Tag: # NYDOH

Posted in #reimbursement, NY Providers, Payer Updates, Payers and CPT reinbursement, Pharmacy (Various Insurance Payers), Training

Healthfirst Pharmacy Update Contrast agent reimbursement

Posted on by KR2Medical Billing

The following information applies to the members in the following plans: Managed Medicaid Plans and Personal Wellness Plans (HARP)

Back in 2023, NYS DOH announced that there will be a change to the pharmacy benefits for MMC, HARP members- the pharmacy benefits will be covered but NYRx.

This change was finally implemented in April 2025.

To align closer with this policy Healthfist will NO LONGER reimburse separately for the the following contrast agents used in radiological testing.

Coding: the following codes are affected:

Images via Healthfirst website

NYS Medicaid Pharmacy website: information here

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Posted in #Medicareadvantage, #reimbursement, MVP (NY/VT) Insurance Payer, NY Providers, Payer Updates, Payers and CPT reinbursement, Training, Updates

Oral-Only Phosphate Binders reimbursement- MVP Medicaid, HARP plans

Posted on by KR2Medical Billing

To align with NYS Medicaid ESRD reimbursement for oral-only phosphate binders- MVP will include the reimbursement in the newly aligned Dialysis center APG reimbursement. Effective for any DOS 1/1/2026.

Higlights:

  1. Oral only Phosphate binders for ESRD members no longer will be dispensed through the pharmacy NYRx benefit
  2. The Phosphate binders will be dispensed by the dialysis center
  3. Reimbursement- no separate reimbursement will be made for oral only phosphate binders instead it is included in the new APG dialysis rate
  4. Dialysis centers should not bill a separate claim for these phosphate binders (ESRD patients)
  5. Oral only phosphate binders affected by this change: sevelamer carbonate, lanthanum carbonate, sucroferric oxyhydroxide, and ferric citrate.

NYS APG rate:

The FFS APG weight for APG 168 (dialysis) has increased from 1.3651 to 1.5302. 

For the NYS Medicaid announcement click here .

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Posted in #reimbursement, Education, NY Providers, Payer Updates, Payers and CPT reinbursement

NYS Medicaid POC Syphilis testing coverage

Posted on by KR2Medical Billing

Effective for any DOS August 2025 and thereafter Point of Care testing for Syphilis is covered for all fee fo service Medicaid and Managed Medicaid Members.

Where is this test covered (POS)?

physician/nurse practitioner/licensed midwife private office setting

What kind of POC is covered and reimbursed?

Currently there is only one FDA approved test -Clinical Laboratory Improvement Amendments-waived, rapid syphilis test, Syphilis Health Check™, for the detection of Treponema pallidum antibodies.

Coding:

86780 – Antibody; Treponema pallidum.

Reimbursement Rates:

Physician- https://www.emedny.org/ProviderManuals/Physician/ – select medicine fee schedule

Midwife- https://www.emedny.org/ProviderManuals/Midwife/ select fee schedule

Nurse Practitioner- https://www.emedny.org/ProviderManuals/NursePractitioner/

For more guidance on which providers are allowed reimbursement please read the NYS PDF file here.

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