PHARMACY PROVIDERS, PLEASE
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.
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 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:
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.
Attention Louisiana Medicaid Providers:
Effective June 1, 2018, pharmacy claims submitted to Fee for Service (FFS) Medicaid and Managed Care Organizations (MCOs) will have a diagnosis code requirement at Point of Sale (POS) for tadalafil (Cialis®) when used in the treatment of benign prostatic hyperplasia (BPH). Also, pharmacy claims for tadalafil 20mg (Adcirca®) and sildenafil 20mg (Revatio®) will have a diagnosis code requirement at POS for pulmonary arterial hypertension (PAH). Please refer to www.lamedicaid.com for more information.
ATTENTION PROVIDERS OF HOSPICE SERVICES:
The Louisiana Medicaid Hospice Program fee schedule for federal fiscal year 17, effective date October 1, 2016, has been updated to reflect the federal change from Metropolitan Statistical Area (MSA) codes to Core Based Statistical Area (CBSA) codes. Effective immediately, please utilize the appropriate CBSA codes on the October 1, 2017 fee schedule when filing hospice claims with Molina Medicaid Solutions and Healthy Louisiana managed care organizations (MCOs).
The federal fiscal year 2018 rates are in place and the hospice fee schedule has been posted to www.lamedicaid.com with an effective date of October 1, 2017. All fee-for-service hospice claims from October 1, 2017 to May 22, 2018 will be recycled by Molina.
For questions regarding fee for service claims, please contact Molina Provider Relations at (800) 473-2783 or (225) 924-5040.
The MCOs have been directed to update their fee schedules and recycle any impacted claims within 30 days of the publishing of the updated fee schedule.