11, NUMBER 5
from the Medical Director
I'd like to update you on the
Hospital Preadmission/Length of Stay (LOS) Review Program.
This does not apply to state operated or out-of-state hospitals.
This program was designed to be
implemented in conjunction with the new hospital per diem rate reimbursement
structure that went into effect July 1, 1994.
The hospital pre-admission/LOS program began on August 1, 1994, and all
hospitals will be phased in by January 1, 1995.
No action is necessary on the part of hospitals until they are contacted
by DHH or Unisys regarding their participation.
A series of training sessions will be held around the state for groups of
hospitals prior to their participation in the program.
Complete details about the program will be included in the new Medicaid
Hospital Manual which will be mailed to providers during the month of September.
All program policies for the
pre-cert/LOS program were developed by a DHH Advisory Committee composed mostly
of Louisiana Hospital Association representatives along with representatives
from DHH and Unisys. The program will conduct both preadmission and length of stay
reviews for distinct part psychiatric facilities and long term hospitals using
customized criteria developed by this group.
This comprises approximately 10% of all Medicaid hospital admissions.
Acute care and rehab hospitals, which together comprise the remaining 90%
of all Medicaid admissions, participate only in the LOS review program.
The InterQual review criteria will be used to review acute care extension
requests while customized criteria developed by the Advisory Committee will be
used for long term admissions. Length
of stay will be assigned based on the HCIA Southern Regional 1994 data with
appropriate specialty customization where designated by the DHH Advisory
The InterQual criteria can be
purchased by calling InterQual at (603) 964-7255.
The HCIA Southern Regional Length of Stay criteria can be purchased from
HCIA by calling (800) 568-3282.
Admissions and LOS reviews will be
conducted by review nurses with physician consultant oversight.
Most communications can be conducted between Unisys and hospitals via fax
by submitting the appropriate forms and criteria sheets with the relevant boxes
checked and standard medical documentation included.
Numerous 1-800 fax and phone lines have been installed to facilitate
communication and data submission. Every
attempt has been made by the DHH Advisory Group and by Unisys staff to make
procedures as clear and simple as possible.
In addition, we will fine tune our policies and procedures to make the
program work even better based on comments and interactions with hospitals
already being phased in
Dr. Gregg Pane
in Fee for 21248
BHSF is pleased to inform you of an
increase in fee for CPT code 21248-Reconstruction of mandible or maxilla,
endosteal implant (e.g., blade, cylinder); partial.
The fee has been increased to $1,025.27 effective with date of service
October 1, 1993.
If you have performed this service
since October 1, 1993, and wish to receive the additional fee, you must submit
an adjustment form to Unisys. The
instructions can be found in the Physician Service Manual, page 35-1.
of Code 95807
CPT code 95807-sleep study, three or
more parameters of sleep other than sleep staging, attended by a
technologist-has been funded effective with date of service August 1, 1994, at a
full service fee of $266.00. The
professional component fee for this service will be $106.40.
A limit of two tests per calendar
year per recipient has been placed on codes 95807 and 95808 effective with
publication of this notice. For
example, either two billings of code 95807 or two billings of code 95808 in a
year's time will be payable for a single recipient.
Or one billing of code 95807 and one billing of code 95808 will be
payable for a single recipient. A
third billing of either of these codes will be denied.
of Code 99183
The question has been asked whether
or not physicians must be present during the entire hyperbaric oxygen therapy
session to bill CPT code 99183 - Physician attendance and supervision of
hyperbaric oxygen therapy. The
answer to this question is "YES."
CPT code 99183 is to be used per
dive per patient. The physician
must be physically present on the unit during the entire dive to bill and
receive reimbursement for this service. Documentation
in the dive record must reflect the provider's participation in and presence on
the unit during the dive.
Evaluation and management (E&M)
services may be billed on the same date of service as 99183 if 1) a separate,
identifiable service unrelated to hyperbaric oxygen therapy (HBO) or the
condition necessitating HBO is rendered, and 2) the service could not be
rendered at the time of HBO (e.g., dysuria with a urinalysis office visit for
on Echography During Pregnancy
Effective August 1, 1994, the number
of echographies (CPT codes 76805, 76810, 76815, and 76816) during pregnancy will
be limited to three per recipient per pregnancy without review.
