PHARMACY PROVIDERS, PLEASE
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
Should you have any questions
regarding any of the following messages, please contact Molina Medicaid
Solutions at (800) 473-2783 or (225) 924-5040.
ATTENTION ALL PROVIDERS
CLAIMS VOIDED DUE TO TIMELY FILING ERROR
Based on extensive review, DHH has identified specific fee-for-service claims where the one (1) year timely filing limit was incorrectly applied during claims processing, and determined that some claims were paid in error. The review period covers fee-for-service claims received from December 2012 to September 2014.
In April 2015, Providers were notified by RA messages and by direct mail-outs that they were identified as being paid for inappropriately timely filed claims. Providers whose claim totals were less than one-thousand ($1,000) dollars were voided during the months of April and May 2015.
Providers whose claim total was one-thousand ($1,000) dollars and greater were given three options to address their claims, and if no choice was made, were informed that claims would be systematically voided within 30 days of the notice.
DHH has delayed the voiding of identified claims to allow for a secondary review of this issue. Based on this re-review, it was determined that all initial findings were correct, except for approximately thirty-six (36) claims. Therefore, affected providers will receive corrected notification by direct mail-out.
Providers originally identified who responded by choosing a specific option and those providers who did not chose an option as previously notified, your claims will be systematically voided on the RA of April 26, 2016. These actions will be based on the original letters of notification. No further notification will be transmitted.
Voided claims can be identified on the RA by the Internal Control Number (ICN) of the claim line, which will have a Julian date (the first 4 digits of the ICN) of 6108 (Sunday, April 17, 2016).
We apologize for this error, and for any inconvenience this may cause. Please contact Molina Provider Relations at (800) 473-2783 or (225) 924-5040 should you have questions regarding this notice.
Update to ‘ClaimCheck’ Product Editing
McKesson’s ‘ClaimCheck’ product is routinely updated by the McKesson Corporation based on changes made to the resources used, such as Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) coding guidelines, the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule Database, CMS National Correct Coding Initiative (NCCI) and/or provider specialty society updates. The 'ClaimCheck' product's procedure code edits are guided by these widely accepted industry standards.
These edit changes went into effect for claims processed beginning with the remittance advice of March 1, 2016. Providers may notice some differences in claims editing; however, most claims will continue to edit in the same manner, but when applicable, claims may now pay or deny for a different reason.
For questions related to this information as it pertains to Legacy Medicaid claims processing, please contact Molina Medicaid Solutions Provider Services at (800) 473-2783 or (225) 924-5040. For questions regarding Bayou Health updates, please conrnct the appropriate health plan directly.
ATTENTION OB/GYN PROVIDERS:
The Office of Population Affairs (OPA) is in the process of requesting approval from Health and Human Services (HHS) for a long term extension of the current sterilization consent form as there are no planned revisions to the language used in the current form. Beginning in November, OPA began updating the form on a monthly basis with the expiration date being that of the current month. Molina will accept all forms that were considered current on the date they were signed by the recipient. To ensure having the most current form, providers are encouraged to visit the OPA website, http://www.hhs.gov/opa/order-publications#pub_sterilization-pubs, to print the forms needed for that day.
Please contact the appropriate Managed Care Organization if there are any questions concerning their policies related to the updated forms at the following numbers: Aetna: Provider Relations 1-855-242-0802; AmeriHealth Caritas: Provider Relations 1-888-922-0007; Amerigroup: Provider Relations 1-800-454-3730; Louisiana Healthcare Connections: Provider Relations 1-866-595-8133; United Healthcare of Louisiana: Provider Relations 1-866-675-1607. In addition, if you have any questions regarding fee for service claims contact Molina Provider Relations (800) 473-2783 or (225) 924-5040.
2016 HCPCS Claims Recycle/Fee Schedule Update
Louisiana Medicaid fee-for-service (FFS) claims containing new 2016 Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) codes that were processed from January 1, 2016 through February 23, 2016 will be recycled. This recycle includes claims that previously denied because the new 2016 codes were billed prior to their addition to the claims processing system, as well as new 2016 codes that processed prior to the updates made to the “ClaimCheck” editing product.
