VOLUME 8, NUMBER 2
Provider Relations' Telephones
We would like to remind providers who are calling Unisys,
Provider Relations to telephone Provider Relations' switchboard, not Unisys'
main switchboard. Providers outside
of Baton Rouge should telephone 1-800-473-2783.
Baton Rouge providers should telephone (504)
Planning for the Louisiana Medicaid Provider Training
sessions has been finalized. The
sessions has been finalized. The
sessions or workshops are designated to furnish claims processing information to
those individuals who complete the claim form and reconcile the Remittance
Advice. The sessions are scheduled
over a two-day period at specific times.
We request that all providers review the schedules for Day
One and Day Two of Provider Training and attend the appropriate session on one
of the dates listed in the next column. It
is not necessary, however, to advise either Unisys or the Bureau of Health
Services Financing of plans to attend the training sessions.
Providers are encouraged to bring examples of specific billing problems
and RAs because provider representatives will be available at the training
sessions to give assistance.
- 8:30 A.M. - 11:00
Physicians, Optometrists, Ophthalmologists, Optical
Supplies, Ambulatory Surgical Centers, Independent Labs, Portable X-ray, and
11:15 A.M. - 12:15
Anesthesiologists and CRNAs
1:30 P.M. - 3:00
3:15 P.M. - 4:15
Home Health and Rehabilitation
7:00 P.M. - 8:00
DME and Pharmacy
8:30 A.M. - 9:30
Long Term Care
9:45 A.M. - 10:30
10:45 A.M. - 11:30
7370 Airline Highway
Baton Rouge, Louisiana
1719 East 70th Street
Holiday Inn (Holidome)
1051 By-Pass 165/I-20
2716 N. MacAurthur Drive
505 N. Lakeshore Drive
Lake Charles, Louisiana
Holiday Inn (Holidome)
2032 N. E. Evangeline Thrwy.
Holiday Inn (Holidome)
210 South Hollywood Rd.
SESSION EIGHT: NEW
Dates: 6/6/91 and 6/7/91
2150 Veterans Blvd.
Recipient Eligibility Verification System
Unisys now has a Computerized Recipient Eligibility
Verification System available for providers' immediate use to respond to
telephone inquiries and to provide telephone inquiries and to provide
information regarding recipient eligibility, service limits, and third-party
liability for any date of service in the last 12 months.
In addition, providers will be able to obtain their current check amount.
This system is available 24 hours a day, 7 days a week, except for a
short period on Sundays when the system is being updated.
In addition, new information will be available every Monday so providers
will be able to verify eligibility on a weekly basis.
To access the system, providers must telephone (800)
776-6323 and have their seven-digit Provider I.D. Number, as well as the
appropriate thirteen-digit recipient number and date of service, available.
Procedural instructions will be given to the provider via voice response
Providers should note that the Louisiana Vocational
Technical School's Department of Education is no longer administering Nurse Aide
Competency Testing. For information
about the test, providers can contact Burns and Associates at (504) 785-0279.
All production tapes or diskettes must be sent to the
Unisys, EMC Department
P. O. Box 3396
Baton Rouge, LA 70821
In addition, each production tape or diskette must be
accompanied by a Provider Certification, e.g., Professional Services
Certification, Hospital Services Certification, Pharmacy Certification, or
Third-Party Biller Certification.
The address for certifications of telecommunications,
however, is different from the address for production materials.
All certifications for telecommunications should be sent to the following
address, not the address listed above:
Unisys, EMC Department
P. O. Box 91025
Baton Rouge, LA 70821
EMC Submission Schedule
All EMC submitters should have received a letter in January
and again in February of this year that served as a reminder of our production
schedule. However, for those
providers who did not receive such a letter, the schedule is as follows:
All claims received on Magnetic
tape or diskette before 5:00 P.M. on a Wednesday will be processed over the
weekend. Also, telecommunications
received before 10:00 A.M. on a Thursday will be processed over the weekend.
However, all other tapes, diskettes, and telecommunications not received
by these times will be processed the following week.
