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.
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
who 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.
Attention Pharmacists and Prescribing Providers
Pharmacy claims for proton pump inhibitors for shared health plans or legacy recipients will still be subject to
maximum duration of therapy of 120 days effective July 1, 2013. Claims which exceed the maximum duration of
therapy will deny with EOB 697. To continue therapy past 120 days, MDs will need to get prior authorization.
ATTENTION ALL PROFESSIONAL SERVICE PROVIDERS:
Criteria for Wearable Cardioverter Defibrillator (WCD) Life Vest
Effective immediately, specific criteria must be met for Wearable Cardioverter Defibrillator Life Vest to be an
approved service and reimbursed by Louisiana Medicaid. Please visit www.lamedicaid.com for the web notice, under
the 2013 "Professional Services Program" link. It has also come to the Departments attention, that procedure
code K0606 (WCD Life Vest) has been denied as a non-covered service for Louisiana Medicaid, due to being
inadvertently omitted from the fee schedule. The fee schedule was updated April 2013 to include K0606 effective
October 1, 2008. Prior Authorization is required for this service, to ensure medical necessity of WCD and will
not be used for experimental or investigational purposes. If you have any questions please contact Molina
Provider Relations (800)473-2783 or (225)924-5040.
Attention Professional Services Providers:
It has been brought to the attention of DHH that some of the fees for the new 2013 HCPCS codes were inadvertently added prior to
budgetary reductions. Additionally, revisions have been made to CPT codes 95017 and 95018 to accurately reflect the new
descriptions, units, and fees.
The above items have been corrected and the Professional Services Fee Schedule has been updated. All impacted claims will be
recycled for potential recoupment and/or adjustment of funds. No action is required by providers.
Scheduled Claims Recycle for Primary Care Services with Affordable Care Act Enhanced Rates
DHH has authorized a special check write scheduled for Wednesday, July 17, 2013, in order to address prior paid claims for
specified primary care services rendered by Designated Providers which are eligible for an enhanced rate as required by the
Affordable Care Act (ACA). As CMS approved our methodology on June 6, 2013, the ACA enhanced rates were added to the claims
processing system on June 17, 2013 and eligible Designated Providers began to see higher payment of these services beginning
with the June 25, 2013 check write. The new check write will address claims for dates of service January 1 through June 16, 2013
which were processed before we implemented the enhanced rates into our processing system. EFTs will be released on Thursday, July 18.
Only claims paid under legacy Medicaid or Bayou Health Shared Savings plans (Community Health Solutions of America and United Healthcare)
will be affected. DHH requires approval from CMS regarding the methodology to reimburse enhanced rates for the Prepaid Plans.
Physicians whose Designated Physician form was processed and approved by Molina Provider Enrollment prior to June 17, 2013
will be included in the recycle and systematic adjustment of claims. Advanced Practice Registered Nurses eligible for
enhanced rate payment will be processed at a later date.
Additionally, providers should review any claims on this check write which deny due to the patient having third-party liability (TPL).
They will need to submit the claim to the other insurance first and then submit an adjustment to Molina afterwards in order to receive
the enhanced rate, if applicable.
For more information related to the ACA enhanced rates and affected providers, please see "ATTENTION PRIMARY CARE PROVIDERS:
Affordable Care Act Primary Care Services Enhanced Reimbursement Information" posted to www.lamedicaid.com on June 16, 2013.