Reimbursement For Medicaid Managed Care Organization (MCO) billing guidance, providers must contact the individual plan.
New York Income (PDF, 1.67MB, 214pg.) Update to New York State Medicaid Coverage of Continuous Glucose Monitors. ), Pharmacy Billing Guidelines (PDF, 284.76KB, 55pg. ), Comprehensive Medicaid Case Management (CMCM) Billing Guidelines (PDF, 175.41KB, 52pg.
Medicaid Medicaid FFS billing/claims questions should be directed to the eMedNY Call Center at (800)3439000. ****EUA REVISED/No longer Authorized by FDA for bebtelovimab (Eli Lilly - Q0222) effective 11/30/2022 FDA Announces Bebtelovimab is Not Currently Authorized in Any US Region | FDA Bebtelovimab was commercially available between 8/15/2022 and 11/30/2022. A NYS FFS member or MMC enrollee, who has exhausted prescription refills, may obtain a renewal in one of the following three ways: Reminders regarding original prescriptions: A NYS FFS member or MMC enrollee may obtain a refill in one of the following two ways: NYS Medicaid ensures an ample supply of medication(s) to accommodate for most temporary absences and allows a 90-day supply for most maintenance medications. Please see the chart below for details.
Medicaid either parent is known to have a Robertsonian translocation. **A new prescription is not required when a member is switching from the generic product to the brand product, consistent with the Medicaid FFS Brand Less Than Generic (BLTG) program, which can be found on the Magellan Health Inc. "BLTG program" web page. Family Planning Benefit Program; Medicaid Reference Guide (MRG) Medicaid Reference Guide; Categorical Factors (PDF, 20.35KB, 9pg.) ), Office of Mental Health (OMH) Certified Rehabilitation Services Policy Guidelines (PDF, 11.15KB, 2pg. ), Footwear 1-1-2006 Changes-Updated (PDF, 31.72KB, 1pg.
Additional guidance is given below.
Medicaid FQHCs may participate in the APG reimbursement methodology as an "alternative rate setting methodology" as authorized by Public Health Law Section 2807 (8) (f). This Medicaid Update article clarifies utilizing multiple NDCs for the same drug on the same date of service and does not affect the previous guidance. The Medicaid member/enrollee may contact their pharmacy for a renewal and give the pharmacy consent to contact the prescriber on their behalf. The Office of the Medicaid Inspector General (OMIG) has contracted with the University of Massachusetts Medical School (UMass) to perform Home Health Medicare Maximization Services. Medicaid Pharmacy List of Reimbursable Drugs (Formulary File) A member/enrollee may arrange with a pharmacy for: a possible 90-day supply for certain maintenance medications (members/enrollees may ask their prescriber to increase the day supply dispensed when the member/enrollee has been stabilized on the medication and has been taking their medication on a consistent basis though it may require a new prescription) and/or. ), Podiatry Policy Guidelines (PDF, 11.48KB, 2pg. Medicaid pays for a wide-range of services, depending on your age, financial circumstances, family situation, or living arrangements. Children under the age of 19 may be eligible for Child Health Plus. ), Enteral Product Classification List (PDF, 42.73KB, 7pg), Fee Changes for Wheelchair Cushions & Battery Charger (PDF, 17.52KB, 1pg. Call your local department of social services to find out where you can apply. Health Care and Mental Hygiene Worker Bonus Program. The pharmacy may contact the Medicaid member/enrollee to inquire if a renewal is necessary, obtain consent if necessary, and then contact the prescriber on their behalf. The article titled Attention Pharmacy Providers: New Prescriptions published in the May 2021 issue of the Medicaid Update directed pharmacies to document consent for renewals and refills. Only substances that return positive results or are inconclusive on screening tests (presumptive) or results on screening tests that are inconsistent with clinical presentations are reimbursable for confirmation (quantitative) testing using CPT codes "80321" through "80377" listed on the fee schedule.
