Health Plus (FHPlus).Providers are encouraged to check the Medicaid Eligibility Verification System (MEVS) prior torendering services to determine Medicaid eligibility and the conditions of Medicaid coverage.Providers are strongly encouraged to check eligibility at each visit as eligibility and enrollment statusmay change at any time. If the Medicaid beneficiary is enrolled in a Medicaid managed care plan, thefirst coverage message will indicate "Managed Care Coordinator" or “Eligible PCP” (depending on thedevice used). If they are enrolled in a FHPlus plan, the first coverage message will indicate “FamilyHealth Plus”.MEVS will identify the scope of benefits a Medicaid beneficiary's Medicaid Managed CareOrganization provides through specific coverage codes. When using a touch-tone telephone you willhear the "Description" of each covered service. When using either the Point of Service (POS) orePACES the "Coverage Codes" will be displayed. If the message "All" appears, all services will becovered.Note: Medicaid will not reimburse a provider on a fee-for-service basis if MEVS indicates that theservice is covered by the plan.Providers may call the eMedNY Call Center at (800) 343-9000 with any Medicaid billing issues.Medicaid beneficiaries should contact their local department of social services to learn more aboutmanaged care.Questions? Please contact the Bureau of Program Planning & Implementation at (518) 473-1134.POLICY & BILLING GUIDANCEJanuary 2011 Medicaid Updatepage 6

POLICY & BILLING GUIDANCEProviders are responsible for allsubmitted claimsThe eMedNY system allows enrolled New York State Medicaid providers to submit claims and receivereimbursements for Medicaid-covered services provided to eligible beneficiaries by direct billing or byusing a service bureau or clearinghouse (Section 18 NYCRR 360-7.5 (c)).Regardless of the claim submission method, the provider bears full responsibility for all phases ofthe claim process. This includes the accurate, timely, and compliant submission of Medicaid claimsand the monitoring of reimbursements, including timely disclosure and repayment of overpaymentsobtained from Medicaid.The use of a billing service or clearinghouse does not absolve the provider of these responsibilities.Providers agree to these responsibilities by signing and filing an annual notarized claim certificationstatement, as required, for participation in the eMedNY system.Included in the attestations of the claim certification statement is the acknowledgement that theprovider will keep, for a period of six years from date of payment, records and information regardinga submitted claim and the related payment (if any), and the provider must furnish thisdocumentation upon request. Additionally, the provider certifies an understanding and anagreement to be “bound by all rules, regulations, policies, standards, fee codes and procedures ofthe DOH as set forth in Title 18 of the Official Compilation of Codes, Rules and Regulations of NewYork State and other Department publications.”Questions? Please contact the eMedNY Call Center at (800) 343-9000.January 2011 Medicaid Updatepage 7

POLICY & BILLING GUIDANCERadiology Management Program forFee-for-Service MedicaidNew York State Medicaid will soon implement a radiology management program to ensure thatbeneficiaries receive the most clinically appropriate imaging studies. The program will be applied tooutpatient non-emergency advanced imaging procedures, for fee-for-service beneficiaries.Beneficiaries who are eligible for both Medicaid and Medicare (dual eligible) or beneficiaries who areenrolled in a managed care plan are not included.RadConsult, administered by HealthHelp, is a consultative, educational program that improvesquality and reduces the cost of care by providing expert peer consultation and the latest evidencebased medical criteria for diagnostic imaging. It provides access to consultations with subspecialistsaffiliated with academic radiology departments.Once the program is implemented, practitioners who order CT, CTA, MRI, MRA, cardiac, nuclear andPET procedures will be required to obtain prior authorization.Educational materials and program implementation information will be featured in future issues ofthe Medicaid Update and will also be posted on www.eMedNY.org.January 2011 Medicaid Updatepage 8

