Volume 22, Issue 2
Annual Provider Re-Enrollment Training
Pursuant to the Home and Community Based Services Waiver Program, Standards for Participation Rule
(Louisiana Register, Volume 29, Number 9), currently enrolled Medicaid home and community-based waiver services providers are required to attend an annual Provider Re-Enrollment Orientation conducted by the Bureau of Community Supports and Services (BCSS) in order to continue enrollment.
At this time, only the following provider types are required to attend the annual re-enrollment training: Personal Care Attendant (PT 82), Supervised Independent Living (PT 89), Children's Choice Waiver (PT 03), Pre Vocational (PT 13), Day Habilitation (PT 14), and Supported Employment (PT 98) providers.
The BCSS will be contacting the above-referenced provider types via the U.S. Postal Service with specific information regarding this requirement.
For more information about the Medicaid Home and Community-Based Services Waiver programs, please visit the BCSS web site at:
www.dhh.la.us/BCSS, or email us at: firstname.lastname@example.org.
You may view the Home and Community Based Services Waiver Program, Standards for Participation Rule by visiting the Office of the State Register web site at:
http://www.doa.state.la.us/osr/reg/register.htm (look for the �September 20, 2003� Issue).
Hospice and Nursing Facility Residents
The Bureau is requesting that Hospice providers work more closely with nursing facilities when a Medicaid recipient residing in a nursing facility is enrolled in Hospice. In many cases, the nursing facility has billed and been paid for dates of service after the Hospice election date. This payment to the nursing facility is not appropriate as Medicaid policy mandates that all payments be made to the Hospice provider. The Hospice provider cannot be reimbursed until these claims have been either voided or adjusted. It is important that Hospice providers timely inform the nursing facility that the recipient has elected to receive Hospice and coordinate services in order to facilitate claims processing.
The Bureau would also like to clarify the correct procedures for completion and submission of the BHSF Form 148 as it relates to Hospice and nursing facility services. The following guidelines are used by nursing facility staff and Medicaid field staff.
� The BHSF Form 148 is generated by the nursing facility, not the Hospice provider. Field staff will
not accept a form 148 from the Hospice provider. The completed BHSF 148 must be sent to the
parish Medicaid analyst and to the BHSF Hospice Unit at fax number (225) 342-1411.
� If the BHSF Form 148 is not received by the Medicaid analyst, it is the responsibility of the nursing
facility and Hospice provider to communicate and determine why a 148 was not generated by the
� If the Hospice start date on the BHSF Form 148 received by the field staff differs from the Hospice
start date determined by the Hospice Unit, the start date issued by the Hospice Unit will be used.
The Hospice Unit will send a certified letter instructing the nursing facility to issue a corrected Form
148 within 10 days, explain the discrepancy in dates, and return the corrected form to the Hospice
Unit and send a copy to the parish analyst.
Effective April 1, 2005, Hospice providers must submit a completed Notice of Election and Certification of Terminal Illness form to Hospice Unit for all recipients. This includes Medicaid only and Medicare/Medicaid recipients.
CMS Issues New Survey Guidelines on Pressure Ulcers
On November 12, 2004, the Centers for Medicare and Medicaid Services released new guidelines for surveyors to use when they are evaluating nursing facilities' efforts to prevent pressure ulcers. The new guidelines emphasizes the need to properly assess skin integrity of residents on admission, identify residents at risk for pressure ulcer development, update care plans and demonstrate monitoring of the residents' progress toward healing of existing pressure ulcers.
Facilities can view the new guidelines online at http://www.cmshhs.gov/manuals/pm_trans/R4SOM.pdf.
Online Tracking Incident System for Nursing Facilities
Effective June 2004, the DHH Health Standards Section gave nursing facilities the option of electronically submitting reportable incidents of abuse, neglect, misappropriation and injuries of unknown origin via the Online Tracking Incident System. The data base, known as OTIS, can be accessed via the internet at
http://www.dhh.state.la.us/offices/links.asp. A unique user name and password is required for each person who will be entering data into the OTIS system since the information is resident specific and must comply with HIPAA guidelines. An instruction manual for OTIS is also available online to guide users through the process.
OTIS is efficient and effective. Advantages to using the online reporting system include:
� Required fields are highlighted for the user.
� Much of the information required is available in a drop down format.
� Reports submitted online are legible.
� Each incident entered is assigned a number which gives Health Standards and the submitting facility a reference number that makes it easier to identify reports.
� The tracking of reports is improved for Health Standards and the facilities, thereby decreasing the need to submit duplicate reports.
� Providers have ready access to their reports; which eliminates the need to contact Health Standards for copies of lost or misplaced reports.
� Facilities with an email address on file with Health Standards will receive automatic email notifications to ensure that final reports are submitted timely.
Since the implementation of OTIS, modifications have been made based upon comments received from users. We feel these changes have made it a more user friendly system. We strongly encourage facilities to contact Health Standards concerning any barriers they have encountered in attempting to use the system. To obtain user names and passwords for facility staff, please submit a request on company letterhead signed by the administrator to the attention of Cathy Brunson via the mail at the address indicated below or by fax (225) 342-0157.