A total of three claims with any combination of these codes will be paid
per recipient per pregnancy. A
fourth and succeeding echographies will pend to Medical Review and will be paid
only if they meet the criteria listed below.
Complications related to pregnancy requiring ongoing diagnosis and/or
therapy which necessitates additional echographies.
Documentation supporting medical necessity should be attached.
Abnormal findings on previous echographies which require additional
echographies to further monitor, evaluate, and treat.
Documentation supporting medical necessity should be attached.
The first three claims can be billed
electronically. A fourth and succeeding claim must be billed hard copy.
for CPT Code Z9918
Anesthesia for the removal of
leaking breast implants (code Z9918) has been funded with three base units
effective with date of service October 1, 1993.
This is the date of service on which
the removal itself was funded, but, through error, no mention was made in the
original announcement about the funding of anesthesia for this service.
Claims are to be submitted with appropriate modifiers and minutes.
in Fee for 69450
CPT code 69450 - Tympanolysis
transcanal - was increased from $84.50 to $316.79 effective with date of service
September 1, 1994.
of Code 95810
CPT code 95810 (Polysomnography;
sleep staging with 4 or more additional parameters of sleep, attended by a
technologist) has been funded effective with date of service September 1, 1994
at a full service fee of $300.12. The
professional component fee for this service will be $120.05.
A limit of two tests per calendar
year per recipient has been placed on this code as was placed on codes 95807 and
95808. Therefore, these three codes
are restricted to a maximum of two per year per recipient (any combination).
A third billing within the calendar year of any of these codes will be
in Non-Pay Status
Effective with date of service
October 1,1994, we will place code J9383 (Zoladex-goserelin acetate implant, 3.6
mg) into non-pay status. The code
to bill in its place is J9202 (the code Medicare uses for Zoladex).
The fee for code J9202 is $344.76 for 3.6 mg.
for Code Q0134
BHSF announces the funding of HCPCS
code Q0134 (Collagen implant, urinary tract, per 2.5 cc syringe) effective with
date of service 10/1/94 at $217.00, including shipping and necessary supplies.
Medicaid is adopting Medicare's
guidelines for the use of this treatment modality for Type III stress urinary
incontinence secondary to intrinsic sphincter deficiency (ISD), and will
restrict the reimbursement for this code to five treatment sessions per
recipient. Please refer to the
9/1/94 issue to Medicare's Provider News for additional comments,
information, and policy regarding the use of Contigen implants.
Effective with dates of service
July 1, 1994 and after, non-LHCA or non-state operated in-state hospitals
approved for NICU Level II, NICU Level III, and NICU Level III Regional Units
should bill all NICU days under the baby's name and Medicaid ID number from the
day the baby is placed in this unit. Use
Revenue Code 175. It does not
matter that the mother is still a patient in the hospital.
Regular nursery days and NICU Level
I should continue to be included on the mother's bill as long as the mother is a
patient. Use Revenue Codes 170,
171, or 172 to indicate these types of stays.
On the mother's bill, only the mother's accommodation days will be paid,
which is the same way such claims were paid prior to July 1, 1994.
Bill with the baby's name and number only after the mother has
been discharged or if she was never admitted to the hospital.
The State Plan under Title XIX has
been amended effective August 24, 1994, to provide the payment to the attending
physician for abortions terminating pregnancies resulting from rape or incest in
accordance with provisions of State Law (La. R.S. 40:1299-:34.5 and La. R.S.
40:1299:35.7 as amended and enacted by Act 1 of the Fourth Extraordinary Session
of the 1994 Legislature).
Anesthesia Code List Expanded
The Bureau of Health Services
Financing is pleased to inform you of the following CPT codes that will be
included in the list of anesthesia codes which pay a flat fee.