Providers can expect to see the recycle results on the remittance advice of April 05, 2016. No action is required by providers. The claims included are Professional Services, Radiology and Laboratory, Outpatient Hospital Non-Ambulatory Surgery, and Outpatient Hospital Ambulatory Surgery. For questions related to this information, as it pertains to FFS Medicaid claims processing, please contact Molina Medicaid Solutions Provider Services at (800) 473-2783 or (225) 924-5040.
Updates to Bayou Health-related systems and claims processing changes are plan specific and are the responsibility of each health plan. For questions regarding Bayou Health updates, please contact the appropriate health plan.
REPLACEMENT OF DURABLE MEDICAL EQUIPMENT AND SUPPLIES LOST IN THE MARCH 2016 FLOODING IN DECLARED DISASTER PARISHES
Medicaid recipients who live in one of the declared disaster parishes caused by the March 2016 flooding, and who need to replace equipment or supplies previously approved by Medicaid, may contact a durable medical equipment (DME) provider of their choice to obtain a replacement. The provider must make a request to Molina’s Prior Authorization Unit; however, a new prescription and medical documentation are not required. The provider shall submit the required Prior Authorization Form (PA-01) along with a signed letter from the recipient giving a current place of residence and stating that the original equipment or supplies were lost due to the March 2016 flood.
Additionally, recipients who were approved to receive medical equipment, supplies, Home Health services, Rehabilitation or Personal Care services from a provider in an affected parish who is no longer in business or unable to provide the approved equipment, supplies or services, may obtain the approved items from a another Medicaid provider of their choice. The original authorization will be canceled and a new authorization will be given to the new provider. The provider will need to submit the required Prior Authorization Form with a signed letter from the recipient requesting a change of provider and giving his or her current place of residence.
All other prior authorization requests for equipment, supplies, and medical services will require a prescription from a doctor and documentation to establish medical necessity.
If you have questions about the content of this message, you may contact Molina Prior Authorization at (800) 488-6334.
Attention Fee for Service (FFS) Louisiana Medicaid Providers:
Effective April 1, 2016 the Centers for Medicare and Medicaid Services (CMS) will begin updating the Federal Upper Limits (FUL) on a monthly basis to be in compliance with the Affordable Care Act. Since FFS Medicaid pharmacy claims reimburse on a “lesser of” methodology including the FUL some pharmacy claims may reimburse at a different rate.
Implementation of the National Correct Coding Initiative (NCCI), Medically Unlikely Edits (MUE) for Practitioner and Ambulatory Surgical Center (ASC) Services
The NCCI MUE processing will be implemented for practitioner and ASC services effective for claims processed on and after the remittance date of April 19, 2016 for fee for service claims.
MUEs are applied separately to each line of a claim, not to the total number of units for a procedure code on a single date of service. If the units of service (UOS) submitted exceeds the MUE value for the code on a claim line, the entire line will be denied. Practitioners and ASC providers may see new edit message, “809” that pertains specifically to NCCI MUE edits: 809 - ‘CCI: Units of service exceeds medically unlikely edit’
Providers can expect to see denials due to MUE’s on procedures that may have previously paid when billed in the same manner. With the implementation of MUEs, fee for service duplicate edits have been enhanced; therefore, claims that previously denied as duplicates may now deny via MUE or may deny as maximum services exceeded.
For some procedures (e.g. cholecystectomy), the MUE is an absolute limit. However, for other procedures, providers may occasionally report UOS in excess of the MUE value by reporting the same code on more than one line of the claim. Modifier usage is acceptable when medically necessary and supported by clinical documentation; however, appending a modifier will not override MUE denials.
The MUE value for applicable procedure codes is determined by the Centers of Medicare and Medicaid Services (CMS). These edits are updated quarterly by CMS. For more information, please refer to the prior NCCI MUE notice on www.lamedicaid.com dated March 29, 2016 or visit the CMS Medicaid website, www.medicaid.gov.
Each Bayou Health plan is required to administer NCCI editing, but may have slightly different implementation schedules and/or billing policies related to the mandate. Please contact each plan for information specific to that plan.
For questions related to this information as it pertains to fee-for-service Medicaid claims processing, please contact Molina Medicaid Solutions Provider Services at (800) 473-2783 or (225) 924-5040.
Attention Fee for Service (FFS) Louisiana Medicaid Providers:
Effective April 22, 2016 recipients with a breast and cervical cancer type case will be exempt from copay on Fee for Service pharmacy claims.