Archive for the ‘MEDICAID UPDATES’ Category

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New Requirements for All Billing Providers to Begin on August 22, 2013

Thursday, August 8th, 2013

As previously announced the NYS Department of Health will soon require all billing providers to sign up for electronic funds transfer (EFT) payments and either Electronic Remittance Advice (ERA) or a PDF version of the paper remittance delivered via eMedNY eXchange.

This requirement will apply to existing providers as their current ETIN Certification is renewed over the next year. The recertification notices sent by eMedNY will alert providers if they are required to sign up for EFT and/or ERA or PDF remittances.
For new providers who submit enrollment applications as of August 23, 2013. Please visit www.emedny.org on or after this date for information and instructions for enrolling new providers. Please pay careful attention to the new requirement for a Certification Statement and an EFT Application to accompany each new enrollment packet for billing providers. For more information click here.

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NYS Medicaid Ordering/Prescribing/Referring/Attending (OPRA) Provider Enrollment Impact on Pharmacy Claims

Tuesday, July 16th, 2013

As has been reported in previous Medicaid Updates (April 2011 and June 2012),
provisions of the Affordable Care Act (ACA) require prescribers to be enrolled in state
Medicaid programs to be eligible to order or refer services reimbursed by the fee-forservice
(FFS) Medicaid program. This means that any practitioner not currently enrolled in
NYS Medicaid must do so to continue to order or refer services for FFS beneficiaries.
Effective October 2013, prescriptions written by prescribers that are not enrolled in
NYS FFS Medicaid will deny at the point-of-service. Failure to enroll will impact your
patients’ ability to obtain their medications.
The Department has identified non-enrolled prescribers with high volumes of prescriptions
for FFS beneficiaries. Staff members are proactively reaching out to those prescribers in
an effort to facilitate enrollment in an effort to ensure that patient care is not disrupted.
Non-enrolled providers should visit the eMedNY website at:
https://www.emedny.org/info/ProviderEnrollment/index.aspx
*Scroll to the bottom of the page and click on the specific provider type to begin the
enrollment process.
OPRA Pharmacy-Related
Frequently Asked Questions
1. Why do non-billing physicians and healthcare professionals need to enroll in
the NYS Medicaid program?
The Affordable Care Act and subsequent federal regulations (42CFR 455.410)
include provisions requiring additional screening of Medicaid providers to improve
the integrity of the Medicaid program and to reduce fraud, waste and abuse.
2. What professions must enroll in fee for service Medicaid?
Physicians and other healthcare professionals ordering/referring services provided
under the state plan or under a waiver of the state plan must enroll in Medicaid. The
order or referral must be within the professional’s scope of practice and comply with
program rules regarding ordering/referrals.
2 of 3
3. Do the ordering/referring requirements apply to prescriptions and pharmacy
claims?
Yes, the prescriber listed on the fee for service drug claim must be enrolled in NYS
Medicaid.
4. Do out of state ordering/referring professionals need to be enrolled in NYS
Medicaid?
Yes, out of state professionals ordering/referring for services paid by fee for service
Medicaid must enroll.
5. What messaging will the Pharmacist receive, via NCPDP transaction, if the
prescriber is not enrolled?
Pharmacies will receive a Reject Code of “56″- (Non matched Prescriber ID) in
NCPDP field number 511-FB.
6. Can a pharmacist override a rejected transaction if the prescriber is not
enrolled?
No.
7. What should a pharmacist do once a transaction is rejected?
Pharmacists can either contact the prescriber or return the prescription to the
member to contact the prescriber.
8. I have an order or prescription from a healthcare professional. How do I know
if he/she is enrolled in NYS Medicaid?
Refer to the search tool available at https://www.emedny.org/info/opra.aspx
9. What should a patient do if they are told their prescriber is not enrolled in
Medicaid and therefore their prescription is not covered?
Members should contact their prescriber.
.
10. How does a prescriber enroll as ordering/referring?
Visit the eMedNY
website:https://www.emedny.org/info/ProviderEnrollment/index.aspx and click on
the provider type’s Provider Enrollment page for the OPRA form. Be sure to
complete all required fields, answer all questions and provide all required
documentation. For assistance with enrollment application questions, call CSC at
(800) 343-9000.
3 of 3