POLICY & BILLING GUIDANCENew York City Medical Practitioners, Programs and Facilities That Order Transportation ServicesNew Non-Emergency Transportation Procedure CodesMust Be Used by New York City Medical PractitionersEffective for dates of transportation on or after April 27, 2011, the following procedure HealthcareCommon Procedure Coding System (HCPCS) codes will be required by the federal government to beused for ordering non-emergency transportation for Medicaid enrollees who are not enrolled in amanaged care organization (please note that ambulance procedure codes have not changed, onlyambulette, livery and group ride):HCPCS Codes And Modifiers to Use forTransports That Occur On or After April 27, rtation Codeto Be UsedHCPCS Modifier (tobe only used whereindicated below)Type of ServiceAmbulance(no change fromcurrent codes)A0425A0425-Ambulance: Mileage Outside City OnlyA0426A0426-Ambulance: Advanced Life SupportA0428A0428-Ambulance: Basic Life SupportNY100A0130-Ambulette: One-way trip under 5 milesNY102A0130TNAmbulette: One-way trip over 5 milesNY165A0130HCAmbulette: One-way trip to/from adult day health careNY200A0100-NY202A0100TNLivery: One-way trip over 5 milesNY217A0110-One-way Group ride: AmbulatoryNY218A0110HEOne-way Group ride: WheelchairAmbuletteLiveryLivery: One-way trip under 5 milesGroup Ride-continued-January 2011 Medicaid Updatepage 9

POLICY & BILLING GUIDANCEFor transports that occur on or before April 26, 2011, the current procedure codes should beordered.Beginning March 27, 2011, providers will have the opportunity to order either the current procedurecodes, or the new HCPCS procedure codes, depending on the date of the transport(s). For example, ifon March 30, 2011, a provider orders three months of transportation for a Medicaid beneficiary(who is not enrolled in a Medicaid managed care plan) to a dialysis center, providers should use theold codes for transports on or before April 26, and use the new codes for transports on and afterApril 27.Prior authorization request forms are being revised to allow providers to use the modifier code, whenapplicable to the transport. If you currently use these forms, you will automatically receive a supply ofthe revised prior authorization request forms in March 2011.Annual or Semi-Annual Prior Authorizations:Some programs, such as adult day health care or mental health day treatment, request priorauthorizations on an annual (12-month) or semi-annual (6-month) basis. If you have already orderedtransportation for dates after April 26, 2011, you must submit a new order using the new HCPCSprocedure codes at some time on or after March 27, 2011.Which prior authorization request form should be used?Providers should only use the new federal code set on the new prior authorization form eMedNY 389703. A supply of these forms will be mailed to providers in early March 2011. Note: The neweMedNY-389703 form can be used for trips that occur up to April 26; these forms must be used fortrips that occur on or after April 27.Prior Authorization Guidelines Manual:The Prior Authorization Guidelines Manual has been updated with this new information, and isavailable online at on/index.html. Thismanual provides step-by-step processing instructions for medical professionals who requestMedicaid funded transportation on behalf of their patients.Questions?Questions regarding this article or Medicaid Transportation policy can be referred to the MedicaidTransportation Policy staff at (518) 473-2160, or via email to [email protected] regarding the process for requesting Medicaid-funded transportation services can beaddressed through the Prior Authorization Guidelines Manual, online ation/index.html.Questions regarding forms? Please call the eMedNY Call Center at (800) 343-9000.January 2011 Medicaid Updatepage 10

PHARMACYUPDATESPHARMACYUPDATESPolicy & Billing Guidance from EPIC Secondary Coverage for Medicare Part DPaper Remittance Advice Discontinued:Effective January 1, 2011, EPIC will cease providing paper remittance advices toparticipating providers. To request a detailed explanation of claims transactionselectronically, please contact the EPIC Provider Helpline at (800) 634-1340 to obtain theguidelines and forms needed to receive ANSI X 12N 835 Electronic Remittance Advice.Steps to take if receiving claim denials from Part D and EPIC: Check for billing errors. Identify the correct Part D plan by submitting a Medicare Eligibility transaction (E1) toconfirm current plan information and to bill the correct Part D plan primary and EPICsecondary. Call the prescriber if a Prior Authorization (PA) is needed. If the drug is not covered because it is not on the Part D formulary, ask the prescriber ifan alternative covered drug can be substituted. If the prescriber does not want to changethe drug, notify them that if the Temporary Coverage Request (TCR) line is called(800-634-1340) EPIC will allow up to a 90-day temporary supply of the drug while thePart D plan is contacted to discuss an appeal. Explain that EPIC will cover the drug ifcoverage determination and two levels of Part D appeal are denied. If providers are unable to reach the prescriber and the beneficiary has an immediateneed for the drug, providers should call the TCR line directly and get authorization for athree–day emergency supply.Reminder: If you receive a denial from EPIC, please inform the EPIC member of the reason forthe denial.Questions? Please contact the EPIC Provider Helpline at (800) 634-1340.January 2011 Medicaid Updatepage 11