Medicaid Reference Guide Further information regarding the option process, along with the option forms, are provided here:FQHC Medicaid Reimbursement Option, Health & Safety in the Home, Workplace & Outdoors, Clinical Guidelines, Standards & Quality of Care, All Health Care Professionals & Patient Safety, 2018 Managed Care Visit and Revenue (MCVR) Report, James V. McDonald, M.D., M.P.H., Commissioner, The Latest on New York's Response to COVID-19, Multisystem Inflammatory Syndrome in Children (MIS-C), Health Care and Mental Hygiene Worker Bonus Program, Lyme Disease & Other Diseases Carried By Ticks, Maternal Mortality & Disparate Racial Outcomes, NY State of Health (Health Plan Marketplace), Help Increasing the Text Size in Your Web Browser. Providers should periodically check their respective fee schedules in eMedNY for updates through the eMedNY "Provider Manuals" web page. Pharmacies enrolled in the VFC program may submit claims to FFS and MMC for the administration fee for VFC-eligible vaccinations administered at the pharmacy. FFS coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management (DPDM) by telephone at (518) 473-2160 or by email at, FFS Pharmacy coverage and policy questions should be directed to the Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at, MMC general coverage questions should be directed to the OHIP Division of Health Plan Contracting and Oversight (DHPCO) by email at. Consistent with existing policy, Title 18 of New York Consolidated Rules and Regulations (NYCRR) 505.7(g)(4) require that providers order tests individually. Crisis Intervention - Residential - 5/26/23
Reimbursement Flu.
Medicaid To avoid this overpayment, providers should combine all units of the J-code drug administered and bill it on one claim line with the NDC reported for the claim that has the highest number of units administered. The Medicaid member/enrollee may contact their pharmacy requesting a refill. CPT code "G0480" cannot be billed in conjunction with CPT codes "80305", "80306", or "80307" for drugs/drug classes included in the screening codes (Table: Presumptive Drug Class Screening).
Medicaid WebDiabetes & Diabetes Prevention. WebReimbursement & Coding Changes for Enteral Formula; Family Planning Benefit. Effective September 1, 2021 for New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) will cease coverage for mosquito repellent when prescribed to members/enrollees to prevent Zika virus infections. WebCurrently, school districts and counties only receive Medicaid reimbursement for direct services based on a fee for service model with an annual cost settlement process. ), ICF-DD Billing Guidelines (PDF, 174.17KB, 54pg. FQHCs cannot be negatively impacted in their Medicaid reimbursement due to opting into the APG reimbursement methodology. Health Care and Mental Hygiene Worker Bonus Program.
New York The services in this guidance document are currently reimbursable by NYS Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans. Providers may continue to code multiple lines to denote different NDCs when billing only for physician-administered drugs through the APG Fee Schedule. MMC Plans will notify pharmacy providers about using the brand product SUBOXONE instead of the generic alternative, consistent with Medicaid FFS: MMC Plans will provide guidance on DAW Code requirements. ), Midwife Policy Guidelines (PDF, 243.81KB, 29pg. FQHCs may participate in the APG reimbursement methodology as an "alternative rate setting methodology" as authorized by Public Health Law Section 2807 (8) (f). This CMS billing requirement must be satisfied for all dual-eligible Medicare/Medicaid recipients even if the final claim is not intended to be billed to Medicare. Providers are required to report SARS-CoV-2 diagnostic or serology testing results, including those using SARS-CoV-2 point-of-care tests, to the Commissioner of Health through the Electronic Clinical Laboratory Reporting System (ECLRS) within 