Volume 21, Issue 5
Changes to the Louisiana Medicaid Eligibility Verification Systems
Announced for MEVS, e-MEVS, REVS, and Provider Relations Access
The Centers for Medicare and Medicaid Services (CMS) guidelines concerning release of recipient eligibility information have caused changes in accessing eligibility information for Medicaid recipients. These changes affect all recipient eligibility access including:
Medicaid Eligibility Verification System (MEVS and e-MEVS);
Recipient Eligibility Verification System (REVS); and
Eligibility Inquiries through Provider Relations.
The following changes will occur during the maintenance window the evening of November 27, 2004:
� Only eligibility information for the previous 12 months from inquiry date will be provided.
� Recipient inquiries will be limited to the following choices:
� Recipient Medicaid ID Number and Date of Birth
� Recipient Medicaid ID Number and Social Security Number
� Recipient Medicaid ID Number and Recipient Name
� Recipient Card Control Number and Date of Birth
� Recipient Card Control Number and Social Security Number
� Recipient Social Security Number and Date of Birth
� Recipient Name and Date of Birth
� Recipient Name and Social Security Number
Note: Recipient inquiries through REVS do not inlclude �name� options.
� REVS and Provider Relations will no longer allow access to eligibility information with only the Recipient Medicaid ID Number. An additional piece of verifying information must be given as stated above.
� Card issue date is no longer required when using the card control number.
� Specific dates of service must be requested. A date range in the date of service field on an inquiry
transaction is not acceptable, and Provider Relations will not supply eligibility information for date ranges.
� An error message will be returned through the automated systems if the date is not a valid 8-digit date
Providers should make general recipient eligibility inquiries through one of the automated eligibility systems, e-MEVS, MEVS, or REVS.
Please make any necessary changes to your internal processes to ensure that eligibility inquiries are processed in a timely manner and that the appropriate information is given when making these inquiries. Failure to do so will prevent release of eligibility information.
Antibiotic Injections for Recipients Under Age 21
Effective with date of service October 15, 2004: CPT code 90782 will be placed in non-pay status. Providers should use CPT code 90788 for the reimbursement of injectable antibiotics supplied and administered by the physician.
Therapy Services to be Provided In the Home
The Bureau of Health Services Financing announces that effective October 1, 2004, Rehabilitation Centers will be allowed to provide speech, occupational, and physical therapy services in the homes of recipients with prior approval from the Unisys Prior Authorization Unit. A recipient's place of residence, for these services, cannot include a nursing home.
Requests for services should be submitted on Unisys Form PA01 and PA02. Services should be billed with Unisys Form 102. The Place of Service for home must be indicated on the PA request and on the claim.
HCPCS Codes Required Effective 03/01/04
Claims for dates of service on or after March 1, 2004, must be billed using the applicable HCPCS procedure codes as shown in the chart below even when the Prior Authorization (PA) was approved before March 1, 2004. In these cases, the date of the PA does not impact coding. The date of service determines the appropriate coding.
| State Codes (prior to 03/01/04)
|| HCPCS Codes (effective 03/01/04)
In the future, PA requests and claims should be submitted using the HCPCS code in effect at the time the service is rendered.
Attention Dental Providers - New Dental Claim Form Requirements Effective 01/01/05
Effective January 1, 2005, the 2002 and the 2002, 2004 versions of the American Dental Association (ADA) Claim Form will become the only hardcopy dental claim forms accepted for prior authorization and reimbursement of services provided uner Medicaid�s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Dental, Expanded Dental Services for Pregnant Women (EDSPW) and Adult Denture Programs regardless of the date of service.
All 1990, 1994, or 1999 ADA Claim Forms received by Unisys or the LSU Dental School, Prior Authorization Unit before January 1, 2005 will be processed. In-house and pending claims received on these forms will also be processed. However, any dental claims received on the 1990, 1994, or 1999 Claim Forms on or after January 1, 2005 will be returned to the provider.
