PROVIDER
UPDATE
VOLUME
14, NUMBER 2
APRIL
1997
Anniversary
of the LMPBM
In
April 1996, the Louisiana Medicaid Pharmacy Benefits Management (LMPBM)
Program's primary components, the Point-of-Sale/Prospective Drug Utilization
Review (POS/ProDUR), commenced operations.
This exciting addition to the Louisiana Medicaid Program is now
celebrating its one year anniversary, and we couldn't be more pleased with its
success.
The
essential features of the LMPBM include an emphasis on quality clinical
outcomes, access by providers and pharmacists to the PBM Help Desk, and
conservation of Medicaid funds. In
fact through ProDur's online "Point-of-Sale" database, pharmacists
can verify Medicaid coverage and can access patient and drug product
information within 15 seconds.
ProDUR
enables the Department of Health and Hospitals (DHH) to effectively manage
health care dollars, assure access to health care, and to provide the best
quality care for Medicaid recipients, according to M. J. Terrebonne, director
of DHH's pharmacy program.
The
ProDUR system was designed and implemented under the direction of Carolyn
Maggio, DHH's Research and Development Director. In addition to DHH staff, the project task force includes
representatives from the LSU, Tulane and Ochsner medical academic centers;
Northeast Louisiana University and Xavier University schools of pharmacy;
physicians; pharmacists; and Unisys, the fiscal intermediary.
As
always, thank you for your continued support and participation in the
Louisiana Medicaid Program.
Notice
to Anesthesiologists, CRNAs, Obstetricians, and Other Interested Physicians
Currently
providers bill procedure code 00098 and receive a flat fee of $50.00 for the
reinjection of the epidural catheter when a tubal ligation is performed
several hours after a vaginal delivery.
Effective
for dates of service on or after February 15, 1997, billing procedures and
fees for code 00098 has been changed as follows:
Providers
should continue to use the same modifiers and diagnosis codes with procedure
code 00098 when submitting a claim for an epidural for a vaginal delivery;
i.e., use diagnosis codes in the range of 650-659, 669.5, or 669.6, and
modifiers of AA, AI, AE, 24, 25, etc.
|
Procedure
Code
|
Modifier
|
Fee
|
| 00098
|
AA or AI
|
$162.00
|
| 00098
|
AE or 24
|
$89.10
|
| 00098
|
25
|
$72.90
|
Code
00098 with no modifier will be reimbursed at $162.00.
As
reimbursement for code 00098 is a flat fee determined by the modifier used, it
is not necessary for minutes to be included in the units column (Item 24 G) of
the HCFA 1500 claim form. The
sterilization consent Form 96 must be attached to the claim form.
If the Form 96 is not attached to the claim form, the claim will be
denied. All claims must be
submitted hard copy.
Code
00098 is restricted to one per recipient per lifetime.
Notice
to Physicians
CPT
codes 54150 and 54160, which are circumcision procedures performed on
newborns, have been removed from the global surgery edits. Claims with these 2 codes as well as claims for office visits
that denied because of the global surgery edits will be recycled within the
near future.
Notice
to Physicians: Use of 158-A
Extension of Outpatient Physician Visits Form
Please
remember that the 158-A Extension of Outpatient Physicians Visits Form is to
be used to request an extension of OUTPATIENT PHYSICIAN VISITS ONLY.
Providers
have been using this form to request extensions on other types of limited
services. This is an
inappropriate use of the 158-A form. If
an approval is inadvertently given when the form is inappropriately used, the
approval does not override the policy limitations and the claim will not pay.
Please use this form only as it is designed to be used.
Louisiana
Drug Utilization Review (LADUR) Education
Smoking
Cessation in the Primary Care Setting
By
Tracy S. Hunter, Ph.D., and Philip J. Medon, Ph.D.
Issues
. . .
-
Smoking
cigarettes involves three primary addictive risks.
-
Smoking
cessation efforts and programs must address all three risks.