PHARMACY UPDATESAttention: New York State Medicaid and Family Health Plus PrescribersGrowth Hormones for Beneficiaries21 and OlderGrowth Hormones (Genotropin, Nutropin, Nutropin AQ , Saizen , Humatrope , Norditropin ,Omnitrope , Tev-Tropin , and Zorbtive ) for beneficiaries 21 years of age and older are currentlysubject to the prior authorization (PA) requirements of the Clinical Drug Review Program (CDRP).Prior authorization for beneficiaries 21 years of age and older must be initiated by the prescribercalling (877) 309-9493 and speaking to a clinical call center representative. A CDRP growthhormone worksheet is available to assist providers with the PA process. Please /NYRx CDRP PAworksheet Prescribers Growth Hormones.pdf.After you obtain a PA number ending in W please complete the following process: Provide the pharmacy with the prior authorization number; Provide the pharmacy with the following phone number (518) 473-0912; Inform the pharmacy that they must call (518) 473-0912 after they submit theclaim and it is denied, and Medicaid staff will process the prior authorization.For additional information regarding the CDRP, please visit www.nyhealth.gov andhttp://newyork.fhsc.com or contact the clinical call center at (877) 309-9493.January 2011 Medicaid Updatepage 12

PHARMACY UPDATESImportant Notice to PharmaciesNew York Medicaid PharmacyHome Delivery PolicyThe Department has received numerous requests from providers foradditional clarification regarding Medicaid’s policy on pharmacy homedelivery.Prescription drugs, over-the-counter products, medical/surgical supplies, anddurable medical equipment (DME) can be delivered to the homes of Medicaid beneficiaries (non institutional residences), provided pharmacies implement and operate a distribution and deliverysystem that reflects “best practices”.If a pharmacy chooses to provide this optional service to their customers, the following criteria willapply to home delivery provided to Medicaid beneficiaries:1. All shipping and delivery costs are the responsibility of the pharmacy.2. Medicaid beneficiaries can not be charged for delivery if Medicaid reimburses for all or anyportion of the item being delivered.3. The pharmacy should inform the beneficiary or their designee of the pharmacy’s deliveryschedule, verify the date and location for the delivery, and notify the beneficiary that a signaturewill be required at the time of delivery. The number of times a pharmacy attempts to deliver isleft to the discretion of the pharmacy.4. The pharmacy must advise the beneficiary or their designee, either verbally or in writing (e.g., apatient information leaflet) of the correct handling and storage of the delivered prescriptions.5. The pharmacy is accountable for proper delivery and will obtain a signature from the beneficiaryor their designee confirming the delivery. A waiver signature form is not an acceptable practice,and such forms will not serve as confirmation of delivery. Delivery confirmation must bemaintained by the pharmacy for six years from the date of payment and must be retrievableupon audit. Delivery industry tracking receipts that contain a signature qualify as a signature forreceipt of delivery. Electronic signatures for receipt are permitted only if retrievable and kept onfile by the pharmacy.6. The pharmacy is liable for the cost of any prescription damaged or lost through distribution anddelivery.Questions? Please contact the Office of Health Insurance Programs at (518) 486-3209.January 2011 Medicaid Updatepage 13

PHARMACY UPDATESUpcoming ChangesNew York State Medicaid PreferredDiabetic Supply ProgramEffective March 1, 2011, modifications will be made to the New York State Medicaid PreferredDiabetic Supply Program (PDSP). The Department of Health has selected Abbott, Bayer and LifeScanas preferred manufacturers.Preferred blood glucose monitors and corresponding test strips from the preferred manufacturers willbe available without prior approval. Beneficiaries currently using non-preferred products will require anew fiscal order to obtain preferred monitors and strips. If preferred products do not meet abeneficiary’s medical needs, a non-preferred product will require prior approval. Prior approval isbased on documentation of medical necessity. If approved, non-preferred products are billed usingHCPCS codes on the DME claim form.Note: In order to facilitate a smooth transition, the implementation of the new Preferred Supply List(PSL), will be phased-in as follows: As of February 1, 2011, only Abbott, Bayer and LifeScan blood glucose monitors will beavailable through the PDSP. Therefore, providers are strongly encouraged to dispensemonitors manufactured by Abbott, Bayer or LifeScan effective immediately. This willensure that beneficiaries will not have to switch monitors on March 1, 2011. Test strips for non-preferred meters will remain on the PSL through February 28, 2011.The current PSL is available at s.asp.Providers are encouraged to frequently visit the PDSP Web site for updates to the program.Additional information is available on the following Web sites:www.nyhealth.gov or http://newyork.fhsc.com or www.eMedNY.orgQuestions?PDSP Policy: (518) 486-3209Prior Approval: (800) 342-3005Billing: (800) 343-9000January 2011 Medicaid Updatepage 14

