Archived Homepage Notices

Attention: Change Healthcare/Optum Cybersecurity Incident, Delay Reason Code 15 (Natural Disaster) Guidance

Due to the cybersecurity incident that occurred with Change Healthcare/Optum on February 21, 2024, claims that exceed the timely filing limits may be submitted electronically using Delay Reason 15 (Natural Disaster). There is no additional documentation required to use Delay Reason 15; however, where particular claims require documentation, such as invoices for pricing, the claim and all necessary documentation should be submitted as a paper claim along with the delay reason form indicating delay reason 15. Providers should also maintain documentation that supports being affected by this incident.

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Attention: A New Provider Communication has been Posted for DME and PHARMACY providers

Updated Durable Medical Equipment, Orthotics, Prosthetics and Supplies (DMEPOS) Fiscal Order Acceptance Policy

Effective May 15, 2024, the following updates have been made to the DMEPOS fiscal order policy. If a fiscal order is missing required information (outlined on page 12 of the DMEPOS Policy Guidelines Manual), certain changes to fiscal orders may be obtained verbally by DMEPOS and pharmacy providers when using appropriate tracking methods. The provider must confirm, and keep on file, proof that the changes were requested by the ordering provider.

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Attention: A New Provider Communication has been Posted for DME and PHARMACY providers

Update to Coverage and Billing of Continuous Glucose Monitors and Related Supplies in the Preferred Diabetic Supply Program

Effective June 3, 2024, Continuous Glucose Monitors (CGM) and related supplies listed in the Preferred Diabetic Supply Program (PDSP) will only be available from a Medicaid enrolled pharmacy provider. Durable Medical Equipment, Prosthetics, Orthotics and Supply (DMEPOS) providers will no longer be able to dispense CGMs and related supplies listed in the PDSP.

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Attention: The 2024 DME Policy Guidelines, DME Procedure Codes & Coverage Guidelines manual, The Medical Supply Procedure Codes & Coverage Guidelines manual, and DMEPOS Fee Schedule have been updated.

Any changes reflected in the manuals are effective for dates of service beginning April 1, 2024. Questions related to coverage criteria and guidelines can be directed to the Office of Health Insurance Programs at OHIPMedPA@health.ny.gov. Pharmacy coverage questions can be directed to NYRx@health.ny.gov. Billing related questions can be directed to GDIT at (800) 343-9000.

Attention: A provider communication has been posted regarding the reorganization of the Durable Medical Equipment, Prosthetics, Orthotics, and Supply (DMEPOS) Procedure Code Manual and Fee Schedules.

Questions related to this communication can be directed to the Office of Health Insurance Programs at OHIPMedPA@health.ny.gov.

Reorganization of the 2024 Durable Medical Equipment, Prosthetics, Orthotics and Medical Supplies (DMEPOS) Procedure Code Manual and Fee Schedules

Attention: A Dental Provider Communication is Now Available

NYS Medicaid Dental Policies - All Stakeholder Webinar Frequently Asked Questions (FAQ)

Attention: 2024 NYS MEDICAID DENTAL POLICY AND PROCEDURE CODE MANUAL AND UPDATED FEE SCHEDULE

Updated guidance documents include:

• 2024 Dental Policy and Procedure Code Manual
• Updated Fee Schedule
• Revisions Table

The revised documents are effective January 31, 2024 and may be referenced online on the Dental Manual Page

Attention: A Dental Provider Communication is Now Available

The New York State Department of Health (DOH) hosted the New NYS Dental Policies informational webinar on January 2, 2024 regarding updates to the New York State Medicaid Dental Policy Program effective January 31, 2024. The slides and replay to this webinar are now available. The replay to this webinar can be accessed here: https://www.youtube.com/watch?v=3dCOwBqDGwM

Presentation on the New NYS Dental Policies

Attention: A DME and Pharmacy Provider Communication is Now Available

The following provider communication has been posted for DME and Pharmacy Providers:

Addition of Parenteral Nutrition HCPCS B4187

Attention: A DME and Pharmacy Provider Communication is Now Available

The following provider communication has been posted for DME and Pharmacy Providers:

Enteral Nutrition Pricing Increase

Attention: Electronic Visit Verification (EVV) Update for PDN Provider

An important update regarding EVV is available at the link below. The update pertains to both Licensed Home Care Services Agency (LHCSA) PDN providers and Independently Enrolled RN and LPN PDN providers: https://www.health.ny.gov/health_care/medicaid/redesign/evv/2023-11-13_pdn_comm.htm

Additional information regarding EVV can be found at: https://www.health.ny.gov/health_care/medicaid/redesign/evv/

Questions regarding EVV can be directed to EVVhelp@health.ny.gov
Questions regarding PDN can be directed to OHIPMEDPA@health.ny.gov

Attention: A Dental Provider Communication is Now Available

Clinical Criteria Guidance to Updated Dental Medicaid Dental Benefits Effective 1/31/2024

Attention: It's almost time for HealthHelp's Provider Satisfaction Survey

HealthHelp's Provider Satisfaction Survey is going out to providers and facilities beginning November 28, 2023.

As a user of Consult, specialty benefits management services administered by HealthHelp, your feedback is vital for improving our processes. HealthHelp provides easy ways for you to obtain authorizations: through our online web application, fax, phone authorization through our call center, and IVR automated touch phone system. We would like your input on any of the methods you have used to contact HealthHelp.

Please help us make the most of this opportunity by encouraging participation that helps us improve the provider experience!

Visit HealthHelp.com/Survey to participate. The survey link will be active beginning on November 28th. We look forward to hearing from you!

Attention: A Dental Provider Communication is Now Available

Updates to the New York State Medicaid Program Dental Policy and Procedure Code Manual

Attention: Clarification to Durable Medical Equipment, Orthotics, Prosthetics and Supplies (DMEPOS) Fiscal Order Acceptance Policy

The following clarification is being made to the DMEPOS fiscal order policy. The documents that are acceptable for a fiscal order have not changed, but clarification has been added for the following:

• Facsimile or electronic orders are acceptable for validation of a telephone orders
• Steps necessary by providers if verification of a telephone order is not provided by the ordering practitioner

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Attention: Pharmacy Billing Guidance for Brand Name Drugs with New Generic Launches

All new drugs to market are subject to clinical and fiscal review by NYRx, the Medicaid Program, for formulary placement and prior authorization requirements. The review process may occasionally cause a delay between newly launched generic drug market availability and NYRx coverage activation. During this time, pharmacists should continue to utilize the brand name drug with an appropriate Dispense-As-Written (DAW) code, in NCPDP field 408-D8. This guidance does not supersede the prescribing provider’s designation of "DAW", if indicated.

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Attention: Update Regarding Accu-Chek® Guide Test Strips compatible with MiniMed (Medtronics) Insulin Delivery System, HCPCS A4253

The Accu-Chek Test Strips that are compatible with the MiniMed Insulin Delivery System and Accu-Chek Blood Glucose Monitor are not part of the Preferred Diabetic Supply Program for NYRx, the Medicaid Pharmacy Program. Effective October 1, 2023, using code A4253, select providers can directly bill for these strips via professional claim type. All other providers will need to submit for prior approval (PA). Prior approval requests can be submitted electronically through ePACES or mailed in on a paper PA Form.

Requests for HCPCS A4253 for test strips that are compatible with glucometers with voice synthesizers will continue to require prior approval. Documentation requirements for these test strips as outlined in the DMEPOS Procedure Code manual are still in effect.

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Attention: Updated Continuous Glucose Monitoring Criteria

Effective October 1, 2023, NYS Medicaid criteria for Continuous Glucose Monitoring (CGM) has changed. The Department has revised the insulin criteria requiring frequent adjustments. The criteria now only specify that members with a diagnosis of type 1 or type 2 diabetes must have an insulin treatment plan or insulin pump. Frequent adjustments are no longer a criterion for CGM. This represents an expansion of NYS Medicaid coverage and alignment with current national coverage standards. Billing for CGM has not changed.

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Attention: NYRx Medicaid Providers - Pharmacists as Immunizers Fact Sheet

In accordance with New York State (NYS) Education law, pharmacists certified to administer immunizations are authorized to administer to patients 18 years of age and older, as recommended by the Advisory Committee on Immunization Practices (ACIP) of the Center for Disease Control and Prevention (CDC).

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Attention: A Residential Health Provider Communication is Now Available

The document, "Out-of-State Skilled Nursing Facility Claims Require Prior Approval" has been posted.

Click here to access the document.

Attention: NYRx Medicaid Providers - Dispense Brand Name Drug when Less Expensive than Generic Program

Effective 7/13/2023, the following changes will be made to the Dispense Brand Name Drug When Less Expensive Than the Generic Program:

• Dexilant, Oseni, Protonix suspension, Pylera, Vascepa and Viibryd will be ADDED to the program

Click Here to Read More

Attention: A DMEPOS Provider Communication is Now Available

Click Here to access the document.