-
The
AHCR recommends that smokers are routinely identified and intervention takes
place with tobacco users are every office visits.
The
health and economic consequences of cigarette smoking are widely reported and
known to health care workers and the public.
Many smokers attempt to quit three or four times before they are
successful. Primary care
clinicians and pharmacists are in a position to influence the health of the
residents of the State of Louisiana by providing clear cut, simple advice to
patients who currently smoke to stop.
The
Health Consequences of Smoking
The
tobacco addiction entails behavioral and physiologic dependence on nicotine.
Smoking cigarettes involves three primary addictive risks.
Smoking cessation efforts and programs must address all three addictive
risks:
-
A
habit-forming substance that stimulates repeat behavior:
-
A
pleasure-causing chemical that produces a positive reinforcement; and
-
A drug
that is self-administered on impulse, with dosage control by the user.
Psychoactive
Effects
Nicotine
is the psychoactive agent that is the physically addictive component of
cigarette tobacco. The
pharmacologic actions of nicotine are quite complex and potent, and often
unpredictable. It can cause
various physiologic effects; it acts as both a stimulant and a central nervous
system depressant. Nicotine, in
appropriate doses, acts on the central nervous system to cause EEG changes,
tremors, convulsions, nausea, vomiting, and dizziness.
Nicotine effects the central nervous system in the locus ceruleus and
mesolimbic-dopaminergic. It
increases activity in the locus ceruleus (which is critical in regulating
vigilance and arousal, stress reactions, and psychosomatic reactions).
The result is an increase in arousal and concentration skills, and a
decreased stress response. On the
mesolimbic-dopaminergic system - the pleasure center of the brain - nicotine
acts like other drugs such as cocaine. Drugs
that stimulate this system often result in drug seeking behavior to recreate
the pleasure sensation.
Cardiovascular
Effects
Nicotine
has a profound effect on cardiovascular health. It elicits a discharge of epinephrine from the adrenal
medulla, thus increasing heart rate and blood pressure.
Contributing to the sympathomimetic response is activation of
chemoreceptors of the aortic and carotid bodies, resulting in
vasoconstriction, tachycardia, and elevated blood pressure.
Additionally there is a concomitant increase in oxygen consumption and
a decreased oxygen-carrying capacity. The
health consequences are exacerbation of angina, myocardial infarction,
hypertension, peripheral vascular disease, and stroke.
Nicotine
Tolerance
Tolerance
develops to several of nicotine's effects including the nausea, vomiting, and
dizziness seen in first time smokers. But
even chronic smokers experience increased blood pressure, heart rate, hand
tremors, a decreased skin temperature, an increase in certain hormonal levels,
and a lowering of the body weight set-point.
As tolerance develops, there is a concomitant increase in withdrawal
symptoms when nicotine is removed. These
symptoms include irritability, anxiety, restlessness, difficulty
concentrating, drowsiness, headaches, increased appetite, and sleep
disturbances. Women report more
distress during withdrawal symptoms than do men.
Basic
Primary Care Practice Standards
The
Agency for Health Care Policy and Research (AHCPR) publishes a guide for
clinicians, "The Clinical Practice Guidelines on Smoking Cessation,"
Number 18. The following
procedures were abstracted from this document which reflects a thorough review
of medical evidence from clinical studies from 1978 to 1994.
They
recommend that office systems routinely identify and intervene with all
tobacco users at every office visit. The
system they recommend and have found to be effective can be summarized as:
Ask, Advise, and Assist.
Ask
The
first step in the suggested protocol is for the clinician to ask about
tobacco-use of every patient, at every office visit. Tobacco usage should be routinely obtained with other vital
signs data and recorded in the patient's chart.
Tobacco-use stickers prominently displayed on all patient charts flag
smoking status or change in status and keep the issue active.
If computer based records are kept, a date field should be dedicated to
tobacco-use status.