Bureau of Health Standards
500 Laurel Street
Baton Rouge, La. 70802
Post Office Box 3767
Baton Rouge, La. 70821
Use of Electronic Signatures in Medical Records
In a memorandum dated February 11, 2005, DHH Health Standards informed nursing facilities about new guidance issued by the Center for Medicare and Medicaid Services (CMS) regarding the use of electronic signatures in medical records. The new guidance states that long term care providers (skilled nursing facilities and nursing facilities) can implement the use of electronic signatures for their clinical record documentation, including the Minimum Data Set (MDS), if it is permitted by state and local law and authorized by the long term care facility's policy. The policy must identify those persons who are authorized to sign electronically and have safeguards in place to prevent unauthorized use of electronic signatures.
On January 13, 2005, CMS issued a clarification to the above guidance. The clarification says that nursing facilities may implement the use of electronic signatures for clinical record documentation
whether or not the clinical record is entirely electronic. The intent of the clarification is to allow
certified long term care providers who have the capability, to implement electronic signatures for their MDS documentation regardless of whether other parts of the clinical record are maintained
New KIDMED/Preventive Medicine Claim Submission Requirements
A January 2004 DHH rule required all Medicaid providers submitting KIDMED/Preventive Medicine claims to submit detailed claim data, including the actual screening and immunization services and the immunization status. They must also submit suspected conditions and referral information related to suspected conditions. This requirement applies to both electronic and paper claims. Electronic 837P KIDMED transaction must include the K3 segment, and the "File Extension" must be "KID",
Providers billing paper claims using the CMS 1500 Claim Form with only the screening codes must now submit the KM-3 claim form with all detail information. Educational edits currently appear on any electronic and hard copy claims payments if all applicable KIDMED claims detail is not provided. Effective April 1, 2005, Edits 517 (KIDMED format required - claims must be submitted in KIDMED format), 518 (KIDMED information missing - immunization and suspected condition information required) and HIPAA reason code 16 will be used to deny claims that are submitted on the 837P without KIDMED detail or on the CMS 1500 Claim Form.
Changes in Dental Billing Procedures Effective June 1, 2005
The Medicaid Program is transitioning dental EMC Proprietary submitters to the X12N 837 HIPAA mandated transaction. Effective June 1, 2005, all dental EMC Proprietary files will be returned to the submitter unprocessed. Therefore, we encourage you to move to the mandated HIPAA 837D as soon as possible. If you have not chosen a Vendor, Billing Agent, or Clearinghouse (VBC), you may go to www.lamedicaid.com to find an approved VBC to submit the 837D HIPAA mandated transaction. If you have any questions or need additional information regarding electronic billing, please call the HIPAA EDI Support Line at 225-237-3318.
Date of Services on Dental Claims
The date of service on a dental claim must reflect the actual date that the service was completed/delivered (please refer to page 16-11 of the Medicaid Dental Services Provider Manual). The Dental Surveillance and Utilization Department continues to identify dental providers who have billed and been paid for root canal therapy prior to the completion of the service. Dental claims shall not be filed prior to the completion/delivery of the service. This includes, but is not limited to, root canal therapy, a complete or partial denture and space maintainers. At a minimum, Medicaid will recover the payment for all claims billed when the date of service on the claim does not reflect the date the service was completed. If you have any questions, you may contact Terri Norwood, Program Specialist - Program Operations Section, at 225-342-9403.
Timely Completion of Mental Health Rehabilitation Assessments
Assessments for mental health rehabilitation (MHR) services must be completed within 30 days of approval. Please refer to Section 5, page 5-3 of the current MHR provider manual which states:
"The assessment must be completed within 30 days of approval. Extensions must be approved by the PA Unit."
If there are extenuating circumstances, the MHR provider should thoroughly document the reason for the request for the extension. The PA staff will then determine if the extension is warranted on a case by case basis.
If you have further questions, please contact Dawn R. Matte, Program Coordinator, at 225-342-1247.
Changes in Billing Procedures and Reimbursement for Certified Nurse Practitioners,
Clinical Nurse Specialists, and Certified Nurse Midwives
Effective for dates of service on or after July 1, 2005, Medicaid will require that all services provided by Certified Nurse Practitioners (CNP), Clinical Nurse Specialists (CNS), and Certified Nurse Midwives be billed identifying the CNP, CNS, or certified nurse midwife as the attending provider and using their individual Medicaid provider number.
Unless otherwise excluded by Louisiana Medicaid, the services covered are determined by individual licensure, scope of practice and collaborative agreement.
This is a change in Medicaid policy. There will no longer be a "list" of billable services for these providers. The collaborating physician must be currently enrolled in Louisiana Medicaid. Collaborative agreements must be available for review upon request by authorized representatives of Louisiana Medicaid.
