Ordering/Prescribing/Referring (OPR) Providers Must Revalidate for Claims to be Paid
Federal regulation requires State Medicaid agencies to revalidate the enrollment of all providers every five years. For many providers Medicaid payment is contingent on the ordering/prescribing/referring (OPR) provider also revalidating their enrollment in Medicaid. OPR providers who do not comply with the revalidation requirement will be terminated from the Medicaid Program.
The NYS Department of Health has determined that many providers are at risk for not being paid for their services because the OPR provider has not complied with the revalidation requirement. Because this has the potential to result in significant non-payable claims for you/your facility, we urge you to reach out and encourage your OPR providers to revalidate their enrollment. Please remember to confirm that your OPR provider is enrolled before rendering service at: www.emedny.org/info/opra.aspx.
- The Claim Adjustment Reason Code for non-enrolled OPR provider on your 835 remittance will be: B7 – This Provider was Not Certified/Eligible to be Paid For this Procedure/Service on this Date of Service.
- If performing a claim status look for Claim Status Code 91 with Entity Code 1P.
The required revalidation form and instructions are available at https://www.emedny.org/info/
Champion E-Correspondence, August 2015 – from the AAP’s Medical Home Chapter Champions Program on Asthma, Allergy and Anaphylaxis
New Yorkers Against Gun Violence (NYAGV) Statement on Walmart Decision to No Longer Sell Military Weapons (October 2015)
Walmart’s decision to stop selling military AR-15 firearms that are at the heart of a shareholder lawsuit by Trinity Church is a clear indication that economic pressure to influence the gun industry is effective. The decision is an acknowledgement that military purposed firearms, designed to kill quickly and efficiently on the battlefield, have no legitimate sporting function and do not belong in America’s schools, malls, churches or movie theaters. This is an encouraging first step. Read More.
New Rules for Students to Carry and Use Asthma, Allergy and Diabetes Medications in the School & on School Trips (August 2015)
On July 1st of this year a new law took effect which allows you to sign a form that will let your school age patients bring to school and self-administer, if necessary, their own asthma and allergy medication in school. The new law and regulations also allow students with diabetes to self- administer glucagon and insulin and to check their blood sugar levels during the school day.
In all instances, the physician must attest that the student has the capacity to understand his/her chronic illness and that the student understands when and how to self-administer medication to address onset of illness or testing during the school day. Both the parent and the physician need to agree regarding the capacity of the student and the appropriateness of self-administration.
Click the link below for a sample of the form that you will be using if you have students that you believe can handle this responsibility in the school setting and on school trips:
Click here for the new law/regulations:
916 – Pupils with asthma or another respiratory disease requiring rescue inhaler treatment
916-a – Pupils with allergies (effective 7-1-15)
916-b – Pupils with diabetes (effective 7-1-15)
If you have questions, or haven’t heard from your local school districts yet, feel free to share this information with them and with your colleagues on behalf of children and families who you believe could benefit from this new option.
The NYS AAP supported this legislation during the 2014 Legislative Session with a start date of July 1, 2015. It is our hope that all physicians will be contacted by the State Education Department and their local school districts about this option, but in case that doesn’t happen the NYS AAP is sending the information along at this time prior to the start of the new school year.
Measles Update (February 2015)
The recent outbreak of measles across the country and here in New York State creates an opportunity for pediatricians to focus our conversations with families, community groups and the media about the vital importance of universal immunization and the critical protection afforded by herd immunity.
We are the trusted messengers and we must speak out now in all forums about the importance and the safety of immunization and the scientific basis for the AAP/ACIP immunization schedule to keep all children healthy.
Parents who refuse immunizations or request different schedules for immunizing their children are misinformed and perhaps even fearful. But, they are making dangerous decisions that have the potential to not only impact the health of their own children, but also the health of children in their neighborhoods.