Advise
The
next step is to advise (in a clear, strong, personalized manner) the patient
to stop tobacco use. Simple
statements such as, "I think it is important for you to quit smoking now
and I will help you," have been found to be effective. Of course, the more intense the treatment, the more effective
it is in producing long term abstinence but even cessation treatments as brief
as 3 minutes a visit help. Strongly
assert that "I need you to know that quitting smoking is the most
important thing you can do to protect your current and future health."
Personalize your advice to the patient ("You've already had one
heart attack," "Your diabetes is not under control, and you need to
stop smoking").
Mention
the negative effects on the other members of the household ("Your new
grandbaby has asthma, and your smoking makes it worse!").
If the patient does not wish to quit, clinicians should ask the patient
to identify reasons to quit and barriers to quitting.
Reassure the patient that when he or she is ready to quit that you will
be there to assist.
Assist
The
next step is to advise the smoker to:
-
Set a
firm quit date, preferably within two weeks but at a time that is relatively
low stress for the patient.
-
Inform
friends, family, and co-workers of plans to quit and ask for their support
-
Remove
cigarettes from home, car, and workplace, and avoid smoking in these places.
-
Review
previous attempts to quit. (What
helped? What circumstances led to
relapse?)
-
Anticipate
challenges, including nicotine withdrawal, situations such as weekend parties
where resistance could be lowered.
Four
additional tips to advise on successful quitting are:
-
Total
abstinence is essential - not even a single puff - starting on the quit day.
-
Drinking
alcohol is strongly associated with relapse.
-
Having
other smokers in the household hinders successful quitting.
-
Offer
educational materials that are culturally and educationally pertinent for your
patients.
Medicinal
Products in Aid to Smoking Cessation
Encourage
nicotine replacement therapy. Both
the patch and gum are effective medications for smoking cessation.
Use of the patch may be easier for patients with regard to compliance,
but use of the nicotine gum products are effective individualizing the
delivery dose of nicotine. A
nasal spray has recently been approved. (See Table 1 on Page 5.)
Follow
Up
The
clinician should schedule follow-up contacts with the patient, either in
person or by telephone. The first
contact should generally be within two weeks (preferably during the first
week) of the agreed upon "quit date."
A second contact should be attempted within the first month.
During these contacts, the clinician should congratulate successes, and
if a lapse has occurred, solicit a recommitment to total abstinence.
Remind the patient that a lapse does not mean failure and can be a
learning experience. Review the
events associated with the lapse and discuss alternative behaviors.
Prevent
Relapse
To
prevent relapse, offer the ex-smoker additional reinforcement.
Review the patient's success.
Congratulate,
encourage, and discuss the importance of remaining abstinent.
Review the potential health and economic benefits of not smoking.
Inquire about problems encountered or anticipated in maintaining
abstinence.
Allow
the patients to present their own solutions.
Specific problems that can be anticipated include:
weight gain, depressed moods, prolonged nicotine withdrawal, or lack of
social support for cessation from family, friends, or coworkers.
Weight
gain, especially for female patients, is seen as an inevitable side effect of
smoking cessation. About 80% of
smokers who quit smoking do gain weight.
The gain averages about 10 pounds and occurs within the first 6 months
after smoking cessation. The
health effect of the weight gain is not significant compared to the benefits
gained by not smoking, but still may be a major barrier to abstinence.
Efforts to prevent weight gain have been show to undermine cessation
attempts, and it is recommended that weight control efforts not be started
until at least 3 months after cessation of smoking.
Increased physical activity can be encouraged if appropriate for
healthy patients.