The services of the CNP, CNS, and certified nurse midwife may not be billed when they are employed by or under contract with providers whose reimbursement is based on costs that include those salaries.
The reimbursement for services rendered by a CNP, CNS, or certified nurse midwife shall be 80% of the professional services fee schedule and 100% for a limited number of services. Currently services reimbursed at 100% are KIDMED medical, vision and hearing screens, and immunizations.
Services rendered by the CNP, CNS, and certified nurse midwife that are billed and paid with the physician listed as the attending provider are subject to recoupment.
An enrollment packet may be obtained by calling Provider Relations at (800) 473-2783.
Medicaid Enrollment of Physician Assistants
Effective immediately, Louisiana Medicaid will begin enrolling and issuing individual Medicaid provider numbers to physician assistants (PA). Please note the effective date for use of the physician assistant provider number will be for dates of services on and after
July 1, 2005. After that date, Medicaid will require that all services provided by a physician assistant be billed identifying the physician assistant as the attending provider.
Unless otherwise excluded by Louisiana Medicaid, the services covered are determined by individual licensure, scope of practice, and supervising physician delegation. The supervising physician must be a Medicaid enrolled physician. Clinical practice guidelines and protocols shall be available for review upon request by authorized representatives of Louisiana Medicaid.
Services provided by a physician assistant shall not be billed when he/she is employed by or under contract with providers whose reimbursement is based on costs that include these salaries.
The reimbursement for services rendered by a physician assistant shall be 80% of the professional services fee schedule and 100% for Kidmed medical, vision and hearing screens and immunizations. Please note the following billing instructions and enrollment requirements regarding PA services:
� PA services are billed on the CMS 1500 Form.
� Services provided by a PA must be identified by entering the provider number of the PA in block 24K; the name of the supervising physician must be entered in block 17 (name of referring physician or other source), and the group number must be entered in block 33 of the form.
� Physicians who employ or contract with PAs must obtain a group provider number and link the PA's individual provider number to the group number. Physician groups must notify Provider Enrollment of such employment or contract(s) when PAs are added or removed from the group.
Effective July 1, 2005, services rendered by the physician assistant that are billed and paid by Medicaid with the physician as the servicing provider are subject to recoupment.
A Physician Assistant enrollment packet may be obtained by calling Provider Relations at
800-473-2783 or 924-5040.
Changes in Billing Procedures for Long Term Care Facilities
Effective June 9, 2005, at 12 Noon, Unisys will no longer accept any Long Term Care claims billed on a TAD. Any
TADS received by Unisys after June 9, 2005 will be returned to the provider.
The last Unisys generated TADS will be for May 2005 dates of service. This change in billing procedures also applies to claims for prior dates of service.
With only three months remaining before this deadline, it is imperative that you begin submitting claims electronically using the mandated
X12 837I format or hardcopy using the UB-92 claim form prior to the effective date of the change in order to prevent delays in payment.
Please contact Unisys EDI for assistance with electronic billing at 225-237-3318 and Provider Relations for assistance with UB-92 billing at (800) 473-2783 or (225) 924-5040.
Clarification of New CommunityCARE Policy
CommunityCARE recently sent a notice to providers that the U.S. mail is no longer an acceptable method of
requesting or issuing CommunityCARE referrals/authorizations. Since the new policy went into effect, the
CommunityCARE program office has received a number of complaints from PCPs that hospitals are
attempting to fax the entire ER record with each post-authorization request. When requesting
post-authorization of an emergency room visit, hospitals should be including sufficient information regarding presenting symptoms so that the PCP can make an informed decision as to whether or not those presenting symptoms meet the prudent layperson definition of an emergency condition as defined by CMS (*see definition below). In most cases this would be the ER face sheet and/or triage notes. Listing the presenting symptoms as
"fever" "burn" or "cough" is not sufficient information for the PCP to make an informed decision. It is also NOT appropriate to list only a diagnosis. Diagnosis is not a presenting symptom, and the PCP's decision cannot be based upon the diagnosis. Ideally, in an effort to assist the PCP in providing the recipient with follow-up care, the hospital/emergency room physician should include what treatment was rendered and what follow-up instructions were given to the recipient. If the PCP should need additional information for appropriate follow-up care, it should be requested by the PCP at a later date, and can be mailed.
* Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of medical attention to result in:
� placing the health of the individual (or in the case of a pregnant woman, the health of the woman
or her unborn child) in serious jeopardy
� serious impairment of bodily function
� serious dysfunction of any organ or body part
Referral/Authorization of Office Visits
The CommunityCARE Program has become aware that providers are regularly providing services via routine office visits to CommunityCARE enrollees who are not linked to them. They are then
requesting after-the-fact referral authorizations with the expectation that the PCP should or must approve the request. It is inappropriate for a physician's office to provide non-urgent services to an enrollee who is not linked to them and expect the PCP to authorize that visit after-the-fact.
CommunityCARE policy states that "Providers who are not an enrollee's PCP shall obtain
referral/authorization for non-emergent care from the PCP prior to providing services to a CommunityCARE enrollee."
