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