NOTE: This schedule will be
Professional Services Certification
In January of this year, a revised Professional Services Certification was mailed out to all providers
that would need to use the form when submitting production tapes or diskettes.
Effective immediately, these providers should note that the old
certification, the Professional Certification (only), is no longer valid and
that the new certification must be used. For
those providers who did not receive a copy of the new Professional Services
Certification, we have provided a copy in the attachments section of this issue
of the Provider Update. Providers
should photocopy this attachment until an original can be obtained from Unisys.
Providers who have questions about the new certification
form should contact our EMC Coordinator, Jerrold Perry, at (504) 924-7051 or 1-800-473-2783.
For HCFA 1500 claim forms, physicians must remember to
enter the attending physician provider number in Item H next to the list of
charges, not in the blank for the prior
authorization number. If the
provider number is entered in the wrong item, the claim will be denied.
Specimen Collection and Handling
The SURS (Surveillance and Utilization Review Subsystem)
Unit would like to remind providers that, effective 7/1/83, fees associated with
the collection, handling, and/or conveyance of specimens to laboratories are not
payable. The codes for these
procedures include codes 99000 and 99001. The
only exception to this policy is procedure code 99004, Collection of eye culture
specimens, which continues to be payable. In addition, hospitals and independent laboratories may bill
for routine specimen collection under procedure codes 36400, 36405, 36410, and
Injections covered by the Medicaid Program are limited to
those listed in the next column:
recipients under the age of 21 should be billed with the CPT-4 immunization
injection codes (For further clarification, providers should review page 5 of
the August 1990 Provider Update).
procaine penicillin or bicillin for recipients under the age of 21 should be
billed with CPT-4 code 90782, and the type of drugs should be specified.
There is a limit of no more than one injection of penicillin or bicillin
adrenalin equivalent injections should be billed with code J0170 (Adrenalin
injections; 3 units/day).
following trauma should be billed with procedure code 90703, and the type of
injury/trauma should be specified.
Allergy Desensitization, injections should be billed with CPT-4 procedure
codes 95120 and 95160.
Injections of Factor
VIII (hemophilia) should be billed with procedure code J7190, and the type
of Factor VIII should be specified.
Gold therapy for
treatment of rheumatoid arthritis should be billed with procedure code
J2910, and the type of drug used (gold, Myochrupine, or Solganol) should be
injections for Rhogam (only) should be billed with CPT-4 procedure code
The claim must reflect an RH factor diagnosis, or this procedure will
deny per "medical review guidelines."
A diagnosis of "pregnancy" is insufficient.
hemodialysis injection codes are listed on pages 4-17 and 4-18 of the
Professional Services Provider Manual.
These codes are to be used according to the instructions provided in the
manual. In addition, other
hemodialysis codes, as well as instructions for the use of these codes, can be
found in the Hemodialysis Center Services
Additional CPT-4 Procedure Codes for Optometrists
Effective with date of service 1/1/91, the Bureau of Health
Services Financing will allow optometrists to bill and to be reimbursed for the
CPT-4 procedure codes 90100 through 90170
Codes 90200 through 90280, except for code 90225.
Intermediate Care and Long Term Care Facility Medical Services.
Codes 90300 through 9-370 Rest Home, Domiciliary or
Custodial Care Facility Medical Services. Codes
90400 through 90470.
Codes 90500 through 90580.
Codes 92018, 92019, 92120, and 92130
Codes 92230 and 92235
Codes 92265, 92270, 92286, and 92287
Codes 92531 through 92547, except for 92533 and 92543
Removal of Ocular
Codes 65205 through 65222
Excision or Removal
of Lesion Involving More Than Skin.
Codes 67820 and 67825
Probing and Related
Codes 68800 through 68840, except for 68825
Ultrasound, Head and Neck.
