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.

ATTENTION PROVIDERS
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 Louisiana Fee for Service (FFS) Medicaid Providers:

Effective July 2, 2018, pharmacy claims submitted to Fee for Service (FFS) Medicaid for Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors: deutetrabenazine (Austedo®), tetrabenazine (Xenazine®), and valbenazine (Ingrezza®) will have a clinical pre-authorization requirement at Point of Sale (POS). Please refer to www.lamedicaid.com for more information.

Attention Louisiana Fee for Service (FFS) Medicaid Providers:

Effective July 1, 2018, pharmacy claims submitted to Fee for Service (FFS) Medicaid for sacubitril/valsartan (Entresto®) will no longer have a clinical pre-authorization requirement at Point of Sale (POS). Please refer to www.lamedicaid.com for more information.

ATTENTION ALL PROVIDERS
INCORRECT USE OF ICD-10 CODES WILL RESULT IN CLAIM DENIALS

Louisiana Medicaid will be completing the final transition from the ICD-9 Crosswalk to the ICD-10 Code set with date of processing September 4, 2018 forward. Once implemented, ICD-9 codes will no longer be accepted on claims with dates of service 10/1/2015 and after. Below are common provider errors identified during testing that will result in future claim denials.

  • Invalid ICD-10 codes
  • Header codes sent as ICD-10 codes are non-payable
  • ICD-9 codes in ICD-10 fields

Effective September 4th, 2018, Medicaid will implement edits requiring a valid ICD-10 diagnosis code to be reported in the principal diagnosis field. Claims submitted without a valid principal diagnosis code will denied. The edits will include:

  • 433 – Missing/Invalid Diagnosis
  • 131 – Primary Diagnosis Not on File
  • 132 – Secondary Diagnosis Not on File
  • 151 – Mixed ICD Code Sets
  • 152 – Invalid ICD Code on Date of Service

When determining diagnoses, please ensure the diagnosis is applicable for the age and gender of the patient on the billed claim. The age and gender restrictions on the ICD-10 code set are from CMS guidelines and are tighter than currently in the system for the ICD-9 code set.

Attention Louisiana Fee for Service (FFS) Medicaid Providers:

Effective immediately, prescribing providers should use the revised (July 2018) Healthy Louisiana Prior Authorization (PA) Form when requesting a prior authorization for a recipient enrolled in Fee for Service (FFS) Medicaid or a Managed Care Organization (Aetna, AmeriHealth Caritas, Healthy Blue, Louisiana Healthcare Connections, and United Healthcare). Prior authorizations for select specialty drugs must be submitted as usual on designated specialty PA forms. Please refer to www.lamedicaid.com for more information.

Attention Louisiana Fee for Service (FFS) Medicaid Providers:

Effective August 1, 2018, Fee for Service (FFS) Medicaid and Managed Care Organizations (Aetna, AmeriHealth Caritas, Healthy Blue, Louisiana Healthcare Connections, and United Healthcare) will have diagnosis code requirements at Point of Sale (POS) for eculizumab (Soliris®) and paroxetine mesylate (Brisdelle®). Please refer to www.lamedicaid.com for more information.

Attention Louisiana Fee for Service (FFS) Medicaid Providers:

Effective July 1, 2018, for Fee for Service (FFS) Medicaid, over-the- counter (OTC) pharmacy claims submitted at Point of Sale (POS) for Long Term Care recipients will deny since coverage of OTC drugs are part of the per diem. Please refer to www.lamedicaid.com for more information.