Recent Changes to New York State Medicaid Program

Recent changes to the New York State Medicaid Program affect vaccine administration for pharmacies, claiming process for nurse practitioners, documentation requirements for transportation providers, and prior authorization for physical and occupational therapists.  We summarize these changes below.

Vaccine Administration by Pharmacies

Specially trained pharmacists who obtained an immunization certification may administer the following NY Medicaid covered vaccines: flu, pneumococcal, meningococcal, tetanus, diptheria and pertussis (administered to patients 18 or older) and Zoster vaccines (administered to patients 50 or older) pursuant to either a patient specific order or a non-patient specific order. To obtain reimbursement, the pharmacy must be enrolled with NYS Medicaid. Pharmacy interns cannot administer vaccines. Medicaid will only reimburse for services rendered to fee-for-service non-dual enrollees. Medicaid managed care patients and dual enrollees will be able to obtain such services through their MCOs or Medicare. Pharmacists must document the immunization services in accordance with State law requirements, must obtain and keep patient specific orders or non-specific orders on patient file with the pharmacy, and ensure that the prescriber’s NPI is on the claim before submitting claim for payment.

Change to Claiming Process for Nurse Practitioners

Now that nurse practitioners with more than 3,600 hours of clinical experience are able to practice with more autonomy as of this year, the NYS’ Medicaid contractor intends to modify its claiming processes to reflect these changes. For accurate claims processing, the Medicaid contractor still requires that the NPI of a collaborating physician be on file with NY Medicaid.

Documentation Requirements for Transportation Providers

To be reimbursed, transportation providers must record and maintain for six years specific information for each leg of the trip. Providers of ambulette services must maintain the beneficiary’s name and Medicaid number, date of transport, origination of the trip and time of pick up, destination of the trip and time of drop-off, vehicle license plate number and the full name of the driver (printed). Providers of ambulance services must have the pre-hospital care report. NYS Medicaid also recommends, although does not currently require, that drivers attest in the trip documentation to the following: “I provided the indicated transportation services,” followed by the driver’s signature. Furthermore, the weekly emed-NY generated prior authorization roster listing the authorized trips should also be preserved for six years. Certain documents, while not primary documentation (and thus will not be sufficient to support reimbursement) could serve as “supplemental” documentation. Such documents include a driver/vehicle manifest or dispatch sheet, prior authorization by an approved official with subsequent checkmarks, prior authorization roster or an attendance log from a day program.

Prior Authorization Changes for Physical Therapists/Occupational Therapists

NYS Medicaid eliminated the requirement of obtaining prior authorization for rehabilitative services, including speech, physical and occupational therapy, prior to the provision of these services. A prior authorization is still required but it may now be obtained before the day of service, on the day of or after the service has been provided. The prior authorization, however, must be obtained prior to billing Medicaid. The limit of 20 therapy visits per therapy type remains in effect.

If you have questions relating to NYS Medicaid program, enrollment or revalidation with NYS Medicaid, have compliance or licensing matters, or have health law questions, please contact our office