By Tammy Bartlett, Billing Manager


MVP Health Care has created reference guidelines that may provide you and your staff with helpful tools that explain HEDIS measures as well as providing the CPT, HCPCS and ICD-10 codes that count towards the completion of these measures.

You will find these coding reference guides by going to mvphealthcare.com, selecting the Provider drop-down, and then selecting the Quality Programs and the Reference Library sections. The Behavioral Health Guide will also be available on their website in the next couple of weeks.

If you have any questions with respect to this notice, please contact Mike Farina at 518-388-2463 or email at mfarina@mvphealthcare.com.


Beginning August 1, 2017, the New York State Department of Health is requiring all Child Health

Plus (CHP) members who originally enrolled in this program through Excellus BlueCross BlueShield to

now complete their renewal for the CHP Program through the New York State of Health Marketplace.

This transition begins with the CHP members who are renewing for an August 1, 2017 effective date.

As a result of this renewal transition, CHP members will be mailed a new Member Identification Card with a new identification number.

In addition, if a CHP member has obtained preauthorization under his or her current identification number, but the preauthorized services will be delivered to the member after the date the member is transitioned to the New York State of Health Marketplace, a new preauthorization must be requested with the member’s new identification number.

As a reminder, please ensure you forward Practicefirst any changes in insurance coverage for your patients, including new identification numbers. This will ensure claims are submitted correctly to the appropriate insurance plan.


Medicare is taking steps to remove Social Security numbers from Medicare cards.  Through this initiative CMS will prevent fraud, fight identify theft and protect essential program funding and the private healthcare and financial information of Medicare beneficiaries.

CMS will issue new Medicare cards with a new unique, randomly-assigned number called a Medicare Beneficiary Identifier (MBI) to replace the existing Social Security-based Health Insurance Claim Number (HICN). This will occur both on the cards and in various CMS systems currently used.  CMS will start mailing new cards to Medicare beneficiaries in April 2018.  All Medicare cards will be replaced by April 2019.

Based on feedback from healthcare providers, practice managers and other stakeholders, CMS is developing capabilities where doctors and other healthcare providers will be able to look up the new MBI through a secure tool at the point of service.  To make this transition easier for you and your business operations, there is a 21 month transition period where all healthcare providers will be able to use either the MBI or the HICN for billing purposes.

Even though your systems will need to be able to accept the new MBI format by April 2018, you can continue to bill and file healthcare claims using either number during the transition period.  Medicare encourages providers to start working with their software vendors to make sure systems will be updated to reflect these changes.

To learn more about this new initiative, please visit:  www.cms.gov/Medicare/SSNRI/Providers/Providers.html

For Billing questions, please contact Tammy Bartlett at 716-389-3223 or tammyb@pracfirst.com


By Tammy Bartlett, Billing Manager



We have received numerous letters from CMS for our clients that indicate PQRS criteria has not been met and  payment adjustments will occur, reducing Medicare payments by 2% for 2017 dates of service. The payment adjustments are based on services rendered in 2015. We will forward the letters to the applicable clients, as we receive them.

If you received a letter from CMS regarding reduction in payments and believe you have been incorrectly assessed, please review the payment adjustment resources located on the PQRS webpage at:


As mentioned in previous communications with our providers, Practicefirst recommended to report via a PQRS Qualified Registry.  By utilizing a registry, providers become eligible for measures group reporting, thus decreasing the required number of patients to report on.

As a reminder, due to the increasing requirements of PQRS reporting, Practicefirst no longer provides PQRS reporting services to providers at a reasonable cost.


MVP issued FASTFAX #50W on October 20, 2016 to the provider community regarding Preventive Visits and Modifier 25. Preventive visits (codes 99381-99397) are payable on the same date of service as a separately identifiable E&M service (i.e. 99213). The E&M would be submitted with modifier 25. The additional services for the E&M must be documented in the medical record and the claim should include both the preventive visit diagnosis code(s) and the relevant condition diagnosis code(s).

If the preventive code is not billed, the visit will not count for the preventive service quality measures (well child, adolescent and adult measures).

For additional information, please visit MVP’s website at http://www.mvphealthcare.com/provider/provider-resource-manual.html, select Section 15 for Payment Policies and then select the Modifier Policy from their bookmarks.

