Provider Update

Volume 16, Issue 3

June/July 1999

Changes in Medicaid Identification Numbers Personal Care Program Announced
CLIAs to be Applied to Laboratory Claims VALSTAR to be Covered by Medicaid
CNPs and Chiropractors Must be Added to Group Number GSP to be Assigned to Codes 11975, 77976, and 11977
Precert Billing Clarified Questions from Provider Relations Workshops
Wound Care Billing Request for Interpretations
CPT Code 95145 Removed Provider Address Information
CPT Code 54660 Made Payable Warning to Providers About Duplicate Billing
RN Qualifications for Psychiatric Home Health Visits Electronic RAs not Proof of Timely Filing
Referring Physician Name Required LADUR Education Article

Changes to Medicaid Identification Numbers

For the last several months, the Department of Health and Hospitals and Unisys have been working diligently to ensure that all Louisiana Medicaid systems are Year 2000 ready. In conjunction with the Y2K readiness efforts, we would like to emphasize strongly to you that the current 13-digit recipient identifying number will be changing as well. This 13-digit number is and always has been an important identifying number for Medicaid recipients and the providers who serve Medicaid recipients.


The Medicaid recipient identification number presently assigned to recipients is a 13-digit number that includes as a part of the number a two- digit parish code as the first and second digits of the number, and a two-digit eligibility category code as the third and fourth digits of the number. If your billing service, clearinghouse, or accounting system depends on the current 13-digit recipient ID numbers to identify parish codes, please take the necessary steps to account for this change and make arrangements to collect this information from another source. Additionally, the 12th and 13th digits represent the household member. The use of an "intelligent" number that houses pieces of information in this manner has caused billing difficulty for the provider community. Whenever a recipient moves or changes category of eligibility, a new number is issued. Thus, providers are continually changing numbers for their recipient patients. In spite of the best efforts by DHH to systematically link multiple ID numbers to a single recipient, problems have continued. Many claims have denied for name, number, or eligibility issues, and the provider has had the burden of locating another ID number with which to re-bill claims.    

In an effort to resolve these issues, beginning July 6, 1999, a permanent 13-digit person number will be assigned to each Medicaid recipient. The most current 13-digit recipient ID number will be frozen and will become the permanent person number for all individuals on the Unisys recipient file on June 30, 1999. Please remember, however, that although the numbers may "look" the same, the numbers will not denote any pieces of information as in the past.               

Recipients added to the file as of July 1, 1999 and after will be assigned a new permanent 13-digit number. These newly assigned 13-digit numbers may look somewhat unusual to you (i.e., #0000000000001, 8888888888888, 0000000000025, 0000000486100, 0000761147692).


This does not mean that other identification numbers previously issued to recipients may not be used to bill claims for services rendered. Any 13-digit number that was a valid recipient number and is still on the recipient file may be used to bill claims. In fact, in asituation where services were pre-certified or prior authorized using a certain number other than the new, permanent 13-digit person number, it will be necessary to bill using the number under which the pre-certification or prior authorization was issued.           

Beginning in July, 1999, we encourage providers to make note of the identification number confirmed or obtained from Unisys REVS or MEVS eligibility inquiries as this number will be the PERMANENT number. For dates of service and pre-certification and prior authorization after July 1, 1999, the permanently assigned 13-digit person number will be used by all DHH and Unisys systems.


Information previously obtained from the "intelligent" number is currently available and will be supplied as a part of the response given when making eligibility inquiries through MEVS or REVS. Although a parish name or number will not be provided, the response message returned to the provider will supply all information required to serve the recipient. The following is some of the information received from MEVS or REVS:

Recipient resides in Community CARE parish and is Community CARE recipient.          
Response will include a message indicating that the recipient is Community CARE, the name of the recipient's PCP, and the PCP�s phone number to allow the inquiring provider to contact the PCP for a referral before providing services.

Recipient is eligible through category of service that limits coverage of certain services or by certain providers.     
Information provided as part of eligibility response. Ex., If the recipient is covered through the Medically Needy Program, which does not cover certain services, and the provider calling is a provider of non-covered services, the response will include a message indicating that the recipient is Medically Needy and the services provided by the calling provider would not be covered.

Recipient is QMB eligible.             
Response will indicate recipient is QMB eligible. In cases where the recipient is Pure QMB, the response will state, "This recipient is only eligible for Medicaid payment of deductible and co-insurance of services covered by Medicare. This recipient is not eligible for other types of Medicaid assistance."

Recipient is Presumably Eligible. 
Response will indicate that the recipient may be eligible for outpatient ambulatory service only. You must call 1-800-834-3333 to verify current eligibility.

Recipient is a child.          
Response will indicate recipient is EPSDT eligible, meaning the recipient is under 21 years of age and eligible for all services and service limits allowed for children. All eligibility and service limit information is related to the inquiring provider in this same manner. However, the provider still must know and understand policy limitations.        Providers must access and verify eligibility through REVS or MEVS. This will provide the eligibility information formerly provided by the 13-digit recipient number and the paper cards that were replaced by permanent, plastic identification cards


The Medicaid Eligibility Verification System (MEVS), an automated eligibility verification system using a swipe device or PC software, and the Recipient Eligibility Verification System (REVS), an automated telephonic eligibility verification system must be used to verify Medicaid recipient eligibility prior to providing services. Both MEVS and REVS are Y2K ready and require that 8-digit date (service dates, dates of birth, etc.) must be entered when making eligibility inquiries through these systems. Entry of anything other than 8-digit dates will prevent a valid eligibility response. The provider will receive a prompt to enter an 8-digit dates accompanied by an example, to allow continuation of the inquiry. Please be sure to use 8-digit dates for all dates required when using MEVS or REVS. It is imperative that the most current 13-digit recipient ID number or the newly assigned person number be used to prevent any difficulty in obtaining eligibility information through MEVS or REVS.  

Parties interested in MEVS may obtain a list of participating telecommunications vendors and fees by contacting Unisys Provider Relations at (800) 473-2783 or (225)924-5040. REVS may be accessed with a touchtone phone by dialing 800-776-6323 or (225) 216-7387.

*Pharmacy POS providers may continue to use the 16 digit CCN number for POS processing.

CLIAs to be Applied to Laboratory Claims

                Effective January 1, 1998 HCFA mandated that the Medicaid Program begin applying Clinical Laboratory Improvement Amendments (CLIA) claims processing editing to all laboratories submitting claims for services and denying those that did not meet the required criteria.             

Claims are to be edited to insure payment is not being made to:

  • Labs which do not have a CLIA certificate
  • Labs submitting claims for services rendered outside the effective dates of the CLIA certificate and 
  • Labs submitting claims for services not covered by their CLIA certificate.     

Louisiana Medicaid maintains a provider CLIA file with the required information on that file. Therefore, providers do not have to include their CLIA certification number on claim forms.  

Notices were included on several remittance advices, provider training manuals and newsletter articles in late 1997 to let providers know about the required change. From January 1998 to November 1998 explanation of benefits (EOB) message codes were given on providers' remittance advices as a means of letting the providers know this needs to be corrected/updated. In November 1998 claims began denying if they did not meet the required criteria established by HCFA. 

Below are the three CLIA editing codes that Medicaid is applying to claims. You will find the code, a description of the code, why the code is applied and what actions are needed to clear the denial.

Code:  387 - No CLIA number on our file     
Action: Medicaid checks the provider's CLIA file for the presence of a CLIA number; if there is no CLIA number, claims will deny with code 387. 

To clear this edit code the provider needs to fax a copy of his/her CLIA certificate to Provider Enrollment at 225-342-3893. Providers should allow 2 weeks before submitting any new lab claims or resubmitting the previously denied claims.

Code:   329 - CLIA number does not cover date of service                
Action: Medicaid checks to see if the date of service on the claim falls within the provider's CLIA certificate effective thru expiration dates; if the date is outside the range, claims will deny with code 329.      

To clear this edit code providers should fax a current copy of their CLIA certificate showing the new effective/expiration dates to Provider Enrollment at 225-342-3893 or call Provider Relations at 1-800-473-2783 or 225-924-5040 for information on where to obtain an updated certificate.

Code:  386 - Not payable with CLIA cert. type               
Action: Medicaid checks to see if the procedure code billed is payable under the provider's certification type; if the procedure code is not listed as payable, the clams will deny with code 386.         

To clear this edit code providers should bill the appropriate codes allowed under their CLIA certification type. Providers with regular accreditation, partial accredited or registration certificate types are allowed by CLIA to bill for all lab codes. Providers with waiver or provider-performed microscopy (ppm) certificate types can only be paid for those waiver and/or provider-performed microscopy codes approved for billing by HCFA. Below is a listing of payable codes for each restricted CLIA certificate type.          

Providers with waiver or provider-performed microscopy (ppm) certificates wishing to bill for codes outside their restricted certificate types should call Provider Relations at 1-800-473-2783 or 225-924-5040 for information on where to obtain the appropriate certificate. (Please note: If your certificate type is upgraded, claims can only be paid for dates of service that fall within the upgraded cert dates.)

CLIA Waiver Certificate (type 2) Payable Codes

G0054 thru G0057 Q0116
80061 80101
81002 81003
81025 82044
82270 82273
82465 82947
82962 82985
83026 83036
83718 83986
84478 84830
84999 85013
85014 85018
85610 85651
86308 86318
86588 87072

CLIA Provider-Performed Microscopy (type 4) Payable Codes

G0026 G0027
Q0111 thru Q0115 81000
81001 81015
81020 89190
G0054 thru G0057 Q0116
80061 80101
81002 81003
81025 82044
82270 82273
82465 82947
82950 thru 82952 82962
82985 83026
83036 83718
83986 84478
84830 84999
85013 85014
85018 85610
85651 86308
86318 86588

Note: Listing does not include those codes exempted from CLIA editing.

Wound Care Billing

                We have received several questions regarding billing for outpatient wound care.  Regarding wound care, hospitals may only bill for the use of the treatment/observation room and the medical supplies. Wound care is not considered a rehabilitation service and will not be prior authorized as a rehabilitation service. If wound care services are provided by a physical therapist, the therapist's time is not to be billed.

CPT Code 95145 Removed

                Effective with date of service April 8, 1999, CPT code 95145 was removed from the Global Surgery Periods edits. This action allows the providers to bill physician visits with the code during the GSP time frame.

Precert Billing Clarified

                We have been receiving inquiries regarding the billing of recipients if a request for pre-certification of an inpatient hospital stay is denied OR if an extension is denied following approval of the initial precert.           

If a request for precertification is denied because medical necessity is not met, the recipient cannot be billed. If the case had met medical necessity, it would have been precerted; thus, if it was not medically necessary for the recipient to be in the hospital, the provider should never have admitted the patient. This same logic applies to the extensions - if it is not medically necessary for the patient to be in the hospital, then discharge would be in order. 

Providers also should not bill recipients simply because they were late in submitting their precertification information.        

One situation where a provider could bill the recipient is when the recipient presents himself to the hospital as a private-pay patient, not informing the hospital of his Medicaid coverage.               

When a hospital's precertification request (initial request or extension request) is denied due to timely submittal, the physician may have payment services considered paid only if the claims, along with an admit and discharge summary and a letter requesting a precertification override, are submitted to Unisys Provider Relations Correspondence Unit, P O. Box 91024, Baton Rouge, La., 70821. These claims will be reviewed for medical necessity and special-handled for processing. The same procedure is to be followed by the physician if a hospital fails to request initial precertification.              

If additional assistance is needed regarding billing of recipients, please contact Unisys Provider Relations at (225) 924-5040 or (800)473-2783.

CNPs and Chiropractors Must Be Added to Group Number

                This notice is a reminder to physicians who employ or contract with certified nurse practitioners and/or chiropractors to provide services to Medicaid recipients must notify Provider Enrollment at 225-342-9454 of such employments or contract(s) so that the provider number of the CNP and/or chiropractor can be linked to the physician�s group number on our files.  

This means that all certified nurse practitioners and chiropractors who provide services to Medicaid recipients must have individual provider numbers. This also means that physicians who do not have group numbers are required to apply for a group billing number if/when they contract with or employ a CNP or chiropractor.         

In billing for services, the individual provider number of the CNP or chiropractor who provided the service must be declared in Item 24K on the HCFA 1500(Field 21, Data Element 29 for EMC billers), and the physician�s group number must be listed in Item 33 (Field 9, Data Element 14 for EMC billers).

Hyperbaric Oxygen Diagnosis Code Correction

In the April 1999 edition of the Provider Update, there was a mistake in the list of diagnosis codes for hyperbaric oxygen therapy. The list included the code 40.0. The correct code is 040.0.

CPT Code 54660 Made Payable

                CPT procedure code 54660 (Insertion of testicular prosthesis) was made payable on the procedure file effective with date of service February 1, 1999 at a fee of $290.60 for the surgeon and a fee of $58.12 for the assistant surgeon. The anesthesia base unit figure = 3.

RN Qualifications for Psychiatric Home Health Visits

                This message will serve as a reminder of Registered Nurse qualifications for psychiatric home health visits. The following is taken from the Minimum Standards for Licensing Home Health Agencies (LAC 48:1. Chapter 91).                

Only RNs who have met the following credentials shall make psychiatric nurse visits. Experience must have been within the last five years. If not, documentation must support psychiatric retraining, or classes, or CEUs to update psychiatric knowledge.          