Hardcopy billing providers should request the 2002 or the 2002, 2004 claim forms from the ADA as soon as possible in order to comply with the effective date.
Providers who are currently using older version of dental software to print hardcopy dental claims should contact their software vendor as soon as possible for updated (2202 or 2002, 2004) dental software to comply with the effective date.
Should you have any questions regarding this information, you may contact Unisys Provider Relations by calling (800) 473-2783 or (225) 924-5040 or the Dental Prior Authorization Unit by calling (504) 619-8589.
Information for ICF/MR Providers
Due to concerns voiced by some providers, changes to the ICAP reimbursement methodology related to the direct care floor are being developed at this time. Due to the substantive nature of the changes, a new Notice of Intent must be promulgated which will necessitate postponement of the implementation. The new implementation date has not yet been determined.
Providers should have reviewed the Shadow Rate report sent to ICF/MR facilities in July and now be in the process of updating and/or correcting the data as necessary. We will be sending out the revised Shadow Rate report in October based on updated information submitted prior to September 30, 2004.
DHH is in the process of reviewing resubmitted ICAPs received subsequent to release of the original shadow rates. Many providers are resubmitting ICAPs resulting in substantive increases in the facility reimbursement rate which cannot be statistically validated. As a result of the reviews, providers will be contacted as deemed necessary to submit further documentation to support such changes.
A cursory review of ICAP submittals reveals that many providers are still completing the ICAPs incorrectly. Of particular notice is that in the Maladaptive Behavior Section, severity and frequency are not being scored independently, i.e., providers are scoring non-serious behaviors such as being disruptive as a serious behavior because of the frequency of occurrences. For a behavior�s severity to be scored as a �3. Very serious: a severe problem� or �4. Extremely serious: a critical problem� there must be a behavior modification plan in place which minimizes the frequency of occurrences. When a behavior is prevented it should be rated as occurring �less than once a month.� Remember to have the instruction in front of you when completing the ICAP.
Due to copyright issues, we are no longer asking providers to complete the Louisiana Level of Need, (LA-LONS).
RATE AND AUDIT WEBSITE
Please check the Rate and Audit website at www.dhh.state.la.us/rar. The website is updated on a regular basis. Questions and answers from the ICAP trainings have been posted on the site.
Effective with date of service July 1, 2004, the following CPT codes were added to the list of codes payable to Clinical Nurse Specialist, Certified Nurse Practitioner, and Nurse Midwife.
Louisiana Drug Utilization Review (LADUR) Education
Hepatitis C Treatment and Monitoring
W. Greg Leader, Pharm.D.
Associate Dean and Director
School of Pharmacy - The University of Louisiana at Monroe
Anand Dalal, Ph.D. Candidate
School of Pharmacy - The University of Louisiana at Monroe
� Chronic viral hepatitis is the primary cause of chronic hepatic disease...
� Rapid referral of acute cases is important...
� Currently, two different therapies have been approved in the United States for the treatment of Hepatitis C infection.
Chronic viral hepatitis is the primary cause of chronic hepatic disease (including cirrhosis and hepatic cellular carcinoma) in the world, and infection with Hepatitis C virus is the principle form of chronic viral hepatitis in the United States. Despite a recent decline in the number of new cases, concern exists over millions of asymptomatic patients who acquired the virus in the decades prior to adequate testing and surveillance. This article is the second of two parts and focuses on the treatment and monitoring of Hepatitis C.
Currently there are about six genotypes of the Hepatitis C virus with the majority of patients being infected with strains 1, 2 or 3. Most patients in the United States are infected with genotype 1, which is the most difficult to treat. The primary goals of therapy are the eradication of the virus, decreasing morbidity and mortality, and prevention of liver disease progression. Rapid referral of acute cases is important, as early treatment with interferon-alfa appears to decrease the risk of chronic infection. Patients should be counseled to abstain from alcohol use, and potentially hepatotoxic medications should be avoided.