It is imperative that we keep working with these families if they are in our practices or known to us in our communities. We should use the current crisis and the media coverage to help families make the right decision for their own children and for the children with whom they share child care, school, and community. And here in New York we have some support from laws and regulations that require immunization for entry to public school and, in New York City, entry to child care. Also, we do not have philosophical exemption, so it is a little harder for families to just “decide” not to immunize as they can in other states. But, even with these protections, we have seen the number of children who are not immunized on time increase due to misinformation and fear on the part of parents who often get their information from the internet or from “alternative” sources.
Pediatricians across the state need to join the NYS AAP, the New York State Department of Health and the New York City Department of Health and Mental Health to firmly and publically support universal immunization against preventable and serious childhood diseases. We need to stand up and clearly articulate the critical importance of maintaining herd immunity. We need to clearly state in every situation that all children should be immunized appropriately.
Our message is clear. Vaccines work. Vaccines are safe. This is our message to parents, to the public and to the media.
I urge you to speak out in any way that you can and as often as you can. This is a seminal moment in New York…we can make a difference and at this time, on this issue and we must make a difference.
Danielle Laraque, MD, FAAP
Chair, NYS AAP
Information About Ebola (October 2014)
The global impact of Ebola is devastating three countries in western Africa, and earlier this month a Liberian man, who had contracted the virus and traveled to Texas, died. Two nurses were subsequently diagnosed with the deadly virus and yesterday, a physician who treated Ebola patients in Guinea tested positive for Ebola at Bellevue Hospital in Manhattan. We are closely monitoring the news and any additional messages from the NYC Department of Health and Mental Hygiene and the federal Centers for Disease Control and Prevention. We’ve also learned that the second nurse infected during the care of the Dallas patient thankfully is now free of Ebola virus and will be released from care. The entire family and others who had contact with the deceased Dallas patient also have been cleared.
It is understandable that Americans have become more concerned about Ebola. NYS AAP, District II is also acutely aware of the multiple activities informing physicians and the public at large regarding the epidemic of Ebola in West Africa and the implications for NYS preparedness. In that vein, the following are some key facts for you to know and to share with your colleagues, staff and families:
TRANSMISSION OF THE VIRUS: The Ebola virus is very difficult to catch. It is not airborne, and can only be transmitted by direct contact with the body fluids of an infected individual (blood, vomit, feces, urine, saliva or semen). Further, those infected cannot spread the disease during the incubation period. Only people with active symptoms are contagious. These factors make Ebola far less contagious than most infectious diseases.
SYMPTOMS OF THE VIRUS: Symptoms of Ebola include fever, severe headache, muscle pain, weakness, diarrhea, vomiting, unexplained bleeding and stomach pain. These symptoms are similar to those of many other illnesses. It can take up to 21 days for symptoms of Ebola to appear, but the CDC says the average is 8 – 10 days.
Physicians are urged to work with their institutions and physician networks in preparedness efforts which will be ongoing. To learn more about Ebola transmission, symptoms and treatment, please visit the Centers for Disease Control and Prevention (CDC) website or the New York City Department of Health and Mental Hygiene (NYCDOHMH) website. If you have any questions regarding the order from the NYSDOH Commissioner of Health regarding the prevention and control of Ebola, please submit your questions by email to Ebola.Preparedness@health.ny.gov.
Download a PDF version of the Ebola Palm Card here: http://www.nyc.gov/html/doh/downloads/pdf/cd/ebola-palm-card.pdf
Information You Can Use (April 2014)
- Vitamin K for Newborns – Vitamin K administration to newborns has been expanded to up to six hours after birth. All other requirements remain in place.
- School Immunization Requirements – Information detailing the recent amendment to Public Health Law, Rules and Regulations addressing school immunization requirements that become effective July 1, 2014 is available here.
- ICD-10 Codes – ICD-10 codes implementation is delayed until at least October 2015.
