RA Messages for June 1, 2010


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 www.lamedicaid.com


On May 11th, CMS data available for individual NDC's was upgraded and a new edit message 149 - DESI INEFFECTIVE-NOT PAYABLE was implemented. This edit will deny payment for the claims with NCPDP Error Code 70 - Product/Service Not Covered.


Effective May 1, 2010, Molina Healthcare purchased the Health Information Management Division of UNISYS Corporation. With this acquisition, the Louisiana Medicaid fiscal intermediary transitions from UNISYS to Molina Medicaid Solutions. This transition will be seamless to providers, who will continue to interact with the same staff at the same contact telephone numbers and addresses as in the past. Please visit the LA Medicaid website, www.lamedicaid.com, for more information and a link to the Molina Healthcare website.


Louisiana Medicaid has identified an issue where pregnancy-related anesthesia claims deny when a physician/anesthesiologist initiates the anesthesia for a procedure (initiation ONLY) and the CRNA monitors the anesthesia throughout the procedure (monitoring ONLY). In these cases, when billed with appropriate modifiers, both claims should process correctly. We found that one of the claims (either doctor or CRNA) paid and the other claim denied for edit 748 (only 1 delivery allowed in 6 month span). The logic has been corrected and related denied claims were recycled on the RA of May 11, 2010. Some of the recycled claims will deny again for a correct edit. Providers must work these claims and resubmit them with corrections for payment if appropriate. We apologize for any inconvenience caused by this issue.


Effective with date of service May 10, 2010, Louisiana Medicaid has updated the claims processing system related to procedure codes allowed to be billed with either the '80' or 'AS' modifier. This update was part of the preparation for the implementation of ClaimCheck editing which uses the American College of Surgeons as its primary source for determining if an assistant surgeon is clinically valid for a surgical procedure. Some procedures not previously allowed may now be reimbursable--and some procedures that were allowed will no longer be reimbursed to the assistant surgeon or assistant at surgery. The list of covered procedures can be found on the Medicaid website, www.lamedicaid.com, and then using the ClaimCheck icon. Questions concerning this notice may be directed to Molina Medicaid Solutions Provider Relations at (800) 473-2783 or (225) 924-5040.


The reimbursement rate reductions for professional services effective with dates of service Aug 4, 2009-Jan 21, 2010, have been implemented. Providers will begin seeing these reductions on the RA of May 25, 2010. Refer to the Office of the State Register's website at http://doa.louisiana.gov/osr/ for published rules detailing these reductions. Providers should monitor the LA Medicaid website, www.lamedicaid.com, for updates to the Professional Services Fee Schedule to occur in the near future. A supplement to the fee schedule will also be posted detailing the procedure codes affected by the reductions.

Claims for dates of service Aug 4, 2009-Jan 22, 2010 that were adjudicated prior to May 25, 2010 are currently being assessed to determine an approach to systematic adjustment. No action is required by providers. Continue to monitor future RAs for details regarding these adjustments. Contact the Provider Relations unit at (800) 473-2783 or (225) 924-5040 with questions related to the implementation of the rate reductions.


POLICY UPDATE: Claims for KIDMED (EPSDT) screening services must be submitted within one year from the date of service. This policy for the timely filing of KIDMED screening claims (electronic and paper) has changed from the previous requirement of submission of KIDMED claims within 60 days from date of service. KIDMED claims that are not received for processing within the 60 day time period will continue to receive the EOB edit 435 as a reminder to the provider that the claims should be submitted within 60 days; however, the claim will not deny for this reason. Providers should strive to continue to submit KIDMED claims within 60 days in order for the claims to be adjudicated, and paid claims to be reflected on the RS-O-07 series of reports. In addition, the periodicity rate utilized in KIDMED monitoring may be affected unfavorably if claims are not routinely submitted for processing within 60 days from date of service. Providers should contact the Provider Relations Unit at (800)473-2783 or (225)924-5040 with questions related to this policy change.


It has come to our attention that some claims that processed on the RA of May 25,2010, were reimbursed referencing the wrong fee on file as a result of the rate reductions implemented last week for dates of service 8/4/2009 forward. The affected claims are identified as those with Evaluation and Management codes for children 0 through 15 years of age. The programming logic has been updated and the reimbursement of future claims beginning with the RA of 6/1/2010 will not be affected by this error. Claims that reimbursed erroneously on the RA of 5/25/2010 will be systematically adjusted and appear on the RA of 6/8/2010. No action is required by providers.

Please note that the aforementioned claims to be adjusted on the RA of 6/8/2010 will be adjusted again in the near future. This will be done to account for the delayed implementation of rate reductions for children 0 through 15 years of age to 90% of 2009 Region 99 Medicare fees effective for DOS 1/22/2010 forward.