(Refer to the 2004 Unisys CommunityCARE Provider Training Packet).
Enrollees who present for non-urgent care at the office of a physician who is not their PCP, and the visit has not been authorized by their PCP prior to that visit, should not be treated. The enrollee should be advised of their assigned PCP and that the card does not cover services unless they were referred by their PCP. The CommunityCARE program does not expect or encourage PCPs to approve after-the-fact requests for referral/authorization for non-urgent office visits. The PCP is the enrollee�s "medical home." The PCP�s role is not to just issue referral/authorizations at an enrollee�s request. The PCP�s role is to provide regular, routine care within the scope of their practice and provide written referral/authorizations for specialty care as deemed medically necessary by the PCP and as appropriate for low level emergency room services. An enrollee is not entitled to go see another PCP provider when they are unable to see their PCP for same day services.
Questions regarding CommunityCARE policy may be directed to Unisys Provider Relations, or the CommunityCARE Program Office at 225-342-1304.
Frequently Asked Questions About Electronic Data Interchange (EDI)
In an effort to assist submitters and providers with their electronic claims, the Electronic Data Interchange (EDI) Department has compiled a list of frequently asked questions and the answers.
How can I obtain a Submitter ID?
� Submitter IDs are issued by the Unisys Provider Enrollment Department. The necessary forms may be obtained at http://www.lmmis.com/provweb1/HIPAA/HIPAAindex.htm. Look for the
EMC Enrollment Packet.
How do I link a provider to my submitter ID or add another provider to my submitter ID?
� For a provider to be linked to a submitter ID, the provider will have to submit a
Provider's Election to Employ Electronic Media Submission of Claims for Processing in the Louisiana Medical Assistance Program Form and a
Medicaid Electronic Media Limited Power of Attorney (if submitting through a third party). Both forms may be found in the EMC Enrollment Packet.
What is my submitter ID?
� The submitter ID is a seven-digit number issued by Louisiana Medicaid that begins with 450. If you do not have your number available, submit a written request on letterhead showing your submitter name and address, to request a copy of the original correspondence. The request must be signed by an authorized party and submitted hardcopy to Unisys - Provider Enrollment, P.O. Box 80159, Baton Rouge, LA 70898.
Is my provider linked to my submitter ID?
� When a provider number is initially linked to a submitter ID, the provider receives a letter giving them the submitter ID and the date of linkage. This letter should be forwarded to the third party biller as needed. For a third party to ensure that all providers are linked to their submitter ID, the submitter must complete and submit a
Request for Third Party Biller Linkage Information form. This form must have an original signature and be submitted hardcopy to the Unisys Provider Enrollment Department (see address above). Turnaround time is approximately three (3) weeks.
What is the status of my EDI Submitter ID application?
� The turnaround time for issuing submitter IDs is approximately three (3) weeks. Once the number has been issued, a letter is mailed to the Pay-To Address on file notifying the provider of the submitter number and effective date. This letter should be forwarded to the third party biller as needed. It is unnecessary to contact Unisys Provider Enrollment Department prior to three (3)weeks from submission date.
How do I update my address information on the Louisiana Medicaid files?
� An Address/Telephone Change form must be completed and submitted to the Unisys Provider Enrollment Department at the address above. The form must be completed in its entirety and should
include both the provider number and submitter number. The form requires an
Why is it important to maintain my information on the Louisiana Medicaid files?
� It is important to ensure that all information is correct on the Louisiana Medicaid files because automatic closures are performed periodically to close all submitter numbers that have not submitted to production within twelve (12) months. Also if returned mail is received for a submitter, and Unisys is unable to locate the submitter, the submitter number is closed. To ensure that a number remains active, it is necessary to keep all information up to date.
Where can I find a list of Vendors/Billing Agents/Clearinghouses (VBCs) that have been approved?
� An updated VBC list may be obtained at:
http://www.lamedicaid.com/provweb1/HIPAA/HIPAAindex.htm. See the VBC List link for the latest report. This report shows the status of VBCs in the testing phase with Louisiana Medicaid and is updated monthly.
Do I need to test before submitting into production?
� All submitters of Long-Term Care claims have to test before submission to production. If the vendor of the software that will be used to transmit claims has been approved by Louisiana Medicaid, no further testing is required for all other claim types. If the vendor's software is not approved, the submitter must wait until the vendor has successfully completed all required testing before submitting claims to production.
How do I get my submitter password?
� Passwords are required for submission of both test and production claims. Passwords may be obtained by sending an email to *email@example.com (the * asterisk is part of the email address). The email should include the following information: Submitter number, Submitter Name, name of software vendor, contact person name, telephone number and email address. The Unisys EDI Department will send the ID and password via return email.
How do I submit claims into production?
� After all testing requirements have been met for your claim type, you may begin submitting to production. Send an email to *firstname.lastname@example.org (the * asterisk is part of the email address) and include the following information: submitter ID, submitter name, claim type (physician, dental, etc.), software vendor's
name, contact person and phone number. Also indicate if you have a password or not and include a request to begin to submit to production. The EDI Department will email you when the submitter is moved to production. Additional questions should be directed to your vendor.
