RA Messages for February 22, 2011


PHARMACY PROVIDERS, PLEASE NOTE!!!

If you are unsure about the coverage of a drug product, please contact the PBM help desk at 1-800-648-0790.

Please file adjustments for claims that may have been incorrectly paid. Only those products of the manufacturers which participate in the Federal Rebate Program will be covered by the Medicaid program. Participation may be verified in Appendix C, available at www.lamedicaid.com


ATTENTION PROVIDERS

The Bureau of Appeals has transferred to the Division of Administrative Law effective January 1, 2011. When initiating a formal appeal, the request should be sent to:

Division of Administrative Law/HH Section
P.O. Box 4189
Baton Rouge, LA 70821

Any appeal requests that have already been submitted to the old Bureau of Appeals address will be forwarded to the Division of Administrative Law.


ATTENTION PHARMACY PROVIDERS LOUISIANA MEDICAID REIMBURSEMENT OF TAMIFLU� SUSPENSION

Louisiana Medicaid does not pay for compounded prescriptions, nor has the billing process been established to allow the submission of compounded prescriptions. Due to the shortage of commercially manufactured oseltamivir (Tamiflu�) suspension, Louisiana Medicaid will only allow pharmacies to bill the quantity of Tamiflu� capsules utilized in the mixing of the suspension as ordered by a prescribing provider's prescription. This will be allowed as long as the shortage of the manufactured Tamiflu� exists. Pharmacies may receive letters from the Louisiana Medicaid Pharmacy Audit Section which is verifying the quantity of Tamiflu� capsules dispensed. In some instances, pharmacies have submitted billed quantities for the final compounded quantity and not the total number of capsules used in the mixing of the suspension. Following the instructions above will avoid the overbilling of quantities and/or charges. When a pharmacy is attempting to bill Medicaid as the secondary payor, the claim must be submitted to Medicaid on the NCPDP paper Universal Claim Form.
 

ATTENTION ALL GNOCHC AND TAKE CHARGE FAMILY PLANNING PROVIDERS

We have identified a claims processing issue that occurred with the implementation of the GNOCHC Program in the Greater New Orleans Area. When recipients are eligible for both the GNOCHC Program and the TAKE CHARGE Family Planning Waiver Program, claims submitted for services by the TAKE CHARGE providers have denied indicating that the recipient is in the GNOCHC Program. For these recipients, services provided by either program are allowed. The claims processing logic for TAKE CHARGE claims has been corrected to allow these claims to process and pay appropriately. Denied claims are being reprocessed on the RA of 2/22/2011. We apologize for any inconvenience this has caused to providers rendering services to these recipients.


ATTENTION ALL PROVIDERS 2011 HCPCS UPDATE

The Louisiana Medicaid files have been updated to reflect the new and deleted HCPCS codes for 2011. Refer to the Professional Services Fee Schedule on the LA Medicaid website, www.lamedicaid.com. Claims denied due to use of the new 2011 codes prior to their addition to our system will be systematically adjusted on March 3, 2011, and no action is required from providers. Appropriate editing and coverage determinations for the new codes are still underway and systematic adjustments for some previously processed claims may be necessary in the future. Providers should continue to monitor RA messages for future updates for the 2011 HCPCS updates.

Additionally, the "Assistant Surgeon/Assistant at Surgery Covered Procedures List" under the 'ClaimCheck' icon on the website homepage will be updated to reflect the applicable 2011 procedure codes. As a reminder, 'ClaimCheck' uses the American College of Surgeons (ACS) as its primary source for determining assistant surgeon designations.

TThe 2011 'Current Procedural Terminology' manual includes information on the appropriate reporting of the new codes. It is the intent of Louisiana Medicaid that these instructions be followed. All payments are subject to post payment review and recovery of overpayments.


ATTENTION ASC (NON-HOSPITAL) AND FREE STANDING ESRD FACILITIES SYSTEMATIC CLAIMS ADJUSTMENT FOR RATE REDUCTIONS EFFECTIVE JAN 1, 2011

The effective date for the 2% rate reduction for ASC (Non-Hospital) and Free Standing ESRD Facilities services has been changed from December 1, 2010 to January 1, 2011. Refer to the LA Medicaid website (www.lamedicaid.com) and the Office of the State Register's website at http://doa.louisiana.gov/osr/ for published rules detailing these reductions. The system has been updated to reflect this change. Claims for dates of services December 1, 2010-December 31, 2010 that were adjudicated prior to the new January 1, 2011 effective date will be systematically adjusted on the RA of February 22, 2011. Providers should reference the "Fee Schedules" link on the homepage of the LA Medicaid website (www.lamedicaid.com) for the most current fees. Contact the Provider Relations unit at (800) 473-2783 or (225) 924-5040 with questions related to the implementation of the rate reductions or adjustment of claims.
 


ATTENTION PROFESSIONAL SERVICE PROVIDERS

As part of the Correct Coding Initiative, we would like to remind providers to refer to the Current Procedural Terminology (CPT) manual for the most appropriate procedure code to bill for the insertion of Mirena. We realize that this contradicts previous published policy, and providers may void and re-bill claims within the two year timely filing period. Providers should contact the Provider Relations unit at (800) 473-2783 or (225) 924-5040 with billing or policy questions.  



ATTENTION PROFESSIONAL SERVICE PROVIDERS AND OUTPATIENT HOSPITALS: DIABETES SELF MANAGEMENT TRAINING (DSMT)

Effective February 20, 2011, Louisiana Medicaid will provide coverage for Diabetes Self-Management Training services rendered to Medicaid recipients diagnosed with diabetes. For coverage details for DSMT services, refer to www.lamedicaid.com. Providers should also monitor the website for updated information and upcoming policy. Providers should contact the Provider Relations unit at (800) 473-2783 or (225) 924-5040 with billing or policy questions.r to comply with federal requirements to include the National Provider Identifier (NPI) on all claims, changes to current claims processing will be made over the next two months. Providers using the Molina Form 213 for Physician Crossover Adjustments, Professional Crossover Adjustments, Durable Medical Equipment Adjustments, Durable Medical Equipment TPL Adjustments, and Physician Adjustments will need to begin using the CMS-1500 claim form; providers using the Rehabilitation forms for claims and adjustments (102, 202) will instead be required to use the CMS-1500 form. Over the coming months, changes to Dental (209, 210), Pharmacy (211), and KIDMED (KM-3) claim forms will also be introduced to accommodate these federal requirements. Providers who have software vendors must alert their vendors of the changes. Please monitor the Louisiana Medicaid website, www.lamedicaid.com, for an implementation schedule and more details.