Codes 76511, 76512, 76516, 76519, 76529, 76970, 76986, and
Codes 82948 and 83052
Special Services and
Codes 99070 and 99082
Codes 95881, 95882, and 95999
Codes 97110 through 97114 and 97139
The code optometrists were allowed to bill prior to 1/1/91 are printed on
page 4-22 of the Professional Services Provider Manual.
Pharmacists and Prescribers
Recently, we have received several inquiries from
several pharmacists regarding the Federal Upper Limit for the drug Slo-Phyllin
80mg/15ml syrup (The generic name for the drug is Theophylline anhydrous.).
In researching the Approved Drug
Products with Therapeutic Equivalence Evaluations and the July 1990 Federal
Upper Limit Listing, we have determined that the upper limit of 0.0045 per
ml applies to the Theophylline 80mg/15ml oral elixir, not the syrup.
Thus, effective 10/1/90, an update in the drug file was made to reflect
the removal of the Federal Upper limit of the syrup.
Effective for services 4/30/90, the drug Vasocon A was
returned to payable status because the Food and Drug Administration no longer
considers the drug to be a less than effective drug.
NEW LMAC Limits
The following changes should be made to Appendix A of the
EFF. DATE: 2/01/91
EFF. DATE: 2/01/91
EFF. DATE: 2/01/91
For states to continue receiving federal matching of their
expenditures for outpatient drugs dispensed to Medicaid recipients, Section 4401
of the Omnibus Budget Reconciliation Act of 1990 requires a drug manufacturer to
enter into a rebate agreement with the federal government.
In accordance with Section 4401 of OBRA 1990, the
Department of Health and Hospitals, Bureau of Health Services Financing, will
reimburse for only those drug products in which the pharmaceutical company is
participating in a rebate agreement with the Department of Health and Human
On March 19, 1991, a listing of pharmaceutical
manufacturers that are participating in the Medicaid drug rebate program was
sent to all physicians, dentists, and pharmacists who are providers in the
Louisiana Medicaid Program. The
listing is labeled Appendix C and
should be included in the provider manuals for dentists, physicians, and
Effective for prescription services beginning April 1,
1991, the Louisiana Medicaid Program will provided coverage for only those drug
products labeled by the pharmaceutical companies identified in Appendix
Corrections to Appendix
C include the following:
Providers should correct the manufacturer code for MD Pharmaceuticals.
The code should be 43567.
Providers should add code 00033 for Syntex Laboratories.
Providers should add code 00173 for Glaxo and Allen and Hanbury.
Providers should correct the code for Alza Corporation.
The code should be 17314.
The Federal Upper Limits (FUL) and Louisiana Maximum
Allowable Costs (LMAC) will remain in effect.
Also, the therapeutic categories, cough and cold preparations, anorexics
and cosmetic drugs, will remain nonpayable.
We would like to emphasize the importance of the proper use
of the National Drug Code (NDC) number. Accurate
records must be maintained by Medicaid-participating pharmacies, and the
appropriate NDC codes must be used on all pharmacy claims submitted for payment.
Inaccurate records may result in billing the wrong manufacturer for the
If a provider is unsure about the coverage of a specific
drug, he should call Unisys' Provider Relations Unit at 1-800-473-2783 or (504) 924-5040.
Nursing Home Providers
Any contact or verification from Veterans Affairs regarding
a decrease in VA benefits or an increase in the income the patients are allowed
to retain for their personal use must be reported to the local Office of Family
Support to allow for timely readjustment of patient liability and protected
Transportation Claims for Trips Over 400 Miles
Effective 5/1/91, the Department of Health and Hospitals
discontinued the procedure of prior authorizing transportation claims for trips
over 400 miles. Now, these claims
can be mailed directly to Unisys/Louisiana Medicaid for processing.
Thus, providers should submit these claims in accordance with standard
filing procedures to the following address:
P. O. Box 91022
Baton Rouge, LA 70821
In addition, those claims previously authorized by DHH and
all transportation providers who submitted claims for trips over 400 miles are
being reviewed monthly on a post payment review basis by the SURS Unit at
Unisys. So far, the reviews
indicate two areas where numerous violations occur:
Providers Are Not Complying With Documentation Requirements.