11. Does this requirement apply to managed care providers?
The ordering/referring enrollment requirement does not apply to services paid
through a Medicaid managed care plan. However, if the service is carved out of the
plan benefit package and is paid fee for service, the requirement applies.
12. When must the attending professional be enrolled (institutional claims)?
The attending professional must be enrolled if the Referring NPI field is blank on the
institutional (837I) claim. This is because the Attending NPI is considered the
ordering/referring provider in the absence of a Referring NPI.
13. In a clinic there are nurses and other health professionals that support the
physician; do these professionals need to enroll as ordering/referring
providers?
In medical clinics, nurses and health professional support staff are not typically
ordering or referring services, so they would likely not need to enroll as
ordering/referring professionals. Note that if these staff are reported in the Attending
NPI field on the clinic claim, the medical practitioner who is responsible for
ordering/referring should be reported in the Referring NPI field.
14. Do medical residents need to be enrolled?
Medical residents should enroll with NY Medicaid once they are licensed. Medical
residents not yet licensed should provide the attending/supervising physician’s
name & NPI number on all prescriptions written by that resident.
15. What is the time frame for compliance?
Providers should be reporting ordering/referring professionals on claims now. It is
expected that enforcement of the enrollment requirement in claims processing will
begin in October 2013.
16. What is the turn-around time for the expedited enrollment process?
Most enrollments are processed within 30 days of receipt of a completed
application.
17. Can the Medicaid enrollment be back dated?
After receiving their enrollment approval letter, the provider may request retroactive
enrollment by contacting the Bureau of Provider Enrollment at
ffspe@health.state.ny.us
18. Do the Medicaid numbers expire since they are not being used – how often,
what is the reactivation process?
The Medicaid enrollment will not be automatically terminated for non-billing.
However, providers will have to revalidate their enrollment periodically.
NEW
As has been reported in previous Medicaid Updates (April 2011 and June 2012), provisions of the Affordable Care Act (ACA) require prescribers to be enrolled in state Medicaid programs to be eligible to order or refer services reimbursed by the fee-forservice (FFS) Medicaid program. This means that any practitioner not currently enrolled in NYS Medicaid must do so to continue to order or refer services for FFS beneficiaries.
Effective October 2013, prescriptions written by prescribers that are not enrolled in NYS FFS Medicaid will deny at the point-of-service. Failure to enroll will impact your patients’ ability to obtain their medications.
The Department has identified non-enrolled prescribers with high volumes of prescriptions for FFS beneficiaries. Staff members are proactively reaching out to those prescribers in an effort to facilitate enrollment in an effort to ensure that patient care is not disrupted.
Non-enrolled providers should visit the eMedNY website at: https://www.emedny.org/info/ProviderEnrollment/index.aspx
*Scroll to the bottom of the page and click on the specific provider type to begin the enrollment process.
OPRA Pharmacy-Related Frequently Asked Questions
1. Why do non-billing physicians and healthcare professionals need to enroll in the NYS Medicaid program?
The Affordable Care Act and subsequent federal regulations (42CFR 455.410) include provisions requiring additional screening of Medicaid providers to improve the integrity of the Medicaid program and to reduce fraud, waste and abuse.
2. What professions must enroll in fee for service Medicaid?
Physicians and other healthcare professionals ordering/referring services provided under the state plan or under a waiver of the state plan must enroll in Medicaid. The order or referral must be within the professional’s scope of practice and comply with program rules regarding ordering/referrals.
3. Do the ordering/referring requirements apply to prescriptions and pharmacy claims?
Yes, the prescriber listed on the fee for service drug claim must be enrolled in NYS Medicaid.
4. Do out of state ordering/referring professionals need to be enrolled in NYS Medicaid?
Yes, out of state professionals ordering/referring for services paid by fee for service Medicaid must enroll.
5. What messaging will the Pharmacist receive, via NCPDP transaction, if the prescriber is not enrolled?
Pharmacies will receive a Reject Code of “56″- (Non matched Prescriber ID) in NCPDP field number 511-FB.
6. Can a pharmacist override a rejected transaction if the prescriber is not enrolled?
No.

