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Related post: Section I - Purpose Statement The purpose of this document is to assist the provider community in understanding and complying with the New York State Medicaid (NYS Medicaid) requirements and " Billing and submitting claims. " Interpreting and using the information returned in the Medical Remittance Advice. This document is customized for Pharmacies and should be used by the provider as an instructional as well as a reference tool. Version 2009 - 1 (10/01/09) Page 3 of 54 Section II - Claims Submission Pharmacies are required to submit most of their claims to NYS Medicaid electronically. However, certain types of claims are allowed to be submitted in electronic or paper formats. Examples of these types of claims are: claims requiring attachments, such as manufacturers� invoices for manual review and pricing, and claims exempt from the Drug Utilization Review (DUR) requirement. Providers are required to submit an Electronic/Paper Transmitter Identification Number (ETIN) Application and a Certification Statement before submitting claims to NYS Medicaid. Certification Statements remain in effect and apply to all claims until superseded by another properly executed Certification Statement. You will be asked to update your Certification Statement on an annual basis. You will be provided with renewal information when your Certification Statement is near expiration. Pre-requirements for the Submission of Claims Before submitting claims to NYS Medicaid, all providers need the following: " A Certification Statement This is a submitter identifier issued by the eMedNY Contractor. All providers are required to have an active ETIN on file with the eMedNY Contractor prior to the submission of claims. ETINs may be issued to an individual provider or provider group (if they are direct billers) and to service bureaus or clearinghouses. The ETIN application is available at www.emedny.org by clicking on the link to the web All providers, either direct billers or those who bill through a service bureau or clearinghouse, must file a notarized Certification Statement with NYS Medicaid for each ETIN used for billing. The Certification Statement is good for one year, after which it needs to be renewed for electronic billing continuity under a specific ETIN. Failure to renew the Certification Statement for a specific ETIN will result in claim rejection. Version 2009 - 1 (10/01/09) Page 4 of 54 The Certification Statement is available on the third page of the ETIN application at www.emedny.org or can be accessed by clicking on the link above. Pursuant to the Health Insurance Portability and Accountability Act (HIPAA), Public Law 104-191, which was signed into law August 12, 1996, the NYS Medicaid Program adopted the HIPAA-compliant transactions as the sole acceptable format for electronic claim submission, effective November 2003. Pharmacies are required to use the HIPAA-compliant National Council Buy Ethionamide for Prescription Drugs Program (NCPDP) 5.1 electronic format. In addition to this document, direct billers may also refer to the sources listed below to comply with the NYS Medicaid " NCPDP Standard Version 5.1 Implementation Guide explains the proper use of the standards and program specifications. This document is available at " NYS Medicaid NCPDP 5.1 Request and Response Companion Guides (CGs) provide instructions for the specific requirements of NYS Medicaid for the NCPDP 5.1. This document is available at www.emedny.org by clicking on the link to the web " NYS Medicaid Technical Supplementary Companion Guide provides technical information needed to successfully transmit and receive electronic data. Some of the topics put forth in this CG are testing requirements, error report information, and communication specifications. This document is available at www.emedny.org by clicking on the link to the web page below. eMedNY Companion Guides and Sample Files Pre-requirements for the Submission of Electronic Claims In addition to an ETIN and a Certification Statement, providers need the following before submitting electronic claims to NYS Medicaid: " A User ID and Password " A Trading Partner Agreement Version 2009 - 1 (10/01/09) Page 5 of 54 User ID and Password Electronic submitters need a user ID and password to access the NYS Medicaid eMedNY system through one of the communication methods available. The user ID and password are issued to the submitter at the time of enrollment in one of the communication methods. The method used to apply for a user ID varies depending on the communication method chosen by the provider. For example: An ePACES user ID is assigned systematically via email while an FTP user ID is assigned after the submission of a Security Packet B. This document addresses certain requirements applicable to the electronic exchange of information and data associated with health care transactions. The NYS Medicaid Trading Partner Agreement is available at www.emedny.org by clicking on the link to the Direct billers (either individual providers or service bureaus/clearinghouses that bill for multiple providers) are encouraged to submit production tests to CSC before they start submitting Medicaid claims for the first time after enrollment or any time they update their systems or start using a new system. This testing will assist providers in identifying errors in their system and allow for corrections before they submit actual Information and instructions regarding testing are available at www.emedny.org by clicking on the link to the web page below: eMedNY Companion Guides and Sample Files The following communication methods are available for submission of electronic claims " CPU to CPU " Simple Object Access Protocol (SOAP) Version 2009 - 1 (10/01/09) Page 6 of 54 eMedNY eXchange is a method in which claims can be submitted and works similarly to typical electronic mail (email). Users are assigned an inbox in the system and are able to send and receive transaction files. The files are attached to the request and sent to eMedNY for processing. The responses are delivered back to the user�s inbox where they can be detached and saved locally. For security reasons, the eMedNY eXchange is accessible only through the eMedNY website www.emedny.org. Access to the eMedNY eXchange is obtained through an enrollment process. To enroll in eXchange, you must first complete enrollment in ePACES and at least one login attempt must be successful. File Transfer Protocol (FTP) is the standard process for batch authorization transmissions. FTP allows users to transfer files from their computer to another computer. FTP is strictly a dial-up connection. FTP access is obtained through an enrollment process. To obtain a user name and password, you must complete and return a Security Packet B. The Security Packet B can be found at www.emedny.org by clicking on the link to the web page below: This method consists of a direct connection established between the submitter and the processor, and it is most suitable for high volume submitters. For additional information regarding this access method, please contact the eMedNY Call Center at 800-343- The eMedNY Gateway or Bulletin Board System (BBS) is a dial-up access method that is only available to existing users. CSC encourages new trading partners to adopt a different access method for submissions to NYS Medicaid. (For example: FTP, eMedNY Simple Object Access Protocol (SOAP) The Simple Object Access Protocol (SOAP) communication method allows trading partners to submit files via the internet under a Service Oriented Architecture (SOA). It is most suitable for users who prefer to develop an automated, systemic approach to file Version 2009 - 1 (10/01/09) Page 7 of 54 Access to eMedNY via Simple Object Access Protocol must be obtained through an enrollment process that results in the creation of an eMedNY SOAP Certificate and a SOAP Administrator. Minimum requirements for enrollment include: " An ETIN and Certification Statement for the enrollee�s Provider ID obtained prior to " The enrollee must be a Primary ePACES Administrator or " The enrollee must have existing FTP access to eMedNY Additional information about 'Getting Started with SOAP' is available on emedny.org by clicking on the link to the web page below:
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