Providers must complete the MT-4
(Daily Trip Log) form in its entirety. Many
times providers omit odometer readings, vehicle I.D. numbers, and the driver's
name. In addition, providers must
complete two lines on the MT-4 form for each of the recipients who are
transported two ways.
The Mileage Billed Does Not Coincide With The Mileage Indicated On The
Providers are billing more mileage
than can be substantiated by the MT-4 forms.
Before billing the Medicaid Program, providers must check the total
mileage of each driver to determine the accuracy of the mileage report.
In addition, providers must bill for the actual miles of each trip, not
for an estimate of the mileage.
If billing violations are found in a post payment review, the Medicaid
Program could recoup payments.
Requests for Exceptions/Adjustments to Cost Per Discharge Limits
The bases for requesting an exception or adjustment to the
cost per discharge limits applicable to inpatient services are outlined on pages
9-1 and 9-2 of the Hospital Provider Manual. The specific methodology used by Medicaid to review requests
for adjustments or exceptions for hospital providers who are subject to the
TEFRA cost per discharge limitations are further delineated below.
Such adjustments are intended to take into account factors which could
result in significant distortions in the operating costs of inpatient hospital
services. Such adjustments may be
necessary to ensure comparability of cost reporting periods.
The hospital must provide sufficient documentation in a format specified
below and as otherwise requested by the State.
A hospital's operating costs may be adjusted upward or
downward, as appropriate, under the circumstances specified below.
An adjustment shall be made only to the extent that the hospital's
operating costs are reasonable, attributable to the circumstances specified,
separately identified by the hospital, and verified by audit.
An exception or adjustment shall be granted only when the hospital's
operating costs exceed the rate of increase ceiling applicable for the cost
reporting period. An exception/adjustment shall not be granted when increased
costs are attributable solely to decreases in utilization. Requests for adjustments or exceptions must be submitted no
later than 180 days from the Medicaid Notice of Provider Reimbursement (NPR).
Extraordinary Circumstances: The
hospital must demonstrate that it incurred unusual costs (in either a cost
reporting period subject to the ceiling or the hospital's base period) due to
extraordinary circumstances beyond its control.
These circumstances include, but are not limited to, strikes, fire,
earthquakes, floods, or similar unusual occurrences with substantial cost
effects. These are generally adjustments applicable only to that
specific cost reporting period and are not a "permanent" adjustment
which would trend forward to subsequent cost reporting periods.
Change in Case Mix/Increase in Intensity of Services:
The hospital has added or discontinued services in a cost reporting
period after its base period:
The hospital has experienced a change in case mix as a result of the
addition or discontinuation of services that results in a distortion in the rate
of cost increase; and
The hospital submits data/documentation summarizing the case-mix changes
and the resulting change in costs.
If increased costs are attributed to the addition of a new unit or service, the
costs and discharges for this unit/service should be isolated and these costs
shall then be added with the current period target amount for the applicable
cost reporting period for which the adjustment is requested.
The direct operating costs related to this unit/service may be limited to
only routine operating costs or may include related ancillary costs if these
differ significantly from those applicable to discharges in the base period.
This revised total inpatient operating cost shall then be divided by the
revised number of discharges (the number of discharges attributable to the new
unit/service plus the current period number of discharges without the new
unit/service discharges). The
figure derived would be the adjusted target rate.
This would be a "permanent" adjustment which would then flow
forward to subsequent cost reporting periods if the new unit/service was in
operation for the full twelve months of the cost reporting period.
If the new unit/service has been operating less than twelve months, a
one-time adjustment for that cost reporting may be granted, but a
"permanent" adjustment will then need to be calculated using the
subsequent cost reporting period which includes a full twelve months of
operation. The provider must
specifically identify the new inpatient unit or service responsible for the
increase in inpatient operating costs; identify the date on which a new
unit/service became operational; specify the direct costs of the new
unit/service and the portion of those costs included in Total Program Inpatient
Operating Costs; and identify indirect costs incurred specifically as a result
of the addition of the new unit/service. The
request must identify actual increases in indirect costs specifically
attributable to the addition of a new unit or service.