Attention: A DME Provider Communication is Now Available

Click Here to access the document.

Attention: HealthHelp's Provider Satisfaction Survey is going out to providers and facilities beginning June 13, 2023

As a user of Consult, specialty benefits management services administered by HealthHelp, your feedback is vital for improving our processes. HealthHelp provides easy ways for you to obtain authorizations: fax, phone authorization through call center, and IVR automated touch phone system. We would like your input on any of the methods you have used to contact HealthHelp.

Please help us make the most of this opportunity by encouraging participation that helps us improve the provider experience!

Visit HealthHelp.com/Survey to participate. The survey link will be active beginning on June 13th. We look forward to hearing from you!

Attention: Important Information Regarding Electronic Claims Capture and Adjudication (ECCA) for Pharmacy Providers

To submit ECCA transactions, a Personal Identification Number (PIN) is required. Additionally, the pharmacy must have an Electronic Transmitter Identification Number (ETIN) on file with eMedNY. These should be submitted in NCPDP Processor Control NCPDP filed 104-A4.

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Attention: Coordination of Benefits & Workers Compensation Coverage

New York State (NYS) Medicaid providers are required to bill applicable third parties that may be liable for a claim before billing NYS Medicaid. Medicaid is always the payor of last resort and federal regulations require that all other available resources be used before Medicaid considers payment.

The article titled Reminder: Medicaid Requires Coordination of Benefits, published in the November 2021 issue of the Medicaid Update, directed providers to exhaust all existing benefits prior to billing the Medicaid program. Providers should always ask a Medicaid member if they have other third-party coverage to ensure the proper coordination of benefits. This includes Workers Compensation Coverage. If a patient has a work-related injury, for which they have an open Workers Compensation case, Workers’ compensation coverage must be utilized prior to billing the NYRx Medicaid Pharmacy Program.

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Attention: A DMEPOS Provider Communication is Now Available

A Provider Communication, "Information for Physicians and other Practitioners who prescribe Enteral Products for Medicaid Members, including Members affected by the Managed Care NYRx/ Fee for Service Transition" has been posted.

Click here to access the document.

Attention: *Program Update* - NYRx Providers Dispense Brand Name Drug when Less Expensive than Generic Program

On April 3rd, 2023, the brand-less-than-generic (BLTG) criteria was temporarily relaxed for Ventolin HFA, to allow pharmacists time to order the appropriate stock of that product for members. The Department wanted to ensure member access to albuterol HFA products following the change in benefit from Medicaid Managed Care to NYRx, the Medicaid Pharmacy Program, on April 1st, 2023. Effective May 8th, 2023, the Ventolin HFA BLTG criteria will be reinstated. Pharmacies should review their inventory to ensure their supply will reflect this change.

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Attention: Enteral Policy/Enteral Web Portal Training Webinar

The New York State Department of Health, Office of Health Insurance Programs, Bureau of Medical Review has launched a web portal for enteral formula authorizations. The portal allows entry of information by practitioners and dispensing providers directly into a web portal rather than using a telephonic interactive voice response (IVR) system. The current telephonic IVR will still be available and can continue to be utilized for authorizations. The web portal and IVR will work interchangeably, and an authorization can be completed if practitioners and dispensing providers use different entry methods.

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Attention: A DME Provider Communication is Now Available

A Provider Communication, "Information for DMEPOS Providers and Pharmacies dispensing Medical Supplies for Members affected by the Managed Care NYRx/ Fee for Service Benefit Transition" has been posted.

Click Here to access the document.

Attention: Matching Origin Codes to Correct Prescription Serial Number in Medicaid

Reminder: Prescriptions billed to NYRx, the Medicaid Pharmacy Program require the appropriate origin code and corresponding serial number; the information describes the format the prescription was received. Serial numbers are a unique alphanumeric number on the bottom right of an Official New York Prescription Form (ONYSRx). The table below describes all the different circumstances a prescription may be obtained at various pharmacy types; and will assist in choosing the correct match. Note: Prescription drug orders received from a ‘care coordinator’ or other party other than the prescribing practitioner are not valid.

Click Here to read more.

Attention: NYRx - Claims Submitted 4/1 – 4/4/2023

Beginning April 1, 2023, all Medicaid members in Mainstream Managed Care started receiving their prescription drugs through NYRx, the Medicaid Pharmacy Program.

NYRx system updates have been made as of today, 4/4/2023 at 12pm EST. If a claim was submitted between 4/1/2023-4/4/2023 and a rejection was received, please resubmit the claim to NYRx today. Additional updates and information will be shared as available.

Click Here to read more.

Attention: Important Information for Pharmacies Regarding the Pharmacy Transition/NYRx

On April 1, 2023, Medicaid members enrolled in mainstream Managed Care (MC) plans, Health and Recovery Plans (HARPs), and HIV-Special Needs Plans (SNPs) had their pharmacy benefits transitioned to NYRx, the NY Medicaid Pharmacy program supported by eMedNY. In January 2023, the New York State Department of Health (DOH) provided valuable information in the form of a New York State Medicaid Update.

Click Here to read more.

Attention: Medicaid Fee-for-Service Providers Dispense Brand Name Drug when Less Expensive than Generic Program

Please see the update to the Dispense Brand Name Drug When Less Expensive Than Generic Program for changes effective March 31, 2023.

Attention: Updated PDN Provider Manuals

The 2023 Private Duty Nursing Policy Guidelines and Procedure Code Manuals have been updated. Any changes reflected in the manuals are effective for dates of service beginning April 1, 2023.

• Clarification of PDN policies, procedures, and documentation requirements
• Information regarding the Medically Fragile Children and Adult Program
• Links to PDN Provider Directories
• Information regarding PDN fees set by DOH

Questions related to the revised manuals can be directed to the Office of Health Insurance Programs at OHIPMedPA@health.ny.gov. Billing related questions can be directed to eMedNY at (800) 343-9000.

Attention: 2023 NYS Medicaid Dental Policy and Procedure Code Manual and Updated Fee Schedule

• 2023 Dental Policy and Procedure Code Manual
• Updated Fee Schedule
• Change Summary Table

The revised documents are effective January 1, 2023 and may be referenced online at: https://www.emedny.org/ProviderManuals/Dental/

Attention: Updated DME Provider Manuals

Attention: The Enteral Web Portal is live as of March 2nd, 2023.

Attention: NYS Medicaid Enteral Prior Authorization Enhancements - Web Portal Launch and Training Sessions

The New York State Department of Health, Office of Health Insurance Programs, Bureau of Medical Review will be launching a new web portal for enteral formula authorizations. The portal will allow entry of information by practitioners and dispensing providers directly into a web portal rather than using a telephonic interactive voice response (IVR) system. The current telephonic IVR will still be available and can continue to be utilized for authorizations. The web portal and IVR will work interchangeably, and an authorization can be completed if practitioners and dispensing providers use different entry methods.

Click here for detailed information.

Attention: An Updated DME Provider Communication is Now Available

The document, "Correction-2023 Coding Changes for Continuous Glucose Monitoring" effective January 1,2023 has been posted.

Click here to access the document.

Attention: Medicaid Fee-for-Service Providers Dispense Brand Name Drug when Less Expensive than Generic Program

Effective 1/19/2023, the following changes will be made to the Dispense Brand Name Drug When Less Expensive Than the Generic Program:

• Glumetza will be ADDED to the program

Click Here to Read More

Attention: A DME Provider Communication is Now Available

The document, "2023 Coding Changes for Continuous Glucose Monitoring" effective January 1, 2023 has been posted.

Click here to access the document.

Attention: Medicaid Pharmacy Benefit Transition - MU Special Edition

Effective April 1, 2023, NYS Medicaid members enrolled in mainstream Medicaid Managed Care (MMC) Plans, Health and Recovery Plans (HARPs), and HIV-Special Needs Plans (SNPs) will receive their pharmacy benefits through the NYRx Pharmacy program instead of through their MMC Plan. The pharmacy benefit transition to NYRx does not apply to NYS Medicaid members enrolled in Managed Long-Term Care (MLTC) Plans [e.g., MLTC, Programs of All-Inclusive Care for the Elderly (PACE), Medicaid Advantage Plus (MAP), the Essential Plan, or Child Health Plus (CHP)]. Transitioning the pharmacy benefit from MMC to NYRx will provide NYS with full visibility into prescription drug costs, allow centralization of the benefit, leverage negotiation power, and provide a uniform list of covered drugs with standardized utilization management protocols simplifying and streamlining the drug benefit for NYS Medicaid members. NYS Medicaid consumers have comprehensive drug coverage and equitable access to an extensive network of over 5,000 pharmacy providers.