I. RN with master�s degree in psychiatric or mental health nursing. 
II. RN with a bachelor�s degree in nursing and one year experience in an active treatment unit, a psychiatric or mental health hospital or outpatient clinic. 
II. RN with a diploma or associate degree with two years experience in an active treatment unit, a psychiatric or mental health hospital or outpatient clinic.            

 For additional information, please refer to the Minimum Standards for Licensing Home Health Agencies (LAC 48:1. Chapter 91).      

Additionally, the services must be prior authorized as medically necessary and provided only to recipients who meet Medicaid�s homebound criteria.

Referring Physician Name RequireD

                Effective with date of service May 1, 1999, it is mandatory that the referring physician�s name and/or provider number be included in Item 10 on the Unisys 101 Home Health claim form. If this item is left blank, the claim will deny. For electronic billing, the attendingphysician portion must be completed.           

If the referring physician is an enrolled Medicaid provider, you must enter his name and/or Medicaid provider number. If the referring physician is not an enrolled Medicaid provider, his name is to be entered.

Personal Care Program

                EPSDT Personal Care Services (PCS) is a program for Medicaid recipients under the age of 21 who meet medical necessity criteria. The recipient's physician must give a referral or order for the services, complete a 90-L form, and approve a plan of care. Services are provided by a Personal Care Services worker through a Medicaid enrolled Personal Care Attendant agency. Generally, tasks are limited to those dealing with:

1. Personal hygiene
2. Meal preparation and eating
3. Household services for the recipient
4. Accompanying the recipient to and from medical appointments  

 These services are not intended to provide respite. In addition, a recipient receiving Waiver PCA services is not eligible for EPSDT PCS. Prior authorization of services is necessary. Requests from the PCA agency for prior authorization of EPSDT Personal Care Services must be sent to Unisys. The KIDMED office may be called at 1-800-259-4444 to obtain the names of PCA agencies. For questions regarding the prior authorization of PCS, contact the Unisys Prior Authorization Unit at 1-800-807-1320.

VALSTAR to be Covered by Medicaid

                Effective with date of service, April 1, 1999, VALSTAR (valrubicin) Sterile Solution for Intravesical Instillation will be covered by Medicaid for the treatment of cancer of the bladder. Listed below are the fees to be paid by Louisiana Medicaid for this drug.

Strength - 200 mg/5 mL
Description - 5 mL Single-Use Vial
Code - J9193
Projected Fee - $349.05 per vial

GSP to be Assigned to Codes 11975, 11977, and 11976

                Effective with date of service March 15, 1999, a Global Surgery Period (GSP) of 10 will be assigned to codes 11975 (insertion, implantable contraceptive capsules) and 11977 (removal with reinsertion, implantable contraceptive capsules). A GSP of 0 will be assigned to code 11976 (removal, implantable contraceptive capsules).

Questions From Unisys Provider Relations Workshops

Pharmacy Questions

Q:       Does the plastic ID card show lock-in status?
A:           Lock-in status is not indicated on the card itself. A POS electronic response message will identify lock-in information for the pharmacy provider.

Q: How may a pharmacy claim be paid if the recipient is locked-in to another pharmacy?
A:                Only in emergency situations, when life-sustaining medicines are required, or in cases when the lock-in pharmacy cannot supply medications (such as intravenous medications) may a pharmacy be paid for prescription drug services rendered to a recipient locked-in to another pharmacy provider. Specific billing instructions for this situation are on p. 22 of the 1998 Pharmacy Training packet and p. 4-9 of the Prescription Drug Services provider manual.

Q:                Does Medicaid pay for diabetic supplies for straight Medicaid, non-insulin dependent recipients?
A:        Yes, excluding long term care residents.

Q:      Can pharmacy providers be paid by Medicaid for diabetic supplies for a recipient who is Medicare eligible and in a long term care facility?
A:   No.

Q:      Have the physicians been made aware of the diagnosis codes necessary for payment of prescriptions for H2 antagonists?
A:          Yes.

Q:    Must Medicare be billed prior to billing Medicaid for nebulizers for long term care residents?
A:          No. Medicare pays for nebulizers for only Medicare/Medicaid eligibles who do not reside in long term care facilities. Providers must bill Medicare first for any Medicare/Medicaid eligible who does not reside in a long term care facility.

Q:           If a prescription for a long term care resident isn't covered by Medicaid, is it the recipient's responsibility to pay, or should the prescription be provided by the long term care facility?
A:  Non-routine medications or supplies may be billed to the recipient. Routine medications or supplies are included in the per diem paid to the nursing home and should not be billed to the recipient.

Long Term Care Questions

Q:                Should Medicaid cards for long term care recipients be returned to the State if the recipient dies?
A:           No, long term care facilities should destroy the Medicaid cards in such instances.

Q:           How would the following scenario be reported on the TAD: a recipient leaves for home and is gone for 16 hours, returns to the facility, and then leaves again for more than 24 hours?
A: The absence of 16 hours is not reported. An absence must be reported once it exceeds 24 hours; therefore, the second absence must be reported on the TAD.

Q:        If a recipient has several absences within a month, should the sets of leave days be listed by leave type (i.e., home leave days together and then hospital leave days together) or in chronological order?
A:              Leave days should be listed in the order in which they occur regardless of leave type.

Q:         Where do long term care providers obtain the initial 148 form?
A:  This form should be obtained from the parish Medicaid office.

Q:             Should the nursing facility in which the recipient resides keep the recipient's plastic Medicaid ID card, or should the card be kept by the recipient's family?
A:               The plastic ID card should be kept by the nursing facility, as the facility is responsible for the patient's care. If an emergency should occur or if other care should be needed, the nursing facility should give a copy of the card to providers rendering services to the recipient. This will allow the providers to verify eligibility and access recipient information necessary for reimbursement of their services.

Q:    Are all providers required to purchase a "swipe" device?
A:               Obtaining a swipe device is optional, not mandatory. REVS will always be available at no charge to verify eligibility. However, the swipe device will provide printed verification of eligibility, whereas the REVS line will not.

Q:   How should claim denials for error code 290 be rectified?
A:       Error code 290 indicates that the recipient has other insurance coverage. A claim for services must be submitted to the other insurance company. Once the other insurance processes the claim and produces an explanation of benefits (EOB), services are to be billed to Medicaid on the TAD with the EOB attached. The six-digit TPL carrier code and any amount paid by the other insurance should be entered on the TAD in the appropriate shaded portion.

Q:           In the above scenario, what should be done if the other insurance is no longer in effect?
A:         If coverage is no longer effective, the provider should submit the TAD and the EOB or other documentation verifying that the coverage was not in effect for the date of service to the Provider Relations Correspondence Unit as indicated on p. 100 of the 1998 Long Term Care/Hospice Training packet.

Q:           When billing on the TAD, should providers report the first day of hospital or home leave?
A:     Providers do not need to report an absence if it is less than 24 hours.

Q: When a resident leaves for the hospital in one month, and the leave goes over into the next month, how is this reported on the TAD.
A:         The first month's absence is reported through the last day of the month. The second month's absence is reported beginning with the first of the month (entering "01" in the "from" date of the home and hospital leave days section of the TAD). Our computer will automatically calculate the correct number of absence days based on the provider's reporting of absent days in both months.

Q:               How can it be assured that the name of a new resident added to the TAD will be pre-printed in the future?
A:  If the entry adding a recipient to the TAD indicates a status code of "6," the recipient's name should begin to appear on the pre-printed TAD produced each month. Depending upon when Unisys receives the TAD adding the recipient, it may take up to a month for the recipient's name to appear on the pre-printed TAD.

Q: Can the TAD be billed electronically?
A:  The TAD has not been approved by DHH to be billed electronically.

Q:   A recipient must be discharged from the long term care facility once his hospital leave exceeds 30 consecutive days. Does this 30-day rule apply to home leave days also?
A:         Yes. Once an absence exceeds 30 consecutive days, the resident must be discharged. If the recipient subsequently returns to the facility, he must be added to the TAD, and the 51-NH certifying re-admission must be attached to the TAD.

Q:                Sometimes when a resident comes in and several months are being back-billed, Unisys does not pay for one of the months. Why does this happen?
A:                In general in such a situation, all months should be paid. When billing for a new admission, remember to indicate the admit code from the 51NH for the month of entry. All subsequent months must indicate "6" for the admit code. The 51NH must be attached to the TAD, and the comment section should indicate that the recipient is a new admission and the 51NH is attached.

Q: Is the cost of physical therapy included in the long term care facility per diem?
A:     All therapy for a skilled level patient is included in the long term care per diem. For patients who are at a non-skilled level of care, these services can be provided by a home health agency. The home health agency must apply for prior authorization of these services and should bill the Medicaid program directly.

Q:                Who is the program director at DHH over the long term care program?
A:           John Marchand is the Section Chief for Institutional Reimbursement and Lisa Deaton is the Section Chief for Health Standards.

Q:         If a resident exceeds his resources for only one month, should he be deleted from the TAD?
A:         Yes.

Q:    Where on the 212 adjustment/void form should a level of care change be noted?
A:      Item 10 should be used to indicate the correct level of care. In addition, a new 51-NH indicating the new level of care should be attached to the completed 212 form.

Hospital Questions

Q:       When a patient comes to the hospital emergency room and is then admitted as an inpatient, should the precertification be requested to begin at the time the patient was admitted to the emergency room for observation or the time he became inpatient?
A:        The precertification should begin at the time the patient came into the emergency room, and the emergency room charges should be included in the bill for the inpatient stay.

Q:  If the last day approved under a precertification falls on the weekend and the patient continues to be a patient, when would an extension request be submitted to precertify additional days?
A:               If the expected discharge day is on Saturday or Sunday, the extension request may be submitted to Unisys on Monday.

Q:   If the physician intends to send the patient home but then changes his mind about the discharge, how should this be handled with regard to precertification?
A:              An extension request should be submitted to Unisys for any days in addition to those already precertified.

Q:                In what situations may a hospital bill for its hospital-based ambulance?
A:       The hospital must be approved by DHH to provide hospital-based ambulance services. A hospital-based ambulance can be used to pick up a patient for transport to the hospital. A hospital-based ambulance cannot be used to transfer a patient to another facility or to take a stretcher-bound patient home or to a nursing home. Such services must be provided by a Medicaid non-emergency ambulance service.

Q:             For hospitals with a special care unit that is not an NICU, is there any special coding for precertification for sick infants?
A:                No. Precertification only applies when a newborn goes to NICU or remains in the hosital when the mother is discharged from the hospital. Then precertification must be obtained for the baby.

Q:               If a newborn is started in NICU and then improves enough to be moved to Level 2?
A:           If the initial request was submitted with the baby in NICU and criteria were met, the baby was approved for a length of stay. If additional days are needed and the level of care has changed, then the change in level of care should be indicated when an extension request is submitted.

Q:     In situations in which a recipient is suicidal or homicidal, should it be documented why staff did a certificate of need?
A:          Recipients under 21 or over 65 years of age must have a certificate of need signed by a team not associated with the hospital. Providers should include this documentation with their precertification requests. This is also true for an ordinary admit of a recipient under 21 to a free-standing psychiatric facility. If this is documented as an emergency admission and criteria are met, then the certificate of need can be signed by admitting hospital team.

Q:  How can hospital personnel be authorized to discuss specific precertification cases with Unisys?
A:         For confidentiality reasons, Unisys staff will only discuss precertification details with persons authorized by the hospital. In order for the hospital to have a name added to the list of authorized hospital personnel, that person's name should be shown as the contact person on a PCF01 submitted by the hospital. When the hospital's utilization review department submits a PCF01 with a name as the contact person, that name is added to the list of authorized hospital personnel.

Q:         What is the time limit for appeals submitted to DHH?
A: Appeals should be submitted within 30 days of the denial letter being sent to the facility from the Unisys Precertification department.

Q:       Why doesn't Unisys keep a PCF01 on file when the case is rejected?
A:   Unisys keeps a copy on file, but providers must resubmit everything (including the PCF01) when pursuing a rejected precertification. The amount of documentation Unisys receives is tremendous, and it is not feasible to attempt to retrieve a PCF01 when providers submit additional information on a case.

Q:       Do nurses read the information sent by the hospitals?
A:                Yes. It is not necessary for providers to send Unisys a copy of the patient's entire chart. Providers should send a day-to-day current (last 48 hours) summary. The most recent information should be submitted, including the chart documentation that supports the criteria related to the diagnosis being submitted. Submitted documentation should support the dates for which precertification is requested.

Q:       For emergency room admissions, Unisys considers the admission to have begun at the start of the ER visit. Is this when the 24-hour count (to determine deemed inpatient status) begins?
A:          Yes. Medicaid policy requires that admissions greater than 24 hours are considered inpatient, regardless of whether the patient was actually admitted as inpatient by the facility.

Q:              If consent (documented on OFS Form 96) is obtained by a physician who subsequently leaves the hospital staff and is unavailable, can a new physician sign the physician statement on the form in Section IV and perform the tubal ligation?
A:         Yes. All of the form must be completed according to the published instructions.

Q:          Must procedures be added to the precertification file if they are done later in the stay after the precertification has been obtained?
A:      Outpatient surgical procedures performed within 48 hours of admission must be added to the precertification file. If the outpatient surgical procedure is performed later in the stay (after the first 48 hours), that procedure need not be added to the precertification file.