For
printed copies of the Clinical Practice Guideline, A Quick Reference Guide
for Smoking Cessation Specialists, a consumer version (available in
English and Spanish), telephone AHCPR at 800-358-9295 or write AHCPR
Publication Clearinghouse, P. O. Box 8547, Silver Spring, MD 20907. These
smoking cessation guidelines are available through the Internet at http://www.ahcpr.gov/guide/.
|
Table
1: Nicotine-Replacement
Therapies
|
|
|
|
|
Brand Names and Strengths
|
Dosing
|
|
|
|
|
Prescription
Transdermal Systems
|
|
|
|
|
|
Habitrol
(21, 14, or 7 mg/24 hours)
|
Healthy
patients: 11 mg for 4-8
weeks, then taper to lower strengths every 2-4 weeks.
|
|
|
|
|
Prostep
(22 or 11 mg/24 hours)
|
Patients
greater than or equal to 100 l.: 22
mg patch for 4-8 weeks then taper.
Start patients less than 100 lb. On 11 mg patch for 4 weeks.
|
|
|
|
|
Nonprescription
Transdermal Systems
|
|
|
|
|
|
Nicoderm
CQ (21, 14, 6 mg patches/16 or 24 hours
|
Light
smokersA: one 14 mg/24 hour patch for 16 hours per day for 6
weeks, then one 7 mg/24 hour patch for 16 to 24 hours per day for 2
weeks.
Heavy
smokers B: one 21 mg/24 hour patch for 16 hours daily for 6
weeks, taper in two week increments.
|
|
|
|
|
Nicotrol
(15 mg/day/16 hours)
|
Heavy
smokers B: 15 mg/day for 6 weeks.
|
|
|
|
|
Nonprescription
Chewing Gum
|
|
|
|
|
|
Nicorette
(2 or 4 mg)
|
2
mg (for patients who smoke 24 or fewer cigarettes/day) or 4 mg for more.
Chewed and placed in check intermittently over 30 minutes every
hour for 6 weeks, then taper to every 2-4 hours for 4 weeks, then to
every 4-8 hours for 3 weeks. Do
not exceed 24 pieces daily or for longer than 12 weeks.
|
|
|
|
|
Prescription
Nasal Spray
|
|
|
|
|
|
Nicotrol
NS (10 mg/ml)
|
One
or two 1 mg dose (each dose is two 0.5 mg, one in each nostril) per hour
initially, increased if needed but not to exceed 5 doses per hour (or 40
daily) for up to 8 weeks, then taper over 4-6 weeks.
|
|
|
|
|
LightA
= Less than or equal to 10 cigarettes/day
HeavyB
= More than 10 cigarettes/day
|
|
|
|
Attention
DME Providers: Procedure Code
Changes
Durable
Medical Equipment providers should note the following changes that have been
made to the procedure code file for DME items.
DME
PROCEDURE CODE ADDITIONS
A4335
- Incontinence supply; miscellaneous
A4455
- Adhesive remover or solvent (for tape, cement, or other adhesive)
A4628
- Oropharyngeal suction catheter, each
A4629
- Tracheostomy care kit for established tracheostomy
K0101
- One arm attachment
K0102
- Crutch and cane holder
K0103
- Transfer Board (25")
|
K0104
- Cylinder Tank Carrier
K0132
- Male external catheter with or without adhesive, with or without anti-reflux
device, each
K0133
- Intermittent urinary catheter, disposable, straight tip
K0134
- Intermittent urinary catheter, disposable, coude (curved) tip
K0135
- Intermittent urinary catheter, reusable, straight tip
K0136
- Intermittent urinary catheter, reusable, coude (curved) tip
K0280
- Extension drainage tubing, any type, any length, with connector/adaptor, for
use with urinary leg bag or urostomy pouch, each
K0281
- Lubricant, individual sterile packet, each
K0407
- Urinary catheter anchoring device, adhesive skin attachment
K0408
- Urinary catheter anchoring device, leg strap
K0409
- Sterile water irrigation solution, 1000 ml.
