RA Messages for September 2, 2014
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
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 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.
ATTENTION PROFESSIONAL SERVICES PROVIDERS:
Effective for dates of service June 1, 2014 and forward, DHH has revised policy to remove
the three Emergency Department visit limit per calendar year. Emergency Department visits
will no longer be included in the 12 outpatient visit limit. All impacted claims with date
of service on or after June 1, 2014 will be recycled for adjustment of funds and removal of
emergency room visits from inclusion with the 12 outpatient visit limit. 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.
Guidelines for Teaching Facilities and Billing for Physician Services Updated August 2014*
Teaching physicians may bill for the services performed by residents in teaching facilities
if the following criteria are met and the services are covered by the Medicaid Program.
If there is on-site supervision or retrospective supervision within 24 hours of the
services being rendered and the teaching physician signs or initials approval/concurrence
with the treatment/services, the service may be billed. Emergency services include, but are
not limited to:
- Emergency Department visits
- Surgical procedures
- Laboratory procedures
- Radiology procedures
Planned Surgical Services
If the teaching physician is present and available in the suite, on call or otherwise
available in the event intervention is necessary, the service may be billed. The teaching
physician must document supervision by signing, initialing, or initialing a signature stamp
on the operative notes and the pre- and post-surgery evaluations. Planned surgical services
include, but are not limited to:
- Primary surgery
- Assistant surgery
- Anesthesiology, and
- Other physician specialty services necessary to the primary surgery.
Non-Surgical Hospital Admissions and Subsequent Visits
If the admission and discharge summaries are signed or initialed, non-surgical admissions may be billed for services rendered by a resident. A signature stamp which has been initialed by the teaching physician may also be used to indicate approval of services. If the hospital stay is routine and exceeds seven days, the teaching physician should sign or initial the progress notes at least once a week. In acute care or serious illness situations, the teaching physician's signature or initials should appear on the daily notes.
If the progress notes for each prenatal visit are signed or initialed by the teaching physicians, the teaching physician may bill for prenatal visits and other services associated with prenatal care. Deliveries may be billed by the teaching physician if the record documents his/her presence in the suite or participation in the delivery or if he/she is on call in the facility or on call at a reasonable distance. Reasonable distance is defined as a distance of no more than twenty minutes from the delivery suite. Signature or initials should appear on the chart within 12-14 hours of delivery if the teaching physicians' presence was not necessary in the delivery room.
*All Other Services
The teaching physician may bill for services such as interpretation of x-rays, laboratory services, etc., by signing and initialing the appropriate report and charts. Sign off of resident notes should be done at the time of service or within a maximum of one week to assure supervision of the resident and to allow a reasonable time to sign off on the electronic and/or hard copy record. This time allowance for record sign off does not negate the obligation of standard oversight/supervision in real time. Residents must have faculty supervision for all direct patient care in accordance with national Residency Review Committee (RRC) requirements. Residents cannot be enrolled as participating providers if practicing in a teaching facility. They can be enrolled as participating providers for services rendered outside of the teaching facility.
Remember, only the professional component of pathology and laboratory services performed in
inpatient and outpatient hospital settings may be billed to Louisiana Medicaid by the
teaching or supervising physician. One must own, rent, or lease laboratory or x-ray equipment in order to bill full service.
Attention Hospital Providers and Physicians Performing OB Delivery Services
RE: Deliveries Prior to 39 Weeks
Babies born prior to 39 weeks gestation for reasons that are not medically necessary have a high risk of spending their first days in the NICU unnecessarily. This unnecessary NICU admission is detrimental to the baby and also very costly for taxpayers. It is the intent of the Department of Health and Hospitals to not pay for deliveries prior to 39 weeks that are not medically necessary. This is a joint endeavor between Louisiana Medicaid and Blue Cross Blue Shield of Louisiana.
Effective with date of service September 1, 2014 forward, the Department intends to deny hospital and physician claims for the delivery of a baby prior to 39 weeks that is not medically necessary. Claims for the anesthesia related to the delivery will not be impacted by this policy.
The Department will use the Louisiana Electronic Event Registration System (LEERS) data from the Office of Public Health Vital Records to validate that the delivery was not prior to 39 weeks or if prior to 39 weeks, that it was medically necessary. Currently, LEERS creates a file on a monthly basis with the birth records and sends this data to Molina. The LEERS data will be changing to a weekly process so claims can be validated and processed more timely. Claims from the hospital, delivering physician (and assistant surgeon if applicable) for a delivery will be held within the Molina claims processing system until LEERS updates the birth record information for those claims. After the claims and LEERS are matched up, all claims will be allowed to continue processing unless LEERS indicates the delivery was prior to 39 weeks and not medically indicated.
Instructions for Delivering Physicians and Hospitals:
- Following delivery, please select the corresponding medical reason from the LEERS
Singleton Births Below 39 Weeks Gestation Worksheet
- If there was no medical reason, select the �None, No medical reason� check box.
If a provider feels a claim has been denied inappropriately, please follow these steps:
- The physician will need to log into LEERS to review the data they certified on the birth record.
- The physician will then need to speak to the birth clerk at the facility to determine what data was entered on the birth record and whether an amendment needs to be requested if the data is not correct.
- If what is on the birth record does not correspond with the file, the birth clerk may contact Vital Records LEERS Hotline at 504-593-5101. It is recommended that the birth clerk from the facility contact the hotline since they are more familiar with the birth record process.
- If a facility needs to correct the data on the birth file, they may request an amendment form through the Vital Records LEERS Hotline at 504-593-5101. The completed form should be returned to Vital Records by the facility for processing. Vital Records will provide verification of this amendment to the hospital provider. This form will need to be attached to the claim and resubmitted via hard copy for payment to Molina.
For questions related to this information, please contact Molina Provider Services at (800) 473-2783 or (225) 924-5040.