May 8, 2023Attention: 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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- May 2, 2023
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.
- April 26, 2023
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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- April 17, 2023
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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- April 17, 2023
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.
- April 10, 2023
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.
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- April 10, 2023
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.
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- April 2, 2023
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.
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- March 17, 2023
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.
- March 14, 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.
Highlights of the update include:- 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.
- March 9, 2023
Attention: 2023 NYS Medicaid Dental Policy and Procedure Code Manual and Updated Fee Schedule
The 2023 Manual and updated Fee Schedule are now available on eMedNY.
Updated guidance documents include:
- 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/
- March 7, 2023
Attention: Updated DME Provider Manuals
The 2023 DME Policy Guidelines, Procedure Code Manual, and DME Fee Schedule have been updated. Any changes reflected in the manual are effective for dates of service
beginning April 1, 2023. 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.
Click Here to access the manuals.
- March 3, 2023
Attention: The Enteral Web Portal is live as of March 2nd, 2023.
Complete the EFT Form