24 hours. Presumptive drug class screening tests using Common Procedural Terminology (CPT) codes "80305", "80306" or "80307" are the first step in the process. Medicaid FFS members will continue to access these medications by presenting their Medicaid benefit card to the pharmacy. Medicaid FFS billing/claim questions should be directed to the eMedNY Call Center at (800) 3439000. If a facilitys Medicaid reimbursement under APGs is lower than what their payment would have been under the Federal Prospective Payment System (PPS) rate, the facility is entitled to receive a supplemental payment reflecting the difference between what they were paid under APGs and what they would have been paid using the PPS rate. Crisis Intervention - Residential - 5/26/23
New York WebUpdate to Fee-for-Service Reimbursement for Federally Qualified Health Center Claims After Third-Party Payers and Managed Care Visit and Revenue Reporting Requirements. ), DME Provider Letter (Fee Schedule Revision) (PDF, 102.45KB, 2pg), DME Provider Letter (Providers and Orderers) (PDF, 57.02KB, 4pg. Attention Dental and Dental Clinic Providers - Edit 868 Process Revised and Streamlined, Attention: Hospital & Clinic Employed Physicians Enrollment in the Medicaid Program, Attention : Laboratories, Physicians, & Other Ordering Providers (Triple Test), Attention Pharmacy Providers - Edit 867 Process Revised and Streamlined, Attention Teaching Physicians Who Supervise Residents, Basis Of Payment For Durable Medical Equipment For Managed Care Recipients, Comprehensive Case Management: Payment Guidelines, Conditions For Ordering Enteral Nutrition, Delivery of Prescription Drugs, OTC Products, Medical/Surgical Supplies & DME, Enteral Formula Prior Authorization Program, Fee-for-Service Enrollment and Maintenance Form Packets Will Soon Change, Highlights of Changes in The Medicaid Program, Laboratories Billing Molecular Diagnostic Procedure Codes, Lawsuit Decision-Provider Assistance Needed: Aliessa/Adamolekum et. FFS claim questions should be directed to the eMedNY Call Center at (800)3439000. Specific plan information can be found at the. Bebtelovimab was commercially available between 8/15/2022 and 11/30/2022. MMC billing and/or PA requirement questions should be referred to the. ), Free Standing or Hospital Based Ordered Ambulatory Manual Policy Guidelines (PDF, 11.55KB, 2pg.
Medicaid New York's Medicaid program provides comprehensive health coverage to more than 7.3 million lower-income New Yorkers (as of December, 2021.) Screening for drugs using immunoassay or enzyme assay using multichannel chemistry analyzers should be billed using code "80307". Effective September 1, 2021 for New York State (NYS) Medicaid fee-for-service (FFS) and effective November 1, 2021 for Medicaid Managed Care (MMC) Plans [including mainstream MMC Plans, HIV (Human Immunodeficiency Virus) Special Needs Plans (SNPs), as well as Health and Recovery Plans (HARPs)], coverage of non
New York ), Personal Emergency Response Services (PERS) Billing Guidelines (PDF, 160.89KB, 48pg. The following is an example of how to properly bill the above claim for a drug from an APG Group: In Example 2. the third line from Example 1 is removed and all units provided to the patient are added to Line 2.
Provider Manuals Medical records must support the need for each drug or drug class being tested and must be kept on file, in accordance with regulations, for audit purposes. FQHCs may participate in the APG reimbursement methodology as an "alternative rate setting methodology" as authorized by Public Health Law Section 2807 (8) (f). *The fees and effective dates below are current as of December 2021. FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000. ), Silhouette Seat Cushion & Back (PDF, 23.33KB, 1pg. For patients two years of age and older, pharmacues may administer influenza vaccines. ), Limited Licensed Home Care Services Agency (LLHCSA) Billing Guidelines (PDF, 169.67KB, 50pg. WebGuide.
