RA Messages for September 10, 2013
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.
Attention Providers: Medicaid RAC Provider Education Seminar
The Department of Health and Hospitals and Myers and Stauffer LC is hosting a Provider Education Seminar on the new Medicaid Recovery Audit
Contractor (RAC) program mandated by the Centers for Medicare and Medicaid Services (CMS). Seating for the seminar is limited and will be
reserved by registration only. The seminar will be streamed live for those who are not present at the seminar and recorded for future
viewing by those providers who cannot attend or view by live stream.
To reserve a seat, please register for the RAC Provider Education Seminar by emailing:
Please include specific questions you or your organization may have about the RAC in your email.
Date: September 18, 2013
Time: Seating begins at 8:30 a.m., seminar 9:00 a.m. - 11:00 a.m.
Location: 628 North 4th Street, Baton Rouge-1st floor, room 118
Attention Pharmacists and Prescribing Providers:
Effective September 1, 2013 Louisiana Medicaid will reimburse enrolled pharmacies for the 2013-2014 influenza
vaccines and administration of the vaccines for recipients who are nineteen years and older when the
administering pharmacist is an enrolled Medicaid provider. The cost of the vaccine will not be reimbursed for
recipients under the age of nineteen as these vaccines are available through the Louisiana Vaccines for
Children (VFC) program. Only the administration fee will be reimbursed for these recipients. See
ATTENTION PROVIDERS: PAYMENT ERROR RATE MEASUREMENT (PERM) TO BEGIN 10/01/2013
LA 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 LACHIP
programs. The results of these reviews will be used to produce a national error rate which will be reported
to Congress. If chosen in a random sample, your organization will soon receive a Medical Records
Request from the review contractor, A+ Government Solutions. A period of 75 days from the date of receipt
of the request will be given to submit the requested documentation. If no documentation or incomplete
documentation is submitted, the claim(s) will be considered to be an error and is subject to a payment
recovery through withholding of payment, and/or a possible fine. REMINDER: 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 PERM INFORMATION: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/PERM/Providers.html.
Attention Electronic Billers/Submitters of Institutional Claims
We want to remind providers and submitters that the following Bill Type codes are the only codes that are
acceptable for the Louisiana Medicaid Program, including Bayou Health claims and encounters. The file extension
of the electronic claim file is also very important in combination with the Bill Type codes.
For file extension 837I � UB9 the acceptable Bill Type codes are: 11X, 12X, 13X, 14X, 18X, 71X, 72X, 76X, 81X,
82X, 83X, 85X, 86X; 89X
For file extension 837I � HOM (Home Health) the only acceptable Bill Type code is 33x. When billing Home Health
claims electronically you must use the file extension 837I � HOM.
For file extension 837I � LTC (Long Term Care) the only acceptable Bill Type codes are: 21X, 65X, 66X.
These codes are ONLY acceptable for Long Term Care billing. Hospitals may not use these codes.
Electronic 837I billing files that are submitted with Bill Type codes not included in those listed above will
be rejected and not entered into the claims processing system. One of the most common errors identified for
file rejections is the use of Bill Type 33x with file extension 837I- UB9.
Providers must review the billing instructions for their provider type to ensure use of acceptable Bill Types
for their program. Providers using a Bill Type from the list above that is not acceptable for the specific
provider type/medical program will receive a denial of 042 � Invalid UB Bill Type.
ATTENTION PROVIDERS: CONTINUED ACA ENHANCED REIMBURSEMENT CLAIMS RECYCLES AND IMPLEMENTATION OF ENHANCED PAYMENTS FOR APRNS
Pursuant to the claims payment logic implemented in June 2013, Molina will recycle previously paid specified primary care service claims provided by Designated Physicians and eligible Physician Assistants in order to allow the enhanced payments as directed by the Patient Protection and Affordable Care Act. The recycles will cover the following:
- Providers whose Designated Physician forms were processed in late June but eligible for enhanced payments for dates of service beginning 01/01/2013. These providers did not have their claims recycled during July to receive the enhanced rate.
- Additional claims with dates of service 01/01/2013-02/19/2013 which were paid at the incorrect facility rate.
In addition, new claims payment logic was implemented in mid-August to allow Advanced Practice Registered
Nurses to receive enhanced rates. However, the majority of claims that are potentially eligible for enhanced
payment did not have a referring provider ID on the claim. DHH will post ACA enhanced reimbursement information
to the provider manual in the near future. To help facilitate providers receiving the enhanced rates, please
note the following:
- Claims submitted via CMS 1500 (paper) require that a valid Designated
Physician's NPI be listed on item 17b - Referring Provider
- Claims submitted via v5010 837P (electronic) require that the Designated Physician's NPI be listed in a
NM1 segment with the Qualifier DN. The NMl segment may be billed at either the Claim level 2310A or the Line l
Claims for APRNs that do not have the Designated Physician listed as the referring provider on their claims
will not receive the enhanced rate, nor will previously paid claims be recycled without this critical piece of
Providers should submit an adjustment for APRN claims that did not have the required Designated Physician's NPI
included in the appropriate location on the previously paid claim. This can be done by paper using the 213
Adjustment Form or electronically via the 837P adjustment format. The Designated Physician's NPI must
be entered correctly on the adjustment as indicated above for either paper or EDI adjustments in order to receive
the enhanced payment.
Update to �ClaimCheck� Product Editing
Effective with the Remittance Advice of September 3, 2013:
McKesson�s �ClaimCheck� product is routinely updated by the 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, and/or provider specialty society updates. The �ClaimCheck� product�s procedure code edits are guided
by these widely accepted industry standards. The edit changes will affect claims processed beginning with the
remittance advice of September 3, 2013. Providers may notice some differences in claims editing as most claims
will continue to edit in the same manner but when applicable, claims may now pay or deny for a different reason.
Providers will continue to be notified when routine updates are made in the future.
For questions related to this information, please contact Molina Medicaid Solutions Provider Services at
(800) 473-2783 or (225) 924-5040.