For more information on the Medicaid Pharmacy Benefit Transition please see the New York State Medicaid Update - October 2022 Medicaid Pharmacy Prescription Drug Benefit Transition Part One: Special Edition

Attention: Help's Provider Satisfaction Survey is going out to providers and facilities beginning November 29, 2022

As a user of Consult, specialty benefits management services administered by Health Help, your feedback is vital for improving our processes. Health Help provides easy ways for you to obtain authorizations: online web application, fax, phone authorization through call center, and IVR automated touch phone system. We would like your input on any of the methods you have used to contact Health Help.

Please participate to help us improve our processes with your feedback. The survey takes about five minutes to complete.

Please help us make the most of this opportunity by encouraging participation that helps us improve the provider experience! Visit HealthHelp.com/Survey to participate. The survey link will be active beginning on November 29th. We look forward to hearing from you!

Attention: Healthcare Worker Bonus (HWB) Program – Vesting Period Two

The New York State Department of Health (NYSDOH) is pleased to announce that the HWB Program Portal is now open to facilitate submission by eligible employers on behalf of their employees who qualify for bonus payments for Vesting Period 2. Vesting Period 2 is the timespan between April 1, 2022 and September 30, 2022. The HWB Program Portal will be open for submission for a period of thirty (30) days.

For more information on the Healthcare Worker Bonus (HWB) Program, please visit the NYSDOH HWB Program webpage which also includes a Frequently Asked Questions (FAQ) page. Qualified employers are encouraged to routinely review these resources for the latest information. The FAQ page will continue to be updated as additional information becomes available.

Attention: Healthcare Worker Bonus (HWB) Program Frequently Asked Questions have been updated

The Healthcare Worker Bonus (HWB) Program Frequently Asked Questions have been updated on the Frequently Asked Questions page. Qualified employers are encouraged to routinely review these resources for the latest information.

The Department is committed to updating the information it has provided as new questions come in and are answered. To this end, the Department has established an email address (NYSWorkersBonus@health.ny.gov) dedicated to the HWB program. Please direct your inquiry to this inbox to make sure your questions are received and processed. The Department has also established the HWB Call Center dedicated to answering questions about the online claims portal and assisting qualified employers with submitting their claims. The HWB Call Center can be reached at 1 (866) 682-0077.

Attention: Healthcare Worker Bonus (HWB) Program Town Hall Series

A new slide deck from the Healthcare Worker Bonus (HWB) Program Town Hall Series is now available on the New York State HWB Home Page. Additionally, please see the Frequently Asked Questions page where many new FAQs have been added. Qualified employers are encouraged to routinely review these resources for the latest information, which will be updated on a regular basis.

The Department is committed to updating the information it has provided as new questions come in and are answered. To this end, the Department has established an email address (NYSWorkersBonus@health.ny.gov) dedicated to the HWB program. Please direct your inquiry to this inbox to make sure your questions are received and processed. The Department has also established the HWB Call Center dedicated to answering questions about the online claims portal and assisting qualified employers with submitting their claims. The HWB Call Center can be reached at 1 (866) 682-0077.

Attention: Healthcare Worker Bonus (HWB) Program – Town Hall Webinar Update

Thank you for your continued interest in the Healthcare Worker Bonus (HWB) Program. In order to communicate most effectively with the most amount of interested stakeholders, the Department of Health has decided to pre-record upcoming Healthcare Worker Bonus Program Town Hall Webinars, and will post them to the NYS Healthcare Worker Bonus (HWB) Home Page. Moving forward, the Department will plan to post a new recording each week, on Friday, until further notice.

Click Here to Read More

Attention: Healthcare Worker Bonus (HWB) Program – Town Hall Webinar Update

The 11 a.m. and 1 p.m. sessions for this Friday's scheduled Healthcare Worker Bonus (HWB) Program Town Hall Stakeholder Webinar have now reached max capacity. A recording of the webinar will be posted to the NYS HWB Home Page in the near future. Please note: Information regarding future HWB webinars will be shared once available.

For more information in the interim, please visit the NYS HWB Home Page as well as the Frequently Asked Questions regarding the HWB Program. Qualified employers are encouraged to routinely review these resources for the latest information. Additionally, updated FAQs will be available this Friday, and additional Town Halls/registration information will be available in the near future.

Attention: New York State Launches Health Care and Mental Hygiene Worker Bonus (HWB) Program and Submission Portal

The New York State Department of Health (Department) will be hosting an informational webinar to review with qualified employers recently enacted legislation requiring the payment of bonuses to eligible workers as per Part ZZ of Chapter 56 of the Laws of 2022. This webinar will provide a general overview of the NYS HWB Home Page and will include the following topics of interest to all qualified employers:

Click Here to Read More

Attention: New York State Launches Health Care and Mental Hygiene Worker Bonus (HWB) Program and Submission Portal

Dear Provider:

New York's essential frontline health care and mental hygiene workers have seen us through a once-in-a-century public health crisis that transformed our state into a model for battling and beating COVID-19. As part of the Fiscal Year 2023 New York State Executive Budget legislation, $1.2 billion has been allocated by Governor Hochul and the State Legislature via the Health Care and Mental Hygiene Worker Bonus (HWB) Program for the payment of bonuses to "recruit, retain, and reward health care and mental hygiene workers" who meet specified eligibility requirements.

Click Here to Read More

Attention: HealthHelp's Spring 2022 Provider Satisfaction Survey

HealthHelp's Spring 2022 Provider Satisfaction Survey is currently in process. As a user of Consult, your feedback is vital for improving their processes, and your participation is encouraged to share your experience as a provider. Please visit HealthHelp.com/Survey to participate.

Attention: Electronic Visit Verification (EVV) Implementation – Private Duty Nursing (PDN)

The 21st Century Cures Act (the Cures Act) was signed into law on December 13, 2016, mandating that states implement Electronic Visit Verification (EVV) for all Medicaid-funded personal care services (PCS) and home health care services (HHCS) that require an in-home visit by a provider. New York State’s Department of Health (Department) implemented EVV use for all Medicaid-funded PCS on January 1, 2021 and will implement EVV use for all Medicaid-funded HHCS on January 1, 2023, which include skilled nursing and private duty nursing (PDN). To confirm that the services you provide are within the scope of EVV, please see the EVV Applicable Billing Codes document for procedure and rate codes that are impacted. EVV is required for both Medicaid Managed Care and Fee-for-Service

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Attention: Medicaid FFS Practitioners Administering Drugs: Updated Practitioner Administered Drug Policies, Billing Guidance and Clinical Criteria Worksheets for Certain Drug(s)/Drug Classes

The New York State (NYS) Medicaid program has issued policies and billing guidance for certain drugs/drug classes for physicians, nurse practitioners (NPs), and midwives. These drugs are eligible for reimbursement when the clinical criteria outlined on the NYS Department of Health (DOH) “New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance” web page, located here, and listed web page Medicaid Update articles, are met. Drug claims must include documentation of clinical criteria as well as the following:

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Attention: The Utilization Threshold Program has been revised effective July 1, 2022. Click on the Link below for additional details.

Click Here to Read More

Attention: The DME Procedure Code Manual and DME Fee Schedule have been updated

The DME Procedure Code Manual and DME Fee Schedule have been updated for June 1, 2022. Any changes reflected in the manual are effective for dates of service beginning June 1, 2022. Questions related to coverage criteria and guidelines can be directed to the Office of Health Insurance Programs at OHIPMedPA@health.ny.gov. Billing related questions can be directed to GDIT at (800) 343-9000.

Attention: A Private Duty Nursing (PDN) provider communication was posted regarding the April 1, 2022, transition of the PDN Medically Fragile Children’s Program to the Medically Fragile Children and Adult (MFCA) Program

Effective April 1, 2022, the New York State Fee-for-Service (FFS) Medicaid Private Duty Nursing (PDN) Medically Fragile Children’s Program transitioned to the Medically Fragile Children and Adult (MFCA) Program. FFS Medicaid will offer PDN fee enhancements to all enrolled Medicaid PDN providers (enrolled Licensed Home Care Agencies, and independent Registered Nurses and Licensed Practical Nurses) who enroll in one or both components of the MFCA Program. The two components will consist of the Medically Fragile Children and Adult Training and Experience component and the Private Duty Nursing Medically Fragile Children and Adult Provider Directory component.

Click Here to Read More

Attention: New Provider Enrollment Portal Is Live!

Today, 4/1/2022, the new Provider Enrollment Portal is live and available to use for practitioners. Please visit our Provider Enrollment Portal page for information on how to sign up, log in and use the portal:

https://www.emedny.org/portal/

This new portal will enable practitioners to perform numerous maintenance transactions using an easy online process. This alternative to the current paper enrollment process will reduce turnaround time by the eliminating the need for United States Postal Service delivery. The portal also provides step-by-step on-screen instructions to guide practitioners through the process. Paper maintenance forms will continue to be accepted. Group, Business, and Institutional providers will have portal functionality in future releases.