We are also adjusting our fees for codes 36488, 36489, and 64510 as
listed below. These changes are
effective with date of service September 1, 1994.
is the placement of central venous catheter (subclavian, jugular, or other vein)
for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy;
percutaneous, age 2 years or under. It
will be paid at $91.17.
is the same as above, percutaneous, over age 2.
It will be paid at $80.77.
is the injection of anesthetic agent, stellate ganglion (cervical sympathetic).
It will be paid at $162.50.
is echocardiography, real time with image documentation (two dimensional) with
or without M-Mode recording, transesophageal; placement of transesophageal probe
only. The fee for 93313 has not
changed; it remains at $49.98.
These codes should be billed without
modifiers or minutes.
Taxpayer ID Information for All Providers
The Internal Revenue Services
considers a taxpayer identification number (TIN) as incorrect if either the name
or number shown on an account does not match a name and number combination in
their files or the files of the Social Security Administration (SSA).
If you do not take appropriate action to help BHSF correct this problem,
the law requires us to withhold 31% of the interest, dividends, and certain
other payments that we make to your account.
This is called backup withholding.
In addition to backup withholding,
you may be subject to a $50 penalty by the IRS for failing to give us your
correct name/TIN combination.
An individual's TIN is his or her
social security number (SSN). However,
sometimes an account or transaction may not contain the actual owner's correct
SSN. An account should be in the name and SSN of the actual owner.
A corporation's TIN is the IRS
number assigned to the business entity by the IRS.
The name and number in the Medicaid records must match what is in the IRS
Please send any necessary
information changes to the address below or FAX to Provider Enrollment Section
at (504) 342-3893.
Bureau of Health
P. O. Box 91030
Baton Rouge, LA 70821-9030
Attention: Provider Enrollment Unit
of Payable Code for Chiropractors
Effective with dates of service
September 1, 1994, CPT Code 97250 (Myofascial release/soft tissue mobilization,
one or more regions) is being added to the list of codes payable to
chiropractors. The fee for this
code is $25.61.
The appearance of the monthly
medical card produced by Unisys will be changing effective with the November
The new card will be printed on an 8
1/2 x 11 sheet, folded in half, and sealed into a one-piece mailer.
The card's edges will be perforated for easy removal.
The top half of the card will
contain recipient eligibility information and the bottom half will contain
messages, notices, and other pertinent Medicaid information.
You will find a sample of the new
card provided on the following page. Please
note that only the inside portion of the card is shown.
The outside contains mailing information.
Sample of Card
Drug Utilization Review (LADUR) Education
Therapy in Acute Otitis Media
Otitis Media Treatment in
Antimicrobial therapy can shorten the duration of symptoms of otitis media and
prevent complications such as mastoiditis and meningitis. Some studies show that Streptococcus pneumonia accounts for
approximately 35% of acute otitis media, non-typable strains of Hemophilus
influenza accounts for approximately 25% of cases, Moraxella catarrhalis
accounts for about 15% of cases and about 5% of cases is secondary to
Streptococcus pyogenes. Important
to note is that about 70-90% of M. catarrhalis and about 30-40% of H. influenza
otitis media produce beta-lactamase and are resistant to amoxicillin in vitro1.
Interestingly, about 15% of cultured middle ear fluid aspirate were
sterile in some studies2.
Amoxicillin has been considered the
drug of choice for initial treatment of acute otitis media.
Other agents have been used as alternatives3.
Antimicrobial resistance in acute otitis media is not clear.
Persistent symptoms may be secondary to a concurrent viral infection.
Recurrent infections may be secondary to a new bacterial strain 4 ,
The State of Louisiana has a drug
formulary that allows the practitioner latitude in the selection of drug
therapies. The drug program thus
provides for optimal drug coverage and flexibility for both the patient and
practitioner. The Department of
Health and Hospitals believes that the nature of the drug program improves the
health of recipients and reduces overall health costs to the state.
However, it is incumbent upon the prescribing practitioner to select drug
therapy on the basis of both appropriateness of drug therapy for the clinical
diagnosis and cost containment.
The Provider Update
illustrates the potential of the prescribing physician as a sentinel for the
patient's health care decisions while following guidelines necessary for a
complete drug program.