K0410
- Male external catheter, with adhesive coating, each
K0411
- Male external catheter, with adhesive strip, each
XX004
- Administration set, small volume nonfiltered pneumatic nebulizer, disposable
K0169
- Small volume nonfiltered pneumatic nebulizer, disposable
K0170
- Administration set, small volume nonfiltered pneumatic nebulizer,
non-disposable
K0171
- Administration set, small volume nonfiltered pneumatic nebulizer
K0172
- Large volume nebulizer, disposable, unfilled, used with aerosol compressor
K0173
- Large volume nebulizer, disposable, prefilled, used with aerosol compressor
K0174
- Reservoir bottle, non-disposable, used with large volume ultrasonic
nebulizer
K0175
- Corrugated tubing, disposable, used with large volume nebulizer, 100 feet
K0176
- Corrugated tubing, non-disposable, used with large volume nebulizer, 100
feet
K0177
- Filter, non-disposable, used with aerosol or ultrasonic
K0180
- Aerosol mask, used with DME nebulizer
K0183
- Nasal application device, used with CPAP device
K0184
- Nasal pillow/seals, replacement for nasal application device, pair
K0184
- Headgear, used with CPAP device
K0186
- Chin strap, used with CPAP device
K0187
- Tubing, used with CPAP device
K0188
- Filter, non-disposable, used with CPAP device
K0189
- Filter, non-disposable, used with CPAP device
K0192
- Tubing, used with suction pump
K0193
- Continuous Positive Airway Pressure (CPAP) device, with humidifier
K0194
- Intermittent Assist Device with Continuous Positive Airway Pressure (CPAP),
with humidifier
K0268
- Humidifier, used with CPAP device
K0277
- Skin barrier; solid 4x4, or equivalent, with built-in convexity, each
K0278
- Skin barrier; with flange (solid, flexible, or accordion) with built-in
convexity, any size, each
K0279
- Skin barrier; extended wear
E0791
- Parenteral infusion pump, stationary, single, or multichannel
E0192
- Low pressure and equalization pad
K0284
- External infusion pump, mechanical, reusable, for extended drug infusion
L1885
- KO, single or double upright, thigh and calf, with functional active
resistance control
L5617
- Addition to lower extremity, quick change self-aligning unit, above knee or
below knee, each
L5845
- Addition, endoskeletal, knee-shin system, stance flexion feature, adjustable
L5846
- Addition, endoskeletal, knee-shin system, microprocessor control feature,
swing phase only
L5930
- Additional, endoskeletal system, high activity knee control frame
L5985
- All endoskeletal lower extremity prostheses, dynamic prosthetic pylon
L2860
- Addition to lower extremity joint, knee, or ankle, concentric adjustable
torsion style mechanism, each
L3890
- Addition to upper extremity joint, wrist, elbow, concentric adjustable
torsion style mechanism, each
XX058
- Category IV enteral product, 100 calories = 1 unit, Vivonex T. E. N.
XX073
- Category IV enteral product, 100 calories = 1 unit, Advera
XX074
- Category IV enteral product, 100 calories = 1 unit, Crucial
XX075
- Category IV enteral product, 100 calories = 1 unit, Diabetisource
XX076
- Category IV enteral product, 100 calories = 1 unit, Isosource
XX077
- Category IV enteral product, 100 calories = 1 unit, Vivonex Plus
XX078
- Category IV enteral product, 100 calories = 1 unit, Sandosource Peptide
XX079
- Category IV enteral product, 100 calories = 1 unit, L-Elemental Plus
XX080
- Category IV enteral product, 100 calories = 1 unit, Pro-Peptide
XX081
- Category IV enteral product, 100 calories = 1 unit, Peptamen VHP
XX082
- Category IV enteral product, 100 calories = 1 unit, Impact 1.5
XX083
- Category IV enteral product, 100 calories = 1 unit, Renacal
XX084
- Category IV enteral product, 100 calories = 1 unit, Pro-Peptide VHN
Diabetic
Shoes Code Changes
The
following is a list of codes which have been made non-payable and the codes
which have replaced them. The
descriptions remain the same for each code replacement.