How do I start getting a production 835?
� Because a submitter cannot revert to proprietary electronic remittance advices once they transition to a production 835, a testing process is employed to ensure that the submitter is prepared to process the 835 upon receipt. To request a test, please contact the Unisys EDI Department at *email@example.com (the * asterisk is part of the email address).
After I submit a file, what do I need to do to make sure my file has been accepted?
� A TA1 is available immediately upon transmission and a 997 functional acknowledgement is available within 24 hours. Both acknowledgements should be checked to ensure that the file was received and accepted. Both files may be obtained by calling the same bulletin board system where the files were transmitted.
What is a TA1?
� The TA1 segment acknowledges the receipt of an X12 interchange header and trailer from a previous interchange. If the header/trailer pair was received correctly, the TA1 reflects a valid interchange regardless of the validity of the contents of the data included inside the header/trailer envelope. The validity of the data contained within the actual transaction will be acknowledged in the 997.
What is a 997?
� The 997 is a functional acknowledgment generated after the X12 transaction has been received. The 997 checks the file syntactically for errors and lets the submitter know if the entire file has been accepted or rejected.
Can I get a good TA1 and 997 and my file still reject?
� Yes. It is possible to get a good TA1 and 997 and the file then fails a business edit. The TA1 and 997 ensures that the file is syntactically correct for a HIPAA transmission. A business edit is an edit established by the Department of Health and Hospitals to identify known problems that occur with regularity.
I sent a file and was not paid on my RA; what happened to my claims?
� You should check to see that you got a good TA1 and 997. If the file was accepted for processing, it could have failed for a business edit. Check the file to ensure that it did not include any data that would cause the file to drop for a business edit. If no problems are identified, contact your third party biller or the Unisys EDI Department at 225-237-3200 ext. 2 for assistance.
I submitted my claims to a Clearing House or Billing Agent and have not received payment. What should I do?
� You should contact your Clearing House or Billing Agent to ensure that the claims were submitted to Louisiana Medicaid. If the files were submitted, you should see if they received a good TA1 and 997 or whether or not there were data problems that would cause the file to drop for a business edit. If the claims still cannot be located, the Clearing House or Billing Agent should contact the Unisys EDI Department for help.
Ambulatory Surgery Transition
As the Medicaid Program has transitioned from the use of ICD-9 procedure codes to using CPT/HCPCS procedure codes for billing outpatient ambulatory surgeries (Revenue Code 490), hospitals have asked for clarification of the new billing process. The following information is provided to assist hospitals with this new billing process.
� The ambulatory surgery claim line will be reimbursed at the lesser of billed charges or the appropriate grouping rate.
� If two or more ambulatory surgeries (HR490) appear on a claim, only one HR490 claim line will be paid. We will pay up to the grouping rate for the procedure in the highest reimbursement grouping (based on the statement above) and deny the other procedure line.
� The grouping rate constitutes full reimbursement for all services provided.
� Although all but the "major" ambulatory surgery will deny, providers should submit all procedures and charges related to those procedures on the same claim. Procedures may not be "split" and billed separately. Recipients may not be billed for other procedures/charges.
� Providers may not bill recipients if an ambulatory surgical procedure code is not on the current group listing. The code will deny because it is not on the list; and the provider must notify DHH that the code is not on the list.
On a monthly basis, the Bureau will review those claims that are denied and determine what codes are being billed. A determination will be made whether or not to include those codes on the ASC schedule and Outpatient Surgery Fees, and, if so, into which group will they be placed.
If the determination is made to add a new code, any previously submitted denied claims will be reprocessed by the fiscal intermediary. RA messages will also be published when new/additional codes are added to the listing.
Detailed billing of other services related to the ambulatory surgery is required. Please continue to provide this detail on these claims.
Claims Processing Issues
Unisys began processing Medicare Plus Choice claims effective December 1, 2004. Since we started this process, we have identified several provider errors related to claim submission. In an effort to eliminate any inconvenience to providers and unnecessary time delays in processing these claims, we want to address these concerns for corrective action.
� Please read the cover sheet instructions carefully when completing the sheet. Some providers are entering incorrect information or leaving necessary fields blank. Some examples are:
� Entering data in both Co-Pay and Deductible fields when only one of the fields should be completed;
� Entering data in either the Co-Pay or Deductible fields when no Co-Pay or Deductible is indicated on the accompanying EOB;
� Failing to enter the Medicare Payment Amount or entering incorrect data in this field; and/or
� Entering requested amounts on the cover sheet that are not consistent with the same information on the EOB.
� Only claims for dates of service on or after December 1, 2004 can be processed by Unisys. Claims with dates of services prior to December 1, 2004 will be rejected. Please do not submit claims with earlier dates of service to Unisys.