7. What should a pharmacist do once a transaction is rejected?
Pharmacists can either contact the prescriber or return the prescription to the
member to contact the prescriber.

8. I have an order or prescription from a healthcare professional. How do I know if he/she is enrolled in NYS Medicaid?
Refer to the search tool available at https://www.emedny.org/info/opra.aspx

9. What should a patient do if they are told their prescriber is not enrolled in Medicaid and therefore their prescription is not covered?
Members should contact their prescriber.
.
10. How does a prescriber enroll as ordering/referring?
Visit the eMedNY website:https://www.emedny.org/info/ProviderEnrollment/index.aspx and click on the provider type’s Provider Enrollment page for the OPRA form. Be sure to complete all required fields, answer all questions and provide all required documentation. For assistance with enrollment application questions, call CSC at (800) 343-9000.
11. Does this requirement apply to managed care providers?
The ordering/referring enrollment requirement does not apply to services paid through a Medicaid managed care plan. However, if the service is carved out of the plan benefit package and is paid fee for service, the requirement applies.
12. When must the attending professional be enrolled (institutional claims)?
The attending professional must be enrolled if the Referring NPI field is blank on the institutional (837I) claim. This is because the Attending NPI is considered the ordering/referring provider in the absence of a Referring NPI.
13. In a clinic there are nurses and other health professionals that support the physician; do these professionals need to enroll as ordering/referring providers?
In medical clinics, nurses and health professional support staff are not typically ordering or referring services, so they would likely not need to enroll as ordering/referring professionals. Note that if these staff are reported in the Attending NPI field on the clinic claim, the medical practitioner who is responsible for ordering/referring should be reported in the Referring NPI field.

NEW 14. Do medical residents need to be enrolled?
Medical residents should enroll with NY Medicaid once they are licensed. Medical residents not yet licensed should provide the attending/supervising physician’s name & NPI number on all prescriptions written by that resident.
15. What is the time frame for compliance?
Providers should be reporting ordering/referring professionals on claims now. It is expected that enforcement of the enrollment requirement in claims processing will begin in October 2013.
16. What is the turn-around time for the expedited enrollment process?
Most enrollments are processed within 30 days of receipt of a completed application.
17. Can the Medicaid enrollment be back dated?
After receiving their enrollment approval letter, the provider may request retroactive enrollment by contacting the Bureau of Provider Enrollment at ffspe@health.state.ny.us.
18. Do the Medicaid numbers expire since they are not being used – how often, what is the reactivation process?
The Medicaid enrollment will not be automatically terminated for non-billing.However, providers will have to revalidate their enrollment
periodically.

Posted in HEALTH DEPARTMENT UPDATES, MEDICAID UPDATES | No Comments »

New York Launches Their Medicaid EHR Programs This Month

Monday, November 14th, 2011

On November 7th, the Medicaid Electronic Health Record (EHR) Incentive Program launched in New York. This means that eligible professionals (EPs) and eligible hospitals in New York will be able to complete their incentive program registration. More information about the Medicaid EHR Incentive Program can be found on the Medicare and Medicaid EHR Incentive Program Basics page of the CMS EHR website.

If you are a resident of New York, and are eligible to participate in the Medicaid EHR Incentive Program, visit your State Medicaid Agency website for more information on your state’s participation in the Medicaid EHR Incentive Program. Click on a State below to access its website.

As of November 7th, 39 states have launched Medicaid EHR Incentive Programs and through October, 23 states have issued incentive payments to Medicaid EPs and eligible hospitals who have adopted, implemented, or upgraded certified EHR technology. CMS looks forward to announcing the launches of additional states’ programs in the coming months.

For a complete list of states that have already begun participation in the Medicaid EHR Incentive Program, see the Medicaid State Information page on the CMS EHR website.

Want more information about the EHR Incentive Programs?
Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

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NYS Department of Health Medicaid Managed Care Call September 14

Wednesday, September 7th, 2011

Do you have questions regarding prescription drug coverage for your Medicaid patients when, starting October 1, their pharmacy coverage will be transitioned to Medicaid Managed Care?