New York State Medicaid Update - August 2021 Volume New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) require member/enrollee consent prior to requesting a renewal or new prescription from a prescriber and before submitting a claim for a refill. Note: Providers should bill CPT code "96365" to be reimbursed for the infusion/injection when administering J0248 (remdesivir). Medicaid pays for a wide-range of services, depending on your age, financial circumstances, family situation, or living arrangements. Update to New York State Medicaid Coverage of Continuous Glucose Monitors. WebCurrently, school districts and counties only receive Medicaid reimbursement for direct services based on a fee for service model with an annual cost settlement process. No dispensing fee or member co-payment applies. Reimbursement for these vaccines may be based on a patient specific, or non-patient specific, order. Additionally, this coverage now includes twin pregnancies, but not higher multi-gestational pregnancies. ), Long Term Home Health Care Program (LTHHCP) Billing Guidelines (PDF, 180.25KB, 52pg. This financial assistance is being implemented as part of the American Rescue Plan Act (ARPA) signed into law on March 11, 2021. **** EUA REVISED/No longer Authorized by FDA for bebtelovimab (Eli Lilly Q0222) effective 11/30/2022 FDA Announces Bebtelovimab is Not Currently Authorized in Any US Region | FDA. Exception requests will be handled on a case-by-case basis. The ordering prescriber must be actively enrolled as a NYS Medicaid provider, unless otherwise exempt and the prescribers National Provider Identifier (NPI) is required on the claim for the claim to be paid. The fees below are specific to FFS. * For individuals enrolled in an MMC Plan, providers must check with the individual's MMC Plan for implementation details and billing guidance. ), Personal Care Billing Guidelines (PDF, 168.20KB, 49pg. ), Chiropractor Billing Guidelines (PDF, 414.89KB, 61pg. This modifier should only be appended to drugs or biologicals that are single-dose vials or packages; "UD" - required to identify a 340B purchased drug in addition to the corresponding HCPCS system and NDC. The Medicaid Reference Guide is arranged in five sections: Categorical Factors; Income; Resources; Other Eligibility Factors; and Reference. The Medicaid member/enrollee may contact their prescriber for a renewal. The fees below are specific to FFS. A fax received as a failed electronic prescription order may not be used to bill a prescription/fiscal order to Medicaid. NY State of Health automatically applied higher tax credits without enrollees needing to take any action. Reimbursement Rates only available through Medicaid Managed Care Organizations (MMCOs) Mobile/Telephonic Crisis Intervention - 5/26/23 Rate codes are only available through Medicaid Managed Care Organizations (MMCOs) to individuals 21 and older. Medicaid Managed Care (MMC) enrollees will continue to access immunization services through their health plans. If a provider bills in this manner and the drug is assigned to a single APG group, the provider will be overpaid; both claim lines will pay in full. Under this statewide formulary, NYS Medicaid FFS and MMC will: *All agents are subject to FDA-approved quantity/frequency/duration limits. WebWelcome! ), Physician Billing Guidelines (PDF, 463.33KB, 78pg. This manual is intended for use by both Medicaid Managed Care Plans (MMCP) and 29-I Health Facilities. For NCPDP claim transactions that are denied for edit "02291", the corresponding Medicaid Eligibility Verification System (MEVS) Denial Reason Code "738" History Not Found for Administrative Vaccine Claim will be returned as well as the NCPDP Reject code "85", Claim Not Processed. All Patient Refined Diagnosis Related Groups (APR-DRGs): Hospital Inpatient Reimbursement Rate Reform Effective December 1, 2009 al. The payment allowances for the above infusion administration codes include all costs for any saline, any other fluid, and/or any other drug used for the infusion and any post-infusion patient monitoring. WebNew York State Medicaid Advantage Plus (MAP) Plans Behavioral Health Billing and Coding Manual (Released July 1, 2022) - This guidance outlines the claiming requirements necessary to ensure proper BH claim submission with respect to MAP Plans. If claims have been submitted with multiple lines for a single J-code drug that paid through the APG Group, these claims were overpaid. ), Inpatient Billing Guidelines (PDF, 410.89KB, 70pg. ), Pharmacy Policy Guidelines (PDF, 320.58KB, 46pg.