� Please do not enter payment amounts in field 54 of the UB-92 claim form unless a private insurance is also involved and has processed the claim. Medicare payment amounts should not be entered on the claim form.
� The Plan carrier code on the claim and on the cover sheet must match and must be the correct carrier code for that Plan.
� Ochsner 65 was purchased by Humana; but the carrier code did not change. The carrier code for Humana Gold Plus is H19510.
Claims submitted without the plan EOB and a six-digit carrier code beginning with an "H" will deny with an error edit 275 (Medicare eligible). Both the EOB and the correct carrier code are required for these claims to process properly.
Please review this information carefully and take corrective action to prevent processing delays. Any questions regarding the information presented in this article should be directed to Unisys Provider Relations at (800) 473-2783 or (225) 924-5040.
Changes in Required Certification of Electronically Submitted Claims
Historically, all claims submitted electronically to Louisiana Medicaid have required a completed hardcopy Certification Form for each file transmitted to Unisys. Effective January 1, 2005, the individual certification forms were replaced with an Annual Certification Form. These forms must be on file to allow ongoing submission of electronic claims. The first deadline for receipt of completed Annual Certification forms is May 15, 2005 and will be retroactive to January 1, 2005.
The Annual Certification form and an Address Change form MUST be completed and returned to the Unisys EDI Department before May 15, 2005. Failure to submit a completed Certification form will result in closure of the submitter number and all electronic files will be dropped from the system without being processed.
It is the responsibility of each provider submitting electronic claims to Louisiana Medicaid to ensure that all rules and regulations are followed. The provider should submit an Annual Certification form to each billing agent/clearinghouse for their records. Providers should work with their billing agent/clearinghouse to ensure that they submit the required Certification form to Unisys prior to May 15, 2005.
Additionally, it is the provider's responsibility to ensure that the information on the Louisiana Medicaid files are accurate and complete. If address or telephone changes are made after the completion of the Annual Certification form, a completed Address Change Form will be required. Contact Unisys Provider Enrollment at 225-237-3370 to obtain the necessary forms for updating information.
It is the responsibility of each third-party biller to ensure that similar certification forms are received from each provider for whom they submit electronic claims to Louisiana Medicaid. These forms must include language that the provider:
� Attests to the truth, accuracy and completeness of all claim information
� Understands that all claims are paid using Federal and State funds and
� Any falsification or concealment of a material fact may be prosecuted under federal and state laws. These provider Certification forms must be kept on file for a minimum of five (5) years.
Future Certification Forms
During the 4th Quarter of each year, correspondence will be mailed to all open submitters requesting updated information such as addresses, telephone numbers, etc. and will include the Annual Certification Form. This form will have to be submitted by November 1st of each year. Failure to submit the updated Certification Form will result in termination of the submitter number thus preventing the ability to transmit electronic claims to Louisiana Medicaid.
Frequently Asked Questions
What if I do not return this required Certification form before the deadline?
� The submitter number will be closed and all claims submitted will be dropped from the system without being processed. No further notification will be made to the submitter.
Does this mean that if my submitter number is closed, that my client's claims will not be processed?
What should I do if a third party submits my claims for me? Do I have any risk?
� You should speak with your third party submitter before the deadline to ensure that they are in compliance with this requirement. If the required Certification form is not received before the
deadline, your claims will not be processed and you may have an interruption in payment.
How do I verify with my third party biller that they have completed this form?
� You should call the third party who does the submission of your claims to Louisiana Medicaid. The Unisys EDI Department is not authorized to disclose this information to you. Remember, the contractual arrangement is between the provider and the third party biller.
What if I have already submitted certification forms for files submitted during 2005?
� They will be maintained on file, but this all-inclusive Certification form will supersede all others received in 2005.
Will I still have to submit individual Certification forms for all claims submitted prior to January 1, 2005?
� Yes, individual Certification forms will continue to be required for all previously submitted claims. This annual process covers only claims received by Unisys after January 1, 2005.
How can I obtain the required Annual Certification form for 2005?
� The form and Address Change Form will be mailed to you in early April. It is important that you ensure that your address is correct on our files prior to this date. You may email your name, submitter number and correct mailing address to *firstname.lastname@example.org (the asterisks is part of the address).
Regional LADUR Committee
The Department of Health and Hospitals is currently accepting nominations for the Region 4 Drug Utilization Review Committee. The committee consists of three pharmacists and one physician who meet monthly to review clinical issues on recipient drug profiles and send information to the medical
community. One pharmacist opening is currently available.
Committee members must be available to meet monthly for one to three hours and must meet the following requirements:
� Pharmacy degree from an accredited U.S. pharmacy school
� Licensed to practice pharmacy in Louisiana
� No previous sanctions from the state of Louisiana
� Provide services to Louisiana Medicaid recipients
� Practice in one of the following parishes:
|| East Carroll
|| Red River
|| West Carroll
Please use the form below for your nomination and return with a brief resume to:
Unisys: Louisiana Medicaid
8591 United Plaza Blvd., Suite 300
Baton Rouge, LA 70809
ATTN.: S. DELAVILLE
LMMIS REGION FOUR DRUG UTILIZATION REVIEW COMMITTEE NOMINATION
(PLEASE PRINT OR TYPE)
NAME: ______________________________________ PHONE:_____________________
PARISH: ____________________________ EMPLOYER:________________________
I am nominating the above mentioned for consideration as a member in the LMMIS REGION FOUR DRUG UTILIZATION REVIEW COMMITTEE.
