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.
ATTENTION PROVIDERS
PAYMENT ERROR RATE MEASUREMENT (PERM) 2017 IS NOW IN PROGRESS
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: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/PERM/Providers.html.
ATTENTION: LTC and ICF-DD PROVIDERS
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 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
www.lamedicaid.com 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
www.lamedicaid.com 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
www.lamedicaid.com for more information.
ATTENTION OUTPATIENT HOSPITAL PROVIDERS:
LARCs Inserted in the Outpatient Hospital Setting
For long-acting reversible contraceptives (LARCs) inserted in the outpatient hospital setting, hospitals receive an additional payment for the LARC device when it is inserted during an outpatient hospital visit. Payment for the LARC device in the outpatient hospital setting is in addition to the reimbursement for the outpatient hospital claim. Previously, providers had been instructed to bill the outpatient claim for the outpatient visit on the UB-04 and the claim for the LARC device on the CMS 1500 claim form.
Effective July 1, 2018 and forward, providers inserting LARCs in the outpatient hospital setting may bill the DME revenue code of 290 with the appropriate accompanying HCPCS code for the LARC device on the UB-04. Providers should consult the DME fee schedule for covered LARCs and their reimbursement.
Please contact the appropriate managed care organization with any questions concerning their billing instructions for LARCs inserted in the hospital setting. For questions related to this information as it pertains to fee-for-service Medicaid claims processing, please contact Molina Medicaid Solutions Provider Relations at 1(800) 473-2783 or (225) 924-5040.
ATTENTION PROVIDERS OF PEDIATRIC/EPSDT SERVICES:
The Louisiana Medicaid Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Periodicity Schedule has been released with an effective date of 5/1/2018. The 2018 EPSDT Periodicity Schedule provides guidelines for the health supervision of infants, children and adolescents under the age of 21 years related to medical screenings, developmental and behavioral assessments, applicable procedures, and sensory screenings guidelines. Louisiana Medicaid has adopted the Bright Futures EPSDT Periodicity Schedule promulgated by the American Academy of Pediatrics with two exceptions:
- The Louisiana Medicaid EPSDT guidelines are for ages zero through 20 years and 364 days (The AAP Bright Futures EPSDT Periodicity Schedule provides guidance for patients through age 21); and
- The Louisiana Medicaid schedule has stricter requirements for lead assessment and blood lead screening in keeping with the Louisiana public health rule LAC 48:V.7005-7009 and the Medicaid Professional Services Manual, “Public Health Surveillance Mandates” section.
A copy of the 2018 Louisiana Medicaid EPSDT Periodicity Schedule can be found at the following link: http://www.lamedicaid.com/provweb1/ProviderTraining/packets/2018ProviderTraining/2018_EPSDT_Periodicity_Schedule.pdf
More information about Bright Futures may be found on the American Academy of Pediatrics’ website:
https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-guide/Pages/default.aspx.
More information about lead poisoning prevention in children can be found at the following link: http://www.lead.dhh.louisiana.gov/.
For questions regarding this message and/or fee for service claims, please contact Molina Provider Relations at (800) 473-2783 or (225) 924-5040.