For Billing questions, please contact Tammy Bartlett at 716-348-3923 or tammyb@pracfirst.com


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By Becky Amann



Univera and Excellus have partnered with InstaMed to provide electronic funds transfers (EFT’s), beginning May 1, 2016. This service is offered free of charge to practitioners and is available for all lines of business.

Transition to InstaMed from PaySpan will not be automatic. Providers must register with InstaMed by September 30, 2016 or your Univera and Excellus remittances will convert to paper. Practitioners began to receive letters from InstaMed in mid-May regarding this process.

Practicefirst is in the process of transitioning EFT’s and remittances to InstaMed for the majority of our clients whom we have enrolled in Payspan previously. If you are unsure if we previously handled that enrollment, please contact our Jr. Credentialing Coordinator, Elisa Mize at (716) 566-4511.



Effective September 1, 2016, all pre-authorizations for T.E.N.S units must be requested through Univera and Excellus’s Clear Coverage. This applies to all lines of business that require preauthorization and impacts the following specialties: Pain Management, Internal Medicine, Family Practice, Neurology Physicians, Neurosurgeons and Orthopedic Surgeons.

If you have any questions related to Clear Coverage, please contact their Customer Care Medical Intake Unit at 1-800-363-4658.



As we mentioned in our May Client Memo, in an effort to make user data more secure and to improve system performance, eMedNY will be installing a new feature that will impact ePACES users when signing on to the ePACES application. This new feature, commonly called CAPTCHA, is a program that can distinguish whether the user attempting to sign on is a human or a computer.

EFFECTIVE June 1, 2016: When users attempt to sign on to ePACES from the eMedNY website, the user will be asked to verify that he/she is a person and not a computer by selecting specific images. Once the user has successfully verified the correct images, he/she will be allowed to sign into the ePACES account. If the incorrect images are selected, the user will be asked to verify another set of images before being allowed access to ePACES.

This new feature is widely utilized by other secure websites. Many people are familiar with it and have probably had to use it to gain access to those secure websites. The NYS Department of Health is adding this feature to help secure your data, and to prevent unauthorized computer-automated access to ePACES that could adversely impact ePACES performance.

IMPORTANT NOTE: All users will need to have installed Internet Explorer (IE) version 10 or greater or any alternative browsers including Google Chrome, Mozilla Firefox, or Apple Safari. IE versions 9 and below will NOT be supported. Please be sure to coordinate with your IT department to upgrade your internet browser, if necessary, before the effective date shown above.

Questions about ePACES can be directed to the eMedNY Call Center at 800-343-9000.


Providers began to receive notices from the New York State Dept. of Financial Services (DFS) in early May, regarding the liquidation of Health Republic (HR). The superintendent of DFS, Maria Vullo, has been appointed as the liquidator of HR and has been directed to take possession and control of HR’s property and assets.

Practicefirst has previously submitted all claims to HR and not required to resubmit them based on the liquidation process. We have a record of all claims submitted to HR.

Per HR’s website regarding claims payment: Based on information available to date, any funds available will be applied first to administrative expenses incurred from the liquidation process and then to a portion of the claims submitted by providers and members. Under the NYS Insurance Law, administrative expenses and policy claims must be paid in full before any other claimants may receive distributions.

Information regarding the liquidation of HR can be found under the provider section of their website at: http://www.healthrepublicny.org/

For Billing questions, please contact Becky Amann at 716-348-3902 or beckya@pracfir


By Jacqueline Lucas, Billing Manager


As you know, effective March 27, 2016, electronic prescribing for both controlled and non-controlled substances is now required in New York State. In order to process Electronic Prescriptions for Controlled Substances (EPCS), a prescriber must have selected and be utilizing a certified electronic prescribing computer application that meets all federal requirements. This application had to be registered by the practitioner with the NYS Dept. of Health, Bureau of Narcotic Enforcement (BNE).


Beginning July 1, 2016 UHC Community Plan will start offering a Health and Recovery Plan (HARP). This is a new Medicaid plan benefit for members with significant behavioral health needs.  Any provider that is currently participating in UHC Community Plan will automatically participate in the HARP plan.  However, if you wish to opt out of HARP you must notify UHC in writing by April 15, 2016. The mailing address is:

UnitedHealthcare PCDM
PCDM Fulfillment
780 Shiloh Rd
Plano TX 75074

If you have any questions regarding this new plan, please contact UHC at 866-362-3368


In the near future, I will reach out to you for a convenient time to meet with physicians and your office staff.  My goal is to enhance our current processes to ensure we provide the most comprehensive billing service for all.  Please feel free to contact me prior to our meeting for any questions you may have. I look forward to meeting you in person.