Q:   Sometimes patients are admitted and then the physician wants to perform an outpatient procedure on the second day of the stay. What must the hospital do in these cases?
A:              If an outpatient procedure is to be performed on the day of admit or the day after, the hospital's utilization review department should submit this information to Unisys as soon as they are aware of it. This should be submitted as an update on a PCF01 with accompanying documentation showing the medical necessity for the patient to be admitted as an inpatient for what is established as an outpatient procedure.

Q:            When an outpatient procedure is being performed on an inpatient basis and we are trying to add it to the precertification file, what must we submit? Often we don't have access to an operative report.
A:  The outpatient procedure is added by submitting an updated PCF01 to request an update to the existing precertification. An operative report does not have to be submitted if other submitted documentation can show medical necessity.

Q:            If a patient is admitted for a regular vaginal delivery with a tubal ligation done the next day, can this all be documented on the PCF01?
A:           Yes. The patient's stay will be determined by the admitting diagnosis for the delivery, not the tubal ligation.

Q:             If a patient is admitted and the hospital finds out five days later that the recipient has Medicaid, should the hospital wait until the patient is discharged to try to precertify?
A:    No. A patient who has Medicaid must be precertified within 24 hours of admission or on the next business day after admission in order to meet DHH timely submitted regulations.

Q:         If a PCF01 is unintentionally filed with a wrong recipient number, is there any recourse?
A:         Yes. An updated PCF01 should be submitted to Unisys with the correct Medicaid number circled.

Q: How should precertification be obtained if the patient was initially seen as an outpatient and then admitted after an outpatient procedure was performed, and it is after closing time for Unisys?
A:      The facility has 24 hours or until the next business day to submit an initial request for inpatient admission. If this admission is a roll-over from an outpatient stay, the facility will use the outpatient day as the admit date and note on the PCF01 that the admit date is the outpatient day. Specific questions on this process should be directed to the Unisys Precertification department.

Q:      If a patient comes in through the emergency room one evening, kept overnight for observation, and then admitted the next day, how is this handled for precertification purposes?
A:           The date of admit to ER becomes the admit date on the initial PCF01. The facility will note on the PCF01 that the admit date is the ER admit date and will also note that this patient was admitted inpatient after observation in the ER.

Q:           What should a provider do if the patient, upon admission, claims to be self-pay and then produces a Medicaid card once he receives a bill?
A:           The provider should submit a request for precertification when notified of the patient's Medicaid number. The Unisys Precertification department will clarify the patient's Medicaid status at the time of admit. If the recipient had Medicaid at the time of admission, the request for precertification will be denied for timely submittal. Ultimately, the provider may appeal the timely submittal denial through the DHH appeal process.

Q:           Can the patient be billed directly for services rendered if the patient claims to be private pay upon admission?
A:              Yes.

Q:    When a sick newborn transfers to our hospital, should our staff initiate the 152-N process?
A:             The 152-N should be filled out by the transferring hospital where the baby was born, but the receiving hospital may do this as well. It may be more difficult for the receiving hospital to ensure that the mother signs the form.

Q:         Can you please clarify the "admission process." For example, if the physician writes orders to admit a patient for a procedure or for observation, should the hospital automatically begin the request for precertification?
A:             Not necessarily. If the doctor writes orders to admit patient for observation or for a procedure, the patient is not being admitted to the hospital as an inpatient. If, however, the doctor writes orders for an inpatient admission, the patient is considered an inpatient and is subject to all the rules governing inpatient admission.

Q:     What is the P.O. Box for Medicare Part B crossovers which didn't automatically crossover?
A: The address is Unisys, P.O. Box 91023,Baton Rouge, Louisiana 70821.

Q:               We have several instances where the OB schedules a sterilization procedure but, because they don't accept Medicaid, they have never requested the patient to sign the OFS 96 form. Can we get paid for these claims?
A:              No. In order to receive payment from Medicaid, the recipient must have signed the OFS 96 form according to policy guidelines (no other form is acceptable). The only exception to this rule is if the sterilization is done during the same stay as a delivery. In that case, providers may be paid for the delivery stay less the charges related to the sterilization. Instructions for billing claims for this are included in the hospital provider manual.

Q:      Are prior authorization and precertification the same thing?
A:           No, they are two different processes. Prior authorization pertains to prior approval that must be obtained for certain surgical procedures or to durable medical equipment and supplies. Precertification refers to registering and obtaining approval for inpatient hospital stays.

Q:             Once a hospital has a contact person added to the Unisys list of authorized persons, how long does the contact person's name remain on the list?
A:             Contact persons authorized by the hospital remain on the list until the hospital requests that the name be removed.

Q:           How does Unisys know the fax number to use to send precertification information?
A:          The hospital's authorized fax number is taken from the PCF01. If the hospital needs to change the fax number, the new fax number should be entered on the PCF01 and circled prominently(so Unisys staff will notice it).

Q:                There have been occasions where Unisys Precertification staff have told me that I am faxing too many pages (and if I mail them I don't make timely filing). What do I do?
A: You should not need to send that many pages. All we are looking for is the most pertinent information, which means that you should only fax documents from the day before precertification has ended and the day that precertification is ending. This should not result in that many pages. If you need specific help on a case and what to fax or mail, call Unisys Precertification for guidance.

Q:                When is the best time to request additional days?
A:    The best time to request additional days is on the expected discharge day. This way you are submitting the most current information (and giving Unisys the best information on which to base a decision) and are complying with timely submittal requirements.

Q:           If a recipient receives therapy visits in excess of those authorized, may he be billed for visits in excess of those approved?
A:            Yes. The extra visits are considered non-covered by Medicaid and may be billed to recipient.

Q:                In regard to electronic claim filing, must a submitter contact the Unisys EMC department if submitting two different files with two different provider numbers within a 24-hour period?
A:                Yes. Submitters should notify EMC if submitting more than one file within a 24-hour period.

Q:                What should a provider do if an attorney sends him a payment for an accident-related claim that has already been filed to Medicaid?
A:            The provider should direct the attorney to DHH in order to make reimbursement arrangements with the State. Call Third Party Liability at 342-3888.

Q:   Is Medicaid considering expanding the 24 hour outpatient rule?
A:           Not at this time.

Q:                What should a provider do if a date of birth is incorrect on the state file and the recipient or parish office is not cooperating with updating the file?
A:             Providers can use the social security number, rather than the date of birth, to retrieve eligibility information on REVS/MEVS. Ultimately it is the patient's responsibility to have the file corrected through the parish office. Finally, providers may send a letter and supporting documentation to the Unisys Provider Relations Correspondence Unit requesting the correction.

Q:           As a free standing psychiatric unit, we do not need the Community Care referral number for our claims, but other providers performing services for our patients (such as the radiologist) will need it. How can they get information on the PCP and obtain a referral?
A:             This information can be retrieved on the REVS and MEVS system. The provider will need to contact the PCP to obtain a referral.

Q:                Several months ago Medicaid changed the diagnoses required for reimbursement of hyperbaric oxygen services. We have certain patients that are still receiving HBO services, but their diagnoses are no longer among those acceptable for HBO. Will we still get paid?
A:   If the diagnosis is not on the most recent approved list for hyperbaric oxygen services, Medicaid will not reimburse charges for the services.

Q:        Is it acceptable to change the diagnosis on these claims in order for them to be paid?
A:      As long as documentation supports the diagnosis billed on the claim, it may be used. If the primary diagnosis is on the list of diagnoses required for hyperbaric oxygen services, the claim should pay.

Q:                Are there any plans to expand the Community Care program?
A:                Unisys is not aware of any such plans. However, such inquiries may be directed to the Community Care unit at DHH.

Q:               If hospital staff believe they have submitted a PCF01 to Unisys, and Unisys does not show that is has been received, what is the hospital's recourse?
A:             If the hospital staff have a transmittal number, Unisys will trace it. For specific information on a case needing to be traced, call Unisys Precertification.

Q:      Several months ago, we offered a transmittal number in order to trace certain faxes for cases that were denied due to untimely submittal, but were told that the tracing could not be done. Why?
A:         Our fax system has the capacity to reproduce fax transmissions for seven days. If the request to trace a transmission is submitted more than seven days from the fax date, Unisys cannot reproduce that transmittal document. Therefore we cannot override a denial for timely submission based on that transmittal report.

Q:              How many pages can the Unisys faxes accept?
A:         Our faxes can accept an unlimited number of pages. The fax receiving system operates 24 hours a day

Q:              Is there any recourse if we have to appeal a precertification case from last month or any time over a week ago?
A:   Appeals are handled through the DHH appeal process. Providers have 30 days from the denial in order to appeal.

Q:      At what point must a hospital obtain precertification?
A:                Precertification must be obtained at the point that the recipient is admitted to the hospital or after the recipient has been in the emergency room or observation for greater than 23 hours, 60 minutes.

Q: If the last authorized day of a precertification falls on a Monday, may the precertification extensions be submitted on Friday?
A:  The extension may be submitted on Friday. However, the data submitted with the request will be outdated by Monday and the review nurse may not be able to approve days. Remember that the data submitted for extension of stay must be current. The best solution for a case with the last authorized day on Monday is to submit the extension request on Monday with current data.

Q:             In the past we have submitted the PCF02 on Monday morning when the last authorized day was the previous Friday. Is this acceptable?
A:             If the last authorized day is Friday, the extension request may be submitted on the following Monday without penalty for timely submittal.

Q:            What can the hospital do if the additional information that Unisys is requesting is not available?
A:          The hospital should resubmit the data available and submit documentation that the requested data is not available and why. It is possible that your days may not be approved if the requested data is not available for review.

Q:     What is the time limit on precertification for retroactively eligible recipients?
A:  The facility has up to one year from the date that the recipient was added to the Medicaid files in order to request precertification.        

Q:            Does this one-year timely filing limit for precertification also apply to those patients who have exhausted their Medicare Part A during a hospitalization?
A:    No. When a facility bills Medicare and receives their notification from the Medicare fiscal agent that the recipient has exhausted Medicare Part A benefits, the facility should submit the precertification request at that time.

Q:             When was the Unisys turnaround time on precertifications changed from four hours to 24 hours?
A:               This change was made approximately three years ago.

Q:             Once a hospital has submitted a precertification request with a primary diagnosis on the PCF01, may the hospital then submit an update in order to change the primary diagnosis on the precertification file?
A:         No. The initial length of stay was approved based on the primary diagnosis. Therefore, changing the diagnosis after approval invalidates the initial days approved.

Q: If the patient comes in for a vaginal delivery and then has a C-section, should this patient be precertified at the time of admission, or should the hospital wait until the delivery in order to make sure that the correct diagnosis/procedure is on the precertification file?
A:   The hospital should precertify for a vaginal delivery upon admission and then submit an update or an extension request noting the C-section delivery date in order to receive the correct number of days for the C-section delivery.

Q:             Since it seems simple enough that a vaginal delivery has a two-day stay and a C-section has a four-day stay, why do hospitals need to go through precertification in order to get paid for these days?
A:             If all vaginal deliveries were approved for two days, what would happen to the patient who was admitted in labor for two days and then delivered? What about the C-section patient who labored for one day and then delivered? In both cases there are more days needed than two or four. That is why all deliveries require precertification.

Q:                When is it necessary to precertify a patient who has exhausted his Medicare Part A benefits?
A:       Once the Medicare benefits have been exhausted, from date on which Part A benefits are exhausted the hospital stay becomes Medicaid only and must be approved by Unisys Precertification. The initial submittal must have proof that Medicare Part A is exhausted attached. The precertification initial request should be submitted as soon as the hospital receives notification that Medicare Part A benefits are exhausted.

Q:            As a free-standing psychiatric facility, we often send our patients to the acute care hospital which is located next door. Who should bill Medicaid?
A:  The facility in which the patient is admitted should bill Medicaid. If the patient must be sent to a second facility without being discharged from the first facility, the first facility should bill Medicaid for all days of admission and should reimburse the second facility for any services performed there.

Q:    If a patient, admitted with both Medicare and Medicaid, just had a baby and the baby is sick, should the newborn be precertified, since the baby will most likely have both Medicare and Medicaid as well?
A:          The newborn will be Medicaid eligible and not necessarily Medicare eligible. Therefore, Medicaid precertification will be necessary once the newborn is admitted to NICU or if the newborn remains hospitalized after the mother has been discharged.

Q:     If a patient is a pure QMB and Part A benefits have exhausted, can the patient be billed for the hospital charges?
A:       Yes. Medicaid will only consider charges which Medicare pays for pure QMB recipients. Because the recipient does not have Part A coverage, Medicaid will not consider the hospital inpatient charges.

Q:                If a patient with HMO coverage opts to utilize an out-of-network provider and the HMO denies resulting claims, can that provider bill the patient?
A:                Yes. Medicaid will not consider charges that are denied by an HMO because the recipient used an out-of-network provider or because the recipient did not follow HMO-required protocol.

Q:            A patient has both Medicaid and TPL (other insurance). The other insurance has denied claims due to injury caused by an accident. Liability insurance has paid and reimbursed the patient, who reimbursed the hospital. Is this acceptable?
A:               This is acceptable as long as the provider never filed any of those claims with Medicaid. Once a provider is paid by Medicaid, he may not subsequently void his claims in order to accept reimbursement from a settlement or similar liability payment.