Click Here to Read More

Attention: Policy Guidelines and Procedure Codes for the Hearing Aid manual have been updated for April 1, 2022

Please note, the policy guidelines and procedure codes for the Hearing Aid manual have been updated for April 1, 2022. Any changes reflected in the manual are effective for dates of service beginning April 1, 2022. Questions related to policy or coverage guidelines can be directed to the Office of Health Insurance Program’s Division of Operations and Systems at OHIPMedPA@health.ny.gov. Billing related questions can be directed to GDIT at (800) 343-9000.

Attention: Fee for Service DMEPOS Medical Supply Quantity Update

The following change in maximum quantities will be effective for dates of service on or after March 1, 2022.

Current billing guidelines and reimbursement rates are still in effect.

Questions:

For questions related to policy and coverage guidelines contact the Bureau of Medical Review at 1-800-342-3005 or by email at OHIPMEDPA@health.ny.gov

Attention: New Provider Enrollment Portal Coming Soon to eMedNY

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Attention: Westchester County Fee-for-Service Private Duty Nursing Prior Approvals

Effective January 10, 2022, all Fee for Service (FFS) Medicaid Private Duty Nursing (PDN) requests, including those from Westchester County, will be reviewed and adjudicated by the Office of Health Insurance Program’s Bureau of Medical Review PDN Prior Approval Unit.

PDN Providers will continue to follow the current submission process outlined in the PDN Manual PDN Manual on the eMedNY website

All new cases and renewals must be submitted by a Medicaid enrolled PDN provider (independent nurse or nursing agency) though ePACES or through the mail using a paper prior approval request form. Prior approval for all PDN services is required before the start of providing services.

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Attention: Reminder: Private Duty Nursing (PDN) Billing for members with Third Party Health Insurance– Guidance for Claims Submission

As the new calendar year approaches, we want to remind you that zero filled claims require updated documentation from the primary payer to process your claims. If you have previously sent in a letter or Explanation of Benefits (EOB) for calendar year 2021, new documentation will be needed for dates of service after January 1, 2022. If documentation is not received, payment for claims pended for Edit 02304 (zero fill) might be delayed.

It is the billing provider’s responsibility to determine if the member has third party (private insurance) in addition to Medicaid. Medicaid is the payor of last resort and all third-party coverage must be exhausted or documented to be a non-covered service before nursing services are reimbursed by Medicaid.

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Attention: MFA/ Provider Security Authentication Survey

In partnership with the New York State Department of Health (DOH), eMedNY is in the process of enhancing security features when users access eMedNY applications. To ensure the security of the eMedNY application and data that is being entered, eMedNY will be requiring the use of Multi-Factor Authentication (MFA).

As we are currently in the planning stages of the MFA solution, we are looking for your input on what you can support. We ask that you complete this survey so that we can provide an MFA solution that will meet your needs.

Please complete the survey prior to close of business on Monday, November 29th, 2021. Your input is appreciated!

Attention: Scheduled Maintenance for Server Upgrade November 7, 2021

To align with the most current security standards, eMedNY will be upgrading our infrastructure components on November 7, 2021 that will affect a number of applications used by the Provider Community. These applications include:

This upgrade will not affect the current functionality of these applications. In a majority of cases, no action will be needed by you or your organization. However, we do ask that you ensure your web browser is up to date with the most current version. Doing so will allow for the best user experience. If you need assistance with identifying your browser version, please contact your organization's technical support staff or IT department. General questions should be directed to the eMedNY Call Center at (800) 343-9000

Attention: Adult Private Duty Nursing (PDN) Temporary Fee-for-Service (FFS) Increase for the Time Period of November 1, 2021 through March 31, 2022

The American Rescue Plan Act (ARPA) was signed into law on March 11, 2021. Section 9817 provides a financial increase in Federal Medical Assistance Percentage (FMAP) to state Medicaid programs from April 1, 2021 to March 31, 2022 to supplement existing state expenditures on home and community-based services (HCBS). To support and strengthen the Private Duty Nursing direct care workforce, the Department of Health is investing state and federal monies on a one-time basis to supplement FFS Medicaid PDN reimbursement for adult members age 23 and over.

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Attention: Updated Lists of Valid ICD-10-CM and PCS Codes for FFY 2022

CMS has posted updated 2022 ICD-10-CM and 2022 ICD-10-PCS codes to be used for from October 1, 2021 through September 30, 2022.

The 2022 ICD-10-CM files contain information on the ICD-10-CM updates for FFY 2022.

The 2022 ICD-10 Procedure Coding System (ICD-10-PCS) files contain information on the ICD-10-PCS updates for FFY 2022.

Note: There is no GEMs file. As stated in the FY 2016 IPPS/LTCH PPS final rule (80 FR 49388), the GEMs have been updated on an annual basis as part of the ICD-10 Coordination and Maintenance Committee meetings process and will continue to be updated for approximately 3 years after ICD-10 is implemented.

Attention: Updated Billing and Reimbursement Guidelines for HCPCS Code A4232

Effective November 1, 2021 Fee for Service billing guidelines and reimbursement fees for HCPCS code A4232 will be revised. Code A4232 will be added to the Durable Medical Equipment Prosthetic Orthotic Supply (DMEPOS) fee schedule. This item can now be dispensed by DME providers with a Category of Service code 0321 in addition to Pharmacy providers with a Category of Service code 0441 or 0442.

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Attention: HHS Reopening Provider Relief Fund Application and Attestation Portal September 29 for American Rescue Plan and Phase 4 Processing

This listserv notice is to inform Medicaid and Child Health Plus (CHP) providers that on September 10, 2021, the U.S. Department of Health and Human Services (HHS) through the Health Resources and Services Administration (HRSA) announced new funding availability for health care providers affected by the COVID-19 pandemic. This funding includes $8.5 billion in American Rescue Plan (ARP) resources for providers who serve rural Medicaid, Children's Health Insurance Program (CHIP), or Medicare patients, and an additional $17 billion for Provider Relief Fund (PRF) Phase 4 for a broad range of providers who can document revenue loss and expenses associated with the pandemic.

The HHS application portal is scheduled to open on September 29, 2021.

For more information, please visit The CMS website and The HRSA website

Attention: Revised: NYS COVID-19 State Disaster Emergency, Executive Order No. 202

Effective September 01, 2021 the private duty nursing policy guidance issued on March 28, 2020, located at the link below, will be rescinded or modified.

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Attention: The Issue That Caused Some Claims for Services Ordered by Nurse Practitioners to Incorrectly Deny has been Resolved

The Nurse Practitioners Modernization Act of 2014 has been extended beyond its original sunset date of June 30, 2021 to a new date of June 30, 2022.

Unfortunately, some claim submissions with Dates of Services spanning the period from Thursday, July 1, 2021 through Wednesday, July 7, 2021 may have incorrectly denied during the adjudication process; this issue is limited to certain claims in which the ordering/prescriber is a Nurse Practitioner (NP).

General billing questions may be directed to the eMedNY Call Center (800) 343-9000.
Specific policy-related questions may contact the DoH Division of Program Development and Management: for Medical Policy: FFSMedicaidPolicy@health.ny.gov or call (518) 473-2160
Pharmacy Policy: ppno@health.ny.gov or call (518) 486-3209.

Attention: Private Duty Nursing (PDN) Billing Guidance - Clarification to Zero Fill Edit 2304 Implemented June 1, 2021

On June 1st, 2021, a new edit, edit 2304, was set to pend for submission of documentation for zero fill claims for all practitioners. Please refer to the following links for complete information on the edit:

• https://www.emedny.org/Listserv/eMedNYGeneralUpdates/Correction_Edit_02304_will_Pend_for_Manual_Review_for_all_Professional_Claims_5-3-21.pdf
• https://www.emedny.org/Listserv/eMedNYGeneralUpdates/Submission_Guidance_for_Claims_with_Third_Party_12-4-20.pdf

Read More

Attention: Updated Billing and Reimbursement Guidelines for Negative Pressure Wound Therapy (HCPCS Code E2402)

A Provider Communication regarding Updated Billing and Reimbursement Guidelines for Negative Pressure Wound Therapy (HCPCS Code E2402) has been posted. The posting can be found in the Provider Communication link in the DME manual section.

Attention: DME Provider Manuals & Fee Schedule

The 2021 DME Procedure Code Manual, 2021 DME Fee Schedule, and DME Policy Manual have been updated for July 1, 2021. Any changes reflected in the manual are effective for dates of service beginning July 1, 2021. Questions related to policy or coverage guidelines can be directed to the Office of Health Insurance Program’s Division of Operations and Systems at OHIPMedPA@health.ny.gov. Billing related questions can be directed to eMedNY at (800) 343-9000.