Medicaid - Guidance Documents These services are provided through a large network of health care providers that you can access directly using your Medicaid card or through your managed care plan if you are enrolled in managed care. Enter an applicable procedure code listed in Table B and/or C. Up to four claim lines can be submitted with one transaction. Ending the Epidemic. Providers are required to adjust their claims and bill the drugs administered on one claim line (retroactive to July 1, 2019). Questions regarding early fill cumulative amounts for MMC enrollees should be directed to the MMC Plan. Patients either need supportive devices such as crutches, canes, wheelchairs, and walkers; special transportation; or help from someone else to leave their home because of illness or injury OR have a condition that makes leaving the home medically inadvisable. Screening by broad-spectrum chromatographic procedure, which detects multiple drug classes, should be billed using code "80307". WebThis manual applies to services covered by both Medicaid Managed Care (MMC) and Medicaid fee-for-service (FFS) and outlines the claiming requirements necessary to ensure proper claim submission for services delivered by a 29-I Health Facility. either parent has a family history of aneuploidy in a 1st* or 2nd** degree relative; standard serum screening or fetal ultrasonographic findings indicate an increased risk of aneuploidy; parent(s) have a history of a previous pregnancy with a trisomy; and/or. To view a list of procedure codes, providers can refer to the NYS Medicaid Pharmacy Services Fee Schedule. Broad panel tests, reflex tests initiated by the lab, and routine standing orders are not reimbursable.
Medicaid Effective April 1, 2022, for New York State (NYS) Medicaid fee-for-service (FFS), and effective June 1, 2022, for Medicaid Managed Care (MMC) Plans [including mainstream MMC Plans and Human Immunodeficiency Virus (HIV) Special Needs Plans (HIV-SNPs)], will reimburse providers for pediatric vaccine counseling visits as part of the ), Child Care Policy Guidelines (PDF, 273.42KB, 28pg. For additional information on the procedure codes for vaccines found in the tables above, refer to the OTC and Supply Fee Schedule document on the "eMedNY Pharmacy Manual" web page.
Library of Official Medicaid Documents The services in this guidance document are currently reimbursable by NYS Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans. Formulary File. **The same location is defined as a vehicle is not necessary to travel between visits. Division of Finance and Rate Setting REFORM. Division of Finance and Rate Setting REFORM. Are You Receiving Medicaid Correspondence at the Appropriate Address? Providers who are already receiving payment from another source for COVID-19 testing, specimen collection, or monoclonal antibody infusion are not eligible for reimbursement from Medicaid for those tests, specimen collections, or infusions. CHHAs may bill for members who only receive lower-level services when a nurse is sent to collect the specimen (see chart above). The CDC reports there are no current Zika outbreaks worldwide and specifically, "There is no current local transmission of the Zika virus in the continental United States (US)"; therefore, NYS Medicaid will cease coverage of mosquito repellant and will revisit this policy if the situation warrants. The services in this guidance document are currently reimbursable by NYS Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans. Ambulatory Patient Groups (APGs). Effective April 1, 2021, MMC Plans will reimburse providers no less than the Medicaid FFS rate for COVID-19 vaccine administration. If the same number of units were administered for each NDC/J code, providers should choose one NDC to use for submitted claims. Contact the ECLRS Help Desk at (866) 325-7743 or via eclrs@health.ny.gov with any technical questions. Formulary File. Income (PDF, 1.67MB, 214pg.) For VFC-eligible vaccines, regardless of enrollment in the VFC Program, the pharmacy would submit procedure code "90460" (administration of free vaccine) for administration of first or subsequent dose and then submit the appropriate vaccine procedure code(s) with a cost of $0.00. Drinking Water Protection Program. ), Private Duty Nursing Services Billing Guidelines (PDF, 423.37KB, 63pg. Effective April 1, 2022, for New York State (NYS) Medicaid fee-for-service (FFS), and effective June 1, 2022, for Medicaid Managed Care (MMC) Plans [including mainstream MMC Plans and Human Immunodeficiency Virus (HIV) Special Needs Plans (HIV-SNPs)], will reimburse providers for pediatric vaccine counseling visits as part of the ), Prior Approval for Dually Eligible (PDF, 67.27KB, 3pg.
Medicaid
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