Q:             How are claims filed for recipients in the LACHIP program?
A:   This program refers to lowered eligibility threshholds for children under age 19. It does not affect Medicaid billing. Once a child is deemed eligible through LACHIP, he is considered Medicaid eligible and is subject to all usual policies and conditions of the Medicaid program.

Q:        We are having a great deal of problems with our electronic adjustments and voids. What do we do?
A:  You should contact your software vendor to ensure that you are using your billing software correctly and that the software is set up to file adjustments and voids properly. If that does not rectify the problem, you may contact Unisys EMC or have your software vendor contact EMC.

Q:        If an initial precertification is denied for timely submittal, will the whole stay be denied?
A:    Yes. There is no mechanism to resubmit a denied initial request. The entire stay can be appealed through the DHH appeal process. The hospital should file its appeal with the DHH Bureau of Appeals as soon as it receives the denial for timely submittal.

Q:           If a patient comes in at 11:45 p.m., when do we have to request precertification?
A:                It must be submitted the next business day.

Q:   What is the clarification of a "business day"?
A:           The business day is Monday through Friday during regular working hours (8 a.m. until 5 p.m.), not including Unisys holidays.

Q:       What can I do when a precertification is denied for timely submittal, when I faxed it timely but Unisys just did not receive it timely?
A:           Call the Unisys Precertification department with your fax transmission report for that specific case. The Precertification staff will ask you for information from that transmittal. Using this information, the Precertification staff will attempt to trace the fax. If Precertification staff are unable to locate your fax, they will ask you to fax to them the transmittal report for definitive resolution of the fax issue of that case.

Q:                Is a letter from a physician necessary in order to request a reconsideration?
A:                No. Progress notes or other documentation which supports interval criteria for the denied days may be submitted. A letter from the physician sent with the data often can help to identify his medical reasons for keeping the patient in the facility. A reconsideration must be submitted within 24 hours of the denial being sent by Unisys.

Q:               Unisys used to send a letter cancelling duplicate precertification numbers. Why was this stopped?
A:                The number of duplicate precertification numbers became so large that Unisys could no longer cancel each duplicate. The precertification number sent on the provider letter should be used. All other numbers should be disregarded.

Q:                What is the procedure for precertifying a healthy newborn to a mother that has insurance other than Medicaid?
A:       The PCF01 submitted to request the precertification must show the newborn information and must state "Mother is not Medicaid eligible." This PCF01 should be submitted to the attention of Sandy or Janeen.

Q:      How does Unisys precertify a healthy newborn who must remain in the hospital after the mother's discharge because the baby is going to be adopted (state law requires that the newborn be hospitalized for five days)?
A:                Unisys cannot precertify a healthy newborn in this situation, as the Medicaid program will only precertify stays which are medically necessary. Days that the newborn must remain in the hospital but which do not require hospitalization as medically necessary will not be precertified or reimbursed.

Q: How should a hospital precertify a woman who is admitted to the hospital in labor and labors for two days before giving birth?
A:               The hospital must file for precertification the first business day following admission. If the initial approved lentgh of stay (LOS) is not sufficient because the mother labored longer than anticipated, the hospital should then file the PCF02 for an extension and document the labor days, the delivery date, and whether the delivery is a vaginal birth or a C-section delivery.

Q:     May our facility use our old PCF01 forms or must we use the PCF01 version in this packet (the 1998 hospital training packet)?
A:        You may use the old ones, but the one in this packet should be copied from now on. This updated PCF01 form has the specific areas to check update and retrospective review.

Q:       If a Medicaid patient has been precertified, but eligibility expires during the hospital stay, what should the hospital do?
A:      The precertification only determines medical necessity. If the patient loses eligibility for Medicaid during the stay, the hospital should bill the portion of the stay that is covered as a split bill. If the recipient's eligibility is updated to include the remainder of the hospital stay, the hospital may then resubmit an extension request using the previously assigned precertification case number. If a break in coverage has occurred, the precertification department staff can assist the hospital with the steps to take to file a new precertification number to cover the eligible days.KIDMED

Q.              If we receive our RS-0-07 each month, do we still need to check eligibility on each recipient each month?
A.     The RS-0-07 is run at the end of each month to show KIDMED linkages for the following month. It is not a guarantee of eligibility, as eligibility could possibly end after the printing of the report. Eligibility should still be checked each month using REVS or MEVS.

Q.                Can a claims history be used for timely filing?
A.           Yes. Submit the claim hardcopy with documentation showing the date of the denial to the Provider Relations Correspondence Unit with a cover letter requesting override for proof of timely filing.

Q.  How long may the resubmittal turnaround document (RTD) be submitted?
A.         Each RTD indicates a date by which it should be resubmitted in order to be considered for processing.

Q.              May an interperiodic screening be requested by a family member? Would the family member be considered "outside of the formal health care system?"
A.           Yes to both questions.

Q.    We are apparently mixed up with another provider, since they are getting our RS-0-07s. How do we correct that?
A.        Call Provider Relations so Unisys can check the address that the RS-0-07s are being sent to. If the address is correct on file, Unisys can address this internally to their mailing staff.

Q.     We normally send out PKUs to a lab. Can we bill for those lab codes?
A.        No. You may not bill for the performance of a lab test that you do not perform at your office.

Q.              When we bill for a newborn under the mother's name and number, the claim is denied. Does Medicaid tell these mothers to apply for a number? How does that happen?
A.              Form 152-N is used to initiate assignment of a Medicaid number for a newborn. Normally the hospital gets the mother to sign this form while she is in the hospital after delivering, and then the hospital sends the form in to have the baby entered in the Medicaid system and assigned a number. Any physician whose name and address is listed on the 152-N should receive notification when the baby has been assigned a number.

Q.          How long does it take for newborns in the hospital to receive a new Medicaid ID number?
A.        That depends on the office actually processing the paperwork. Usually the numbers are issued within a couple of months.

Q.          If a newborn does not have a Medicaid number yet, and his screening claim is getting close to 60 days old, what can I do?
A.           The KIDMED timely filing edit allows six months for newborns, not the usual 60 days. The edits program adds six months to the date of birth to calculate the date for timely filing. For example, if a child is born on January 1, 1999, the provider has until June 30, 1999 to file any screening claim. A Medicaid number will normally be assigned in this time.

Q:    If a name/number mismatch denial is received after filing the baby's screening claim with the Medicaid number transmitted via the 152-N form, can the 152-N be used with the KIDMED screening to get our claim paid?
A:           In such a situation, the provider should send the screening claim, a copy of the denial received from Unisys, a copy of the 152-N showing the baby was assigned a Medicaid number, and a cover letter requesting that the baby's recipient file be updated to the Provider Relations Correspondence Unit. They will forward the information to the State to have the recipient file corrected and the claim processed.

Q:        If a KIDMED screening and sick visit are performed on the same day for the same patient, must I use an established patient code for the sick visit, even though the patient is new to the clinic?
A:   No. We will pay both the KIDMED screening and a new patient visit code for the same patient, same date of service, and same attending provider if the visit is low level.

Q: If a person is not eligible and then is made eligible retroactively, how can proof of timely filing requirements be met?
A:      On the retroactive eligibility form, Form 18-SSI, there is an issue or certification date in the upper right hand corner of the form. This date is when "the clock starts ticking" for timely filing purposes. For services other than screenings, providers would have one year from the issue or certification date on the 18-SSI in order to file claims timely. If the claim is within that one year window, but the date of service is over a year old, the claim should be filed hardcopy with a copy of the Form 18-SSI and a cover letter explaining the situation to the Provider Relations Correspondence Unit for handling.

Q:             May a stamped signature be used on the KM-3 form where a signature is required?
A:         Medicaid will allow a stamped signature as long as there are handwritten initials along with the stamped name.

Q:               Who signs the KM-3 form?

A:                Normally the person performing the screening signs the KM-3.

Q:             When filing KM-3s electronically, are there fields to enter the next appointment day and time?
A:             Unisys specifications provide fields for next screening appointment date and time. Providers should check with their electronic billing software vendors if unsure how to enter this information into the claim.

:      If a CP-0-51 shows a denial indicating that the claim is a duplicate of a previously paid claim, how can the previously paid claim be found?
A:              If the claim denied as a duplicate of a previously paid claim, one must check his past remittance advices to find the first claim that already paid (same recipient, same provider number, same date of service, same procedure). If the claim denied as a duplicate of a previously approved claim that did not appear on a remittance advice yet, check future remittance advices to find the first claim once it pays.               

Q:            If more than three referrals are required as a result of KIDMED screening, should two KM-3s be submitted, since the KM-3 only has space for three referrals?
A:           Providers should submit one KM-3 with three referrals only and record the additional referrals in the patient's chart.

Q:                If a recipient is under care for a treatment with another provider's office (not in-house), should item 32 on the KM-3 indicate that the recipient is under care?
A:   Yes.

Q:    If a child is seen for a KIDMED screening, can the child be referred to the clinic's physician on the same day?
A:   Yes, but the physician cannot charge for any higher office visit that 99212.

Q:        In the above situation, if the child has a screening done by the nurse and is then seen for an office visit by the physician, is the office visit code still limited to 99212 or lower?
A:  Yes.

Q:                What should be done if a child comes in to the KIDMED clinic with a grandparent or other relative who does not have any necessary information to complete the KM-3 regarding immunization status?
A:    Items 29 and 30 of the KM-3 regarding immunization status should be completed based on whatever information is available regarding the patient's history. If it is determined that an immunization is appropriate, it may be performed and billed on the HCFA-1500.

Q:             It appears there are times when the recipient's next screening date according to the RS-0-07 does not coincide with the periodicity schedule and screenings that have been paid. What can we do about this?
A:                This has been reported and Unisys is looking into the problem. Providers should continue to screen according to the periodicity schedule in the manual and should clearly document that they are doing so.

Q:      A child's parent has called and requested that the child's linkage be changed from one provider to another, but the new linkage has not become effective yet. If the new provider performs a screening, how should it be billed?
A:              This situation should be very infrequent. Normally a provider would wait to perform the screening until after the recipient appears on his RS-0-07. If there is some reason the screening must be performed immediately, the former provider (to whom the child is still linked) may refer in writing the child to the new provider in order for the screening to be performed. In this situation, the former provider's Medicaid number must be entered in block 9 of the KM-3 form. Provider linkage questions should be directed to the KIDMED Hotline at 1-800-259-8000.Q: In the situation above, does a copy of the referral need to be sent with the KM-3?A:           No, but it should be kept in the patient's chart or medical records so that it can be retrieved if necessary for an audit or monitoring visit.

Q:     I screened a child, incorrectly billed the claim with his sibling's name and ID number, and received payment. I voided the paid claim to correct the record, but now the correct claim for the correct child is denying for timely filing. Is there any way to be paid for the correct claim?
A:                If Unisys did not receieve the correct claim until after the 60-day filing limit, there is no mechanism for paying the claim.

Q:                When exactly is a recipient's KIDMED eligibility terminated upon turning 21? At what point will a recipient no longer be eligible for KIDMED services?
A:         If a recipient's twenty-first birthday is on the first day of the month, his eligibility ceases with the first day of the month. If his birthday is any other date during the month, his eligibility ceases at the end of the month.

Q:      As an FQHC, we perform a KIDMED screening and determine that the patient needs to see the physician on staff for an identified condition. How would we bill the physician visit - under our X9928 encounter code?
A:  No. Medicaid will not pay for both an encounter code and a KIDMED screening to the same provider for the same recipient on the same date of service. A low level visit could be billed under the physician provider number.

Q:                If a mental health condition is noted during a screening, and the child is seen by the KIDMED clinic's BCSW on a different day, may the BCSW visit be billed using a KIDMED counseling/consultation codes? If the BCSW visits are to be one time a week for several weeks, may these visits also be billed with the same code?
A:     The answer to the first part of the question is "yes." The answer to the second part of the question is "no." EPSDT Consult Codes are short-term codes not designed with episodic or continuous therapy in mind. EPSDT BCSW Consult Codes (X0189) is not for treatment for mental illness or emotional disturbances. That type of ongoing therapy is payable by Louisiana Medicaid under the Mental Health Rehabilitation Program or through the EPSDT Health Services Program where psychiological counseling can be performed by a licensed therapist. Appropriate referrals should be made.

Q:                What constitutes "short-term?"
A:   Short term is considered to be less than six weeks.

Q:   Is there a limit of nurse consults that can be billed per month?
A:                Such visits are subject to post-pay review for appropriateness, particularly if numerous visits are being billed consistently. Documentation must justify the need for a nurse consult. Recoupment of payments can be made on those consults billed inappropriately.

Q:                Clarify the appropriate use of the interperiodic screening code.
A:             An example of use of the interperiodic screening code would be when there is a referral from the school indicating a child needs to be checked for a problem observed at school. The five components of the medical screening must all be documented in order to bill the interperiodic screening. The interperiodic screening is a result of a perceived problem, so a well diagnosis would not be appropriate.