Currently, two different therapies have been approved in the United States for the treatment of Hepatitis C infection: interferon monotherapy and combination therapy with interferon-alfa and ribavirin. Because of increased efficacy, the 1999 NIH Consensus Guidelines recommended that Hepatitis C be treated with a combination of interferon alfa-2b and ribavirin.
More recently, the combination of polyethylene glycol and interferon has resulted in a longer acting interferon, pegylated interferon, that allows for once a week dosing. The combination of pegylated interferon combined with ribavirin has increased efficacy compared to the combination of interferon alfa-2b and ribavirin. Currently, two pegylated interferons exist, peginterferon-alpha-2a (Pegasys�) and peginterferon-alpha-2b (Intron-A�), and both have been shown to be effective in treating infections caused by genotype 1 as well as genotypes 2 and 3. No current clinical trials have compared the two pegylated interferons with respect to efficacy and safety, and current studies of the individual agents cannot be compared due to differences in study designs.
Ribavirin is an oral nucleoside analog with broad anti-viral activity. It is ineffective against the Hepatitis C virus when given as monotherapy; however, it significantly increases the efficacy of interferon when the two are combined. Currently three ribavirin products are available, Rebetol�, Copegus�, and Virazole�. These products are interchangeable and can be used with either of the pegylated interferons.
Recommended treatment dosages depend on the product used and the virus genotype. Figure 1 is an algorithm for the treatment of Hepatitis C based on viral genotype. It is important to have baseline HCV RNA levels immediately before therapy to serve as an aid in determining therapeutic response in patients that have genotype 1. In patients with end stage renal disease requiring hemodialysis, the dose of peginterferon-alfa 2a should be reduced to 135mcg. Peginterferon-alfa 2a and 2b are contraindicated in patients with autoimmune hepatitis or hepatic decompensation (Child Pugh Class B and C) before or during therapy. Combination therapy with ribavirin is contraindicated in pregnant women or patients with hemoglobinopathies.
Figure 1: Hepatitis C Treatment Algorithm
Figure 2: Diagnosed Hepatitis C Patient Receiving or Not Receiving Drug
Current data from the Louisiana Medicaid population indicate that 75 percent of the patients diagnosed with Hepatitis C infection from 1999-2001 received drug therapy (Figure 2). Of those receiving therapy, 75% received monotherapy and 25% received combination therapy (Figure 3). Of these patients, 75% of recipients receiving monotherapy discontinued therapy and 66% of recipients receiving combination therapy discontinued therapy (Figure 4). It should be noted that these figures are based on data collected from 1999-2001, which was shortly after the NIH recommendation for combination therapy and before the NIH recommendation for combined peginterferon-alfa and ribavirin therapy.
PREDICTORS OF SUCCESS
Based on clinical trials, the following factors predict a favorable response to therapy:
� Genotype other than type 1
� Lower baseline viral levels
� Less fibrosis or inflammation on liver biopsy
� Lower body weight or body surface area
� Younger age
� Female patients
� Lack of steatosis
Figure 3: Treated Patients Receiving Monotherapy or Combination Therapy
In addition to these physiologic markers, adherence to treatment is one of the best ways to improve response. One study demonstrated that response was increased when patients took
� >80% of their interferon alpha and
� >80% of their ribavirin for
� >80% of the duration of combination therapy
One of the primary concerns with interferon alpha therapy is lack of compliance due to adverse effects. The education of the patient and their caregivers concerning adverse effects and their management is important to improve adherence to therapy. Although major adverse effects can occur, minor adverse effects are more common and can be bothersome. Six to nine out of ten patients treated with interferon alpha will experience flu-like symptoms (malaise, fever, chills, myalgia, tachycardia, and headache) after the first few doses. Later adverse effects include anorexia, fatigue, malaise, reversible alopecia, skin rash, and weight loss. Approximately 25% of the population will develop neuropsychiatric adverse effects including depression, personality disorders, short-term memory loss, inability to concentrate, irritability, and insomnia. Neutropenia, mild anemia, thrombocytopenia and irreversible thyroid dysfunction may also occur.
