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: 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 Pharmacists and Prescribing Providers of Bayou Health Shared and Legacy Plans:
Effective October 1, 2013 short-acting beta2 agonist inhalers (albuterol, levalbuterol, and pirbuterol)
will have a quantity limit of six inhalers per calendar year. Pharmacy claims for omalizunab
(Xolair �) will require a valid ICD-9-CM diagnosis code and a minimum age of 12 years.
See http://www.lamedicaid.com/ for more information.
ATTENTION LOUISIANA BEHAVIORAL HEALTH PROVIDERS UPDATE TO THE NOTICE DATED 8/15/13 CONCERNING NEW
EDIT 133 FOR BEHAVIORAL HEALTH CROSSOVER CLAIMS
In July, you were notified that effective 8/6/2013 (date of payment), Medicare crossover claims for
Behavioral Health services would be denied with new Edit 133 and the claims would automatically be sent
to Magellan for processing. In August, you were notified of a delay in the automatic transfer of these
claims until late August or September.
This notice is to convey another delay in this transfer process. DHH and Magellan are working to resolve
the outstanding issues to allow these claims to be processed by Magellan in a timely manner.
Providers will continue to see Edit 133 denials in Molina's processing system, and all of these claims
(with payment date 8/6/2013 and after) will be appropriately processed by Magellan as quickly as possible.
As before, no action is required on the part of the provider.
We apologize for any inconvenience this may continue to cause as we work to through the final steps
in this new process.
ATTENTION PHARMACISTS AND PRESCRIBING PROVIDERS
>OF BAYOU HEALTH SHARED AND LEGACY PLANS
Effective October 15, 2013 pharmacy claims billed for
omalizumab (Xolair �) for shared health plans or legacy recipients will require
a prior authorization (PA). Claims billed without a PA will deny with EOB code
485 (PA required). See www.lamedicaid.com for more information.
ATTENTION PHARMACISTS AND PRESCRIBING PROVIDERS
Effective October 1, 2013 pharmacy claims for concurrent use
of different Short-Acting Beta2 Agonis inhalers (SABAs) will deny with a
therapeutic duplication (EOB 482).See www.lamedicaid.com for more information.
ATTENTION BILATERAL PROCEDURES
As indicated in the Remittance Advice messages dated July
24-August 7, 2012, when billing for bilateral procedures performed during the
same session (unless otherwise directed in CPT), providers are to use the-50
modifier (Bilateral procedure) with the appropriate CPT code and place a "1" in
the units field of the claim. The site specific modifiers 'LT' (Left side) or
'RT' (Right side) may be used on appropriate CPT codes only when services are
performed on either the right OR the left side. Providers should not use the 'LT'and
'RT' modifiers on the same procedure code instead of the -50 modifier.
Claims processing is being updated to look for and deny
inappropriately billed bilateral procedures. Providers can soon expect to see
claims denied with error codes 707 and 710 when billed incorrectly.
707- Bilateral-Resubmit with modifier 50-One Unit
710- Bilateral-Void Paid Claim-Resubmit with Modifier-50
Overpayments due to fragmented claim submissions are subject
to review and recovery of the overpayment.
For questions related to this clarification, please contact
Molina Medicaid Solutions Provider Services at (800) 473-2783 or (225) 924-5040.