ANTIMICROBIALS FOR ACUTE OTITIS MEDIA6
40 mg/kg in 3 doses
mg/kg in 2 doses
mg/kg erythromycin - 150 mg/kg
sulfisoxazole in 4 doses
acid -- Augmentin�
40- mg/kg amoxicillin - 10 mg/kg
clavulanic acid in 3 doses
40 mg/kg in 2 or 3 doses
8 mg/kg in 1 or 2 doses
30 mg/kg in 2 doses
mg/kg in 2 doses
axetil -- Ceftin�
500 mg in 2 doses
30 mg/kg in 2 doses
Guidelines for Otitis Media
Amoxicillin is the most rational choice for the initial treatment of
acute otitis media when there is not a high incidence of ampicillin-resistant H.
influenza and B. catarrhalis.
If these resistant organisms are commonly observed, then one of the beta-lactamase
resistant antibacterials should be used (i.e., Pediazole
If these treatments fail, the more expensive cephalosporins may be used
such as Suprax,
or Ceclor. It is unnecessary and costly to use cephalosporins as a first
line of treatment for otitis media.
Choice of Initial Therapy in
Pediatric literature suggests
that most children with acute otitis media are treated without a specific
bacteriological diagnosis, and may have infections resolve during treatment with
less than optimal drugs8.
Comparative clinical trails have
generally shown that most of the drugs used to treat acute otitis media are
about equally effective7. Medical Letter consultants consider amoxicillin a suitable
first choice for most patients. For
those who have recently taken amoxicillin or live in areas with a high pattern
of betalactamase resistance, the use of alternative drugs may be warranted.
Despite the increasing prevalence of
resistant pathogens, the Medical Letter consultants still consider amoxicillin
the drug of choice for initial treatment of most children with acute
1. ME Pichichero, Pediatr Infec Dis J, 13:527, Jan 1994
Bluestone et al, Pediatr Infec Dis J, 11:57, 1992
erythromycin with a sulfonamide, amoxicillin/clavulanic acid, and various oral
Arola et al, J. Pediatr, 116:697. 1990
Del Beccar et al, J. Pediatr, 120:81, 1992
Formulary:Prescribing Guidelines, PCS Health Systems, Inc, Clinical Pharmacy
Medical Letter, vol 36 (issue 917) p. 20, March 4, 1994
Klein, Pediatric Infec Dis J, 12:973, Dec 1993
THERAPY IN URINARY TRACT INFECTIONS
Guidelines for Urinary Tract
Patients should take sulfonamides and antimicrobial agents with a full
8-ounce glass of water. Several
additional glasses of water should be taken every day.
When using sulfonamide derivatives, additional water intake is
recommended to prevent crystalluria.
Some sulfonamides may make some people more sensitive to sunlight.
Sulfa drugs have been associated with the development of agranulocytosis,
aplastic anemia, and other blood dyscrasias.
Periodic CBC monitoring in patients on long-term therapy is recommended.
For uncomplicated UTI, use sulfamethoxazole/trimethoprim or
ampicillin or amoxicillin as single dose or short course therapy.
Consider chronic antimicrobial prophylactic therapy for patients with
recurrent UTIs. Effective
treatments include 50-100 mg nitrofurantoin daily (assess renal function for
appropriate dosing) and 1/2 tablet regular strength sulfamethoxazole/trimethoprim
daily. Monitor efficacy on a
More expensive fluoroquinolones are not recommended as first line
treatment for an uncomplicated UTI.
OF URINARY TRACT INFECTIONS1
Acute, Uncomplicated UTI
2DS tabs x1 or 1 DS tab BID x 3 days
100 mg BID x 7days
200 mg QB x 10 days
Complicated UTI (not for
400 mg BID x 10 days
200 mg BID x 10 days
500 mg BID x 10 days
400 mg QD x 14 days
Guidelines for Fluroquinolone Use1
All quinolones except for lomefloxacin can interact with theophylline,
increasing the theophylline levels. Use
care when changing the doses of either drug.