Attention: Medicaid Two Week Payment Lag

THIS ANNOUNCEMENT ONLY APPLIES TO PROVIDERS AND MANAGED CARE ORGANIZATIONS (MCOs) THAT ARE CURRENTLY APPROVED FOR SUSPENSION OF THE MEDICAID LAG PAYMENT.

Please review the attached announcement from Michael Ogborn, Medicaid Chief Financial Officer, Division of Finance and Rate Setting and the list of provider IDs that pertain to the announcement. If your facility’s provider ID is not on the attached list, your facility is not affected by this announcement.

If you have any questions, please send an email to lag@health.ny.gov.

Attention: IMPORTANT INFORMATION

Attention: Webinars for the Interactive Voice Response System (IVR) for Medicaid Fee for Service (FFS) Enteral Product Authorizations

The New York State Department of Health, Office of Health Insurance Programs, Bureau of Medical Review will be conducting webinars for ordering providers, pharmacies, and Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) providers on the use of the IVR system for enteral product prior authorizations.

Read More

Attention: Uploading Documents to Prior Approvals Using ePACES

When submitting for Prior Approval (PA) using Medicaid’s electronic transmission system, ePACES, supporting documentation, such as letters of medical necessity, physician orders, clinical notes, manufacturer quotes, pictures, etc., can be uploaded directly to the PA request through the ePACES system.

Read More

Attention: Webinars for the Interactive Voice Response System (IVR) for Medicaid Fee for Service (FFS) Enteral Product Authorizations

The New York State Department of Health, Office of Health Insurance Programs, Bureau of Medical Review will be conducting webinars for ordering providers, pharmacies, and Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) providers on the use of the IVR system for enteral product prior authorizations on the following dates:

• March 25, 2021 at 1:00 PM
• April 7, 2021 at 10:00 AM
• April 13, 2021 at 1:00 PM
• April 22, 2021 at 1:00 PM

Read More

Attention: 2021 DMEPOS Policy Manual

An updated DMEPOS Policy Manual has been posted. Changes pertaining to Medicaid Enrollment of Fee for Service DME providers are effective immediately. All other changes to the policy manual are effective March 10, 2021. The new policy manual can be found under the Provider Manual tab in the DME section on eMedNY.org. Questions regarding the updated policy can be directed to the Bureau of Medical Review at 1-800-342-3005 or ohipmedpa@health.ny.gov.

Attention: Email Addresses: Private Duty Nursing Directory for Medically Fragile Children

The Private Duty Nursing (PDN) Directory for Medically Fragile Children has been updated to include provider email addresses. The Directory is located on the Department of Health Website at: https://health.ny.gov/health_care/medicaid/redesign/pdn_children/index.htm

If you have any questions regarding enrollment, please contact the eMedNY Call Center at 1-800-343-9000.

If you have general questions regarding participation in the Directory, please email PDNDirectory@health.ny.gov

Attention: Updated Coverage Criteria for E0467- Home Ventilator, Multi-Function Respiratory Device

Please note, a Provider Communication has been posted regarding Updated Coverage Criteria for HCPCS E0467 – Home Ventilator, Multi-Function Respiratory Device. The posting can be found in the Provider Communication link in the DME Provider Manual section.

Attention: Reminder: Private Duty Nursing Directory for Medically Fragile Children is Now Available

Reminder: The Private Duty Nursing Directory for Medically Fragile Children is Now Available. A Provider Communication with information on how to enroll in the Directory has been posted on the Private Duty Nursing Provider Communications page.

Attention: eMedNY to Enhance X12 Translation and Validation Rules

Starting on December 7, 2020, eMedNY will deploy changes to the production environment that enforces compliance to X12 version 5010 Healthcare Transactions and improved message handling of validation errors in the X12 999 Implementation Acknowledgement..

Read more here.

Attention: Updated Lists of Valid ICD-10-CM and PCS Codes for 2021

CMS has posted updated 2021 ICD-10-CM and 2021 ICD-10-PCS codes to be used for from October 1, 2020 through September 30, 2021.

• The complete list of the 2021 ICD-10-CM valid codes and code titles are availble
  here.
• The complete list of the 2021 ICD-10-PCS valid codes and code titles are availble here.

Attention: The Slide Deck from the September 15th Webinar for Private Duty Nursting (PDN) is Available

On September 15, 2020 a webinar regarding PDN Directory and Updates to Fee Schedule occured. The Slide deck is now posted on the Private Duty Nursing Manual page. In addition, the video is posted on the Provider Training Videos page.

PDN Slide Deck from September 15, 2020 Webinar

Attention: A Provider communication for Private Duty Nursing (PDN) has been posted

A Provider communication regarding changes to Private Duty Nursing Fees and Current PAs has been posted. The posting can be found on the Private Duty Nursing Provider Communications page. In addition, the PDN Fee Schedule has been posted at the Private Duty Nursing Manual page.

Attention: Webinars for Private Duty Nursing (PDN) New PDN Directory and Updates to Fee Schedule

The Bureau of Medical Review will be conducting webinars on September 9, 2020 at 10:00 AM and September 15, 2020 at 1:00 PM for independent nurses (RN/LPN), nurse agencies, discharge planners, case managers and ordering providers to present the new PDN Directory and enhancements to the Private Duty Nursing Fee Schedule.

Read More

Attention: The DME Procedure Code Manual and Fee Schedule have been updated for September 1, 2020.

Any changes reflected in the Manual and Fee Schedule are effective for dates of service beginning September 1, 2020. Questions related to Policy or Coverage Guidelines can be directed to the Office of Health Insurance Program’s Division of Operations and Systems at OHIPMedPA@health.ny.gov. Billing related questions can be directed to the eMedNY Call Center at (800) 343-9000.

Attention: Change to the Dispensing Validation System (DVS) Authorization Time Frame

A Provider Communication regarding changes to the Dispensing Validation System (DVS) has been posted. This posting can be found in the Provider Communications links in the DME and Hearing Aid Provider Manual sections.

Attention: Updated Criteria for HCPCS Code A4670-Automatic Blood Pressure Monitor

Effective July 6, 2020, Fee for Service coverage criteria and reimbursement for HCPCS code A4670 will be updated and may be dispensed without prior approval. The new coverage criteria will be as follows:

Updated Criteria for HCPCS Code A4670-Automatic Blood Pressure Monitor

Attention: WMS Roster Replacement Project Survey

As the Department of Health moves toward implementing the WMS Roster Replacement Project, we need to understand each Plan's current implementation efforts. We are requesting that you take a few minutes and answer some survey questions associated with your "Go Live" readiness. Your responses will help us to best fine tune and refine our ongoing support and assistance. Please complete only one survey from your organization. We are asking that you respond no later than COB Friday, June 12, 2020.

Attention: 1.5% Across the Board (ATB) Medicaid Payment Reductions

Effective for dates of service on or after April 2, 2020 and each State Fiscal Year thereafter, all non-exempt Department of Health state funds Medicaid payments will be uniformly reduced by 1.5%. For services subject to the 1.5% reduction, all fee-for service payments will receive a decrease to Medicaid checks and/or Electronic Funds Transfers for dates of services on or after April 2, 2020. Conversely, managed care payments to health plans will be reduced through a 1.5% reduction to premium rates effective April 2, 2020. Remittances will reflect the prospective 1.5% reduction (appearing as an "FC2" recoupment) starting in cycle 2231, which has a check release date of 06/10/2020 (distressed providers will have a check release date of 05/27/2020). Retroactive adjustments to previously submitted claims with dates of service spanning April 2, 2020 through May 13, 2020 will be made at a future date.

Read More

Attention: Electronic Visit Verification (EVV) Technical Assistance Call

On April 14, 2020, New York State Department of Health (NYSDOH) announced that following a series of engagements with a wide variety of stakeholders and carefully considering input from Medicaid beneficiaries, family caregivers, providers, advocates, partner agencies and Electronic Visit Verification (EVV) solution providers, including information gathered from a Request for Information (RFI), New York has elected to proceed with the Choice Model for implementing EVV.

Following NYSDOH’s commitment for continued collaboration and communication with EVV stakeholders, NYSDOH would like to invite stakeholders to attend a Technical Assistance Call scheduled for Monday, April 20th, 2:00 p.m. – 3:00 p.m.

Please use the following link to register prior to the event:

Additional details can be found here

NYSDOH looks forward to continued collaboration with the EVV stakeholder community.