The primary problem associated with ribavirin therapy is the development of a reversible hemolytic anemia that usually occurs in the first eight weeks of therapy and appears to be dose related. Less severe adverse effects such as fatigue, irritability, itching, skin rashes, nasal symptoms (stuffiness, sinusitis), and cough may also occur.
Both interferon and ribavirin are teratogenic and should be avoided in pregnant women. Women of childbearing age and male partners of women of childbearing age should be counseled concerning these effects. Women of childbearing age receiving therapy or having sexual intercourse with a male partner receiving therapy with these agents should be strongly counseled to use two reliable forms of birth control during therapy and for up to six months following discontinuation of therapy.
Figure 4: Therapy Completers vs. Non-completers
Because adherence to therapy is crucial to a sustained viral response, consideration should be given to medically managing any adverse effects. Many adverse effects can be managed by decreasing the dose as opposed to discontinuation of therapy. Flu-like symptoms can be alleviated through appropriate use of acetaminophen or non-steroidal anti-inflammatory agents. Liberal use of antidepressants is encouraged to treat depression, and hematopoietic growth factors (erythropoietin, granulocyte colony stimulating factor) should be considered for the treatment of anemia or leukopenia instead of drug discontinuation or dose reduction; however, this therapy is costly.
MONITORING OF THERAPY
In addition to confirming the diagnosis through liver biopsy and measurement of serum HCV RNA by PCR, patients should be tested for Hepatitis C genotype (or serotype) to help determine the duration of therapy. Prior to instituting therapy, complete blood counts (including hemoglobin, white blood cell count and platelet count) and aminotransferases should be measured to establish a baseline, and patients should be counseled concerning the benefits and risks of therapy with particular attention to potential adverse events. In addition, a thyroid stimulating hormone level and pregnancy test should be evaluated at baseline. Adverse effects, symptoms, pregnancy test, complete blood count, and aminotransferases should be assessed 1, 2 and 4 weeks after the initiation of therapy and then every 4 to 8 weeks thereafter while the therapy continues. In patients with HCV genotype 1, HCV RNA should be measured by PCR at week 12, and the patient should be evaluated for response to therapy. Those patients who have not had at least a two log 10 unit decrease in HCV RNA (e.g. 500,000 IU to 5,000 IU) should have therapy discontinued, as they are unlikely to respond to further therapy. Viral RNA should be evaluated at the end of therapy (24 weeks for genotypes 2 and 3 and 48 weeks for genotype 1) to determine end-of-treatment response and again six months after therapy is discontinued. If the patient has a negative test for Hepatitis C viral RNA six months after therapy, the chance for long-term cure is excellent.
Despite the advances in therapy, there are still a substantial number of patients who do not have a sustained virologic response, particularly those infected with HCV genotype 1. Newer agents under investigation may provide more effective and safer therapy. In addition, newer ways to deliver interferon, new interferon preparations such as gamma interferon, and drugs that may stimulate interferon production are under investigation.
In addition to these investigational therapies, a new strategy being investigated in patients who have been treated with interferon and ribavirin and have failed therapy or relapsed, is retreatment with peginterferon-alfa and ribavirin. In addition, ongoing maintenance therapy with low dose interferon is being investigated for the prevention of liver disease progression in nonresponders.
The combination of peginterferon-alfa and ribavirin is the treatment of choice for Hepatitis C infection. Adherence is crucial to successful therapy. Strategies including patient counseling and education, appropriate management of adverse effects, and, if necessary, dosage reduction can improve adherence. In addition to improving adherence, providers can decrease the cost of therapy by identifying non-responders early and stopping therapy. Early removal of therapy in non-responders at 12 weeks reduces patient exposure to adverse effects and decreases the cost to the health care system.
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