Jackie Lucas

For Billing questions, please contact Jackie Lucas at 716-348-3923 or jackiel@pracfirst.com.


As you know, Health Republic ceased operations effective November 30, 2015. Claims processing and payments ceased in early November.  Due to the non-payment of claims, we have adjusted the outstanding balances owed by Health Republic from your Accounts Receivable. We have a history of each unpaid encounter in case the government makes a determination to issue payments on these claims. The total amount of Health Republic adjustments will be reflected in your month-end reports for March.

If you would like information regarding these adjustments, please contact Becky Amann at 716-348-3902.


by Jackie Lucas, Medical billing Manager

Billing Updates


Mandatory Payment Reduction of 2% Continues until Further Notice for the Medicare FFS Program – “Sequestration”

Medicare Fee-For-Service (FFS) claims will continue to incur a two percent reduction in Medicare payment until further notice. The claims payment adjustment will continue to be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments. Though beneficiary payments for deductibles and coinsurance are not subject to the two percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the two percent reduction. CMS encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to continue discussions with beneficiaries on the impact of sequestration on Medicare’s reimbursement. Questions about reimbursement should be directed to your Medicare Administrative Contractor (http://go.usa.gov/cymuF).


Railroad Medicare’s (RMC) Medical Review (MR) unit will begin a service-specific review of Evaluation and Management (E/M) CPT code 99285, emergency department visit, requiring highly complex medical decision making. RMC selected this code based on internal data analysis. At the conclusion of this review, they will publish their findings on their website.


On March 27, 2016 electronic prescribing of all controlled and non-controlled prescriptions (including syringes and medical devices), commonly referred to as e-prescribing will become mandatory for all prescribers in New York State. This regulation is one of the multiple sections of the Internet System for Over-Prescribing Act (I-STOP) program passed in 2012.  Most providers who use an electronic health record (EHR) can easily e-prescribe using the same software.  Those who do not have an EHR system in place will have to purchase an electronic prescribing computer application for one of the various software platforms based on their practice and e-prescribing needs.  For more information on electronic prescribing of controlled substances please visit



Changes to Performance and Quality Programs

Pay for performance (P4P) 2016—Focus will be on Primary Care Physicians (PCP’s)

  • Only PCP’s will be eligible to participate
  • P4P incentive payments will be contingent on PCP meeting threshold targets
  • The 2016 P4P program includes Medicaid members

The following measures have been added to the program:

  • HEDIS Medication Management for people with Asthma 75% Compliance
  • Measures replaced: HEDIS Appropriate Asthma Medications

The following measures have been eliminated from the program:

  • HEDIS Monitoring Persistent Meds ACE or ARB
  • HEDIS follow-up with 7 days after hospitalization for Mental Illness

For more information about Blue Cross’s 2016 P4P program, log onto bcbswny.com/provider and go to My Account>Reports>pay for performance>2016 P4P.


In July 2015, we notified you that effective July 1, 2015 Medicaid would no longer reimburse partial Medicare Part B coinsurance amounts (20% of the Part B coinsurance). Medicaid did not implement this change until December 17, 2015. In February, Medicaid began making claim adjustments for dates of service 7/1/15 through their revision date of 12/17/15. Weekly Medicaid EFT’s/checks will be reduced until all of these claims are re-processed.

For Billing questions, please contact Jackie Lucas at 716-348-3923 or jackiel@pracfirst.com


By Jacqueline Lucas, Medical Billing Director 


PF will aggregate your IRS Form 1099’s through February 15th.  These forms (1099-Misc) represent all of the payments made to you during calendar year 2015.  The IRS matches the aggregate of all 1099’s to the appropriate line of your entity’s tax return, to make sure recipients properly report their income.  In addition, any interest paid on claims is separately reportable on IRS Form 1099-Int.  This information is also matched and it is critical to properly report this income on the correct line of your tax return to avoid IRS scrutiny for under reporting income.

By law, insurance carriers are required to mail them by January 31st.  However, our past experience indicates that they do not comply with the due date and therefore they are not all generally received until the third week in February.  At that time, we will send them to you by mail or through our courier service. If you have any questions, please feel free to contact us.