Attention: Delay Reason Code 15 (Natural Disaster) Guidance

During the State of Emergency or until the issuance of subsequent guidance by the NYSDOH prior to the expiration of such state disaster emergency declaration, claims that would normally have been required to be submitted during the State of Emergency exceeding the timely filing limits may be submitted electronically using Delay Reason 15 (Natural Disaster/State of Emergency). Additional documentation for Delay Reason 15 does not need to be sent at this time. Upon claim review, if the normal claim submission timeframe does not fall within the State of Emergency, documentation may be requested to support the use of Delay Reason 15. All other documentation, such as invoices for pricing that are not related to Delay Reason 15, is still required.

Questions

General questions for claims submission should be directed to GDIT (CSRA) at 1-800-343-9000. Questions on specific claims that are pended for review should be directed to the Bureau of Medical Review, Pended Claims Unit at 1-800-342-3005 (option 3).

Attention: Medicaid Fee-for-Service (FFS) Prescribers Important Message about Prior Authorization (PA) Fax Requests

Due to technical difficulties, we are currently unable to accept fax requests for prior authorization. Requests for prior authorization may be initiated by calling the Prime Therapeutics State Government Solutions at 1-877-309-9493.

We apologize for any inconvenience this has caused and will let you know when you may resume faxing requests for prior authorization.

Information regarding the NY State FFS Medicaid Preferred Drug Program can be found at: https://newyork.fhsc.com/providers/PDP_about.asp

Attention: ETIN Recertification Window Extension

In response to the ongoing public health emergency, New York State Medicaid is extending the recertification window for expiring ETINs by an additional sixty (60) days. Providers will remain bound by the terms of the previously signed existing agreement.

If you have any questions, please contact the eMedNY Call Center at (800) 343-9000.

Attention: New DME Provider Communication posted

A Provider Communication regarding the addition of new HCPCS code E0467, Home Ventilator, Multi-Function Respiratory Device has been posted in the provider communications link in the DME manual section on eMedNY.org. Questions related to policy or coverage guidelines can be directed by email to OHIPMedPA@health.ny.gov or by phone at 1-800-342-3005. Billing related questions can be directed to GDIT at (800) 343-9000.

Addition of NEW HCPCS Code E0467

Attention: New Private Duty Nurse Provider Communication posted

Please note: Provider Communications regarding guidance on Medicaid changes to Private Duty Nursing (PDN) and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Policy have been issued in response to the current novel coronavirus (COVID-19) outbreak.

You can view the details here:
Medicaid Changes to Private Duty Nursing (PDN) Policy

Attention: COVID-19 Provisional Temporary Provider Enrollment

Pursuant to section 1135(b)(1)(B) of the Social Security Act, the Centers for Medicare and Medicaid Services New York State is offering Provisional Temporary Enrollment for the duration of the public health emergency. For ease of enrollment, we are offering multiple options for enrollment. New York's goal is to quickly enroll Providers into New York State Medicaid so that they can react to the emerging health crisis.

Click Here for more information.

Attention: COMING SOON: COVID-19 Provisional Temporary Provider Enrollment

Pursuant to section 1135(b)(1)(B) of the Social Security Act, the Centers for Medicare and Medicaid Services approved New York’s request to provisionally, temporarily enroll providers for the duration of the public health emergency.

New York will waive several screening and enrollment requirements for providers seeking provisional, temporary enrollment. Minimum data requirements will be collected to facilitate claims transactions, including but not limited to NPI and license. Further details on the provisional, temporary enrollment process will be available soon!

Inquiries specifically related to an ongoing COVID-19 enrollment or maintenance issue should be addressed via email to providerenrollment@health.ny.gov with "COVID-19 Enrollment" in the subject line. Please include pertinent information (e.g., provider name, NPI, etc., as applicable) and/or Enrollment Tracking Number, if known.

If you have any questions, please contact the eMedNY Call Center at (800) 343-9000.

Attention: Across the Board (ATB) Medicaid Payment Reductions

Effective for dates of service on or after January 1, 2020, through March 31, 2020, and each State Fiscal Year thereafter, all non-exempt Department of Health state funds Medicaid payments will be uniformly reduced by 1%. For services subject to the 1% reduction, all fee-for service payments will receive a decrease to Medicaid checks and/or Electronic Funds Transfers for dates of services on or after January 1, 2020. Conversely, managed care payments to health plans will be reduced through a 1% reduction to premium rates effective January 1, 2020. Remittances will reflect the 1% reduction (appearing as an "FC2" recoupment) starting in cycle 2219, which has a check release date of 3/18/2020.

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Attention: Pre-Adjudication Message About MBI

The Centers for Medicare and Medicaid Services (CMS) has replaced all Medicare Social Security-based member identifiers, also known as the Health Insurance Claim Number (HICN), with a new Medicare Beneficiary Identifier (MBI).

Effective January 1, 2020, in alignment with the CMS Medicare Card Replacement Initiative, eMedNY will reject all inbound claims with Medicare COB data that contains the HICN of the Medicare Member; the MBI is required for all COB reporting for clients with Medicare reported on a claim as COB after January 1, 2020.

Click Here To Read More

Attention: State to Implement Across the Board (ATB) Medicaid Payment Reductions Provider Notification Letter

The FY 2020 Enacted Budget authorizes the State to implement an across the board (ATB) reduction to Medicaid payments up to $190.2 million State share. Pursuant to this authority, such payment reductions will apply for dates of service January 1, 2020, through March 31, 2020, and each State Fiscal Year thereafter. All non-exempt Department of Health state funds Medicaid payments will be uniformly reduced by 1%. For services subject to the 1% reduction, all fee-for service payments will receive a decrease to Medicaid checks and/or Electronic Funds Transfers for dates of services on or after January 1, 2020. Conversely, managed care payments to health plans will be reduced through a 1% reduction to premium rates effective January 1, 2020.

Attention: NEW Fee-for-Service (FFS) Private Duty Nursing (PDN) Assessments

To accommodate prior approval requirements associated with the Private Duty Nursing Program, the Department of Health has made available the UAS-NY Community Health Assessment(CHA) and Pediatric Assessments within the UAS-NY Application for use on behalf of the Fee-For-Service Private (FFS) Duty Nursing (PDN) Program.

Read More

Attention: eMedNY Provider Outreach and Training Page Enhancements!

Please take a look at our updated Provider Outreach and Training page on eMedNY.org. We've added a convenient dropdown menu on the tab to quickly go to all of the Provider Outreach and Training pages. Most importantly, did you know we can provide personalized and private training at your facility on ePACES, Medicaid Billing procedures, Claim form completion, Issues related to claims processing, MEVS, Prior approvals, DVS, Assistance with denied and rejected claims, troubleshooting Medicaid billing issues?

• Contact the Provider Outreach team for assistance and training.
• View the Training Calendar and register for seminars and webinars
• Find useful reference materials and resources
• View training videos

Click here to view the new Provider Outreach and Training page of the website.
Questions can be directed to the eMedNY Call Center at 800-343-9000.

Attention: New Frequently Asked Questions (FAQs) for Managed Care Enrollment (834) and WMS Roster Replacement

Frequently Asked Questions (FAQs) for the Medicaid Managed Care Enrollment (using ASC X12 834 transactions) and WMS Roster replacement have been posted under eMedNY HIPAA Support. FAQs will be updated weekly and may be found at, https://www.emedny.org/HIPAA/5010/834FAQs/index.aspx

Attention: Private Duty Nursing Webinar by the Bureau of Medical Review Register Now

The Bureau of Medical Review will be conducting a webinar on November 4, 2019 at 10:00 AM for all Private Duty Nurse (PDN) servicing providers, physicians, or any other enrolled Medicaid professional that provides services or assists in the submission of prior approvals. This webinar will review the highlights of the revised manual.

Time will be available at the end of the presentation to answer questions from participants.

To register for the webinar, click here. Or visit the Provider Training Page located on emedny.org.

Read More

Attention: Revised Private Duty Nursing (PDN) Manual Now Available

A revised PDN Manual has been published with an effective date of November 25, 2019. The manual may be found at: https://www.emedny.org/ProviderManuals/NursingServices/index.aspx.

The manual presents PDN Policy and Procedure in a revised, organized format that should provide clearer instructions to providers, streamline processes for prior approval submission, and make it easier to find information within the manual.

Attention: Medicaid Managed Care Enrollment 834 Companion Guide Added

In Spring 2020, DOH will be eliminating monthly rosters from WMS and implementing a daily transmission of all enrollment information via a standard X12 834. As such, DOH is publishing a Companion Guide which provides the technical details for electronic communications and for creating electronic transactions for DOH. This guide is intended to be used along with X12 Implementation Guides, Version 005010.

Managed Care Enrollment – eMedNY Companion Guide

Attention: 2019 Prior Approval Attachment Changes

Effective 9/26/2019, all providers can now upload multiple page PDF attachments to an electronic (278) prior approval (PA) request though ePACES. When attaching documents during the submission process, PDF will now be listed as a format choice for documentation.

