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.


Louisiana Medicaid is mandated to participate in the Centers for Medicare and Medicaid (CMS) Payment Error Rate Measurement (PERM) program which will assess our payment accuracy rate for the Medicaid and CHIP programs. If chosen in a random sample, your organization will soon receive a Medical Records Request from the CMS review contractor, CNI Advantage.

Please be advised that sampled providers who fail to cooperate with the CMS contractor by established deadlines may be subject to sanctioning by Louisiana Medicaid Program Integrity through the imposition of a payment recovery by means of a withholding of payment until the overpayment is satisfied, and/or a fine.

Please be reminded that providers who are no longer doing business with Louisiana Medicaid are obligated to retain recipient records for 5 years, under the terms of the Provider Enrollment Agreement.

For more information about PERM and your role as a provider, please visit the Provider link on the CMS PERM website:


Louisiana Medicaid UB-04 Billing Instructions Manual for Nursing Facility and ICF-DD, has long contained policy requiring Long Term Care and ICF-DD Providers to include a Principal Diagnosis when billing transactions. Previously, there wasn’t an edit in place to validate a valid ICD-10 code was reported- but that will now change.

Effective for Dates of Service August 28, 2018 and forward, Medicaid will implement an edit requiring a valid ICD-10 diagnosis code is reported in the principal diagnosis field. Claims submitted without a valid principal diagnosis code will be denied for correction.

Louisiana Medicaid UB-04 Billing Instructions Manual for Nursing Facility and ICF-DD identifies Other Diagnosis Field as a situational field. While reporting Other Diagnosis is not required, effective with dates of service August 28, 2018 and forward, Medicaid will implement an edit to deny the claim for correction when an invalid ICD-10 code is reported in the Other Diagnosis Field.

Attention Providers of CLIA Waived Tests

CMS mandated Clinical Laboratory Improvement Amendments (CLIA) claim edits are applied to all laboratory services billed on fee for service claims. Claims submitted that do not meet the required CLIA criteria will deny.

Providers with waived or provider-performed microscopy (PPM) certificate types may be paid only for those waived and/or PPM codes approved for their certification types. Providers with these certification types are to add the 'QW' modifier to the procedure code for all applicable CLIA waived or PPM tests they submit for reimbursement.

The fee for service claims processing system has been updated to assure correct processing of claims for laboratory services. Effective for claims processed on or after April 17, 2018 the following Current Procedural Terminology (CPT) codes will require a “QW” modifier effective for the date of service provided below when submitted by providers with the certificate types described above:

Code      CLIA Waived Eff Date

80305     01/01/2017

87633     10/07/2016

87801     03/06/2017

Denied claims submitted with the codes above on or after the effective date listed that were submitted correctly with modifier –QW will be systematically recycled on the remittance of April 24, 2017 without any action required by the provider.

Please visit for a complete listing of effective dates for recently added codes. For more information regarding CLIA, see Appendix A in the Professional Services Provider Manual.

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.

Questions related to Healthy Louisiana managed care organizations’ updates should be directed to the specific health plan.

Attention Fee for Service (FFS) Louisiana Medicaid Providers:

Effective May 1, 2018, Fee for Service (FFS) pharmacy claims for long-acting opioid prescription products will have revised quantity limits. Also, FFS pharmacy claims for concurrent use of opioid and benzodiazepine prescriptions will have edits at Point of Sale (POS). Please refer to for more information.

Attention Louisiana Medicaid Providers:

Effective May 9, 2018, Fee for Service (FFS) Medicaid and Managed Care Organizations (MCOs) will have revisions to the Hepatitis C Direct-Acting Antiviral (DAA) Agents clinical prior authorization and pre-authorization criteria. Please refer to for more information.

Attention All DME Providers
Portable Oxygen Coverage and Reimbursement

Effective with dates of service July 1, 2018, reimbursement will be allowed for portable oxygen equipment for members who need continuous oxygen and require portable units while en route to the doctor’s office, hospital, medically necessary appointments, or travel to or from school for individuals under the age of 21.

All requests for portable oxygen going forward must be submitted using the following procedure codes:

E0430-09 – Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing

E0431-07 – Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing

E0443-09 – Portable oxygen contents, gaseous, 1 month’s supply = 1 unit

Note: E0430-07 using modifier RR for rental will no longer be a billable code for portable oxygen.

It is the expectation of the Louisiana Department of Health that managed care organizations (MCOs) will update their systems to accommodate these corrections in allowable HCPCS codes for portable oxygen in accordance with the requirements set forth above.

Questions regarding this message and fee for service claims should be directed to Molina Provider Relations at (800) 473-2783 or (225) 924-5040.

Updates to Healthy Louisiana related policy, systems and claims processing changes are plan specific and are the responsibility of each health plan. For questions regarding Healthy Louisiana updates and prior authorization requirements, please contact the appropriate health plan.

Attention Louisiana Medicaid Providers:

As of April 1, 2018, Fee for Service (FFS) Medicaid and Managed Care Organizations (MCOs) initiated new diagnosis code requirements at Point of Sale (POS) for attention deficit hyperactivity disorder (ADHD) agents, stimulants, and substance use disorder (SUD) agents. Please refer to for more information.