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.
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
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:
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 PROFESSIONAL SERVICES PROVIDERS:
It has been brought to the attention of DHH that the assistant surgeon
fee on file for Current Procedural Terminology (CPT) code 59514
(Cesarean delivery only;) of $137.44 was inadvertently not included in
the July 1, 2012 and February 1, 2013 budget cuts. The reimbursement
amounts effective on or after the dates of those budget cuts have been
corrected as of July 15, 2014. The Professional Services Fee Schedules
will be updated to reflect those changes. All impacted claims will be
recycled for potential recoupment and/or adjustment of funds. No
action is required by providers.
For questions related to this recycle, please contact Molina Medicaid
Provider Services at (800) 473-2783 or (225) 924-5040.
ATTENTION LOUISIANA APPLIED BEHAVIOR ANALYSIS PROVIDERS
Provider Type BI is only to be used for billing purposes and should
never be used for prior authorization purposes. All claims for ABA
services should be submitted directly to Molina.
H2019 is used when enrolled provider provides direct service.
H2019HM is used when services are delivered by line staff (not the
enrolled provider providing direct service)
G9012 is the supervisions code and should be used when the enrolled
provider is supervising staff who are providing services under code
H2019HM. This is only needed when H2019HM is requested.
If you have questions or concerns, please contact Rene' Huff at
(225) 342-3935 or firstname.lastname@example.org.
Update to 'ClaimCheck' Editing- August 2014
McKesson's 'ClaimCheck' product is routinely updated by McKesson Corporation
based on changes made to the resources used, such as Current Procedural Terminology
(CPT) and Healthcare Common Procedure Coding System (HCPCS) coding guidelines,
the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule database,
National Correct Coding Initiative (NCCI) edits, and/or provider specialty society
updates. The 'ClaimCheck' product's procedure code edits are guided by these widely
accepted industry standards.
The latest product update will affect claims beginning with the date of processing
August 19, 2014 forward. Providers may notice some differences in claims editing that
may include NCCI, pre/post-op days, incidental, mutually exclusive, rebundling, add-on
and multiple surgery reductions. Providers should expect that some claims will continue
to deny for the same error, but when applicable, claims may now pay or deny for a
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 Anesthesia Billing Providers
Issues Concerning Non-OB Anesthesia Services
DHH has completed a review of Shared Plan claims (UHC and CHS) for non-obstetrical anesthesia which
denied for error code 735 (Previously Paid Anesthesia or Supervising Anesthesia- Same Recipient/Date
of Service). The findings identified numerous provider billing errors that are not consistent with
established Louisiana Medicaid policies for billing these services. The review validated the original
denial reason on these claims.
These errors included but were not limited to:
- Services billed involving both an anesthesiologist and a CRNA; the claim for the CRNA was billed
with a different procedure code than the anesthesiologist.
- Where CRNAs were directed by anesthesiologists, the minutes on the CRNA and the
anesthesiologist claims were different.
- Services billed for two procedures where one procedure is included in the other procedure.
- Claims for the same service/same date were billed by two different anesthesiologists and two
different CRNAs for the same procedure.
- Improper anesthesia modifier combinations.
- Claims were re-submitted multiple times with changes made to include inappropriate modifiers.
These denied claims will not be reprocessed as that only would result in claims receiving the same
denial. Billing providers are reminded that when billing UHC, CHS or Legacy Medicaid for non-obstetrical
anesthesia claims, they should follow national coding standards and also consult the on-line Professional
Services Providers Services Manual at
directory link Provider Manuals, for specific billing instructions.
If you have any additional questions or concerns, please contact Darlene White at
(225)342-6159 or Darlene.White@la.gov.
Attention Pharmacists and Prescribing Providers of Louisiana Medicaid Shared Plans and
Effective September 9, 2014, pharmacy claims for all antipsychotic medication
prescriptions will require specific diagnosis codes and Latuda® (Lurasidone),
Fanapt® (Iloperidone), and Saphris® (Asenapine) will have age and dosage limits.
Please refer to www.lamedicaid.com for specifics.