For questions related to submitting documentation through ePaces, call CSRA at 1-800-343-9000.

Attention: Hearing Aid Provider Manual Updates

Please note, the policy guidelines, procedure codes, and fee schedule for the Hearing Aid manual have been updated for September 15, 2019. Any changes reflected in the manual are effective for dates of service beginning September 15, 2019. Questions related to policy or coverage guidelines may be directed to the Office of Health Insurance Program’s Division of Operations and Systems at OHIPMedPA@health.ny.gov. Questions related to billing may be directed to the eMedNY Call Center at (800) 343-9000.

Attention: ePACES Eligibility Verification Display Change

On 7/25/2019, the ePACES eligibility verification display changed for Health Home (HH) and Care Coordination Organizations (CCO/HH) RRE Codes. During this update it came to our attention that the HH, Care Management Agency (CMA), and CCO/HH are being identified as a managed care plan in the "Medicaid Managed Care" field. HH, CMA and CCO/HH are not managed care plans, they provide care management services. A correction to the display is forthcoming.

To distinguish between a Medicaid Managed Care Plan and a HH, CMA, or a CCO/HH, the Managed Care Plan will show the address of the Plan, Phone Number and Plan Code. The address area will be blank for HH, CMA, or CCO/HH. Provider names for HH, CMA, and CCO/HH appearing without an address will also display in the "Medicaid Exceptions" field next to RRE codes A1, A2, or I5-I9 codes.

Click Here To Read More

Attention: New York State Medicaid Health Home Manual Has Been Updated

The Health Home Program announces that the Health Homes Provider Manual - Billing Policy and Guidance has been revised. Providers can access the latest version of this manual in its entirety via eMedNY’s Provider Manuals (Health Homes Manual) or, by visiting the Department of Health’s Health Home Policy and Standards webpage at: https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/policy/index.htm - under: Health Homes Provider Manual.

Attention: DMEPOS Procedure Code Manual and Fee Schedule Updates

DMEPOS Procedure Code Manual and Fee Schedule have been updated. All changes reflected in the manual are effective for dates of service beginning August 1, 2019. Questions related to policy or coverage guidelines can be directed to the Office of Health Insurance Program's Division of Operations and Systems at OHIPMedPA@health.ny.gov. Billing related questions can be directed to eMedNY at 1-800-343-9000.

Fee Schedule

Procedure Codes

Attention: Revised Speech Generating Device Guidelines Now Available

Revised guidelines for Speech Generating Devices were published in the latest revision of the Durable Medical Equipment, Prosthetics, Orthotics and Supplies Manual, effective August 1, 2019. The manual may be found at https://www.emedny.org/ProviderManuals/DME/index.aspx.

The Bureau of Medical Review will be conducting a webinar on August 15, 2019 at 10:00 AM for Speech Language Pathologists, Supporting Clinicians, Ordering Providers and Durable Medical Equipment providers to review the 2019 Speech Generating Device Guidelines.

Read More

Attention: Provider Outreach Training Survey

Did you know eMedNY offers trainings for new providers, ePACES and enrollment related functions?

Is there something you would like training on that you don't see posted on our training page? Please take our survey to help us better understand your training needs:

Attention: Transportation Fee Schedule Updated

Please note, the fee schedule for Transportation providers has been updated for June 10, 2019. Any changes reflected in the manual are effective for dates of service beginning June 10, 2019. Questions related to policy or coverage guidelines can be directed to the Office of Health Insurance Program's Division of Operations and Systems at OHIPMedPA@health.ny.gov. Billing related questions can be directed to eMedNY at (800) 343-9000.

Fee Schedule

Attention: Transportation Fee Schedule Updated

Please note, the fee schedule for Transportation providers has been updated for May 20, 2019. Any changes reflected in the manual are effective for dates of service beginning May 20, 2019. Questions related to policy or coverage guidelines can be directed to the Office of Health Insurance Program's Division of Operations and Systems at OHIPMedPA@health.ny.gov. Billing related questions can be directed to eMedNY at (800) 343-9000.

Fee Schedule

Attention: CHANGES TO CLAIMS EDIT 02292 - MULTIPLE CLAIMS SUBMSSION FOR THE SAME SERVICE

Effective May 1, 2019, edit 02292 (Claims limit exceeded) will be changed from DENY to PAY/REPORT. Claims that fail the edit will be paid and tracked for NYSDOH informational purposes. HIPAA reason code 273 will still be reported on the 835 remittances so that providers can identify patterns and trends for multiple claims submissions.

For questions or assistance, please contact the eMedNY call center at (800) 343-9000.

Attention: Transportation Fee Schedule Updated

Please note, the fee schedule for Transportation providers has been updated for April 24, 2019. Any changes reflected in the manual are effective for dates of service beginning April 24, 2019. Questions related to policy or coverage guidelines can be directed to the Office of Health Insurance Program's Division of Operations and Systems at OHIPMedPA@health.ny.gov. Billing related questions can be directed to eMedNY at (800) 343-9000.

Fee Schedule

Attention: MULTIPLE CLAIMS SUBMSSION FOR THE SAME SERVICE

Effective April 25, 2019, a new edit for multiple claim submissions for the same service will be implemented.

18 NYCRR 540.6 states that any returned claim not correctly resubmitted within 60 days or on the second resubmission is neither valid nor enforceable against the department or social services district.
Based on the regulation above, all claim errors must be corrected by the third submission (the original and two subsequent resubmissions) in order to be paid. A new edit - eMedNY edit "02292" (claim submission limit exceeded) will be set to deny for all claim types after the second claim resubmission. HIPAA reason code 273 will be reported on the 835 remittances for denials arising from this edit.

For questions or assistance in determining the reason for denial of a claim, please contact the eMedNY call center at (800) 343-9000.

Attention: Applications are occasionally updated and may include additional information or requirements that ensure compliance of State or Federal regulations.

• Be aware that application forms (new enrollment, reinstatement/reactivation, revalidation or a change in ownership) with a revision date prior to 01/19
  will be returned when received on or after June 1, 2019.
  Note: The revision date is located on the bottom-left hand corner of each page of the application.
  
  
• When preparing to submit an application you must always download and
  complete the most current version of the form found on Provider Index.

Attention: New guidance on the A1/A2 exception codes on an ePACES Eligibility Response.

There is a NEW ePACES Reference Sheet.

Clarification of A1 & A2 Exception Codes on an Eligibility Response

Attention: NEW Training Course Available

ePACES Dispensing Validation System (DVS) for DME

The ePACES DVS for DME session is intended for Durable Medical Equipment providers

Visit the Provider Training Page for available sessions

Attention: Radiology Important Document Updates

Please note: A Provider Communication regarding changes to Radiology Aid Procedure Codes, IVR Announcement, and Provider FAQs has been posted. The posting can be found in the Provider Communication link in the Radiology manual section.

Consult^TM Procedure Code List

Consult^TM FAQ's

Attention: Hearing Aid Procedure Code Changes

Please note: A Provider Communication regarding changes to Hearing Aid Procedure Codes has been posted. The posting can be found in the Provider Communication link in the Hearing Aid manual section.

2019 Hearing Aid Procedure Code Changes

Attention: School Supportive Health Service Program (SSHSP) Providers

There is a NEW ePACES Eligibility Request Guide for SSHSP providers under ePACES Reference Sheets:

ePACES - Eligibility Request for SSHSP Providers

Attention: Transportation Fee Schedule Updated

Please note, the fee schedule for Transportation providers has been updated for December 31, 2018. Any changes reflected in the manual are effective for dates of service beginning December 31, 2018. Questions related to policy or coverage guidelines can be directed to the Office of Health Insurance Program's Division of Operations and Systems at OHIPMedPA@health.ny.gov. Billing related questions can be directed to eMedNY at (800) 343-9000.

Fee Schedule

Attention: Changes for Approval of Continuous Glucose Monitoring and Insulin pumps for Individuals with Type 1 Diabetes

Effective January 15, 2019, the following changes are being made to New York State (NYS) Medicaid Fee For Service Approval for Continuous Glucose Monitors (CGM) and Insulin pumps.

Read More

Attention: DOULA (Pilot Program) Enrollment Is Now Available

Click the following link for instructions and more information:
www.emedny.org/info/ProviderEnrollment/doula/

Attention: All providers - Claims Pending Review for Edit 02287

Effective October 25, 2018, an additional edit for Delay reason code 11 will be implemented. eMedNY edit 02287 (Delay Reason Code 11 [Other Delay] Requires Manual Review) will pend for review for all claim types. HIPAA reason code 29 (Adjustment Reason Code 29 with no Remittance Remark Code) will be reported on the 835 remittances. Claim status code 718 will be reported when the claim is pended for manual review.

