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.

Institutional Providers Provider Disallowance

Health Management Systems, (HMS), on behalf of the Louisiana Department of Health (LDH), Medical Vendor Administration, has implemented an Institutional Provider Disallowance Project. Federal law requires that LDH recover Medicaid payments made to providers when a liable third party is identified. If it is determined that your office or facility was paid for claims provided to Medicaid beneficiaries who may have been eligible for other commercial health coverage on the dates of service, you will be notified by HMS and will be included in a Disallowance Project Cycle. HMS will provide you with a list of beneficiaries, their associated claims, any potential coverage and instructions on what you need to do.

In accordance with Act 517 of the 2008 Regular Session of the Louisiana Legislature, providers are now able to bill Medicaid-reclamation claims to carriers up to thirty-six (36) months from the date of service.

LDH encourages all providers to utilize HMS' Provider Portal. The portal was designed to process disallowances on-line. The Provider Portal offers many benefits such as: immediate receipt of disallowance notifications, elimination of paper listings, real-time access to disallowance projects, up-to-date claim status, and on-demand reporting. If you wish to self-register, please go to https://ecenter.hmsy.com for additional information or call HMS’s Provider Operations Department toll-free at 888-831-2738. They will assist with your registration to the portal and information on upcoming web-enabled instructional training seminars. LDH recommends all providers to opt out of receiving paper listings in the future and only use the Provider Portal for disallowance projects. The Provider Portal offers and ensures the protection of all PHI associated with these projects.

Professional Providers Provider Disallowance

Health Management Systems, (HMS), on behalf of the Louisiana Department of Health (LDH), Medical Vendor Administration, has implemented a Professional Provider Disallowance Project. Federal law requires that LDH recover Medicaid payments made to providers when a liable third party is identified. If it is determined that your office or facility was paid for claims provided to Medicaid beneficiaries who may have been eligible for other commercial health coverage on the dates of service, you will be notified by HMS and will be included in a Disallowance Project Cycle. HMS will provide you with a list of beneficiaries, their associated claims, any potential coverage and instructions on what you need to do.

In accordance with Act 517 of the 2008 Regular Session of the Louisiana Legislature, providers are now able to bill Medicaid-reclamation claims to carriers up to thirty-six (36) months from the date of service.

LDH encourages all providers to utilize HMS' Provider Portal. The portal was designed to process disallowances on-line. The Provider Portal offers many benefits such as: immediate receipt of disallowance notifications, elimination of paper listings, real-time access to disallowance projects, up-to-date claim status, and on-demand reporting. If you wish to self-register, please go to https://ecenter.hmsy.com for additional information or call HMS’s Provider Operations Department toll-free at 888-831-2738. They will assist with your registration to the portal and information on upcoming web-enabled instructional training seminars. LDH recommends all providers to opt out of receiving paper listings in the future and only use the Provider Portal for disallowance projects. The Provider Portal offers and ensures the protection of all PHI associated with these projects.

Attention EPSDT-Personal Care Services (PCS) Providers:
ACA Requirement to Enter Ordering Provider on Medicaid Claims

In May 2016, a notice was posted to the Louisiana Medicaid web site concerning the requirement for entering Ordering/Referring/Prescribing providers on claims billed to Medicaid.

The Affordable Care Act (ACA) requires physicians or other practitioners who order, prescribe, or refer items or services to Medicaid recipients to be listed on claims and to be enrolled in the Medicaid Program, even when they do not submit claims to Medicaid. The ACA requirements are designed to ensure items or services for Medicaid recipients originate from appropriately licensed providers who have not been excluded from Medicare or Medicaid.

Louisiana Medicaid policy clearly states that EPSDT PCS must be initially ordered by the recipient's attending physician as medically necessary. This must be reviewed by the physician every 180 days or when changes occur in the Plan of Care.

Thus, all claims for EPSDT-PCS must include the name and 10-digit NPI of the ordering physician. Additionally, the ordering physician must be enrolled with Louisiana Medicaid, even if they do not bill Medicaid for services.

EPSDT-PCS providers must obtain the NPI of the ordering physician; confirm that he/she is enrolled in Medicaid; and enter the Qualifier 'DK', the name, and NPI on claims for the patient. Claims editing related to the above changes will be reflected as educational on RA's prior to July 1, 2017.

EPSDT-PCS providers should refer to the provider notices concerning Ordering/Referring/Prescribing Providers dated March 24, 2017 and February 21, 2017 for additional information when the ordering provider is required on claims. It is your responsibility to obtain the ordering provider's NPI, and the notices give further detailed instructions on how to confirm that the provider is enrolled with Louisiana Medicaid.

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 managed care systems and claims processing changes are plan specific and are the responsibility of each health plan. For questions regarding Healthy Louisiana updates, please contact the appropriate health plan.

2017 Assistant Surgeon and Assistant at Surgery Covered Procedures – Revised May 2017

Louisiana Medicaid has republished the 2017 fee-for-service list of allowed procedures for assistant surgeons and assistant at surgery providers. Changes were made to better align with national coding standards and fee-for-service coverage of surgical procedures.

The updated 2017 list has been reposted to the LA Medicaid website (www.lamedicaid.com) under the ‘ClaimCheck’ icon titled, “2017 Assistant Surgeon and Assistant at Surgery List of Covered Procedure Codes – Revised May 2017.” Some procedure codes have been marked out (ex. 22842), as they do not require the services of an assistant surgeon.

This list does not ensure payment but provides a comprehensive list of codes that may be allowed when billed by an assistant surgeon or by an assistant at surgery.

Please contact the appropriate Managed Care Organization with any questions concerning their updates. For questions related to this information as it pertains to fee-for-service Medicaid claims processing, please contact Molina Medicaid Solutions Provider Services at (800) 473-2783 or (225) 924-5040.