An adjustment is only available for actual increases in these costs, not
for the redistribution of existing indirect costs that result from the cost
finding process. Documentation
submitted must be as complete and detailed as possible.
In addressing the amount of the distortion that occurs, specify the basis
for such distortion. Costs must be categorized as capital costs, staffing costs,
supplies, etc. Additional
information such as the number of new personnel employed, special training of
personnel, hours of operation and hourly salary levels of staffing should be
submitted as well. The impact of
the new unit/service on the historical cost structure of the hospital should be
demonstrated by the documentation submitted.
In such an instance, a cost report for the period impacted by the new
unit/service which identifies costs associated with this unit/service by running
these as a subprovider would be acceptable as documentation along with the
impact on the inpatient utilization levels of the hospital and summary of the
patient logs related to the new unit/service. Such summaries should included the patient name, Medicaid
identification number, dates of service, date of payment, total charges by
revenue code (routine or ancillary).
If increased costs are attributed to an increase in intensity or utilization of
a particular ancillary service/cost center for Medicaid recipients, the cost for
this service/cost center for the base period should be componentized by
determining the average Medicaid cost per discharge in the base period and then
inflating up to the current period for which the adjustment has been requested.
Compare the current period cost per discharge for this service/cost
center to the inflated base period cost/discharge.
If current year cost is less than base period inflated, no adjustment is
warranted. If current cost is
greater than inflated base period cost, incorporate current period costs to base
period ancillary cost to adjust base period target rate, then inflate up to
current period to calculate revised cost per discharge limitation. Documentation regarding the utilization in both periods must
be submitted (i.e., number of procedures/units).
Addition of a new service does not necessarily warrant rebasing under Section
6105(a) of Public Law 101-239. In
order to justify rebasing, a permanent, substantial, and significant change in
the nature of services provided by the hospital must have occurred.
For example, addition of a substance abuse unit would not warrant
Length of Stay Changes: When
there is no significant change in the services provided from those in the base
period, but the length of stay has increased due to treatment of more seriously
ill patients, a one-time adjustment (not permanent) may be granted for that
specific cost reporting period in which the change in length of stay occurred.
The adjustment is calculated using the following steps:
Identify the total inpatient operating cost excluding pass-through costs
for the cost reporting period for which the adjustment is requested (Worksheet
D-1, Part II, Line 54);
Identify the number of Medicaid days in the cost reporting period for the
base period and the period for which the adjustment is requested (Worksheet D-1,
Part 1, Line 9);
Convert the target amount for current period to a per diem amount by
multiplying the target rate for the cost reporting period by the number of
discharges and dividing by the number of Medicaid days;
Multiply the per diem amount for the current period by the base period
discharges and divide by the base period days to determine a revised target
Allowable program inpatient costs for the period for which adjustment is
requested shall be the lesser of the revised target amount times the current
number of discharges or the actual inpatient operating costs, plus excludable
If the addition of a new unit also increases the average length of stay, an
additional adjustment may be requested if the permanent and/or one-time
adjustments are not sufficient to permit reimbursement of reasonably allowable
cost-related to the basis for requesting an adjustment.
These procedures and calculations are based on the methodology used by
Medicare for the purposes of reviewing and calculating adjustments to the cost
per discharge limitations in accordance with 42 CFR 413.40.
Requests for adjustment of target rates must be submitted in writing to Carolyn
O. Maggio, P. D., Director, Bureau of Health Services Financing, P. O. Box
91030, Baton Rouge, Louisiana 70821-9030
with the basis for adjustment specifically stated and related documentation
submitted for review. Additional
information may be requested by the State to ensure that adjustments are related
to actual costs and not redistribution of costs.
If desired an example of the above calculations may be obtained by
contacting the Bureau of Health Services Financing, Program Operations Section,
Attention: Ron Jesse.