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) 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.
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.
Attention Intermediate Care Facility Providers
Effective April 1, 2014 the Provider Fee for Intermediate Care Facilities (ICF) days will
increase from $14.30 to $16.15 as allowed by Louisiana Revised Statute 46:2625. Future
Quarterly Fee Reports issued by the Department will reflect this change. Medicaid is
awaiting CMS approval for the rate increase. Once this increase is approved DHH will
recycle claims to pay you the increased rate associated with the fee increase.
AFFORDABLE CARE ACT ENHANCED REIMBURSEMENT RECYCLES - Dates of Service in 2014 and Medicare Crossover Claims
DHH is planning three recycles to adjust previously paid claims eligible for ACA enhanced reimbursement.
The first two recycles involve claims with dates of service in calendar year 2014 that were originally
paid before April 15, 2014. ACA enhanced reimbursement rates changed from 2013 to 2014. Claims paid on
or after the April 15 RA were processed with the 2014 rates and do not require adjustment. Claims paid
before April 15 were paid at 2013 rates and need to be adjusted. The recycles will appear on the May 20
and 27 Remittance Advices (RA), and are spread across two weeks due to the volume of claims affected.
The third recycle addresses Medicare crossover claims eligible for ACA enhanced reimbursement. Eligible
claims paid on or after April 29, 2014 were paid at the enhanced rate and do not need to be adjusted.
Claims paid before April 29 were not paid at the enhanced rate and need to be adjusted. This recycle
will take place after May 27 and include all dates of service in calendar year 2013 and 2014.
Providers do not need to take any action on affected claims.
For further information regarding the ACA enhanced reimbursement,
please visit http://www.lamedicaid.com/provweb1/ACA/ACA.htm.
Attention Pharmacists and Prescribing Providers of Louisiana Medicaid Shared Plans and
Legacy Medicaid:
Effective May 30, 2014, diagnosis codes will be required on pharmacy claims for select
specialty drugs. Please refer to www.lamedicaid.com
for the complete list with appropriate diagnosis codes.
Attention Pharmacists and Prescribing Providers of Louisiana Medicaid Shared Plans and
Legacy Medicaid:
Effective May 30, 2014, pharmacy claims for Victrelis® (boceprevir), Incivek®
(telaprevir), Sovaldi® (sofosbuvir), and Olysio® (simeprevir) will have
therapeutic duplication and early refill edits applied. Please refer to
www.lamedicaid.com for specifics.