Concomitant administration of sucralfate, iron salts, zinc salts, or
antacids with fluoroquinolones is not recommended.
Serum level of quinolone is decreased due to interference with
Fluoroquinolones should not be used in children younger than eighteen
years of age unless skeletal growth is complete.
For children 9-18 years of age with serious infections (e.g., CF) the
benefits may outweigh the possible risks.
Patients should be advised to drink fluids liberally when taking
Fluoroquinolones should be reserved for infections not likely to be
responsive to other antibiotics or as a second line of defense after traditional
therapy has been tried. They are
not first-line agents in treating most UTIs because of high cost of potential
resistance. Inappropriate use of
these drugs will increase the rate of bacterial resistance.
Pichichero, Pediatr Infect Dis J., 13:527, Jan 1994.
Supplies for Adults
There has been some confusion in the
pharmacy provider community regarding Medicaid coverage for disposable insulin
Adult Medicaid eligibles who are not
QMBs (recipients having a one and seven in the third and fourth digits of their
identification numbers) and who are NOT residents of nursing homes are
eligible to receive diabetic supplies through the Medicaid Pharmacy Program.
For disposable insulin syringes, the
prescriptions must contain the prescribing physician's written statement that
the recipient is INSULIN DEPENDENT or INSULIN REQUIRING.
Disposable insulin syringes, blood
glucose monitoring strips, and lancets are to be dispensed in the amount of 100
unit doses or a month's supply, whichever is greater.
Providers are to bill their usual
and customary charges for these supplies. The
maximum payment allowed for these supplies will be the prevailing wholesale cost
Please be advised we have an
extensive pharmacy audit program and observe for compliance with state and
federal regulations in this area. Any
advertised prices are considered general public prices and may be utilized for
Management for Head Injury
In preparation for implementation of
the Head Injury Maintenance waiver, case management agencies interested in
enrolling as providers of case management services for that waiver population
are hereby notified that applications for enrollment are being considered.
Providers will be subject to new
regulations on case management implemented through emergency rulemaking
effective July 22, 1994, and any subsequent department of bureau regulations
issued. Please note that
reimbursement for case management persons with head injuries is available only
for waiver participants. Payment
for claims for other Medicaid-eligible persons with head injuries is not
available. A maximum of 100 persons
will be eligible for waiver services.
Employees providing case management
under this service shall meet a least one of the following criteria.
master's degreed social worker certified as required by state law with a
minimum of one year experience as a social worker in a public or private
social service agency.
registered nurse currently licensed as a registered nurse in Louisiana and
having a minimum of one year experience as a nurse in working with persons
with head injuries.
master's degreed rehabilitation therapist with a minimum of one year
experience working with persons with head injuries.
In addition, case managers shall be
required to participate in training approved by the Head Injury Foundation prior
to providing services.
Requirements for agency enrollment
are completion of PE-50, Disclosure of Ownership form and Board Resolution form.
Agencies may be subject to pre-enrollment inspection.
Enrollment packets may be requested
by telephone or in writing from the following address:
8591 United Plaza Blvd., Ste. 100
Baton Rouge, LA 70809
Attn: Provider Relations
Completed forms and appropriate
attachments are submitted to
Bureau of Health
Provider Enrollment Section
P. O. Box 91030
Baton Rouge, Louisiana 78021-9030
Providers requiring assistance in
completing enrollment forms should contact Provider Enrollment section at (504)
to Case Management Providers
Do not put any data in the prior
authorization field for case management services with a date of service prior to
August 1, 1994. Doing so unnecessarily delays processing as your claims pend
for review, code 190. Services for
dates of services prior to 8/1/94 do not require prior authorization and this
item should be left blank when billing.
of Units for Targeted Case Management
Extensions of case management units
will require the following information prior to review.
Medicaid Identification Number
social security number
A current Plan of
Care/Service Plan (signed)
Service logs for
the current calendar year
for the current calendar year
cover letter indicating why the request is being made and the anticipated
number of units for the remainder of the year.
to Providers of Waiver Services
Home and Community Based Services (HCBS)
waivers provide reimbursement for services necessary to maintain participants,
in the community rather than an institution.