Q:      A KIDMED provider referred one of his KIDMED recipients for EPSDT dental services. The recipient missed the appointment and the dental office charged a missed appointment fee. The same situation happened again. Now the dental office is refusing to see the recipient unless they pay the missed appointment fees. Can the dental provider do this? How should this be resolved?
A:           Once a Medicaid provider has agreed to accept an individual as a Medicaid patient, he can only charge for services rendered. Therefore, a provider should not charge a missed appointment or late fee to a Medicaid recipient. Providers do have the option of picking and choosing from which patients they will accept Medicaid. Providers are not required to accept every Medicaid recipient requiring treatment. However, the provider must discuss the acceptance/non-acceptance decision with the Medicaid recipient.

Q:          A KIDMED provider referred a recipient to his family physician as a result of a KIDMED screening. However, the family physician refuses to provide services until the family pays a previous outstanding balance. Can the provider do this? How should this be resolved?
A:     As in the previous question, providers do have the option of picking and choosing from which patients they will accept Medicaid. Providers are not required to accept every Medicaid recipient requiring treatment, but they must discuss the acceptance/non-acceptance decision with the Medicaid recipient.

Home Health/Rehab Questions

Q:               Do providers ever obtain "instant" prior authorization (PA)?
A:         Sometimes the Unisys Prior Authorization department will give an immediate emergency authorization, such as when a patient is coming home from the hospital. They will often give such authorization for a day or two and then follow the usual PA procedures.

Q:       If a patient has a Medicare HMO which denies services saying "services not covered", then how will Medicaid pay the claim?
A: If the claim is for a service that the HMO simply does not cover and Medicaid does cover it, Medicaid will consider the claim as a straight Medicaid claim. If the claim is denied because the services were "not medically necessary," Medicaid will not pay.

Q:    How is the 13-digit Medicaid number obtained, since it is not on the plastic ID card?
A:                REVS and MEVS give that information to providers checking eligibility.

Q:         Are multiple home health visits authorized for recipients under age 21 only?
A:      Yes. Extended and multiple visits require prior authorization and are only covered for recipients through age 21.

Q:       How may extended home care and physical therapy be requested on a child under three years of age?
A:      Normally physical therapy for children under three years of age is provided through the EPSDT program.

Q:         Will recipients still receive a paper card?
A:    No. Recipients received a paper card and a plastic card the first month of plastic card implementation in their parishes. Thereafter, the recipients will receive nothing else and will use their plastic ID cards.

Q: Can rehabilitation services be provided to nursing home residents even if the nursing home has therapists on staff?
A:               Yes, if the recipient is in an ICF I or ICF II facility and in need of therapeutic services. Services must be prior authorized and medically necessary.

Q:         How may a home health provider bill for rehabilitation services if opting to perform those services?
A:            A provider is automatically able to bill as a rehabilitation provider when enrolled as a home health provider.

Q:      If we provide services to a medically needy recipient, and those services are not covered for medically needy recipients, may we bill the recipient?
A:            Yes. Services not covered under the medically needy program may be billed to the medically needy patient. Providers may bill the patient for non-covered services or those which exceed a service limitation.

Q: Must we notify the patient up front that we will bill them for the non-covered charges?
A:            This is not required, but it is to your benefit (and to the recipient's benefit) to tell the patient he will be responsible for payment.

Q:                How often is the Unisys eligibility system updated?
A:                The Unisys eligibility files are updated daily.

Q:             Since when did providers have to prior authorize home health services?
A:   Prior Authorization only applies to multiple visits/disciplines for those recipients under 21 years of age. This requirement has been in effect for some years now.

Q:               Do we have to do OASIS on every recipient?
A:          No. This is only done at timepoint assessment. Questions regarding OASIS can be directed to Cecole Castello, RN, DHH Coordinator of OASIS at (225)342-2449.

Q:      According to federal guidelines, a registered nurse must have two years of psychiatric experience in order to perform a psychiatric evaluation. Does Medicaid require the same standard?
A:              Yes. For specific personal qualifications information, refer to the Minimum Standards for Home Health Agencies (Chapter 91).

Q:            How can we identify which recipients have another insurance?
A:              Both the REVS and MEVS systems will indicate this with eligibility verification if the State has been made aware of other insurance. If the other insurance has not been reported by the recipient, it likely will not be on file and will not be indicated by REVS or MEVS. That is why it is very important that you ask the patient when he comes in if he has other insurance.

Q:                Under freedom of choice, shouldn't the recipient be allowed to utilize any agency he wants, whether or not it is within their network?
A:           The recipients are free to see anybody they want, but the Louisiana Medicaid program will not pay for services denied by the HMO because the recipient utilized an out-of-network provider. It will be the recipient's responsibility to pay for those services.

Q:    If a claim is paid and then found to have been billed with an incorrect date of service, should an adjustment or a void be filed to correct the wrong date of service?
A:   An adjustment should be submitted indicating the services performed and the correct date of service. Voids are filed when claims are paid with an incorrect provider number or recipient number.

Q:             We know about many children under three years of age who need more aggressive therapy that Early Intervention Center can provide. How can we help those children?
A:         Write to the Medicaid EPSDT program manager at DHH to voice your concerns, including specific instances and any documentation you may have.

Q:                Are social worker visits with recipients over age 21 covered?
A:                This is not a covered service under either the home health or rehabilitation programs.

Q:             What should we do with those patients who have applied for Medicaid, but no determination has been made yet?
A:          Since they have not been deemed eligible yet, they would be considered as private pay patients.

Mental Health Rehabilitation Questions

Q:                May service logs be kept on computer diskette instead of storing the hard copies?
A:          The information may be on disk for
frequent use. However, the hard copies must be kept for a period of five years. Q:          May billing be done once the prior authorization has been received?
A:        Once 80% of the services have been provided and entered, the prior authorization is released to Unisys and the services may be billed.

Q:    Does the agency bill for the psychiatric director's services when he completes a clinical evaluation?
A:          Those services may be billed through the physician's program, as completing a clinical evaluation is not a billable mental health rehabilitation service.

Q:             How would Medicaid be billed when a third-party carrier denies a claim for preventive services because the other insurance does not cover prevention?
A:        Medicaid will pay the claim if it is a covered service, the recipient is fully eligible for all Medicaid benefits, and prior authorization is obtained. On the HCFA 1500, the six digit carrier code must be entered in block 9A, any payment received must be entered in block 29, and the EOB from the other insurance must be attached.

Q:       On many occasions we have not received a Medicare payment because it conflicts with Medicaid policy (and we were following Medicaid policy). Has this conflict been resolved?
A: A recent clarification from HCFA now allows Medicaid to be billed in full for mental health rehabilitation services rendered to Medicaid/Medicare recipients. This policy was issued by provider notice dated 1-15-99.

Q:            We have received notices from the Office of Mental Health (OMH) that nursing home residents do not qualify for mental health services because they are not high need, even though they meet qualifications for PASARR. Is this correct?
A:             Nursing home residents must qualify through both PASARR and prior authorization criteria at OMH in order to be eligible for mental health rehabilitation services.

Q:          We have six different service fees. Which charge do we list on the claim?
A:        The prior authorization you received from OMH should indicate the procedure code approved. Reimbursement is based on the procedure code billed and varies according to the recipient's age (child or adult) and level of need.

Q:     If the psychiatric director sees a mental health rehabilitation patient in the hospital, are those charges covered in the single fee for that prior authorization period?
A:      No. Those charges are billed by the physician through the physician program.

Q:  If our mailing address does not change, but the physical address does, do I need to notify BHSF?
A:       Yes. You should notify BHSF of any changes in your provider information.

Q:       When a recipient has a new Medicaid number, do I bill under the old number or under the new number?
A:     It is best to bill with the new Medicaid number. If the new Medicaid number is different from the Medicaid number on the prior authorization record, you should contact OMH to request an update of the PA to reflect the new Medicaid number.

Q:              If MHRSIS accepts a recipient name or number, but Unisys denies the claim for wrong recipient name or number, how can this be corrected?
A:          The information at the parish office, OMH, and Unisys must all be correct and match. If the recipient number on the PA record is different from the recipient's current Medicaid ID number, contact OMH to have the PA record updated.

Q:    Is the Family Support License not required anymore?
A:              This license is not required by the mental health rehabilitation program.

Federally Qualified Health Center/Rural Health Clinic Questions

Q:      Can immunizations be billed on the same day as a core visit or in the cost report at the end of the year?
A:              At this time, immunizations must be billed using an individual physician or group provider number.

Q:              Can influenza injections be billed out separately from a core visit?
A:  The flu shot is an injection and may not be billed out separately as all injections are "incidental to" core visits.

Q:         What will the eligibility verification system show if a patient sees and has his card swiped by two different doctors on the same day?
A:          The verification system shows physician visits remaining based on the number of visits paid. Claims for visits are paid in the order they are received. In this specific case, both physicians will receive the same information regarding visits remaining, because the number of visits paid will not change within a single day.

Q:     How long does it take to update the date of birth?
A:    It depends on the parish office handling the update. It could be anywhere from two to six weeks.

Q:          May a provider accept money from a recipient if the provider is not part of the recipient's HMO?
A:      Yes. However, the provider should make sure the recipient understands his financial responsibility and the reason for it. Medicaid will not pay for claims denied by an HMO because the recipient used a provider outside the HMO's approved network.

Q:             Will Medicaid pay the deductible on Medicare patients?
A:        If the recipient is a dual QMB, Medicaid pays the coinsurance and deductible on Medicare-covered services AND the full range of Medicaid benefits. If the recipient is a pure QMB, Medicaid will pay the coinsurance and deductible only for Medicare-covered services.

Q:    How are Medicare/Medicaid crossover claims filed if they do not "cross over" automatically?
A:              Medicare/Medicaid crossover claims which do not electronically cross over to Medicaid must be filed hard copy. A copy of the UB92 that was filed to Medicare should be filed to Medicaid, along with a copy of the Medicare EOB. Of course, the Medicaid provider number should be entered in form locator 51.

Q:       If a recipient comes in for a non-covered service, should we bill the recipient our core charges or a fee-for-service charge?
A:               If a Medicaid recipient receives a non-covered service, he is considered a private pay patient for those services and is subject to whatever standards your office sets for private pay patients.

Q:                When the REVS system indicates that a recipient has other insurance, should that insurance be billed prior to Medicaid?
A:                Yes.

Q:    What can we do when we lose a remittance advice?
A: Providers may order individual remittance advices for specific dates, or they may order a provider history if a several weeks' or months' worth of remittance advices are required. This documentation must be kept for five years.

Q:           What type of recipient information can be used for eligibility verification through REVS?
A:               Eligibility may be verified using a Medicaid ID number that has been on file within the past 12 months or using the card control number and either the date of birth or the Social Security number.

Q:        While a nurse practitioner is waiting for his Medicaid provider number to be issued, may his services be billed under the physician's provider number?
A:      The nurse practitioner should wait to bill for services until after he receives a Medicaid provider number. At that point, his claims may be billed with the physician's billing number (block 33 of the HCFA) and the nurse practitioner's attending number (block 24k of the HCFA). Enrollment can be made retroactive if so requested to allow providers to bill for services rendered while waiting to receive a provider number.

Q:                How long have electronic adjustments and voids been available?
A:                They have been available for some time. Providers should check with their vendors to see if their software has adjustment/void capability. Specifications for adjustments and voids are available from the Unisys EMC department.

Q:            Are charge slips used by the physician's office sufficient documentation of services rendered?
A:        That depends on what services are being billed. If the provider has an extensive charge slip that lists taking blood pressure and temperature, and all the provider is billing is a low-level office visit, then the charge slip may be enough. However, it will not be sufficient for a more comprehensive visit. Patient chart notes should be as complete as possible to document services rendered.       

Q:            What if a lock-in recipient has an emergency and goes to a rural health clinic physician who is not his lock-in physician?
A: That treating physician must enter "EMERGENCY" in the diagnosis section of the claim form in order to be paid for the visit.

Q:         May a lock-in recipient see any physician in the clinic?
A:           If the recipient is locked-in to a particular physician within the clinic, then he may only see that lock-in physician .

 Q:            Will a physician assistant ever be able to get his own provider number? (Medicare has agreed to issue physician assistant provider numbers.)
A:                As of right now, DHH is not giving physician assistants their own provider number.

Q:      In order to bill Medicaid, does the overseeing physician have to be in the office with the physician assistant? A:                The supervising physician need not be in the office with the physician assistant, but both must comply with the Physician Assistant Practice Act (LRS 1360:22).

Q:       If a patient comes in with an HMO and has Medicaid secondary, can we accept the HMO copayment from the recipient?
A:        If you accept Medicaid for this patient, you may not accept any copayments.

Q:    In block 33 of the HCFA 1500, may we just stamp the physician's signature on the claim form?
A:           Yes, but there must be handwriting in that block (either a signature must be handwritten, or someone must initial a stamped signature or printed name).

Community Care Questions

Q:          Do the new plastic ID cards give an indication of the recipient's Community Care Physician?
A:         The card itself does not list the PCP. However, the PCP name and phone number are given when eligibility is verified through the REVS or MEVS systems.

Q:                Will the Community Care program be expanded statewide?
A:    There is no plan at this time to expand Community Care to include all of Louisiana.

Q:     What if a Community Care recipient comes to our office saying he has no way to get back to his own parish to his PCP?
A:                In order for the visit to be covered, you must have a referral from the recipient's PCP.          

