Excellus has as a new online preauthorization tool called Clear Coverage.  Clear Coverage includes an interactive question-and-answer medical review, based on Excellus BC/BS specific or InterQual evidence based criteria. This tool provides an instant decision regarding approval or pends for medical necessity review.

Contact your Provider Relations Representative to set up training, or use Excellus’s training request form at the address below.


The Commissioner of Health has approved a new blanket waiver with respect to Medicaid’s electronic prescribing requirements.  Effective March 26, 2017, the new waiver replaced and superseded the prior blanket waiver that was issued in March 2016. The Commissioner of Health will waive the requirements for electronic prescribing based on exceptional circumstances. Please visit the NYS Dept. of Health’s website at the link below for full details.



NGS will be conducting service-specific pre-payment reviews for CPT code 99214. The pre-payment review consists of a medical review of claims prior to payment. Request for records are automatically generated. The records/documentation requested should include the physician’s or the non-physician provider’s notes, orders, medication records, procedure/operative reports and diagnostic reports that will assist in supporting the services submitted. The notes are expected to be signed per signature guidelines. These reviews will help to identify common billing errors, develop educational efforts and prevent improper payments for CPT code 99214.


NGS has conducted a service-specific prepayment review for CPT codes 99354-99357, Prolonged Services. Prolonged (physician) services are payable when they are billed on the same day by the same physician as the companion E&M codes. Please note that Medicare requires face-to-face contact when prolonged (physician) services are reported.

The prepayment review resulted in some of the services being reduced or denied for the following reasons:

  • Direct face-to-face or floor/unit time was not supported.
  • Lacks content of prolonged service needed beyond the usual service of the E&M.
  • Prolonged service with over 50% of the total time of the face-to-face encounter is not being reported with the appropriate companion code (e.g. The E&M companion code  for 99354 are the office or other outpatient visit codes of 99201-99205, 99212-99215. The E&M companion code for 99356 are the initial hospital care codes and subsequent hospital care codes of 99221-99223, 99231-99233).
  • Codes are being reported for family meetings with no appropriate E&M and the patient is not in attendance.
  • Diagnostic testing, (e.g. ophthalmological testing, neuropsychiatric testing, EKGs) is done at time of visit, but the time of the testing is not differentiated from the office visit and appears testing time is included in the reported prolonged time.
  • The rendering provider submitted on the claim was not the provider who actually rendered the service(s) per the submitted documentation.
  • No documentation was submitted for the requested date of service.
  • Documentation lacked the identification of the beneficiary.
  • Illegible documentation was submitted.
  • Duplicate services/claims were billed.
  • No E&M companion code was allowed on the same date of service.
  • The documentation was missing a date. Please note that a dictation date is not sufficient to support a date of service as to when a beneficiary was seen.

For more information regarding NGS’s billing recommendations for these codes, please visit NGS’s website at: After accessing the website, click on:


→ Medical Policy and Review

→ Medical Review

→ Medical Review Focus Areas

→ Evaluation and Management – Jurisdiction K

→ CPT Codes 99354-99357



For Billing questions, please contact Tammy Bartlett at 716-348-3923 or




The Centers for Medicare and Medicaid Services (CMS) has implemented a series of videos for the Medicare Learning Network (MLN) to help providers of all types improve in areas identified with a high degree of noncompliance.

These videos are referred to as Provider Minute Videos as the recordings last anywhere from one to three minutes and are an educational resource to the provider community.

To locate the videos, please access the Provider Compliance section of CMS’s website at:

and click on: CMS Provider Minute YouTube playlist


In mid-April, the NYS Office of the Medicaid Inspector General (OMIG) announced the release of its 2017-2018 Work Plan. The Plan details OMIG’s program integrity focus areas in the Medicaid Program for the State Fiscal year 4/1/17 through 3/31/18.

This Work Plan is focusing on the following to help fight Fraud, Waste and Abuse in the Medicaid Program.

  • Physician Excessive Ordering – OMIG’s Recipient Investigation Unit (RIU) will review recipient data to identify physicians prescribing excessive amounts of controlled substances or providing unnecessary services. Identified providers are then referred for investigation to the Provider Investigations Unit (PIU).
  • Network Provider Review of Managed Care Organizations (MCO) – The Network Provider Review Project Team continues to conduct audits of network providers in MCO’s. The audits will ensure accuracy of claim submissions and confirm that provider records are in regulatory and contractual compliance. OMIG will identify improper claims that contribute to inflate capitation payments. OMIG will coordinate with the MCO’s and their Special Investigation Units in its audit efforts.
  • Provider Investigations – OMIG’s undercover investigators receive services from Medicaid providers and record the provider’s conduct during the undercover operation. The provider’s subsequent claims are reconciled with the investigator’s written report and evidence obtained by the investigator. These undercover operations are conducted t o identify quality-of-care issues and billing problems. They can also identify systemic fraud, such as paying recipients to undergo unnecessary medical tests. These investigations gather important intelligence on how providers/organizations operate and the types of drugs/services being abused. These investigations will continue in the course of OMIG’s program integrity efforts.
  • Recovery Audit Contractor (RAC) – The Medicaid RAC contractor in NYS is Health Management Systems Inc. (HMS). HMS reviews provider’s claims for services rendered to Medicaid recipients through fee-for-service or Medicaid Managed Care. HMS is responsible to identify both overpayments and underpayments. OMIG and HHS collaborate and coordinate their recovery initiatives with several other state agencies and CMS contractors. Audits include review of claims submitted for recipients that are dually eligible for Medicaid and Medicare, retroactive member disenrollment and recovery of capitation payments for beneficiaries who are no longer enrolled or eligible for Medicaid Managed Care coverage.

OMIG’s 2017-2018 Work Plan can be reviewed at:

For Compliance questions, please contact Becky Amann at 716-348-3902 or