Click Here to read more

Attention: New GENERAL BILLING Guideline Posted

Please see the following guide for All Providers:
Guide to Timely Billing

Office of Health Insurance Programs (OHIP)
Division of OHIP Operations and Systems

Attention: New PHARMACY Provider Communication Posted

Please see the following communication for Pharmacy Providers:
ENTERAL PRODUCT CLASSIFICATION LIST

Attention: DME Procedure Manual and DME Fee Schedule Updated

Please note, the procedure codes section and fee schedule of the DME Procedure Code manual has been updated for September 1, 2018. Any changes reflected in the manual are effective for dates of service beginning September 1, 2018. Questions related to policy or coverage guidelines can be directed to the Office of Health Insurance Program's Division of Operations and Systems at OHIPMedPA@health.ny.gov. Billing related questions can be directed to eMedNY at (800) 343-9000.

Procedure Codes

Fee Schedule

Attention: New DME Provider Communication Posted

Please see the following communication for DME Providers:
ENTERAL PRODUCT CLASSIFICATION LIST

Attention: Medicaid Provider Enrollment and Maintenance Feedback Survey Is Now Online

The Department of Health's Bureau of Provider Enrollment and eMedNY are always interested in finding ways to improve the provider experience of enrolling in and maintaining their information with New York Medicaid. We have developed an easy to complete ten question survey to gather feedback about the various processes that are currently followed.

To access the survey, visit here: https://www.surveymonkey.com/r/BPEeMedNYSurvey2018

If you have any questions, please contact the eMedNY Call Center at 1-800-343-9000.

Attention: Timely Billing Webinar is FULL

Due to popular demand, the Timely Filing Webinar with DOH is full. We will send an update through the eMedNY Alert LISTSERV® once more information is available.

Thank you for your patience.

Attention: Important Payment Information Due to July 4^th Holiday

Due to the July 4th holiday, Cycle 2130, will be released on Thursday, July 5th, not Wednesday, July 4th.

This includes the mailing of checks and the release of Electronic Fund Transfers to the provider community.

Please plan accordingly.

If you have questions, please contact the eMedNY Call Center at 1-800-343-9000.

Attention: Instructions for Expedited/Priority Mailing to eMedNY

Please note, there are updated instructions for sending expedited/priority mailing to eMedNY. This option is available for those who need their documents sent to eMedNY immediately.

Click Here For More Information

Attention: Updated DME Provider Manual: Fee Schedule

Please note, the fee schedule of the DME Provider has been updated for May 16, 2018. Any changes reflected in the fee schedule are effective for dates of service beginning April 1, 2018. Questions related to this update can be directed to the Office of Health Insurance Program's Division of Operations and Systems at OHIPMedPA@health.ny.gov. Billing related questions can be directed to eMedNY at (800) 343-9000.

DME Fee Schedule

Attention: Private Duty Nursing Assessment - Clarification of Acceptable Assessment for Prior Approval of Services

NYCRR Title 10 and Title 18 contains regulations for the provision of Medicaid coverage of Private Duty Nursing (PDN) services in the patient's home. Private duty nursing services may be provided when a written assessment indicates that the member needs either continuous nursing services which are beyond the scope of care available from a certified home health agency, or intermittent nursing services which are normally provided by the certified home health agency but which are unavailable.

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Attention: Updated DME Provider Manuals: Procedure Codes and Fee Schedule

Please note, the procedure codes section and fee schedule of the DME Procedure Code manual has been updated for April 1, 2018. Any changes reflected in the manual are effective for dates of service beginning April 1, 2018. Questions related to policy or coverage guidelines can be directed to the Office of Health Insurance Program's Division of Operations and Systems at OHIPMedPA@health.ny.gov. Billing related questions can be directed to eMedNY at (800) 343-9000.

Attention: 2018 Hearing Aid Procedure Codes Section and Fee Schedule

Please note, the procedure codes section and fee schedule of the Hearing Aid manual has been updated for April 1, 2018. Any changes reflected in the manual are effective for dates of service beginning April 1, 2018. Questions related to policy or coverage guidelines can be directed to the Office of Health Insurance Program's Division of Operations and Systems at OHIPMedPA@health.ny.gov. Billing related questions can be directed to eMedNY at (800) 343-9000.

Attention: New Medicare Card Replacement Initiative: Important Update to Medicare Cards

In an effort to combat identity theft and safeguard taxpayer dollars, the United States Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 directing the Centers for Medicare & Medicaid Services (CMS) to remove any reference to Social Security Numbers (SSNs) from all Medicare cards by April 2019. This mandated national undertaking, formerly referred to by CMS as the Social Security Number Removal Initiative (SSNRI), is now known simply as the New Medicare Card replacement initiative.

Click Here To Learn More

Attention: 340B Providers: 340B Drugs and Modifier "UD"

Effective Jan 1, 2018:
Hospitals and clinics should continue to identify 340B drugs by entering a value of "UD" on Medicaid Fee for Service claims.
Medicare cross-over (dual eligible) claims should include "UD" in addition to Medicare modifiers: JG or TB.

For billing questions: eMedNY Call Center (800) 343-9000
For policy questions: Division of Program Development and Management
(518) 473-2160.

Attention: Medicaid Managed Care Network Provider Enrollment

The 21st Century Cures Act requires states to require all Medicaid Managed Care (MMC) Network providers to enroll in the fee-for service (FFS) program as either billing or non-billing providers no later than January 1, 2018.

This applies to NYS Medicaid enrollable provider types located on the Provider Index, that participate or will participate in a Medicaid Managed Care or Children's Health Insurance Program network that provides services to, orders, prescribes, or certifies eligibility for services for, individuals who are eligible for medical assistance.

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Attention: New Medicare Card Replacement Initiative

In an effort to combat identity theft and safeguard taxpayer dollars, the United States Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 directing the Centers for Medicare & Medicaid Services (CMS) to remove any reference to Social Security Numbers (SSNs) from all Medicare cards by April 2019.

Read More

Attention: Topical Oxygen Wound Therapy (TOWT) Continues to be Covered Until Further Notice

Providers, Medicaid beneficiaries and Medicaid Managed Care Organizations (MMCOs) were notified in the May 2017 Medicaid Update that the New York State Medicaid Program was eliminating coverage of topical oxygen wound therapy (TOWT) effective July 1, 2017.

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Attention: Medical Supply Quantity Update

The following changes in maximum quantities will be effective for dates of service on or after August 1, 2017. Current reimbursement rates are still in effect.

DME Medical Supply Quantity Update

Pharmacy Medical Supply Quantity Update

Attention: 2017 DME Procedure Codes Section and Fee Schedule

Please note, the procedure codes section and fee schedule of the DME manual has been updated for May 1, 2017. Any changes reflected in the manual are effective for dates of service beginning May 1, 2017. Questions related to policy or coverage guidelines can be directed to the Office of Health Insurance Program's Division of Operations and Systems at OHIPMedPA@health.ny.gov. Billing related questions can be directed to eMedNY at (800) 343-9000.

DME Procedure Codes

DME Fee Schedule

Attention: Incontinence Supply Management Program

The reimbursement rate changes for Incontinence Supply Management Program products scheduled to take effect April 3, 2017, have been postponed until May 17, 2017. For questions about the Incontinence Supply Management Program, contact the Bureau of Medical Review at 1-800-342-3005 or by email at OHIPMEDPA@health.ny.gov.

Attention: NEW Provider Communication added for DME and Pharmacy providers

2017 DURABLE MEDICAL EQUIPMENT FEE SCHEDULE CHANGES

Attention: Care at Home Waiver (CAH) III, IV, and VI Case Management Providers

New Billing Guidance Effective for Dates of Service Beginning April 1, 2017

Attention: NEW Provider Communications added for DME, Long Term Home Health Care, Managed Care and Pharmacy providers

Incontinence Supply Management Program Fee Schedule Changes

Attention: Incontinence Supply Management Program Update

Current proposed reductions in incontinence supply fees that were effective for dates of service on or after February 15, 2017 have been postponed until March 15, 2017. Additional information and guidance will be issued prior to effective date.

For questions about the Incontinence Supply Management Program, contact the Bureau of Medical Review at 1-800-342-3005 or by email at OHIPMEDPA@health.ny.gov.

Attention: NEW Provider Communication added for DME providers

E0445 - Pulse Oximeter Coverage Criteria Update

Attention: NEW Provider Communications added for DME and Pharmacy providers

2017 DME Procedure Code Changes

Attention: HealthHelp Customer Experience Survey - Winter 2016

HealthHelp (NYS Medicaid Radiology Prior Approval Services) has released their Winter 2016 Provider Survey. HealthHelp uses this survey to improve their programs, revise processes, and to ensure a better provider experience.

Please take a moment to complete the survey at the following link:

http://www.healthhelp.com/survey -- closed