Q:            If a Community Care recipient moves to a non-Community Care parish, how long does it take for the recipient to be unlinked from the PCP?
A:            The linkage should be ended on the first of the month following when the change is reported to the parish office. Linkages normally are not ended in the middle of the month.

Q:         What if a recipient is now living in a non-Community Care parish but is still linked to a PCP? How long do we go about seeing the recipient?
A:       You still need to obtain a referral from the PCP while the linkage is in place.

Q:        What if the PCP refuses to give us a referral, even though he says this is no longer his patient?
A:            You should contact the Provider Relations Representative for your region who will assist in the resolution of this matter.

Ambulance Transportation

Q:             What should we do if we find there is Medicaid coverage for a person who has paid a membership fee to a transportation company?
A:       No action is necessary.

Q:   At a particular hospital, the medical director refuses to sign the MT3 form if he, the attending physician, and the recipient are not in the same room at the same time. How can we handle this situation?
A:           You should report this with specific information so we can call upon the hospital to remind them of their responsibilities.

Q:            What option is available if the physician refuses to sign the MT3, saying the situation was not a true emergency and that the recipient should never have come to the hospital?
A:              In such situations, providers should bill code A0226 for a non-emergency reimbursement. Prior authorization is not required. The cost of the trip should not be billed to the patient since the service is covered.

Q:   Our ambulance claims were denied by Medicare with the reason that the "recipient could have used other means of transportation." Can we get paid by Medicaid?
A:    You should bill code A0226 for a non-emergency reimbursement. No prior authorization is required.

Q:                If we take a recipient to a medical provider who then refuses to sign the MT3 form, do we still get paid?
A:  You can be paid if you document the reason why the provider refused to sign the form. If this is occurring routinely, please report it.

Q:         How do I get assistance with electronic billing?
A:        You may contact Unisys EMC at (225) 237-3303.

Q:       When Medicare clams fail to crossover automatically, do timely filing rules still apply?
A:            Yes. Manually file these claims if they have not crossed automatically within six weeks from your Medicare payment date. These claims must be billed to Medicare within one year from the date of service, or to Medicaid within six months from the Medicare EOB date, whichever is longer.

Q:           May we solicit a Medicare/Medicaid eligible recipient for an ambulance membership?
A:       Yes. However, the recipient must know the membership enrollment is voluntary.

Q:                We provided an emergency transportation service on the same day that another ambulance provider had also provided services. Can we still get paid, or does this exceed limitations?
A:               State approval would be required for payment of the second service on the same day. You should send these claims hardcopy with the 105 certification form and a letter requesting payment for additional emergency services.

Q:            To what hospital should we take the recipient?
A:         The recipient should be transported to the closest facility that can provide the level of care required.

Non-Emergency Medical Transportation

Q:        May a non-emergency medical transportation provider refuse a recipient due to continual dry-runs or abusive behavior?
A:         Yes. The provider should send a letter to the dispatch office indicating the grounds for refusal. The Dispatch office should no longer request that provider to transport that recipient.

Q:       Where may I get statistics of needy regions within the state so that I can provide transportation needs where it is needed?
A:           That information can be obtained by calling the transportation program manager at BHSF at (225)342-0127.

Q:      Since the new plastic ID cards only have a card control number, how is the recipient ID number obtained?
A:      The authorization letter faxed from Dispatch will contain the recipient ID number. In addition, the 13-digit ID number may be obtained through REVS or MEVS using the card control number and other recipient information.

Q:       Why would Dispatch request us to transport a person who is no longer eligible?
A:             The dispatch office will not request you to transport anyone who is not eligible for Medicaid. You may verify recipient eligibility through the MEVS or REVS systems if you think a recipient is not eligible.

Q:              Why is mileage not reimbursed for non-emergency, non-ambulance services?
A:   Non-emergency, non-ambulance medical transportation includes reimbursement of average mileage, but no separate billing is allowed.

Q:       I am a non-profit, non-emergency medical transportation provider. Dispatch is denying me those trips for recipients who need non-emergency transportation on a regular basis for services such as dialysis or chemotherapy. How do I go about providing transportation for those recipients?
A:        Non-profit transportation agencies cannot be reimbursed at capitated rates. Refer to page 6-5 of the Medical Transportation Provider Manula, issued June, 1998.

Q: Is part of the nursing home per diem allotted for transportation?
A:           Yes. The nursing home per diem is meant to include the cost of non-emergency, non-ambulance transportation.

Q:        How many children are allowed to accompany each recipient?
A:       A provider may allow as many as he wishes, but transporting the accompanying children is not payable, nor do we require that they be transported.

Q:                Is there any possibility of raising the reimbursement rates for non-profit providers?
A:                DHH has no plans to increase rates at this time.


Q.            If a recipient has his twenty-first birthday in the middle of the month, is he covered for EPSDT dental services for the whole month?
A. If a recipient's twenty-first birthday is on the first day of the month, his eligibility ceases with the first day of the month. If his birthday is any other date during the month, his eligibility ceases at the end of the month.

Q.                How often should bitewing radiographs be taken for EPSDT patients?
A.                Bitewing radiographs are required at the initial dental screening on all recipients. After that appointment, providers are limited to one set per year per recipient. If on the subsequent checkup appointment no authorized services are necessary, then the program does not require the provider to take radiographs.

Q.          Will nitrous oxide be covered with the procedure sealants?
A.            Currently the program will pay for nitrous oxide with sealants.

Q.               Does Medicaid pay for orthodontics for recipients under 21 years?
A.                Full orthodontic services and maintenance of appliance are provided only in those instances in which treatment is considered medically necessary (i.e. for children with cleft lips and/or palates, hemi-facial hypertrophy, and other craniofacial deformities resulting in a physically handicapping malocclusion.) The program does provide for interceptive orthodontics (minor tooth movement). Reimbursement for interceptive orthodontics will be limited to no more than $200.00, which includes all visits and adjustments/maintenance.

Q.           Is orthodontic treatment payable for treatment of a severe crossbite?
A.  No, treatment is not covered for patients having only crowded dentition or having overjet/overbite discrepancies.

Q.          If a minor crossbite service costs $500.00, can the patient be billed for the $300.00 not paid by Medicaid?
A.      No. If the Medicaid eligible individual has been accepted by the provider as a Medicaid patient, the provider has agreed to accept as payment in full the amounts established by BHSF.

Q.                Why aren't pulputomies on 6-year-olds payable?
A.     Endodontic specialists avoid pulputomies on permanent molars because in some cases it makes the future root canal much more difficult.

Q.               In our practice, our dentist had a stroke and we have a temporary dentist. Does he need a Medicaid provider number?
A.                Yes. To receive reimbursement for services provided under the Medicaid dental program a provider must be an enrolled provider.

Q.          A dentist in Bossier City will be on a 3-month leave. Can our dentist bill under his own number if he goes there one day a week?
A.         Yes. He will be doing the work and should bill as the attending provider.

Q.                Does Medicaid pay for a panorex?
A.               Medicaid will pay for a panorex if the procedure anticipated or the diagnostic necessity justifies the panorex. A full mouth series or panoramic radiograph for screening purposes is not reimbursable in the program (i.e.; a reason for taking the panorex must exist before taking the panorex).

Q.     Will Medicaid ever pay for extractions on recipients who are 21 years old or older?
A.          Currently there is no funding for any expansion of the Adult Dental Program.

Q.    How long after a recipient gets his denture must he wait to have a reline done?
A.        Relines are payable in the adult denture program if a full year has passed since the original denture was delivered or if one year has passed since a reline has been done. Only two major services (one denture and one reline or two relines) are allowed in a seven-year period.

Q.         If a patient dies before the dentures are delivered, how can the provider be paid?
A.                In these situations, partial reimbursement is provided by Medicaid. The provider must contact the prior authorization unit at LSU to get partial reimbursement. The partial reimbursement will be based on the steps completed prior to the death of the patient. The fee for these services will be authorized with the code 05999 (non-specific prosthetics).

Q.          Is it true that providers may file claims with only 4-digit diagnosis codes?
A.             The EPSDT dental and the adult denture programs do not use diagnosis codes. The oral and maxillofacial surgery program uses diagnosis codes which are listed in the ICD-9-CM diagnosis codebook. Claims may be filed with whatever diagnosis code is appropriate; however, some diagnosis codes that are specific to the fifth digit are not on file with Unisys. If there are any questions regarding these codes, providers may contact Provider Relations telephone inquiry unit.

Q.                What is the youngest age at which a recipient may receive dental services?
A.         As long as they are Medicaid eligible, recipients may receive dental services from age 0 on up. The EPSDT program covers recipients until the twenty-first birthday with general dental services, and after that the adult denture program provides for dentures.

Q.     What is the code for non-specific orthodontic work?
A.               The code for all orthodontic services is 08999. All orthodontic services must be prior authorized. Each prior authorization request for orthodontic services must be accompanied by complete documentation, including radiographs, study models, photographs, daignosis, and prognosis.

Q.    Should providers bill their usual and customary fee when filing claims?
A.                Yes.

Q.    Can the REVS line be used to check eligibility for future dates of service?
A.          At this time, recipients eligible on the first day of the month are generally eligible through the entire month. Therefore, if eligibility is verified at some point during the month, generally the recipient will be eligible for the entire month. However, DHH intends to make eligibility valid on a day-to-day basis. At that point, recipient eligibility must be verified each time the recipient is seen.

Q.             What procedure code should be billed for maintenance of orthodontic appliance?
A.      The maintenance fees for Medicaid-covered orthodontic appliances are included in the payment for the appliance. In an instance where the provider must assume care mid-treatment of a full orthodontic case, for a recipient who meets the medically necessary criteria, that provider should contact the dental authorization unit to obtain prior authorization for his services.

Q.            Must patients be over 65 years of age to qualify for adult denture services?
A.      No. Recipients are eligible for the adult denture program once they reach 21 years of age.

Q.     Must we engrave the recipient's name on all dental prosthetic devices?
A.              This requirement has not been made effective yet.

Q.            What is the turnaround time for electronic filing?
A.     Normally claims that are filed electronically are processed in 10 days or less.

Q.         What is the date on which it will be mandatory to use the 1994 ADA form?
A.        That date has not yet been determined.

Q.               What can a provider do about a Medicaid recipient who is a habitual "no-show"?
A.                Providers may discontinue offering services to that recipient after completing their current course of treatment.

Q.        If a procedure is not covered by the Medicaid program, may charges for that procedure be billed to the recipient?
A.              Yes.

Q.    If a recipient insists on a 6 month visit, and Medicaid only provides annual visits, may the recipient be billed for visits that Medicaid does not cover?
A.              Yes, as these are considered non-covered services.

Q.          Can recipients lose eligibility within the month?
A         If recipients� 21st birthday is the first day of the month they will lose EPSDT eligibility on that day. Recipient�s whose 21st birthday is not the first day of the month will maintain eligibility for the remainder of that month.      

Q.            May a Medicaid dental provider fileclaims for another dental provider that is not enrolled with Medicaid?
A.          No. Each dentist must be enrolled as a Louisiana Medicaid provider in order to be reimbursed for services provided to Medicaid recipients.

Q.  Where can I get more information on electronic filing?
A.            Contact the EMC department at (225) 237-3239.

Q.  We have two individual dentists in our practice. Dentist #1 is incorporating and Dentist #2 is part of the group. How do we handle this with Medicaid, since both dentists now only have individual numbers?
A.         Dentist #1 may request that his individual number become a group number. The individual number for dentist #2 must then be linked to provider #1's group number in order for provider #1 to bill for provider #2. Dentist #1 could also apply for a separate group number and then have his individual number and dentist #2's individual number linked to the new group number.

Q.    Is there anything I can do so that my computer generated claim forms don't print out the license number where the provider number goes? Currently, I have to manually change it every time.
A.        That issue sould be discussed with your software vendor.

Q.             What is a spend-down recipient?
A. A spend down recipient is someone who is not normally eligible for Medicaid but, because of catastrophic illness or other circumstances, becomes eligible for Medicaid. Such recipients must "spend down" from their own financial resources an amount of money before Medicaid begins to reimburse providers for services.

Q.  If prior authorization is obtained for a root canal and the patient cancels the service, must eligibility be re-verified when the patient returns at a later date to have the procedure done?
A.             Recipient Medicaid eligibility should be re-verified. However, the prior authorization decision is valid for the length of time specified on the prior authorization letter. Prior authorization does not verify eligibility

Q.           If a provider plans to change banks soon, should he contact (225) 342-9454 to update his direct deposit agreement?
A.    Yes.

Q.    Is it permitted to bill a Medicaid patient when he does not appear for his scheduled appointment?
A.      Once a Medicaid provider has agreed to accept an individual as a Medicaid patient, he can only charge for services rendered. Therefore, a provider should not charge a missed appointment or late fee to a Medicaid recipient. Providers do have the option of picking and choosing from which Medicaid patients they will accept. However, the provider must discuss the acceptance/non-acceptance decision with the Medicaid recipient.

Q.  What happens if the name or the spelling of the name on the card is wrong?
A.           In such a case, any claims for the recipient should be submitted with the recipient's name as it appears on the card. The recipient should contact his parish office to correct his name.

Q.              Where should the prior authorization number be indicated on the dental claim form?
A.               It should be shown in block 38 of the 1994 ADA form.

