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 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.
OB Providers: New NCCI Edits on Codes H0049 and H0050 (Alcohol and/or Drug Screening/Brief Intervention)
The next update to the National Correct Coding Initiative (NCCI) edits may result in the denial of HCPCS
codes H0049 (Alcohol and/or Drug Screening) and H0050 (Alcohol and/or drug services, brief intervention
per 15 minutes). NCCI editing considers them to be incidental to Evaluation and Management services.
It is the intent and policy of Louisiana Medicaid to continue to reimburse for H0049 and H0050. When
these services are appropriately performed on the same date of service as Evaluation and Management
services (E/M), the E/M service may be submitted with modifier 25. Documentation in the clinical record
must substantiate each service.
There has been no change in policy regarding the use and frequency of H0049 and H0050. These codes are
only reimbursable when billed with modifier -TH and reimbursement for these services is restricted to
once per pregnancy.
ATTENTION LTC-PCS PROVIDERS
Due to programming changes implemented October 1, 2013, claims for procedure codes T1019, TOS 19 with
modifiers UB, UN & UP were incorrectly denied with error code edit 210 (PROVIDER NOTCERTIFIED FOR THIS
These claims will be systematically corrected, recycled and paid by October 22, 2013.
Claim denials with error code edits 210 (PROVIDER NOTCERTIFIED FOR THIS PROCEDURE) will receive an
override for edit 241 (CLAIM HELD FOR PRE-PAYMENT REVIEW) in order to allow those claims to be recycled
and paid by the October 22, 2013 Remittance Advice. NO ACTION IS REQUIRED ON THE PART OF THE PROVIDER.
We apologize for any inconvenience this may have caused.
ATTENTION ALL PROVIDERS
The diagnosis code 3051 (Tobacco Use Disorder) will be paid under Medicaid Managed Care (Bayou Health) for health
plan recipients and by Molina for legacy Medicaid recipients. This diagnosis is not paid under LBHP through
Magellan. Claims will be recycled on the 11/22/13 RA.
Please submit claims with a primary diagnosis of 3051 to the appropriate Bayou Health Plan or Molina for
processing. Please refer to the Informational Bulletin 12-18 at www.makingmedicaidbetter.com for the complete
list of behavioral health Diagnosis Codes that are excluded from payment by Magellan.
Attention LTC, ICF-DD, ADHC and Hospice Room & Board Providers
INFORMATION RELATED TO BILLING FOR
SEPTEMBER AND OCTOBER, 2013
We have made revisions to the LTC regular and supplemental payment schedule for October 2013 to clarify when
providers may receive payment in the month of October depending on the date of service on the claim(s).
FOR ALL PROVIDER TYPES LISTED: Any claims billed and processed prior to the October 10th and October 17th cutoff
with dates of service prior to September 2013 for private facilities will appear on the Remittance Advices/check
writes of either 10/15/2013 and/or 10/22/2013.
FOR STATE OPERATED FACILITIES: The check write dates of either 10/15/2013 and/or 10/22/2013 will include
payments to State Operated Facilities.
FOR ADHC PROVIDERS: The system generated claims for September dates of service were paid at a reduced rate in
error on the RA of 09/26/2013. These incorrectly paid claims will be voided on the 10/22/13 RA. Providers must
get their 'regular' billing for September 2013 dates to Molina for processing no later than Noon on Thursday,
October 17th, in order to have these claims processed for corrected payment on the RA of 10/22/2013. Providers
that do not meet this deadline (the regular supplemental billing cutoff) will have the corrected claims
processed in the regular LTC check write of 11/12/2013.
FOR PROVIDERS OTHER THAN ADHC PROVIDERS: The check write dated 10/29/2013 will include the processing of the
MOLINA system generated Adjustments/Voids to make needed adjustments to the provider submitted claims for payment
of September 2013 claims which were made on the RA dated 09/26/2013. This check write will also include any
other September claims submitted by providers for the regular supplemental billing cycle.
Please be sure that you submit bills for all of your September services prior to the October 17th cut-off date or
your 09/26/13 payments will be voided. Providers should submit original claims for September services, not
For questions related to this notification, please contact Molina Medicaid Solutions Provider Services at
(800) 473-2783 or (225) 924-5040.
Attention Providers That Submit Professional Crossover Claims
Paper Crossover Claims Paid In Error
Claims for recipients who have Medicare and Medicaid coverage must be filed with the Medicare fiscal intermediary
within 12 months of the date of service in order to meet Medicaid's timely filing regulations. Claims which fail
to cross over electronically from Medicare must be submitted hard copy to Medicaid within six months from the
date on the Medicare Explanation of Medicare Benefits (EOMB), provided that they were filed with Medicare within
one year from the date of service. This policy is stated in the General Information and Administration Provider
Manual - General Claims Filing Section, found at www.lamedicaid.com, directory link - Provider Manuals.
Due to a system calculation error, the dates for this timely filing edit (971 - Claim Exceeds Filing Limit
Coins/Deduct) were not being correctly edited for Professional Crossover Claims that were submitted to Medicaid
as paper claims. Claims that did not meet the filing requirement based on the Medicare EOB that was submitted
with the claim that paid, but were paid due to this calculation error, have been identified and are being
systematically voided on the 10/22/13 RA.
Providers should not resubmit any of these claims unless appropriate documentation supporting timely filing can
be submitted with the claim. The documentation originally submitted with the claim DOES NOT support timely
filing. If providers have claims for which they can produce documentation that supports timely filing, they
should resubmit (1) the claim, (2) the Medicare EOB, (3) the Molina RA that supports the claim being filed
timely (within 1 year from date of service and/or 6 months from the Medicare EOB payment date), (4) the Molina
RA with the voided claim, and (5) a letter of explanation to: Molina Provider Relations. Attn: Correspondence
Unit, P.O. Box 91024, Baton Rouge, LA 70821. If the dates of service are over two years old, any
reconsideration of these claims will be sent from Molina to DHH for approval.
Attention Providers Regarding Edit 971
We are giving authorization for Molina to override the two (2) year timely filing edit on the related
claims from this specific project. The provider will be responsible for documenting timely filing
on those claims that are over two years old. If documentation of timely filing is not provided, the
claims will deny with instructions not to resubmit.