PRINT NAME: __________________________________________
Louisiana Drug Utilization Review (LADUR) Education
The Importance of Folic Acid in Pregnancy
By: Evangeline Ward, BS Pharm
Staff Pharmacist, Prior Authorization
Office of Outcomes Research and Evaluation
School of Pharmacy
University of Louisiana at Monroe
� When taken in recommended daily dosages, folic acid can help prevent neural tube defects (NTDs) by up to
� In order to achieve full potential, women of childbearing age must supplement with folic acid before and during pregnancy.
� Most women are unaware of the benefits of folic acid and lack the recommended daily amount required
before and during pregnancy in order to prevent NTDs.
According to a report by the U.S. Department of Health and Human Services, approximately 2,500 to 3,000 babies are born with a neural tube defect (NTD) each year. Among the most common NTDs are spina bifida and anencephaly. Although no one knows exactly what causes NTDs, it has been proven that folic acid consumption before and during early pregnancy significantly decreases the risks.
Findings from a study conducted in 2002 by the Cochrane Pregnancy and Childbirth Group demonstrated a 3-fold decreased risk of a first neural tube defect in children whose mothers consumed the recommended daily value of folic acid during pregnancy. Reports from the Centers for Disease Control (CDC) have also concluded that women who take the recommended daily dose of folic acid starting one month before they conceive and throughout the first trimester reduce their babies' risk of birth defects up to 70 %. However, according to a 2002 survey conducted by the Gallup Organization, on behalf of the March of Dimes, only 33% of non-pregnant women between the ages of 18 and 45 receive folic acid supplementation on a daily basis.
What is folic acid?
Folic acid (also known as vitamin B9 or folate) is a vitamin that dissolves in water and is not stored in the body in large amounts. Therefore, water-soluble vitamins like folic acid must be eaten or taken every day to ensure that the body has enough to function properly. Folic acid is available in two forms. The first is a synthetic form supplied by vitamins and the second is a natural form called folate, which can be found in certain foods. In recognition of the benefits of folic acid, the Food and Drug Administration (FDA) requires food manufacturers to fortify enriched grain products, such as breakfast cereals, bread, pasta, and rice, so that each serving contains at least 20% of the recommended daily requirement.
The following values are approximate rates of folic acid absorption by the body according to the Institute of Medicine (IOM):
� 50% rate of absorption from food folate,
� 85% rate of absorption from folic acid fortified foods,
� 100% rate of absorption from vitamin supplements.
Studies have attempted to determine the most beneficial method for folic acid consumption (i.e., diet, supplementation, fortification). Currently study results are conflicting, but when comparing the forms of folic acid, the IOM, the CDC, and the March of Dimes recommend that women who could become pregnant consume folic acid in the form of a multivitamin supplement to ensure adequate absorption.
Some pregnant mothers are unable to consume daily vitamins due to sickness associated with the pregnancy; therefore, dietary supplementation may be a better option. Please keep in mind that, based on rate of absorption, it may require double the amount of folate to ensure the daily
recommended amount of folic acid.
Folic acid through nutritional food source
When selecting folate rich foods, dark leafy greens are almost always a good source of folate, but other sources include the following:
� 1 cup boiled collard greens: 177mcg,
� 1 medium papaya: 115mcg,
� 4 spears steamed or boiled asparagus: 88mcg,
� � cup steamed broccoli: 52mcg,
� 1 cup strawberries: 40 mcg,
� 1 medium orange: 39 mcg.
For those patients who may be unable to obtain the foods needed to maintain a healthy diet, several states, including Louisiana, offer programs that provide nutritious food, at no cost, to qualifying pregnant women. The foods are not only nutritious, but could be a very valuable source of folic acid supplementation for the mothers that can not supply their folic acid needs through vitamins. Table 1 lists some examples of those foods and their potential folate (natural folic acid) content.
These values do not serve as a substitute for nutritional information found on the product label.
per serving amount
Mild Cheddar, Medium Cheddar, Mozzarella
to 18 mcg
Crunchy or Whipped
Peas: chick, black-eyed, split, lentils
Black, Navy, Pinto, Kidney, Soy, Lima
149 to 570 mcg
Apple, Grape, Grapefruit, Orange, Pineapple, V-8
0 to 37 mcg
Corn Flakes, Kaboom
Enriched Quick Grits
Corn Flakes, Product 19
Malt O Meal�-Quick
Nabisco� -Cream of Wheat
Post� -Premium Bran Flakes
Grits, Instant Oatmeal,
King Vitamin, Life, Toasted Oatmeal Squares
150 to 1343 mcg
Figures obtained from product labels and calculated using www.CalorieCounter.net
Patients may not be aware of the nutritional value that may be lost in food preparation. Counseling your patients on food preparation methods may help them maintain maximum nutritional value.