At the request of the Medical Society of the State of New York (MSSNY), on Wednesday, September 14, Department of Health staff led by Janet Elkind, Director of the Bureau of Pharmacy & Policy Operations, will host a call specifically for physicians and their staff to ask questions regarding this important change in Medicaid prescription drug coverage.

The call will take place at 5:00 PM.

The call-in information is:

Call in #: 866-394-2346
Passcode: 590 814 6107

Please confirm your participation in this call by e-mailing mhardin@mssny.org

As has been previously reported in the MSSNY e-news, all physicians that treat Medicaid beneficiaries should be aware that, effective October 1, their patients enrolled in Medicaid Managed Care (MMC) plans will begin receiving their prescription drug coverage through their plans, rather than through the state fee for service program.  The change was one of a myriad of cost-saving measures that were proposed by the Governor’s Medicaid Redesign Team and enacted as part of the 2011-12 State Budget.   Medicaid prescription drug coverage had been “carved out” of MMC since the late 1990s.

MMC plans will establish their own formularies and prior authorization procedures.  However, health plans will be required to include on their formularies all categories of prescription drugs that are currently part of the New York State Medicaid fee for service prescription program.  Consistent with New York’s managed care utilization review laws, plans will also be required to maintain internal appeals systems and assure access to an external appeal to address circumstances where patients are denied coverage for medications that are prescribed by their treating physicians.

MMC plans are required to develop and implement comprehensive implementation and communication plans to assure patient access to needed medications.  These transition plans must be approved by the NYS Department of Health (DOH).  DOH has indicated that it will permit a one-time, temporary fill of non-formulary drugs for up to a 30 day supply of medication.  This would include drugs that are on a plan’s formulary but require prior authorization or step therapy under a plan’s utilization management rules.

Recognizing the confusion that implementation of this change may cause, MSSNY has urged DOH to take a number of steps to reduce transitional issues.  These include asking DOH to maintain a link on its website where physicians will be able to easily check the formularies and prescription authorization procedures that will be established by each MMC plan; assuring MMC plans have sufficient staff to promptly respond to physician requests for non-formulary medications; and facilitating meetings and communications with physicians across the State of New York to get local physician feedback.

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AMA Continues to Press CMS on E-prescribing Penalty

Tuesday, August 30th, 2011

The AMA continues to hear concerns expressed by physicians, states and specialty societies that a significant number of physicians will be subjected to the e-prescribing penalty in January 2012.

Consequently, the AMA’s Executive Vice President, James Madara, MD, called Centers for Medicare & Medicaid Services (CMS) Administrator Donald Berwick, MD, to urge the agency to provide more flexibility so that a 1 percent penalty in 2012 does not affect as many physicians. During the call, Dr. Madara thanked Dr. Berwick for issuing a recent proposed rule creating additional penalty exemptions, but went on to alert the administrator to the concerns being expressed. He urged Dr. Berwick to consider additional steps, such as establishing a new reporting period in 2012 and refraining from applying the penalty until 2013.

The AMA strongly believes that the agency plans to apply the penalty a year earlier than called for by Congress. Dr. Madara’s call follows a July 25 sign-on comment letter to CMS, where the AMA was joined by 92 states and specialty societies in calling for greater program flexibility. The AMA will continue to follow-up with CMS to secure additional changes to the program.

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ATTENTION PHYSICIANS! E-PRESCRIBING INCENTIVE REMINDER:

Thursday, June 23rd, 2011

The New York Medicaid e-prescribing incentive program applies only to non-facsimile electronic transmissions when compliant with Medicare Part D data standards.

E-Prescribing Incentive checks are being returned by prescribers who claim they do not e-prescribe.

PLEASE NOTE THE FOLLOWING:

Electronic Prescription Definition

New York State Pharmacy Regulations (http://www.op.nysed.gov/part63.htm) recognize two distinct types of electronically-transmitted prescriptions:
· a prescription transmitted electronically by facsimile;

  • · a prescription transmitted electronically by means other than facsimile; such non-facsimile prescriptions are required by regulation to be electronically encrypted, meaning protected to prevent access, alteration or use by any unauthorized person.