Currently, the HCBS waivers are Adult Day Health Care Waiver, MR/DD
Waiver, Personal Care Attendant Waiver, and Home Care for the Elderly Waiver.
The Head Injury Maintenance Waiver will be implemented shortly.
Participants must meet all financial
and medical criteria required for Medicaid payment for the alternative
institutional care to qualify for waiver participation.
The number of persons who may participate is limited, and there are
waiting lists for eligibility.
Only persons who have been
determined eligible for a HCBS waiver slot may receive waiver services.
Possession of a valid Medicaid card is not justification for providing
these services. Reimbursement is
available only for authorized services.
In waivers with more than one
service, the case manager notifies the service provider chosen by the
participant using the Form MR/DD 14, which specifies the service to be provided,
number of authorized units of service, and special conditions such as scheduling.
Services are not authorized
and are not to be provided without Form MR/DD 14.
Reimbursement for all services provided without a supporting Form MR/DD
14 must be repaid, and appropriate sanctions may be imposed on the offending
provider, including disenrollment as a provider.
The following services are to be provided only when Form MR/DD 14
has been received from the case manager:
Habilitation (Supervised Independent Living)
Emergency Response Systems
Case Management for the Elderly may
be provided only for persons who have been determined eligible for Home Care for
the Elderly Waiver.
We would like to remind physicians,
optometrists, nurse-midwives , and dentists about their flat fee-for-service
billing and payment methodology in effect since 1987.
Payment for surgery is made as a
surgical package and payment to anesthesiologists for general anesthesia is paid
based on actual time plus base units assigned to the surgical procedure.
Please keep in mind that Louisiana Medicaid does not pay for all
procedures listed in the CPT Code Book, not do they pay for all procedures
covered by Medicare. Louisiana
Medicaid does not pay for some procedures not covered by Medicare.
Consult your program's Provider Manual for specific information.
If you would like Louisiana Medicaid
to consider a procedure for coverage, you must write to the agency and give the
CPT (or HCPC) code, definition, and full description of the service and the
benefits realized from that procedure. It
is helpful to the reviewing physicians is you can also send published material
regarding the procedure.
All procedures described in CPT as
"unlisted" must be accompanied by an operative report or other
substantiation of medical necessity.
Always review your CPT and Provider Manual to determine if there is a
HCPC code describing the procedure before billing an "unlisted"
Emergency Response System
There has been some misunderstanding
regarding documentation required for enrollment as a provider of Personal
Emergency Response Systems.
Medicaid enrolled providers must be
authorized by the manufacturer to distribute the systems.
A letter from a distributor does not constitute appropriate
documentation for enrollment as a Medicaid provider for this service.
Code Fee Adjustments
Effective with date of service
September 1, 1994, the Bureau of Health Services Financing is adjusting its fees
for the following CPT codes. The new fees are listed below.
Health Rehabilitation Reminders
All clients must meet the target population criteria which became
effective on July 1, 1994. Be
certain that the client records contain documentation supporting every component
of that criteria.
Every service provided must be record in the client record. A record must be maintained indicating 1) start time, 2) end
time, 3) total time/units billed, 4) type of service provided (i.e., treatment
integration, individual therapy, etc.), 5) service provider, and 6) a
detailed note describing the service provided.
All staff must be qualified for the service(s) they are providing.
The personnel record must contain copies of degrees and verification of
experience. Remember, QMHPs
experience must be in the delivery of mental health services!
Clients must be given a freedom of choice form to sign for each component
of service that they receive. This
must be signed and kept in the client's chart.
Crisis Services are to be given only to clients with established Mental
Health Rehabilitation Plans. A
person cannot be brought into the program via the Crisis Services.
Medication Administration must be provided by a licensed nurse or
physician or someone who has legal approval to administer medication.
Medication is not to be administered to recipients with other available
access to their medication, this includes children at school.
Schools have a nurse who can administer medication.
Schools cannot provide lists of Medicaid recipients.
Providers must not ask them to do so.