| Deleted
Codes |
Replaced By
|
| Q0117
|
A5500
|
| Q0118
|
A5501
|
| Q0119
|
A5502
|
| Q0120
|
A5503
|
| Q0121
|
A5504
|
| Q0122 |
A5505
|
| Q0123
|
A5506
|
| Q0133
|
A5507
|
For
All DME Providers
Effective
for dates of service on and after February 26, 1997, the Bureau of Health
Services Financing will reimburse DME providers for customized wheelchairs
(HCPC code E1220) at a rate of Manufacturer's Suggested Retail Price (MSRP)
minus 15% for manual type customized wheelchairs, and MSRP minus 12% for
motorized, customized wheelchairs. An
Emergency Rule was published in the February 20, 1997 issue and the Louisiana
Register to implement this rate revision.
This rate revision is being made as a result of, and in response to,
concerns expressed by some providers in the public hearing of October 19,
1996, and afterward, about the effects of the previous rate revision on MSRP
minus 18%.
Reminder
to Physician Providers: Global
Surgery Policy
In
July, 1996, you received manual revisions which included the implementation of
the Louisiana Medicaid Global Surgery Period Policy. Information concerning this new policy was also printed in the
Summer, 1996 edition of the Provider Update.
Please be sure you are aware of this policy when billing claims for
services related to any surgeries covered by this policy.
You
may obtain information concerning whether a particular surgery falls under
this policy by calling Unisys Provider Relations at (800) 473-2783 or (504)
924-5040.
REMINDER: This Global Surgery Period Policy may not be circumvented.
You may not elect to bill for office visits instead of billing for the
procedure. Please do not attempt
to bill in this way.
Notice
to Certified Midwives
Effective
for dates of service on or after February 1, 1997, the following CPT codes
were added to the list of codes reimbursable to Certified Nurse Midwives.
| 99218 |
76818
|
80019
|
84702 |
86901
|
| 99219
|
80012
|
80439
|
84703
|
87070
|
| 99220
|
80016
|
80440
|
85013
|
87072
|
| 99231
|
80018
|
81005
|
85014
|
87086
|
| 99238
|
81002
|
81007
|
85018
|
87087
|
| 99281
|
81015
|
82962
|
85023
|
87088
|
| 99282
|
81025
|
83001
|
85024
|
87110
|
| 99283
|
57061
(w/protocol)
|
83002
|
85025
|
87178
|
| 99432
|
59414
|
84443
|
86317
|
86663
|
| 99440
|
80002
|
86302
|
86403
|
86664
|
| 11977
|
80003
|
86311
|
86580
|
86665
|
| 57170
|
80004
|
86430
|
86689
|
86674
|
| 58300 |
80005
|
86431
|
86701
|
86687
|
| 58301
|
80006
|
82465
|
86702
|
86688
|
| 59020
|
80007
|
82947
|
86762
|
86694
|
| 59025
|
80008
|
83020
|
86781
|
86695
|
| 59050
|
80009
|
83718
|
86850
|
86777
|
| 59300
|
80010
|
83719
|
86900
|
86778
|
| 76810
|
80011
|
83721
|
87211
|
86787
|
| |
|
|
|
90718
|
Codes
59020 and 59025 are payable in an office setting to providers who have verified,
in writing to the state, that they have the capability of performing this
procedure in their office and have registered the equipment necessary to perform
these tests.
If
the place of service is inpatient or outpatient hospital, or the billing
provider is rendering the "interpretation" only in his office,
modifier 26 must be appended to the procedure code.
The
register equipment please contact Provider Enrollment at (504) 342-9454.
Notice
to Providers: Reimbursement for the
Removal of Keloids
Reimbursement
for the removal of keloids shall not be made if the Medical Review Unit
determines that the removal was for cosmetic reasons only.
This
policy shall apply to the removal of all keloids, regardless of size, if the
only reason for which they were removed was cosmetic.
Notice
to Physicians and Providers: CPT
Codes Placed in Non-Pay Status
The
CPT codes which were deleted in the 1997 issuance of the Physician's Current
Procedural Technology have been placed in non-pay status effective for dates
of service April 1, 1997.
