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 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.
Update to 'ClaimCheck' Product Editing
McKesson's 'ClaimCheck' product is routinely updated by McKesson Corporation based on changes made to the resources used,
such as Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) coding guidelines, the
Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule database, National Correct Coding Initiative (NCCI)
edits, and/or provider specialty society updates. The 'ClaimCheck' product's procedure code edits are guided by these widely
accepted industry standards.
The edit changes will affect claims processed beginning with the remittance advice of May 21, 2013 forward. Providers may
notice some differences in claims editing that includes pre/post� op days, incidental, mutually exclusive, rebundling, add-on
and multiple surgery reductions. Providers should expect that some claims will continue to deny for the same error, but when
applicable, claims may now pay or deny for a different reason.
With this update, Louisiana Medicaid (claims that process through the Molina claims processing system) also implemented the
2013 quarter one NCCI edits; however, the code pairs specific to preventive services and immunization administration
have been deactivated based CMS approval. Doing so aligns with our intent and expectations that appropriate immunizations
are to be given at the time of the preventive visit to avoid missed opportunities in both preventive care and immunizations.
Attention Billing Medicaid Recipients:
DHH is receiving many calls from Medicaid recipients stating that they are being billed by providers for
Medicare/Medicaid services. The following is Medicaid policy concerning the processing and payment of
Medicare Crossover claims. Providers are responsible for establishing internal billing procedures to ensure
that Medicaid recipients are not being inappropriately billed for Medicare/Medicaid services. Please note
that Medicaid does not necessarily pay the full Medicare deductible and co-insurance on a claim.
A cost-comparison methodology has been used in the payment of Crossover claims for many years. Providers
may not balance-bill recipients in these instances.
Dual eligibles are recipients who have Medicare and Medicaid coverage. Medicaid will reimburse the provider
an amount up to the full amount of Medicare's statement of liability for co-insurance and deductible
for Qualified Medicare Beneficiaries (QMB).
For claims in which Medicare's reimbursement exceeds the maximum allowable by Medicaid, Medicaid will
"zero" pay the claim. This means that the claim will be shown in the Approved Claims section of the RA
with a "$0" shown in the payment column. This claim is considered "paid in full" and the provider may not
seek additional remuneration from the recipient.
Medicaid will pay up to the Medicare deductible and coinsurance on Medicare approved claims for
non-Qualified Medicare Beneficiaries (non-QMB) receiving both Medicare and Medicaid, provided the procedure
is covered by Medicaid. Medicaid will reimburse the provider an amount up to the full amount of Medicare's
statement of liability for co-insurance and deductible as long as it does not exceed Medicaid's allowable
reimbursement for the service. Medicaid will "zero' pay the claim when Medicare's reimbursement exceeds the
maximum allowable by Medicaid.
If a recipient has both Medicare and Medicaid coverage, providers should file claims in the appropriate manner
with the regional Medicare intermediary/carrier, making sure the recipient's Medicaid number is included on
the Medicare claim form. Once the Medicare intermediary/carrier has processed/paid their percentage of the
approved charges, Medicare will electronically submit a "crossover" claim to the Medicaid FI that includes
the co-insurance and/or deductible.
If the "crossover" claim is denied by Medicare, the provider must submit a corrected claim to Medicare, if applicable.
If the "crossover" claim is not automatically crossed from Medicare and received by Medicaid, then the
provider must submit a hard copy claim for payment of Medicaid's responsibility as appropriate.
Attention Professional Services Providers:
17 Alpha-Hydroxprogesterone Caproate (17P)
Louisiana Medicaid would like to provide clarification regarding policy and current reimbursement of 17
Alpha-Hydroxyprogesterone Caproate (17P). Providers are encouraged to obtain 17P on a proactive basis
to have readily available to facilitate usage in the treatment of members at risk for preterm delivery.
There is no prior authorization required for Fee-for-Service Medicaid. For complete information related
to billing and reimbursement please, refer to the 2010 Policy Update under the Professional Services Program
link on the Louisiana Medicaid website (www.lamedicaid.com). For those recipients in Bayou Health, providers
should contact the member's respective Health Plan for information regarding prior authorization requirements.
Attention Pharmacists and Prescribing Providers
Pharmacy claims for sedative hypnotics for shared health plans or legacy recipients will be subject to maximum
daily dosage limits effective June 18, 2013. Claims which exceed the maximum daily dose will deny with EOB 529. See http://www.lamedicaid.com/
ATTENTION PRIMARY CARE PROVIDERS
On June 6, 2013, DHH received CMS approval for a State Plan Amendment (SPA) authorizing reimbursement of
designated physicians for specified primary care services rendered during calendar years 2013 and 2014 at
an enhanced rate as required by the Affordable Care Act (ACA). Consistent with the approved SPA, with the
June 25, 2013 check write DHH will update the fee schedule and reimburse new claims for eligible services
at the enhanced rate. In July 2013, eligible claims paid in previous check writes will be adjusted to reimburse
for the difference between the Medicaid rate paid and the enhanced rate required. No action of the part of
providers is required.
Billing Multiple Surgical Procedures
Providers are reminded that claims for multiple surgical procedures performed on the same date of service by
the same rendering provider must be submitted at the same time. Overpayments due to fragmenting claim
submissions are subject to review, recovery of the overpayment and additional sanctions as deemed appropriate
by Louisiana Medicaid.
For questions related to this information, please contact Molina Medicaid Solutions Provider Services at
(800)473-2783 or (225)924-5040.