A component of the Mental Health Rehabilitation Option must be offered in
full by the provider. No other
provider can bill for any piece of that component.
(Ex., if you are the Rehab Manager, you are responsible for all necessary
evaluations. If a recipient needs a
psychological evaluation, another Rehab Management Agency cannot provide that
piece for you.) Two different
agencies cannot bill for any one component.
All official regulations must come in writing from the Bureau of Health
Services Financing (BHSF), better known as Medicaid of Louisiana.
If you hear or read something that does not come from BHSF, it is not an
official regulation or policy. If
what you are told or read contradicts the manual, please call Kelly Coreil for
clarification at (504) 342-9319.
for Professional Services Reimbursement Under Pre-Certification/Length of Stay
Effective July 1, 1994, the Bureau
of Health Services Financing began phasing in the implementation of a Hospital
Pre-Admission/Length of Stay (LOS) review program.
Beginning January 1, 1995, BHSF will implement this review program for
all hospitals excluding state-operated and out-of-state facilities.
Distinct part psychiatric facilities and long term hospitals will undergo
pre-admission review and LOS assignment. Acute care and rehabilitation hospitals will participate only
in the LOS review process.
All physician hospital visits
(procedure codes 99221 through 99223, 99231 through 99238, 99251 through 99255,
99431, and 99433) excluding inpatient visits to a state-operated or out-of-state
hospital will be subjected to pre-certification requirements editing.
Follow the instructions below to obtain reimbursement for inpatient
professional services effective with date of service January 1, 1995.
Physician claims will not be paid without a certification on file for the
hospital stay unless appropriate documentation is attached to the claim
identifying the hospital stay (see #3 below).
If the service was performed in a state-operated hospital and the
physician is not based as that facility, then the physician will have to
identify this service by putting a "Y" in item #19 on the HCFA 1500 or
on record type E in charity indicator field for EMC submissions.
For those physicians who are based as the state-operated facility, there
is not need to identify your claims with a "Y" in this field.
The physician should indicate the hospital pre-certification number on
the HCFA 1500 item #23 or on EMC record type E in the prior authorization field
if the physician has access to that number.
To ensure accurate, timely processing of your claim, we recommend that
you place the pre-certification number on the claim.
However, if you do not have access to the pre-certification number, you
can bill your claim without it and the claim recipient ID and dates of service
will be used to find the hospital pre-certification on file.
The pre-certification number will be stored on the claim record and will be
printed on the remittance advice. The
physician visit days will be paid according to the LOS approved dates for the
hospital stay. Before your claim
can be paid, there must be an approved pre-certification record for the
hospital stay on file at Unisys.
In those cases when the hospital chooses not to bill Medicaid, the
physicians may bill their claims with appropriate documentation (admit/discharge
summary) so that medical necessity and LOS can be determined. These claims will pend to the Unisys Pre-Certification
Department for review and decision, and will be assigned a prior authorization
number. The physician will receive
a notice letter indicating approval/denial status, days approved, and the PA
number. Inquiries about
approval/denial or assigned length of stay should be directed to the Unisys
Pre-Certification Department. Your
claim will be processed with the assigned PA number.
These new procedures will not negate
of affect any of the policies and procedures currently in effect for
hysterectomies, sterilizations, and outpatient surgeries performed in an
Effective with dates of service July
1, 1994, you will no longer be required to attach documentation to claims for
inpatient visits exceeding 15 days per year since this limitation has been
The following changes have been made
recently in DME procedure codes:
Code K0195 has been added as a payable code for "Elevating Leg
A price of $84.00 per pair has been added to the file for automatic pricing.
Code Z0100 has been added as a payable code for "Measuring/Fitting
Fee, Stockings." The Prior
Authorization Unit will manually price this item.
Providers who wish to assist their
patients/clients in establishing Medicaid eligibility may become an Enrollment
Center authorized to take Medicaid applications.
Enrollment Centers are provided training, forms, and updated eligibility
information, and are reimbursed for the time involved.
Providers are reminded that
Enrollment Centers receive a pre-application fee and shall not bill time
involved in financial application activities as a Medicaid service such as case