Please
program your billing systems immediately to bill current codes if you have not
already done so.
Notice
to All Providers Whose Services Require Prior Authorization or Pre-Certification
Many
services covered under the Louisiana Medicaid Program require some form of prior
authorization, pre-certification, or extension request.
Please remember that authorization of services does not override any
other Medicaid Program policy and does not guarantee payment of the claim.
This includes, but is not limited to, the following examples:
1.
If a
recipient is not eligible for services on the specified date of service, an
authorization does not override ineligibility and the claim will not be paid.
2.
If a
recipient is Medicare eligible, an authorization does not override the fact that
the claim must be submitted to Medicare for consideration prior to being
submitted to Medicaid.
Please
be aware of this fact when submitting your claims for processing.
Notice
to Providers: Funding of Needle
Aspiration Services
The
Bureau of Health Services Financing is pleased to inform you of the funding of
fine needle aspiration procedures, CPT codes 88170 and 88171, effective for
dates of service March 1, 1997. The
description and fees are as follows:
|
Code
|
Description
|
Fee
|
|
88170
|
Fine
needle aspiration with or without preparation of smears; superficial
tissue (e.g., thyroid, breast, prostate)
|
$50.48
|
|
88171
|
Deep
tissue under radiologic guidance
|
$58.11
|
Each
of these codes has a UVS of "2".
The professional component fee is 40% of the full service fee stated
above.
Providers:
Where to Get POS Brochures
The
Department has received numerous requests for additional copies of our disease
management materials on H. Pylori and GERD.
Our initial order for the brochure, entitled "About Your
Stomach," targeted the Medicaid population identified through paid claims
with an appropriate ICD.9 diagnosis; therefore, our supply of these brochures is
exhausted.
Providers
have our permission to copy the "About Your Stomach" brochure.
In addition, if providers choose, Printing Tech can be contacted for
additional color brochures which can be ordered at the providers' expense in any
specified quantity. Mr. David Kleinpeter is the contact person, and he can be
reached at the following address:
Printing
Tech
College
Drive
Baton
Rouge, LA
(504)
928-5920
Unisys
Provider Relations Reminders to Providers
Provider
Relations Telephone Inquiry Unit
The
Unisys Provider Relations Department has recently made changes to the provider
inquiry lines reached by calling (800) 473-2783 or (504) 924-5040.
Please listen to the new message to determine which line to choose prior
to pressing a line number. When
calling these numbers, you now have the option of choosing one of the following:
|
Types of Calls
|
|
|
Option
1
|
Recipient
or provider eligibility, third party insurance inquiries, or recipient
service limits verification ONLY.
|
|
Examples
|
Recipient
dates of coverage, enrollment with CommunityCARE and Primary Care
Physician, lock-in status and lock-in provider, TPL/Medicare coverage and
effective dates, TPL carrier code and address, service limits remaining,
and provider check amount.
|
|
Option
2
|
Orders
for printer materials ONLY.
|
|
Examples
|
Orders
for provider manuals, training packets, enrollment packets, Unisys claims
forms, fee schedules, TPL carrier code lists, and provider newsletter
reprints.
|
|
Option
3
|
Claim
and policy questions and inquiries.
|
|
Examples
|
Claim
status, precertification status, reimbursement inquiries, claim denial
clarification, problem claim resolution, requests for field analyst
visits, and Medicaid policy inquiries.
|
Pharmacy
providers calling concerning pharmacy claims are instructed to contact the
Unisys POS Unit at (800) 648-0790 for assistance. Pharmacy providers with inquiries regarding DME claims should
still contact Provider Relations. Once
you reach Provider Relations, if you have reached the wrong service line you may
be asked to redial or you may be transferred to another service group.
Thus far this arrangement is working to expedite provider calls and to
make the inquiry process more efficient. As
you contact our service lines, please let us know if you find this arrangement
to be a positive change.
