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.
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
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 lamedicaid.com 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
and the System for Award Management (SAM) website at
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:
Department of Health and Hospitals
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 www.labenfa.com. 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.
ATTENTION ALL PROVIDERS
DHH has identified paid claims associated with administration corrections of member
linkages into Bayou Health Plans. These linkage corrections were necessary to ensure
compliance with internal policies, approved Medicaid State Plan and maintaining audit
controls. Member linkages from February 1, 2012 through June 30, 2014 were evaluated
and claims paid by an incorrect entity (CHS, UHC or Molina) have been identified. On
August 11, 2014 Molina will systematically void all identified paid claims with a denial
reason code 999 Administrative Correction, which will be shown on the Remittance Advice.
In order to rebill, providers must verify the correct entity based on the date of service
by using either MEVS or REVS. To obtain consideration for payment, providers are required
to submit hard copy claims to the correct entity no later than 6 months from the date the
claim is voided. If PA or Pre-cert was obtained on the original claim, providers will not
be required to obtain additional authorization when submitting these specific prior-paid
claims to the correct entity. Documentation must accompany claims verifying the prior
payment and void. This documentation of prior payment will also support the authorization
of the service. Claims submitted within 6 months of the void date will not be denied based
on timely filing.
For this clean-up only, the Making Medicaid Better website
contains a list of affected providers, which includes the provider name, a partial Medicaid
Provider ID (to protect privacy), the number of claims, number of recipients and total of
payments to be voided. Questions may be sent to Bayou Health at
with the subject line addressed to "Retro Claims".
Beginning September 2014, the process of voiding identified paid claims will be repeated
on a monthly basis, to occur around mid-month, for administrative corrections made to
member linkages in the prior month.