Storing and preparation to preserve folate:
� Whenever possible, eat raw vegetables.
� Refrigerate fresh fruits and vegetables, but do not keep them long. The longer they are stored, even in the refrigerator, the more folate will be lost.
� Cooking water destroys folate. Steam or stir-fry vegetables instead of boiling them.
� Dried beans and peas, even when cooked for a long period of time, are good sources of folate.
The March of Dimes defines a birth defect as an irregularity of structure, function, or metabolism
present at birth that results in physical/mental disability or causes death.
Birth defects are generally grouped into three major categories:
� Congenital infections
� Other conditions
Structural/metabolic abnormalities occur when some part of the body is missing, is not shaped or working properly, or when the body is unable to metabolize certain substances due to an inborn genetic error. Neural tube defects (NTDs) are grouped into the structural/metabolic category of birth defects.
Neural Tube Defects
Neural tube defects occur when the brain and spinal cord do not form properly. The neural tube is the embryonic structure that develops into the brain and spinal cord. This structure starts out as a small ribbon of tissue that normally folds inward to make a tube by the 28th day of the pregnancy.
When this process does not work properly, the neural tube does not close completely and the brain and spinal cord may not develop normally. In cases where the brain and spinal cord do not develop properly, the pregnancy sometimes ends in miscarriage or stillbirth.
Ninety-five percent of NTD-affected births are to women with no personal or family history of NTDs. These defects occur between the 17th and 30th day after conception. Generally, this is before most women even realize that they are pregnant. The most common neural tube defects are as follows.
Often called "opened spine"; the bony spinal column and soft tissue layer over the spine do not
form properly, leaving the spinal cord exposed. According to the Spina Bifida Association of America (SBAA), there are an estimated 70,000 people in the United States currently living with this defect. The SBAA also reports that children with a severe case of spina bifida may have bladder and bowel control problems, learning disabilities, and paralysis in their
legs. The average total lifetime health care cost for each infant born with spina bifida ranges from $532,000 to over $1 million dollars per child. Although the exact cause is unknown, the SBAA is dedicated to reviewing the current research and, based on the findings of that research, advises women of childbearing age to consume the recommended daily amount of folic acid to reduce their risk of giving birth to a baby with spina bifida. Spina Bifida is the most frequently occurring and permanently disabling of all birth defects.
A fatal birth defect that happens when the neural tube does not fully close at the top. As a result, part of the skull and brain are missing. Babies with anencephaly die before or shortly after birth.
A condition resulting in abnormal closure of the skull where a portion of the brain is contained in a sac outside the skull.
Unplanned pregnancies occur every day. In fact, about half of all pregnancies are unplanned, which is why it so important for women to have enough folic acid in their body both before and during pregnancy. By the time most women find out they're pregnant, the baby's brain and spine have already formed.
How much folic acid does a woman need?
The U.S. Public Health Service, the Florida Folic Acid Council, the SBAA sponsored by the March of Dimes, and countless other organizations recommend that women of childbearing age need to consume at least 400 micrograms of folic acid daily before getting pregnant and continue taking it into the first month of pregnancy. Doing so can prevent up to 70% of birth defects of the brain and spinal cord. Typically, most women receive less than the recommended amount of 400 mcg of folic acid on a daily basis.
Folic acid's role in preventing birth defects
How folic acid prevents defects of the brain and spinal cord is not well understood. Most studies suggest that it may correct a nutritional deficiency, while others suggest that supplemental folic acid helps some people compensate for errors in how the body processes folates. Although, the exact mechanism of action is unknown as to how folic acid prevents NTDs, studies have shown that the following people are at an increased risk of having an NTD affected pregnancy:
� Caucasians with English/Irish ancestry
� People who do not eat well-balanced diets
� Couples who have already had other NTD affected pregnancies
� Women who have low folic acid levels before they become pregnant and during the earliest
weeks of pregnancy.
An estimated 60 million women of childbearing age do not consume the recommended value of folic acid on a daily basis. How do we combat this problem? The answer is patient education. A folic acid campaign and evaluation study based in southwestern Virginia determined that in highly motivated women, education does appear to influence behavior changes. A telephone survey of women ages 18 to 45 conducted by the Gallup Organization in 2002 showed that many women would be willing to change their behavior and take folic acid if the advice came from a healthcare professional. While yet another study by de Weerd et al, published in 2002, concluded that preconception counseling provided to women planning pregnancy did improve folic acid intake and decreased the risk of NTDs.
In summary, increased folic acid intake significantly decreases neural tube defects and folic acid education has the potential to promote its use. As healthcare professionals we can impact the battle against birth defects by educating women of childbearing age of the benefit of consistent folic acid supplementation.