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

Should you have any questions regarding any of the following messages, please contact Molina Medicaid Solutions at (800) 473-2783 or (225) 924-5040.



The Centers for Medicare & Medicaid Services (CMS) will be hosting PERM Provider Education Conference Calls/Webinars this summer, to provide interactive sessions for providers of Medicaid and Children's Health Insurance Program (CHIP) services. Providers will be informed about PERM updates, trends and responsibilities. There will be opportunities to ask questions and provide feedback to CMS and your state representatives.

For Webinar details, refer to the March/April, 2014 Provider Update Article, located in the Provider portal at

Attention Pharmacists and Prescribing Providers of Louisiana Medicaid Shared Plans and Legacy Medicaid:

Effective July 1, 2014 clinical pre-authorization will be required for the non-preferred direct-acting Hepatitis C agents: Incivek® (telaprevir), Sovaldi® (sofosbuvir), and Olysio® (simeprevir). These claims will deny with EOB code 066 Clinical PreAuthorization Required. The form and worksheet are available at

Attention Pharmacists and Prescribing Providers of Louisiana Medicaid Shared Plans and Legacy Medicaid:

Effective July 15, 2014, pharmacy claims for hydrocodone containing drugs will deny when there is an active prescription on file and a new claim is submitted with a different prescriber. See

Radiation Treatment Management: Billing Clarification

Radiation treatment management is currently submitted using the Current Procedural Terminology (CPT) code 77427 (Radiation treatment management; 5 treatments). Per the CPT definition and guidance, this procedure code represents units of five fractions or treatment sessions regardless of the actual time period in which the services are furnished. Reimbursement reflects payment for the entire service; therefore the 'units of service' submitted must be "1". Please refer to the most current CPT manual for further guidance.

Effective with date of processing July 15, 2014 the Medicaid claims processing system has been updated and claims for procedure code 77427 will deny with error 168 (Deny span date/UVS is greater than 1) if billed with more than "1" in the units field. Spanning of dates for this procedure code will also cause the claim to deny. In addition, when billing radiation treatment management represented by procedure code 77427, the single date of service is to be the last date of the treatment sessions.

Previously paid claims will not be recycled. Original claims or claim adjustments processed on or after the July 15, 2014 date above, regardless of date of service, will process using this new claims processing logic. Providers should take the steps necessary to ensure that billing staff are aware of these changes.

For questions related to this information as it pertains to legacy Medicaid or Bayou Health Shared Savings Plans claims processing, please contact Molina Medicaid Solutions Provider Services at (800) 473-2783 or (225) 924-5040.

Attention All Providers:

If you receive an electronic remittance (835 Transaction) be sure and refer to the article posted on regarding changes to be made in August, 2014. The title of the article is CAS Segments in Loops 2100/2110 of the 5010 835 Transaction and it is dated 6/16/14. Changes are needed to correctly reflect the remaining obligation(s) when other payers have processed the claim prior to Louisiana Medicaid. These obligations are reported in the CAS segments within the 835. If you have questions related to this information, please contact Molina Provider Services at (800) 473-2783 or (225) 924-5040.

New Louisiana Department of Health and Hospitals Adverse Actions Web Search:

As a condition of participation in the Louisiana Medicaid Program, providers are responsible for ensuring current and potential employees, contractors and other agents and affiliates have not been excluded from participation in the Medicaid, or Medicare Program by Louisiana Medicaid, or the Department of Health and Human Services' Office of Inspector General. Providers who employ or contract with excluded individuals or entities may be subject to penalties of $10,000 for each item or services the excluded individual or entity furnished.

Providers have been previously instructed to check the websites of the Department of Health and Human Services' Office of Inspector General at http://exclusions.oig.hhs/search.aspx and the System for Award Management (SAM) website at for any exclusion imposed at the federal level upon hire and monthly thereafter for employees and/or subcontractors that perform services that are compensated with Medicaid/Medicare funds. Please be reminded that the SAM site is only for entities, and providers do not need to check employees on the SAM site.

Effective immediately, providers should check the Louisiana Department of Health and Hospitals Adverse Actions website at upon hire and monthly thereafter for individuals and entities that have had adverse actions imposed. This is a user friendly site that allows single and multiple searches of individuals and entities. The user may also choose to export the database and have it available in an Excel spreadsheet. Providers are required to maintain proof in their records that checks were done for employees and/or subcontractors. This may be done by printing out the result of the search.

All current and previous names used such as first, middle, maiden, married or hyphenated names and aliases for all owners, employees and contractors should be checked. If an individual's or entity's name appears on these websites, this person or entity is considered excluded and is barred from working with Medicare and/or the Louisiana Medicaid Program in any capacity. If the exclusion is learned prior to employment the provider should not employ the person or entity. If the provider learns of the exclusion after hiring the provider must notify the Department of Health and Hospitals within ten working days of discovering the exclusion with the following information:

  • Name of the excluded individual or entity and

  • Status of the individual or entity (applicant or employee/contractor).

If the individual or entity is an employee or contractor, the provider should also include the following information:

  • Beginning and ending dates of the individual's or entity's employment or contract with the agency,

  • Documentation of termination of employment or contract, and

  • Type of service(s) provided by the excluded individual or entity.

These findings should be reported to: or

Department of Health and Hospitals
Program Integrity
P.O. Box 91030
Baton Rouge, LA 70821-9030

This new adverse actions web search tool does not replace the Nurse Aide Registry/Direct Service Worker Registry found at Providers that employee Certified Nursing Assistants (CNA) and Direct Service Workers (DSW) are still required to check these registries upon hire and every six months thereafter.

These requirements are identified in the Provider Enrollment Agreements, the Medical Assistance Program Integrity Law (MAPIL) cited as Louisiana Revised Statute 46:437, referenced in the Louisiana Administrative Code (LAC) Title 50 and the Code of Federal Regulations 42 CFR § 455.436.

All excluded individuals must request reinstatement after the minimum excluded period has been served. There is no automatic reinstatement at either the federal or state level.