Incidentally,
the Unisys Recipient Eligibility Verification System, or REVS line, is still
available. Reached by dialing (800)
776-6323, this automated system allows providers with a touch tone phone to
check recipient eligibility and service limits 24 hours a day, 7 days a week.
NOTE: Provider Relations
lines are NOT available for recipient use, and Provider Relations staff cannot
assist recipients. Please do not issue the Provider Relations telephone numbers
to Medicaid recipients, as recipient inquiries directly reduce the number of
incoming provider calls that can be answered. If
recipients have problems with eligibility, it is appropriate to refer them to
their eligibility worker at the parish office.
Provider
Relations Correspondence Unit
May
providers submit "clean" claims to the Provider Relations Department
hoping to expedite processing of these claims.
However, this actually delays claim processing, as the claims must pass
through additional hands before reaching the appropriate processing area.
In addition, it diverts productivity that would otherwise be devoted to
researching and responding to provider requests for assistance with legitimate
claim problems. Providers are asked
to send "clean" claims directly to the appropriate post office box as
listed on the back page of the May/June 1996 issue of the Louisiana Medicaid
Provider Update. You may also
find a listing of appropriate post office boxes in the 1996 provider training
packet for your provider type.
Providers
who wish to submit claims for research and a written response are encouraged to
submit them to the Unisys Provider Relations Correspondence Unit, P. O. Box
91024, Baton Rouge, LA 70821.
The Provider Relations Correspondence Unit is available to research and
respond in writing to questions involving problem claims and requests to update
recipient files with correct eligibility and third party liability information.
Incidentally, Provider Relations staff do not have direct access to
eligibility files. Requests to
update recipient files are forwarded to the Bureau of Health Services Financing
by the Correspondence Unit, so these may take additional time for final
resolution. Any inquiry requiring
research or special handling (including claim problems, requests to update
recipient eligibility or third party liability information, requests to override
the one-year timely filing limitation, requests to override the yearly
outpatient visit limitation, and ambulance "second trip, same day"
claims) MUST include a separate cover letter on top of the claims or claims
which indicates what the provider is requesting. CLAIMS RECEIVED WITHOUT A COVER LETTER, INCLUDING THOSE WITH
ONLY NOTES WRITTEN ON THE FACE OF THE CLAIM, WILL BE CONSIDERED
"CLEAN" CLAIMS AND WILL BE SENT TO PROCESSING WITH NO RESEARCH OR
SPECIAL HANDLING.
Claim
Special Handling Reminders
1.
Other
than cover letters, attachments should be included behind the claim form itself.
Attaching information other than the cover letter on top of the claim
form will delay handling of the claim.
2.
Requests
for override of the one-year filing limitation must have required documentation
attached to each claim (usually a copy of the remittance advice page showing the
claim was processed with one year from the date of service).
One copy of timely filing verification for several separate claim forms
is unacceptable.
3.
Requests
for override of the yearly outpatient visit maximum must be accompanied by a
158-C form showing the visit was approved by Unisys. Only one copy of the 158-C form should be sent along with
each visit claim form - the "physician copy" should be kept by the
provider for his/her records.
4.
Requests
to update recipient files with correct eligibility and third party liability
information must include a copy of the documentation verifying the eligibility
or TPL information (e.g., a copy of the recipient's Medicaid card showing
eligibility for the date of service in a question or a letter from the
recipient's other insurance indicating coverage has terminated).
5.
Any
request for research regarding a denied claim should include as much
documentation as possible to assist in thorough analysis of the problem.
Provider
Relations Field Analysts
Provider
Relations Field Analysts are available to visit providers on-site and to provide
training to new providers and their office staff.
Providers are encouraged to request their assistance for training staff
in billing Medicaid claims and in resolving complicated billing issues.
However, calls regarding eligibility or to request Unisys claim forms,
manuals, or other policy documentation should NOT be directed to the Field
Analysts. Provider Relations Field
Analysts may be reached through the Telephone Inquiry Unit phone number
mentioned earlier.