To align with NYS Medicaid, Independent Health (IHA) will be eliminating coverage for immunization administration code 90461. This code is not covered by Medicaid. Effective April 1, 2016, 90461 will not be covered for IHA’s MediSource, Essential Benefit Plan or Child Health Plus members.


Univera has announced that Telemedicine services will be available to select members effective March 1, 2016. Telemedicine services will be delivered by MDLive, a nation-wide network of physicians who are board-certified in the state in which the patient is located at the time of service. MDLive physicians will be available by phone or secure video 24 hours a day, seven days a week, including holidays to provide advice and/or treatment for non-emergency medical conditions. If you have any questions regarding Telemedicine services, please contact Univera’s Customer Care Dept. at 866-265-5983.


In-mid January, YourCare issued duplicate EFT payments. They have been identified in providers’ bank accounts beginning on January 19, 2016.  PF has contacted YourCare provider representative, Tina Burns, who indicated they will be reaching out to the various providers requesting a refund check, for the duplicate payments.


Railroad Medicare’s Medical Review unit will begin a service-specific review of Evaluation and Management CPT Code 99214 (office or other outpatient visit of an established patient). This code was selected based on internal data analysis. At the conclusion of the review, they will publish their findings on their website.

For Billing questions, please contact Jackie Lucas at 716-348-3923 or jackiel@pracfirs


By Betsy Priest, Coding Manager


Revisions, addition and deletions to the CPT and HCPCS code set are effective January 1, 2016. Use of deleted codes will delay payment, as we will need to “Chart Return” the charge slips to your office for the correct code.

To determine which clients will be impacted by the 2016 changes, we have compared these changes to each client’s procedures performed in 2015.

We will be faxing, mailing or delivering customized reports to our Clients that are impacted by the 2016 CPT changes.

If you would like a complete listing of all the Deleted, New, and Revised Codes, we can provide that upon request.


During some visits you may spend a lot of time with a patient counseling them or coordinating their care.  If this happens, and you have the correct documentation in your note, leveling of your Evaluation and Management codes can be captured by time in lieu of the 3 main components.

It is a good tool for those patients that use a lot of your time, knowledge and resources and wind up with a very straight forward problem.

A good example of documentation needs for coding by time is: “This encounter was 30 minutes long and over half of that time was spent on counseling and coordination of care”.  You can also give a brief overview of what was discussed, if you would like.  But it will not be needed in this statement if the rest of your note supports that.

Your visit can be coded by time if the statement above is listed in the body of the note.  “This was a 45 minute visit” or “I spent 45 minutes with the patient” is not considered to be acceptable by the payers.

If you would like more information about how we can tailor our services to meet your needs, please contact Betsy Priest, Coding Manager at 716.348.3904 or Betsyp@pracfir


By Jacqueline Lucas, Medical Billing Director


In order to implement corrections to technical errors discovered after publication of the Medicare Physician Fee Schedule, Medicare Administrative Contractors will hold claims containing 2016 dates of services for up to 14 calendar days. The hold should have minimal impact on provider cash flow as clean electronic claims are held for 14 calendar days, under current law.

The holding of claims does not impact 2015 dates of services.


Effective January 1, 2016, IHA will no longer offer coverage for routine physicals (CPT codes 99381-99397) for their Medicare Advantage plans. Claims with dates of service January 1, 2016 and after will be denied as service code not reimbursable.

They will continue to offer coverage for the Annual Wellness Visit as well as the Enhanced Annual Visit in the primary care setting for their Medicare Advantage plans.


Effective March 27, 2016, electronic prescribing for both controlled and non-controlled substances will be required in New York State. In order to process Electronic Prescriptions for Controlled Substances (EPCS), a prescriber must select and use a certified electronic prescribing computer application that meets all federal requirements. This application must first be registered by the practitioner with the NYS Dept. of Health, Bureau of Narcotic Enforcement (BNE).

Per the Dept. of Health, the implementation timelines for EPCS software vary and may be lengthy. If you have not already begun this process, it is recommended that you begin immediately.

Information related to electronic prescribing, including frequently asked questions and information regarding the EPCS registration process, can be found on the BNE’s website at: http://www.health.ny.gov/professionals/narcotic/electronic_prescribing/

For Billing questions, please contact Jacqueline Lucas, our Medical Billing Director. Jackie can be reached at 716-348-3923 or jackiel@pracfirst.com.<