Q.             How long does it take to order a Remittance Advice?
A.        Remittance advices are usually produced within two or three weeks from the date ordered.

Q.             Do recipients get a new card every year?
A.            No. Recipients only receive a new card if theirs is lost, damaged, or stolen or if the recipient's name changes.

Q.            Do REVS and MEVS give eligibility status?
A.               Yes.

Q.    Does Unisys supply the 1994 ADA forms?
A.                No. These claim forms must be purchased from a national claim form vendor or a business printing firm.

Q.             How important is it to indicate the address in block 9 of the dental claim form? It is not on the new card.
A.            The address is not required.

Q.          Would a CommunityCare referral be required for routine dental procedures?
A.      No. Only if the patient is admitted to a hospital for dental services or if the services are provided by an oral surgeon would a CommunityCare referral be required.

Q.          Why is an original signature required on a paper claim but not for an electronically filed claim?
A.              When submitters file claims electronically, they must submit to Unisys a signed certification sheet for each transmission. In a way that is the equivalent of the signature on each paper claim.

Q.               Must dental providers have a different Medicaid number to provide services through the adult denture program?
A.           No. The same provider number may be used to file claims for EPSDT and adult denture services.

Q.          Is electronic filing mandatory?
A.      No, electronic filing is not mandatory. However, providers who choose to file their claims electronically usually have a shorter claim turnaround time (approximately a seven-day claim turnaround). Also, the possibility for errors related to handwritten paper claims is greatly reduced.

Q. What forms are used to file adjustments?
A.         Unisys forms 209 and 210, supplied by Unisys at no charge, are used to file adjustments. Adjustments can also be filed electronically.

Q.     When billing for a root canal, where is the tooth number indicated on the claim form?
A.      The tooth number is shown in the first column under block 37 on the 1994 ADA form.

Q.          How long should copies of the old paper cards be kept?
A.         They should be kept until claims for services rendered during the month of issue are paid.

Q.        On the claim form, should the last name be shown first, or should the first name be shown first?
A.            The 1994 ADA form requires the first name first and the last name last.

Physician Questions

Q:          Does the swipe card device automatically verify eligibility?
A:    The swipe card device will verify eligibility as well as additional information regarding Community Care, service limits, and third party liability.

Q:               Where is the 13-digit Medicaid number on the plastic ID card?
A:    The plastic ID card does not show the recipient's Medicaid ID number. The card control number (CCN) on the card is used with either REVS or MEVS to obtain the 13-digit Medicaid ID number.

Q:           Does the REVS system give TPL information?
A:                 REVS gives the name of the recipient's other insurance and the TPL carrier code.

Q:              What is the correct procedure for filing a claim for removing keloids performed for non-cosmetic purposes?
A:        The provider should submit the claim plus documentation explaining why the procedure is not cosmetic to Provider Relations Correspondence Unit. The diagnosis code must be 701.4.Q:    Should this be done the first time the claim is filed?
A:      Yes.

Q:    What can a provider do if the cost of providing a particular service exceeds the Medicaid reimbursement?
A:                The provider should write to his program manager at BHSF, including invoices or other documentation substantiating the cost of the service.

Q:        Where does Medicaid stand on pain management?
A:  In general, Medicaid does not cover pain management except on days of delivery and surgery for that day only. Oral and patch narcotics are provided for pain management through the Pharmacy Program if prescribed by a doctor.

Q:      Pain management is not covered in conjunction with office visits?
A:       Only the initial diagnostic visit can be billed. No succeeding services can be billed.

Q:         Does Medicaid pay for post-operative pain management after surgery on the same day?
A:     Yes, but not on successive days.

Q: May anesthesia claims be billed using bilateral modifiers?
A:      No. If multiple surgical procedures are performed within the same surgical session, the claim should be billed with the total number of minutes for which anesthesia was administered.

Q:             Our office runs into timely filing problems when recipients do not identify themselves as having Medicaid until after one year from the date of service. May we bill the recipient for these claims?
A: You may bill the recipient for such services.

Q:            If the recipient is out of office visits, may we ask them for payment for visits exceeding their allowed 12 and then request an extension for the extra visits?
A:   Yes. However, if the provider obtains an extension of visits using the 158-A form, the fee paid by the recipient must be returned in its entirety.

Q:    Is there a list of diagnoses for which we can request extension of visits?
A:            There is no such list. Extensions are granted in cases of emergencies (e.g., trauma and life-threatening conditions) and life- sustaining treatments (e.g., chemotherapy for malignant diseases or radiation therapy).

Q:    Is it acceptable to bill the recipient for physician hospital visits when the precertification is denied? What about if the hospital fails to request precertification altogether?
A: The recipient may not be billed if the hospital precertification is denied as not meeting criteria for medical necessity. If the hospital fails to request precertification altogether, or if an admission or extension is denied because the request for precertification was not submitted timely by the hospital, the physician may submit his claims, the admit and discharge summaries, and a cover letter requesting override of the precertification edit to the Provider Relations Correspondence Unit.

Q:   If I render a service in the office and cannot charge for it, should I include it on the HCFA-1500 with a $0.00 charge?
A:    No--there is no need to bill for the charge.

Q:  How should a physician employing a nurse practitioner and physician assistant bill for their services?
A:     Claims for physician assistant services are billed with the employing physician's provider number as the billing provider number. (Physician assistants are not assigned provider numbers by Medicaid.) Nurse practitioner services are billed using the nurse practitioner's number as the attending provider number (block 24K on the HCFA-1500) and the employing physician's number as the billing provider number (block 31 of the HCFA-1500). CNPs can also bill on their own by placing their individual number in Item 24k and 30 and the name of their directing physician in Item�s 17 and 17A.

Q:         Is precertification required for recipients who have Medicare and Medicaid?
A:         Precertification is required if the recipient has Medicare Part B only or if Part A benefits are exhausted.

Q:        How is the HMO copayment handled?
A:            If a provider accepts Medicaid for a recipient who is a member of an HMO, the provider may not collect the copayment from the recipient.

Q: What is the time limit between visits on outpatient consultations for recipients under age 21?
A:                Three outpatient consultations within 180 days are payable without review. It is possible that more consultations would be payable if circumstances warrant.

Q:                How does the diagnosis code affect the consultation limits?
A:  Consultations are not payable for simple , non-complex diagnoses.

Q:               If a physician provides an outpatient consultation and determines that he needs to perform surgery on the patient, can he still bill for the consult?
A:                No. The consultant became the treating physician at the moment he made the decision to operate. Consequently, the fee for the consultation is included in the reimbursement paid to the physician for the surgery.

Q:               If a patient goes to a general practitioner who refers him to an orthopedist, can both providers see the patient on the same day?
A: If the recipient is under 21 years of age, he may see more than one provider on the same day per concurrent care guidelines. If the recipient is 21 years of age or older, Medicaid will only pay one office visit per date of service. If the recipient is 21 or older the range of codes used is different (99201-99215 by GP and 99241-99245 by orthopedist), both will pay.

Q:     With regard to EMC billing, why shouldn't we file claims on Friday after the Unisys office closes?
A:          Because of our processing schedule, files sent to Unisys at this time may be overwritten by subsequent file transmissions.

Q:     Who do providers contact if wanting to perform electronic adjustments or voids?
A:            The vendor of the provider's electronic billing software should be contacted to ensure that the software is set up to allow for electronic adjustments and voids.

Q: Who do vendors contact if they have questions about electronic adjustments or voids?
A:                Vendors should contact the Unisys EMC department at (504) 237-3303.

Q: Can any software vendors set up electronic crossovers?
A:        No. Only Medicare fiscal intermediaries can electronically cross Medicare claims to Medicaid.

Q:    What should we do if several weeks pass and we don't receive our R.A.?
A: If you call Unisys Provider Relations within three weeks of the missing R.A. date and indicate that you did not receive your R.A., one will be mailed to you at no cost. If you do not notify Provider Relations until after three weeks, a copy can be provided at a cost of $.25 per page.

Q:            Does ambulatory surgery require precertification?
A:    No. There are some procedures, however, that require prior authorization regardless of the place of service. These procedures are listed in the 1998 Professional Services training packet.

Q:               If a patient has several procedures performed on the same day at an ambulatory surgical center, how should the facility fees be billed?
A:                Medicaid will reimburse the ambulatory surgical center a facility fee for only one procedure per recipient per day. Only one procedure code should be billed by the ambulatory surgical center.

Q:     If a patient requires several procedures at an ambulatory surgery center, is it acceptable to bring the patient in on different dates of service?
A:        This would be acceptable if there were a medical reason why the patient could not have all procedures performed at once and had to be brought in on different days.

Q:           As a nurse practitioner, my claims are filed with the physician's provider number as the billing number and my provider number as the attending provider number. Will my claims be paid at 80% of the fee schedule or at 100% of the fee schedule?
A:             The claims will be reimbursed at 80% of the fee schedule amount (except for immunizations, which pay at 100% of the fee schedule amount).

Q:            How can claims be paid when the TPL code on the DHH file and the recipient's correct insurance carrier are not the same?
A:          The provider should send the claim, any required attachments, any EOBs from other insurance carriers, and a cover letter explaining the situation to Unisys Provider Relations Correspondence Unit. The Correspondence Unit will forward the documentation to DHH to have the recipient TPL file corrected and the claim paid.

Q:         We have had physician visits to a recipient in a nursing home deny because the recipient has exceeded their 12 visits per State fiscal year. Can we request an extension for these visits?
A:              Yes. These would be requested using Form 158-A, which would be completed and mailed to the Unisys Prior Authorization department. The request will be reviewed and returned to you. If your request is approved, mail your claims, the approved 158-A form, and a cover note to Unisys Provider Relations Correspondence Unit.

Q:   If the physician sees a patient for an office visit within the global surgery period (GSP), can he bill the office visit with a diagnosis different from that of the procedure to get the claim paid?
A:                The physician should use whatever diagnosis is correct for the visit. If this diagnosis is unrelated to the diagnosis of the procedure with the global surgery period, then the office visit claim should not deny for the GSP edit.

Q:                May a circumcision claim be billed under the baby's name and mother's Medicaid number?
A:            Billing a claim for circumcision in this manner will result in a denial for a name and number mismatch.

Q:  When filing a claim for circumcision, is it acceptable to place the newborn's name in blocks 1 and 4 of the HCFA-1500?
A:             Yes. The circumcision claim must have the newborn's name in block 1 and the newborn's Medicaid ID number in block 3 in order to be paid.

Q:                How do we know which lines of the OFS Form 96 (sterilization consent) can be corrected?
A:            Policy in both the Physician Services Medicaid provider manual and the 1998 Professional Services provider training packet details the policy for the completion and correction of OFS Form 96.

Q:        When sending in a corrected claim form, should I send it to the Provider Relations Correspondence Unit?
A:          Not necessarily. If the claim required a simple correction, and the correction has been made, the claim should be submitted to the appropriate claims post office box. Sending it to Correspondence will only delay processing. Claims with attachments that require special handling, such as proof of timely filing or a 158-A extension of visits approval should be sent to Correspondence with a cover letter indicating what attachments are included.

Q:   Will Medicaid pay for both the visit and the casting materials when the physician puts a cast on a recipient?
A:    The cost of the casting materials is included in the reimbursement for the office visit, and no separate reimbursement will be made.

Q:            How will we know when our check is deposited in our account, now that we have direct deposit?
A:          The remittance advice will indicate that direct deposit has been made. The actual time that funds are deposited in your account will depend in part on your bank.

Q:  Are procedure codes 00096 and 00097 payable to everyone?
A: Effective with dates of service 8/2/98, these codes are payable with review to anesthesiologists, non-anesthesiologist-directed CRNAs, and physicians.

Requests For Interpretations of Justification of Medical Procedures Performed

Both DHH and Unisys have recently received calls from physician providers who are requesting that Unisys Provider Relations or DHH Program Operations staff determine or confirm that a procedure to be performed is medically justified. The policy of DHH which has been required of Unisys is that coverage of a procedure code can be verified and the amount of payment for the code given. Consultations regarding medical necessity or justification are not available by phone. Should a treating physician have a dilemma regarding the provision of a treatment course, a written request from the provider to DHH, Program Operations Section, P.O. Box 91030, Baton Rouge, LA 70821, is necessary.

ATTENTION ALL PROVIDERS - Provider Address Information

A part of the responsibility of any Medicaid provider is to keep all provider information current and accurate. In recent months, the Post Office has returned excessive amounts of provider mail, including remittance advices, due to invalid or old addresses. In many cases, when attempts are made to contact these providers, the telephone numbers on file are also invalid or no longer in service.If your address and telephone number are not current and accurate, please send a letter updating this information to:                                     

Louisiana Department of Health and Hospitals
Medicaid Provider Enrollment Unit                                       
P.O. Box 91030                                     
Baton Rouge, LA 70821

The letter should contain your request that your provider file be updated with current information and should include your 7-digit provider number, the old address which is on the Medicaid file and the new address and current telephone number.

Warning to Providers about Duplicate Billing

                DHH is aware of a recent increase in the number of physician clinics being acquired by hospitals as extensions of the hospitals' outpatient departments. Because of different cost reimbursement systems, billing under Medicaid and Medicare is handled differently. Unlike Medicare, whose policy of acquiring physician practices is outlined in regional Carrier Letter No: 98-01 and Regional Intermediary Letter No. 98-01, which reduces the physician payment to offset for the facility expense, Medicaid does not. Under Medicaid, the physician payment is all-inclusive, meaning that all room, supply and incidental costs are included within the physician�s payment.          