- “Teen’s Health Care Bill of Rights” – The new “Teen Health Care Bill of Rights” (revised 2014) booklets and posters, created by NY Chapter 3 and the NYS AAP, are now available. Email firstname.lastname@example.org to place your free order. NYS AAP members from across the state participated in creating this revised edition.
- Physician Procedures Codes & Fee Schedule – Updated Physician Procedures Codes and Fee Schedule is available from SDOH here.
- Foster Care Webinars – You can access the archived versions of both the Foster Care Youth and the Medical Home webinars created by the NYS AAP, NY Chapter 3 and the New York City Administration of Children’s Services at:
The Concussion Act of NYS (July 2012)
The Concussion Act of NYS took effect July 1, 2012, and requires schools to:
- Educate parents, athletes, coaches, athletic trainers, physical education teachers, and school nurses on concussion,
- Remove observed or suspected concussed students from play based on signs and symptoms,
- Withhold further participation until evaluated by, and received written and signed authorization to return to activities from a licensed physician.
- Obtain physician clearance, and when the athlete has been symptom-free off pain killing medicines for a minimum of 24 hours and allow them to begin a monitored progressive six phase return to play.
Current thinking is that optimal recovery of concussed students occurs when there is cognitive, physical, and emotional rest following injury. Additionally, research has shown that 92% of second injuries occur in the first week following the initial injury, and the goal is to allow adequate recovery time before allowing a student to risk re-injury. Pressure to return an athlete before it is safe can be intense from parents and athletes. Primary care physicians are being asked to assist in the process of keeping injured children safe by remaining objective and withholding participation until it is deemed safe with a reasonable degree of medical certainty.
MAKING A CLINICAL DETERMINATION
- Symptoms: somatic (e.g. headache, nausea, dizziness), cognitive (e.g. feeling in a fog), and/or emotional (e.g. lability)
- Physical signs: history of loss of consciousness, amnesia, poor coordination or imbalance, vomiting, sensitivity to bright light & loud noise
- Behavioral changes: irritability, personality changes
- Cognitive impairment: Hard time concentrating, trouble remembering, not feeling themselves, being confused, thinking speed slowed down, taking a longer time to react
- Sleep disturbance: drowsiness, insomnia
WHAT PHYSICIANS NEED TO KNOW ABOUT HOW SCHOOLS WILL MANAGE CONCUSSION
When unfunded state mandates are imposed directly on schools and indirectly on community physicians, communications among all parties is essential to enhance optimal outcomes for your patients. Therefore, it is important to determine how your local districts are planning to comply with the law. The full Informational Detail is available on the AAP District II website.
GRADUATED RETURN TO PHYSICAL EXERTION AND ACTIVITY OR RETURN TO PLAY (RTP)
This is a six step gradual return to activity. The RTP protocol may not start until an athlete is completely symptom-free for a full 24 hours off pain killing medicines, and must remain symptom-free for 24 hours following each stage before progressing further.
Average recovery following concussion is about a week to ten days; protracted recovery with post concussion syndrome is after 21 days. Young teenage girls often have protracted recovery more than any other group.
RETURN TO LEARN (RTL)
More information will be forthcoming about RTL (cognitive return to school), but we anticipate a similar slow exertional challenge as we see in RTP. The graduated steps begin after the student has a medical clearance to return to academics, and is symptom free off pain killing medicines for a full 24 hours. RTL should be an individualized steady progression with the parent’s checking the child daily for a return of symptoms and alerting you if the student is struggling so you can provide appropriate requests for medical accommodations to the school as needed. Unlike a RTP, the RTL might start at any level and progress at a rate individualized to the student’s needs and tolerance. Steps might be skipped as tolerated and might look something like this:
Students with reasonable recovery times typically will get accommodations within the school by the principal. Students with protracted recovery beyond about 10 weeks, a school quarter, are likely eligible for a 504 plan or an IEP, and you might be asked to write a request to support the family at that time.
More information and detail on each section is available on the AAP District II website.
Also you can get more information from Cindy Devore, MD, FAAP at email@example.com