RA Messages for February 23, 2010


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


The LMPBM unit has begun reimbursing for Tadalafil (Adcirca) when an appropriate diagnosis code is submitted on the POS claim. The prescribing provider must document the diagnosis code on the hardcopy prescription or can communicate the diagnosis code over the phone. The acceptable diagnosis codes are:

416.0 - Primary Pulmonary Hypertension
416.8 - Other Chronic Pulmonary Heart Disease


CMS recently issued a reminder to all providers, physicians, and suppliers to allow sufficient time for the Medicare crossover process to work before attempting to bill the patients' supplemental insurers (including Medicaid). Medicare recommends waiting approximately 15 work days after Medicare's reimbursement is made. Medicare indicates to providers on the Medicare Remittance Advice their intention to cross the patients' claims over and issues notifications if claims targeted for crossover do not actually result in successful crossover transmissions. Medicaid processes many duplicate paper crossover claims because providers do not allow sufficient time for the automated Medicare process to be completed prior to submitting a paper claim. Medicaid recommends waiting 15-20 work days before submitting a paper crossover claim. Please do not submit a claim to Medicaid until you have allowed ample time for claims processed by Medicare to cross electronically to Medicaid.


DHH is pleased to inform providers who submit Medicare crossover claims to Medicaid that we are in the process of making the necessary changes in the Medicaid systems and programming logic to allow providers to submit electronic Medicare crossover claims to Medicaid in circumstances where Medicare claims DO NOT cross electronically from Medicare to Medicaid. Once this change is implemented, providers must continue to wait the appropriate time as indicated above before submitting crossover claims electronically, in order to prevent duplicate claim submission. You should discuss this change with your EDI vendor if you are interested in pursuing this option. Please continue to monitor the LA Medicaid website, www.lamedicaid.com, and RA messages for the implementation date of this change and related information.


Effective February 15, 2010, LA Medicaid will implement Radiology Utilization Management (RUM) to ensure appropriate utilization of Department-defined high-tech imaging studies. MedSolutions (MSI) has been selected to provide prior authorization, monitoring and management of these services. Primary care and specialty care providers must request prior authorization for non-emergency outpatient Magnetic Resonance (MR), Computed Tomography (CT), and Nuclear Cardiac imaging. Reimbursement to the rendering provider will be contingent on prior authorization. MSI will begin taking authorization requests from ordering physicians on February 15, 2010, for services provided on or after that date. For tests scheduled to be performed from 02/15 to 02/20, we understand that you may not have time to obtain a prior authorization prior to service performance. Allowances will be made to ensure you and your patient are not penalized for the delay in the launch of the Program. Monitor the Medicaid website www.lamedicaid.com AND the MSI website www.medsolutions.com/implementation/ladhh/index.html for more information and the schedule/registration for orientation webinars.


Louisiana Medicaid has identified that some KIDMED claims for recipients THAT WERE NOT LINKED TO ANY PROVIDER FOR KIDMED SERVICES were incorrectly denied for error 424 (Billing Provider is not the Designated Provider of Record). This has been corrected and the affected claims will be systematically recycled for payment on the RA cycle of 2/9/10. No action is required by providers to correct these 424 denials. Once recycled, if other errors cause the recycled claims to deny for another reason, please take the necessary steps to correct the billing error and resubmit the claim(s). Contact Provider Relations at (800) 473-2783 if have any questions.


The Department of Health and Hospitals has determined that to avoid a budget deficit, a change in the Immunization Pay-for-Performance Initiative (P4P) is necessary. Effective with P4P payments for February 2010 and thereafter, the initial benchmark measurement to receive a payment will be that 50% to 74% of the recipients linked to the participating CommunityCARE PCP must be up to date by age 24 months to be eligible to receive an incentive payment. No changes are being made to the second or third level benchmark or payments. Detailed information on the P4P incentive payment initiative can be found on the www.lamedicaid.com website following the link Pay-For-Performance. For details regarding the Emergency Rule associated with this change, please go to the Emergency Rule section of the Louisiana Register at the Office of the State Register's website http://doa.louisiana.gov/osr/. Contact Unisys PR at (800) 473-2783 or (225) 924-5040 if you have any questions.


The LA Medicaid claims processing system will accommodate claim lines billed with DIFFERENT Place of Service codes on the same day to accommodate situations where it is necessary for the recipient to receive services in two or more different locations on the same date of service. However, all services provided at the same service locations (Place of Service) on the same date of service should be rolled together and billed as one claim line with the total units of service for that location - even when you see the recipient at different times of the day in the same location. Claim lines billed with the SAME Place of Service code and the SAME Date of Service will deny with edit 689.

Additionally, MST claims must be billed using the most current and specific diagnosis code(s) for the diagnosis. General diagnosis codes are no longer acceptable on any LA Medicaid claims. Please ensure that you are using the most current, specific code on your claims submissions. You should obtain the specific code from the mental health professional that performed the evaluation for admission to MST services.


Effective immediately, Long Term Personal Care Service (LT-PCS) providers will no longer be allowed to service specific parishes within a DHH region. All licensed LT-PCS providers will be required to service the entire region in which they are licensed.


Effective with date of service February 22, 2010, LA Medicaid will implement the use of two new modifiers (U2 and U3) and a new prior authorization requirement for providing multiple visits for the same recipient on the same date of service. Multiple visits will be authorized only for recipients under 21 years of age. Please visit the homepage of our website, www.lamedicaid.com, for details.