The duplication occurs when the hospital bills Medicaid on the UB-92 for things such as, but not limited to, revenue code 250 (pharmacy-vaccines provided through the VFC Program), 270 (supplies), and 760 (observation room), and the physician also bills Medicaid for his professional services. These duplicate payments are subject to recoupment.        

 Should you have any questions regarding this, please contact Provider   Relations at 1-800-473-2783.

Electronic RAs not Proof of Timely Filing

                This notice is to remind all EMC providers that at this time Louisiana Medicaid does not accept printouts of MEDICAID electronic remittance advice screens as proof of timely filing. The only proof of timely filing currently acceptable by Medicaid is:(1) a copy of the hard copy Medicaid remittance advice page indicating that the claim was processed within the specified time frame; (2) a copy of a hard copy page from a Medicaid provider claims history indicating that the claim was processed within the specified time frame; or (3) correspondence from either the Medicaid Program or local Medicaid eligibility staff concerning the claim and/or the eligibility of the recipient.                                   

Documentation MUST reference the individual recipient and date of service. Postal "certified" receipts and such are not acceptable proof of timely filing.

LADUR Education Article

Optimal Use of Angiotensin-Converting Enzyme Inhibitors

Roy C. Parish, Pharm.D.Associate Professor of Clinical Pharmacy PracticeCollege of Pharmacy, Northeast Louisiana UniversityMonroe, LAGratis Faculty, Department of Pharmacology and TherapeuticsSchool of Medicine, Louisiana State University LSU Medical Center Shreveport


- Beliefs and practices with regard to the use of ACE inhibitors in heart failure and diabetic nephropathy.

- Recent findings in heart failure and diabetes.

- Suggestions to maximize the benefits of ACE inhibitors in these diseases.

                The introduction of the angiotensin-converting enzyme (ACE) inhibitor captopril in the early 1980s was the result of an exponential growth of knowledge of the biochemical basis of blood pressure regulation that occurred during the 1970s and made possible considerable improvement in the specificity of drug therapy for this and other cardiovascular diseases. Initially FDA-approved for the treatment of essential hypertension, the drug soon gained approval for congestive heart failure. Enalapril and other ACE inhibitors were later marketed and there is now a proliferation of these agents. Despite manufacturer�s claims, there are few practical differences among this growing class of drugs other than their duration of action. Except for the effect of this difference on dosing and possibly on the development of functional renal insufficiency, they will be discussed as a class.  

The ACE inhibitors continue to be the subject of basic and clinical research, and beneficial effects and potential uses of this class are yet emerging. Although an impressive record of benefits in heart failure and diabetic nephropathy is established, there is evidence that these drugs are underutilized in these conditions. Beliefs and practices with regard to the use of ACE inhibitors in these two conditions differ considerably; this article will discuss recent findings in heart failure and diabetes and offer suggestions to maximize the benefits of ACE inhibitors in these diseases.

Chronic Heart Failure (CHF)   

The use of the term Achronic, in place of Acongestive, underscores the growing awareness that the progression of CHF is driven by maladaptive humoral compensatory changes that, in the acute hypovolemic/ hypotensive situation would be beneficial, but in the chronic setting give rise to myocardial remodeling, increased afterload and sympathetic tone, and other alterations that are either directly cardiotoxic or hemodynamically deleterious. The renin-angiotensin-aldosterone system has a central role in these changes. Specifically, angiotensin-II (A-II) may function as a myocardial growth factor that promotes remodeling. Blockade of the conversion of A-I to A-II interrupts this element of the cycle, while lower circulating concentrations of A-II result in decreased afterload and decreased myocardial work. In the CONSENSUS study, enalapril was the first drug to be shown unequivocally to decrease mortality in CHF. Later studies have extended this finding to most of the ACE inhibitors.             

Greater benefit from ACE inhibitors in CHF appears to accrue when therapy is initiated early and when doses are advanced to the upper part of the range recommended by the manufacturer. Clinical practice guidelines recommend ACE inhibitors (if tolerated) in all patients with significantly reduced leftventricular ejection fraction; consideration of these drugs is recommended even in asymptomatic patients and those in New York Heart Association (NYHA) functional class I (minimal disability). These guidelines recommend titrating doses of captopril upward to 50 mg three times a day, or enalapril to 10 mg twice a day. Titration of enalapril and isosorbide dinitrate doses to a mean of 40 mg and 153 mg, respectively, was shown in one study to result in a mean functional improvement of one NYHA class and a clinically significant increase in ejection fraction in 72 of 99 patients (both statistically significant).  

Readmission due to heart failure has been shown to be reduced by enalapril doses of 20 mg/day or more, but not by doses of 5 mg/day or less, or by digoxin or diuretics. Improved readmission-free survival has also been shown to occur in inpatients discharged on ACE inhibitors at these high doses compared with those discharged on lower doses.           

"Triple therapy" withdigoxin, diuretic, and ACE inhibitor was evaluated by meta-analysis, using data from the RADIANCE and PROVED studies: worsening heart failure occurred in only 4.7% of patients continuing ACE inhibitor, diuretic, and digoxin, compared with 19.0% of patients who discontinued ACE inhibitors and 39.0% of patients discontinuing both ACE inhibitors and digoxin.         

A widespread tendency to underdose ACE inhibitors in heart failure is well documented. For example, McDermott and associates found that only 18% of patients discharged on captopril or enalapril were receiving doses recommended by the clinical practice guidelines; Luzier�s group reported that 67% of heart failure patients were receiving ACE inhibitors; of those, 22% were dosed at recommended doses, while 41% received 5 mg/day of enalapril or less. This tendency to underdosing is more pronounced in elderly patients. In a small study of patient records combined with telephone interviews, 21.4% of elderly patients were found to have been prescribed target doses, whereas 68.8% of younger patients were receiving target doses. One study of 819 nursing home patients, 119 of whom met strict criteria for heart failure, found that only 41% of the patients with heart failure and no contraindications to ACE inhibitors were receiving these drugs; most of these patients were receiving doses of 5 mg/day or less of enalapril or 50 mg/day or less of captopril. Other sources generally reflect these findings.       

Studies with various designs have established that both older and newer ACE inhibitors are cost-effective in chronic heart failure; these pharmacoeconomic studies have been reviewed by Szucs.   

The reluctance to introduce ACE inhibitors and advance doses aggressively may be due, in part, to the drugs� reputation for causing functional renal insufficiency. It is now widely accepted that ACE inhibitors are generally not directly nephrotoxic; any agent that acutely lowers blood pressure lowers renal perfusion and results in a transient increase in serum creatinine, which usually returns to baseline after a few days if therapy is continued. Sodium and water deficits are risk factors for renal insufficiency following ACE inhibitor therapy, and care is advised in correcting water and salt replacement before beginning therapy. This can often be accomplished by simply withholding diuretics for one or two days. The use of long-acting ACE inhibitors is a smaller risk factor, perhaps because with the short-acting agents, drug effects are minimal in the latter hours of the dosing interval. Although ACE inhibitors have a low index of renal toxicity, it would seem prudent to withhold therapy with these agents for a few days before and after nephrotoxic drugs or procedures such as radiopaque contrast media are given.

Diabetes Mellitus

In both insulin-dependent and non-insulin-dependent diabetes mellitus (IDDM and NIDDM), damage to the glomerulus progresses in parallel fashion with damage to other microvascular structures. In the United States, diabetic nephropathy is the most frequent cause of end-stage renal disease and replacement (dialysis or transplantation); the point prevalence of end-stage renal disease in IDDM is approximately 40%. In IDDM, nephropathy follows an unrelenting (if not treated) course from hyperfunction through incipient, overt, and finally, end-stage disease; in NIDDM, fewer patients progress to the end stage and the course is more highly variable compared to that of patients with IDDM. Several factors are known to drive disease progression, but A-II and glomerular hypertension are central to the process, and it is inviting to make comparisons with the role of A-II in the progression of chronic heart failure.         

Control of blood pressure is widely believed to be the most important and effective means to prevent or attenuate the development of diabetic nephropathy, both in NIDDM and IDDM. The pharmacologic effects of ACE inhibitors at the afferent and efferent glomerular arterioles, as well as their interference with the putative growth hormone effects of A-II, suggest that ACE inhibitors should be effective renal-protective agents in diabetes. This is, indeed, clearly established. In NIDDM, these drugs have been shown to slow the progression of proteinuria and the decline in renal function in both hypertensive and normotensive patients. In IDDM, ACE inhibitors protect against deterioration in renal function in patients with established nephropathy as well as those with only microalbuminuria.      

The American Diabetic Association currently recommends ACE inhibitors in the following situations:

1: Diabetes, hypertension, and microalbuminuria or overt nephropathy;
2: IDDM and microalbuminuria, even in patients with normal blood pressure;
3: NIDDM and hypertension or progressive albuminuria.      

The cost-effectiveness of ACE inhibitors in both NIDDM and IDDM are well shown. For example, Rodby and associates showed lifetime direct and indirect cost savings of $55,630 per patient with NIDDM and $116,940 per patient with IDDM.          

Some studies suggest that combined therapy with ACE inhibitors and non-dihydropyridine calcium channel blockers may produce additional reductions in blood pressure and proteinuria, with a more favorable adverse effect profile than that of either drug alone.(Bakris & Williams, 1995) This combination may be useful in patients with diabetes and refractory hypertension, but further clinical and pharmacoeconomic studies are needed before firm recommendations can be formulated.


Symptoms of diabetic autonomic neuropathy (impotence, postural hypotension, diarrhea) occur commonly in diabetes, and over half the patients with symptoms have autonomic dysfunction demonstrable by objective testing, such as reduced postural hemodynamic reflexes, loss of resting heart rate variability (electrocardiographic R-R interval variability), and sluggish pupillary reflexes; the five-year mortality rate in patients with abnormal autonomic function on presentation is more than three times that in patients with initially normal autonomic testing. Diabetes and autonomic dysfunction are associated with increased risk of myocardial infarction and sudden death.  

In a retrospective analysis of the GISSI-3 study, Zuanetti and associates found that information on diabetic status was available for 18,131 patients suffering acute myocardial infarction, of whom 2,790 had a history of diabetes. Mortality in the diabetic patients at 6 weeks post-infarction was 8.7% in the group treated with the study drug (lisinopril) versus 12.4% in the untreated group, an effect that was significantly larger than that in non-diabetic patients. Treatment with lisinopril effected a saving of 37 lives per 1,000 patients treated. Similar findings have been reported from other studies.

Recommendations and Precautions            

The improved survival and quality of life resulting from therapy of heart failure with ACE inhibitors are now well established, as is the cost-effectiveness of these drugs. There seems little reason to deny patients these benefits if the drugs are tolerated. Most practitioners believe ACE inhibitors to be first-line agents in heart failure, and practice guidelines now recommend their use in all patients with left ventricular systolic dysfunction as tolerated. The last decade has seen a shift toward earlier use of ACE inhibitors in CHF and initiation of ACE-inhibitor therapy in patients with milder disease as characterized by NYHA functional class.     

ACE inhibitors have been shown unequivocally to have a renal protective effect in IDDM and NIDDM. Although practice guidelines suggest their use in low-risk patients only after signs of renal disease progression appear, it seems likely that these recommendations will be expanded to include use of these protective agents before overt damage is evident.               

The adverse effects of ACE inhibitors have been reviewed elsewhere. A few adverse effects bear emphasis because of their seriousness. These drugs are contraindicated in pregnancy because of reports of fetal oligohydramnios and anencephaly. The anti-aldosterone effects of ACE inhibition and A-II reduction facilitate potassium retention, and careful attention to serum potassium concentration is required when ACE inhibitors are used concurrently with potassium-sparing diuretics or potassium supplementation. Lastly, angioedema of the oral cavity is a potentially life-threatening condition that may occur more commonly than is suggested from Phase III and post-marketing studies, and appears to be more common in African-Americans and in patients with collagen-vascular disease. This is a class effect, and patients experiencing angioedema should probably never receive any ACE inhibitor thereafter. Functional renal insufficiency is largely preventable by correction of fluid and sodium deficits before ACE-inhibitor therapy begins and concerns over its possibility should not deter judicious administration of these drugs.


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Anderson, A., Christiansen, J., Andersen, J., Kreiner, S. & Deckert, T. (1983). Diabetic nephropathy in type 1 (insulin dependent) diabetes: An epidemiological study. Diabetologia, 25, 496-501.

Bakris, G. & Williams, B. (1995). Angiotensin converting enzyme inhibitors and calcium antagonists alone or combined: Does the progression of diabetic renal disease differ? Journal of Hypertension, 13, S95-S101.

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Ziyadeh, F. (1993). Renal tubular basement membrane and collagen type IV in diabetes mellitus. Kidney International, 43, 114-120.

Zuanetti, G., Latini, R., Maggioni, A., Franzosi, M., Santoro, L. & Tognoni, G. (1997). Effect of the ACE inhibitor lisinopril on mortality in diabetic patients with acute myocardial infarction: Data from the GISSI-3 study. Circulation, 96, 4239-4245.