ALL PROVIDERSDid You Know?Medicaid Covers Smoking CessationPharmacotherapiesSmoking cessation therapy consists of prescription and non-prescription agents. Covered agents include nasalsprays, inhalers, Zyban (bupropion), Chantix (varenicline), over-the-counter nicotine patches and gum.Two courses of smoking cessation therapy per recipient, per year are allowed. A course of therapy is defined as nomore than a 90-day supply (an original order and two refills, even if less than a 30-day supply is dispensed in anyfill). If a course of smoking cessation therapy is interrupted, it will be considered one complete course of therapy.Any subsequent prescriptions would then be considered the second course of therapy.Some smoking cessation therapies may be used together.Professional judgment should be exercised when dispensingmultiple smoking cessation products. Duplicative use of any oneagent is not allowed (i.e., same drug and same dosage form andsame strength).Help your patients’ kick thisdeadly habit!NYS SMOKERS’ QUITLINE:(866) NY-QUITS (866-697-8487)For all smoking cessation products, the recipient must have anorder. A prescription is the terminology for an order of a prescription product. A fiscal order refers to an order,which looks just like a prescription—written on a prescription blank, for an over-the-counter product.Prescription nicotine patches will no longer be reimbursed. New York State Medicaid will only reimburse forover-the counter nicotine patches. For more information on the New York State Medicaid Smoking Cessationpolicy, please call (518) 486-3209.January 2011 Medicaid Updatepage 15

ALL PROVIDERSAttention eMedNY Gateway Users:eMedNY Gateway To Be EliminatedThe eMedNY Gateway will be eliminated on April 1, 2011. In order to be prepared for this implementation,eMedNY Gateway submitters are strongly encouraged to consider the alternative options available now.eMedNY eXchange Internet accessibleEasy to use – works just like an e-mailmailboxNo special scripting or software necessaryto upload or download filesFiles retained for 28 days after submissionePACES user ID is used to access youreMedNY eXchange mailbox All HIPAA x12 Batch and NCPDP Batch filessupported Can receive 835 Electronic Remits, PDFremits, PA Rosters Provider Test Environment can be accessedFTP (Dial-up) For those without high speed internet access who wish to continue to use a dial-up methodLogin and file transmission is fully scriptable.All HIPAA x12 Batch and NCPDP Batch files supportedCan receive 835 Electronic RemitsProvider Test Environment can be accessedeMedNY Simple Object Access Protocol (SOAP) – Batch, Real-Time Trading Partners may use SOAP, and the underlining Service Oriented Architecture (SOA) for exchangeof batch files with eMedNY. eMedNY SOAP is an XML based protocol which enables applications to exchange information overHyper Text Transfer Protocol (HTTP). The interface for this access method is completely user defined. Trading partners should discussthis option with their software vendor/programmer to see if this is a good fit. Uses an existing FTP or ePACES user ID. All HIPAA x12 Batch and NCPDP batch files are supported with Batch submission. 270 Eligibility and Meds History (NCPDP) are supported with Real-Time submission.All technical guides for each of these methods are posted in the Companion Guide section of NYHIPAA DeskSupport pages on www.emedny.org. Software vendor listings are also available on the NYHIPAA Desk Supportpages.Questions? Please visit www.emedny.org or contact the Call Center at (800) 343-9000. You may also e-mailyour questions to [email protected] 2011 Medicaid Updatepage 16

ALL PROVIDERSImportant Information about the 1099 FormComputer Sciences Corporation (CSC), the eMedNY contractor for the NYS Department of Health(NYSDOH), annually issues the Internal Revenue Service

insurance, the health care workforce, economics, business, consumer rights and other relevant areas. New York State Medicaid spends more than 53 billion annually to provide health care to more than 4.7 million people in need. In effect, Medicaid is the largest health insurance program in New York State. The