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 http://www.lamedicaid.com/. 

Should you have any questions regarding any of the following messages, please contact Molina Medicaid Solutions at (800) 473-2783 or (225) 924-5040.

INFORMATIONAL UPDATE TRANSITION TO THE NEW CMS-1500 (02/12) FORM FAST APPROACHING FOR PAPER CLAIMS SUBMITTED TO MOLINA AND BAYOU HEALTH SHARED PLANS

Providers were notified in our notice dated February 14, 2014 of Louisiana Medicaid's plans to transition to the revised CMS 1500 (02/12) claim form for paper billing to Molina and Bayou Health Shared Plans.

CLAIM FORM CHANGES:

The significant form change that impacts Medicaid billing is the addition of 8 diagnosis codes to Form Locator 21 (for a total of 12 diagnosis codes) and the addition of an ICD Indicator (to specify whether ICD-9 or ICD-10 is being used). Other changes to the form do not impact your claims submitted to Louisiana Medicaid.

Currently, providers may submit either version 08/05 or version 02/12 of the 1500 claim form. Effective April 30, 2014, Molina will only accept the new CMS 1500 (02/12). After this date, original claims and claim resubmissions must be submitted on version 02/12 - regardless of the date of service.

Important Information for Providers: Although we will accept, key, and capture up to 8 diagnosis codes from the new claim form, claims editing will not change at this time; thus, only the first 4 diagnosis codes are carried through claims processing, and editing is based on current Medicaid policy.

Until the implementation of ICD-10 diagnosis coding, only ICD-9 diagnosis codes are acceptable for billing Medicaid.

PROGRAM CHANGES PLANNED FOR THIS TRANSITION TO THE CMS 1500 FORM:

As we implement the newly revised form, the following changes will be made to transition programs to the CMS 1500 claim form:

  • Professional providers (Physicians, DME, and Professional Crossover) currently using the proprietary 213 Adjustment/Void Forms will be required to use the CMS 1500 02/12 for that purpose.

    Beginning May 19, 2014, professional providers will be required to use the CMS 1500 02/12 In place of the 213 Form.

  • Free Standing Rehabilitation Center providers will be required to transition from the currently used proprietary 102 Claim Form and 202 Adjustment/Void Form to using the CMS 1500 02/12 for original claims, for adjustments and for voids.

    Until further notice, providers using the 102 Claim Form and the 202 Adjustment/Void Form should continue to submit on those forms. Additional information concerning timelines for these program transitions and new billing instructions will be forthcoming.

NOTE: Please visit the Medicaid web site, www.lamedicaid.com, for upcoming information. Billing instructions are being placed on the directory link, Billing Information.

ATTENTION PROVIDERS:

PAYMENT ERROR RATE MEASUREMENT (PERM) 2014 PROVIDER EDUCATION WEBINARS

The Centers for Medicare & Medicaid Services (CMS) will be hosting PERM Provider Education Conference Calls/Webinars this summer, to provide interactive sessions for providers of Medicaid and Children's Health Insurance Program (CHIP) services. Providers will be informed about PERM updates, trends and responsibilities. There will be opportunities to ask questions and provide feedback to CMS and your state representatives.

For Webinar details, refer to the March/April, 2014 Provider Update Article, located in the Provider portal at www.lamedicaid.com.

ATTENTION OBSTETRICAL SERVICES PROVIDERS:

Effective with date of service May 1, 2014, Makena (J1725) administered via intramuscular injection for the prevention of preterm delivery is covered by Medicaid through the Professional Services program.

Please visit www.lamedicaid.com to view the web posting for complete details.

Attention Pharmacists and Prescribing Providers of Louisiana Medicaid Shared Plans and Legacy Medicaid:

Effective May 1, 2014, pharmacy claims for hydrocodone containing drugs will be limited to 720 units in a rolling 365 days. These limits are in addition to the current limits. See www.lamedicaid.com.

Attention Pharmacists and Prescribing Providers of Louisiana Medicaid Shared Plans and Legacy Medicaid:

Effective April 23, 2014, pharmacy claims for Progesterone Vaginal Suppositories with applicable NDCs will be reimbursed when submitted. Quantity limits will be applied as listed on the website. See www.lamedicaid.com.

Attention Pharmacists and Prescribing Providers of Louisiana Medicaid Shared Plans and Legacy Medicaid:

Effective May 12, 2014, pharmacy claims for Victrelis® (boceprevir), Incivek® (telaprevir), Sovaldi® (sofosbuvir), and Olysio® (simeprevir) will have a limited duration of therapy. On May 19, 2014 quantity limits will be applied to these medications. Please refer to www.lamedicaid.com for specifics.

Reactivation of the National Correct Coding Initiative (NCCI) Edits for Preventive Care and Immunization Administration Codes

Effective with the remittance of April 29, 2014, Louisiana Medicaid fee for service processing (legacy and Bayou Health Shared Plans) must reactivate the NCCI edits for preventive care and immunization administration code pairs based on updated CMS direction. These edits will deny the preventive medicine procedure code when billed on the same date as the immunization administration. These edits had been previously deactivated based on prior CMS guidance.

However, CMS has provided the following guidance which will allow both the immunization administration and the preventive medicine evaluation and management (E/M) service to be reimbursed when clinically appropriate, properly submitted and accurately documented.

�If a Medicaid beneficiary receives one or more immunizations and a �significant, separately identifiable� preventive-medicine evaluation and management (E/M) service from the same provider on the same date of service, the provider�s Medicaid claim(s) should include both the immunization administration code� and the comprehensive preventive-medicine E/M code�with modifier 25 appended...

If the provider �bills a comprehensive preventive-medicine E/M code for the same day and does not append modifier 25, the Medicaid PTP edits will deny payment of the preventive-medicine E/M code.�

Louisiana Medicaid fee for service as described above will reimburse both the immunization administration and the preventive medicine E/M services when modifier -25 is properly appended to the preventive medicine procedure code. Documentation in the clinical record must substantiate each service. Providers can expect that when the modifier is not properly appended to the preventive medicine code in these situations, it will deny.

For questions related to this information as it pertains to legacy Medicaid or Bayou Health Shared Savings Plans claims processing, please contact Molina Medicaid Solutions Provider Services at (800) 473-2783 or (225) 924-5040.