The New York Medicaid Program accepts both types of electronically-transmitted prescriptions for standard claim reimbursement. However, pharmacies must verify a prescription is compliant with Medicare Part D data standards and requirements and NYS Pharmacy Regulations before submitting for the e-prescribing incentive.

Claims for prescriptions transmitted electronically by means other than facsimile and not Medicare Part D compliant are recognized by New York Medicaid for claim reimbursement purposes, but do not qualify for the e-prescribing incentive reimbursement.

The e-prescription must originate from the prescriber’s computer system (an electronic health record, electronic medical record, or stand-alone e-prescribing software) and must be transmitted to the retail pharmacy’s computer system.

For more information go to: http://www.health.ny.gov/health_care/medicaid/program/update/2009/2009-11spec.htm

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Medicaid Redesign Team Makes Historic Recommendations

Friday, March 4th, 2011

HISTORIC PROGRESS MADE IN REFORMING MEDICAID IN NEW YORK STATE

New York spends more on Medicaid per capita than any other state in the nation, but we rank only 21st in program quality for patients. In most counties, Medicaid costs alone account for more than half of the entire county tax levy.

To reform the system, Governor Cuomo created a Medicaid Redesign Team. The Team — comprised of health care professionals, stakeholders, and legislators — was charged with reducing costs and improving patient care. The Team held open meetings throughout the state and reviewed more than 4,000 ideas from team members, outside health care professionals, and citizens.

Last week, the Team accomplished their goal, submitting an unprecedented consensus plan that meets the Governor’s budget target and saves over $2.3 billion. What’s more, under the plan, one million New Yorkers will now have access to an innovative “patient-centered” medical program, making New York the national leader in providing this type of personal care. Today, the legislation to enact the plan was submitted to the Legislature to be included as part of the Executive Budget.

If you would like more information on this historic plan, click here to read about the Medicaid report. Thank you.

March 3, 2011

Posted in MEDICAID UPDATES, NEWS FROM THE NYS LEGISLATURE | No Comments »

NYS Medicaid Preferred Drug List effective 7.28.10

Friday, July 23rd, 2010

Attached is the most recent updated Preferred Drug List.  Please feel free to share this with your members or post a link to your website.  If your organization would like to schedule a presentation or if you have any questions or concerns regarding this program, please contact 518-951-2051 .

Please be aware of changes to the preferred and non-preferred status of some drugs on the preferred drug list, effective July 28, 2010.

Please visit: https://newyork.fhsc.com/

The preferred drug list can be found at:

https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf

A ‘quicklist’ of preferred drugs only can be found at:

https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDLquicklist.pdf

All changes to the NYS Medicaid Preferred Drug List will be communicated to providers via the monthly Medicaid Update publications.  Notifications will no longer be mailed to providers.

We appreciate your support of the New York State Medicaid Program.

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NYS Medicaid Preferred Drug List Effective 6.17.10

Wednesday, June 16th, 2010

The following link will take you to the most recent updated Preferred Drug List.  Please feel free to share this with your members or post a link to your website.  If your organization would like to schedule a presentation or if you have any questions or concerns regarding this program, please contact 518-951-2051.

Please be aware of changes to the preferred and non-preferred status of some drugs on the preferred drug list, effective June 17, 2010.

In addition to these changes, the New York State Medicaid Clinical Drug Review Program (CDRP) is expanding to require prior authorization for the following:

  • Growth Hormones (Genotropin®, Nutropin®, Nutropin AQ®, Saizen®, Humatrope®, Norditropin®, Omnitrope®, Tev-Tropin®, and Zorbtive®) for enrollees 21 years of age or older effective June 17, 2010.

Please visit https://newyork.fhsc.com/

The preferred drug list can be found at:

https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf

A ‘quicklist’ of preferred drugs only can be found at:

https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDLquicklist.pdf

Prior Authorization Forms and Worksheets can be found at:

https://newyork.fhsc.com/providers/PA_forms.asp

EFFECTIVE IMMEDIATELY all changes to the NYS Medicaid Preferred Drug List will be communicated to providers via the monthly Medicaid Update publications.  Notifications will no longer be mailed to providers.

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