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.

For information regarding the medication policy and/or criteria associated with this denial, providers may access the Louisiana Medicaid Preferred Drug List (PDL) / Non-Preferred Drug List at


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, AdvanceMed. This cycle measurement will review Medicaid and CHIP payments made in Reporting Year (RY) 2021: July 1, 2019 through June 30, 2020.

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:

Attention Professional and Hospital Service Providers

The Hysterectomy Acknowledgment Form, BHSF Form 96-A has been revised by the Louisiana Department of Health. The revised form, with instructions, is available at under the directory link “Forms/Files/Surveys/User Manuals.”

The BHSF Form 96-A revised 02/2020 is effective with dates of service on and after May 1, 2020 and replaces the BHSF Form 96-A revised 05/06.

Providers will be given a grace period from May 1, 2020 until May 31, 2020 in order to update internal procedures. During that period, either form will be accepted.

Effective with dates of service on and after June 1, 2020, only BHSF Form 96-A revised 02/2020 is to be accepted.

Additional policy regarding the Hysterectomy Acknowledgment Form (BHSF Form 96-A) can be found in the Professional and Hospital Service provider manuals online at

Questions regarding this message and fee for service claims should be directed to DXC Technology Provider Relations at (800) 473-2783 or (225) 924-5040. Questions regarding managed care claims should be directed to the appropriate Managed Care Organization.

The website is transitioning to a new look and feel. The new site will go live on May 15, 2020. The new structure is meant to make finding content easier, and will include an archive page for older content. To assist providers and others navigate the new site, DXC has produced a helpful guide with instructions and shortcuts to frequently visited content. Click to review guide.

If any additional information is needed, please contact DXC at (225-216-6000).