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

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: Eligible Providers

Hurry! If you don’t begin participation in the Medicaid Electronic Health Records Incentive Program by December 31, 2016, you’ll miss out on $63,750 in incentive payments. Please visit the website at for information. A new redesigned web portal will be ready for attestations starting September 19, 2016 at If you need additional information, please contact Kelli Douglas at 225-342-7742 or Gary Dillon at 225-342-4810.

Attention Providers of Breast Reconstruction Surgery

Providers were recently notified that, effective October 1, 2016, Louisiana Medicaid will now cover breast reconstruction post mastectomy of both the effected and contralateral breast for recipients diagnosed with breast cancer.

These procedures must be prior authorized.

It is the responsibility of the primary surgeon to obtain the prior authorization and use the assigned prior authorization (PA) number on his/her claim for the services. Related claims for the facility (hospital or ambulatory surgery center) and the assist surgeon when appropriate will not require a PA number to be present on the claim; however, these claims will pend to Medical Review for confirmation of PA. If the surgeon did not obtain the required PA (i.e., the approved authorization for the procedure isn’t present in the system), the claims for the hospital/ambulatory surgery center and assistant surgeon will be denied.

Questions concerning Medicaid fee for service prior authorizations may be directed to Molina Prior Authorization Unit at (800-488-6334 or 225-928-5263).

Questions concerning the authorization of services through a Healthy Louisiana Managed Care Organization (MCO) must be directed to the appropriate MCO.

Attention Fee for Service (FFS) Louisiana Medicaid Providers:

Effective October 19, 2016, Fee-for-Service (FFS) Medicaid Pharmacy Program will implement a copay exemption for select Preventive Care medications under certain criteria for eligible recipients at Point of Sale (POS). The select Preventive Care medicatons include aspirin, vitamin D 400 IU, folic acid, tamoxifen, raloxifene, tobacco cessation pharmacotherapy, oral fluoride supplements, and erythromycin eye ointment. For more information, please refer to

Update to 'ClaimCheck' Product Editing

McKesson’s ‘ClaimCheck’ product is routinely updated by the McKesson Corporation based on changes made to 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.

This update will affect claims with remittance advice of September 13, 2016 forward. Providers may notice some differences in claims editing. Providers should expect that some claims will continue to deny for the same error, but in some cases claims may now pay or deny for a different reason.

For questions related to this information as it pertains to fee-for-service Medicaid claims processing, please contact Molina Medicaid Solutions Provider Services at (800) 473-2783 or (225) 924-5040.


It was recently noted that hospital revenue code (HR) 636 was not a payable HR code in the Medicaid fee for service claims processing system for Take Charge Plus (TCP) recipients. Adjustments have been made to correct this issue. HR 250 has been payable for TCP recipients since the program began.

In addition to the system changes to add HR 636 as a payable outpatient hospital revenue code for TCP recipients, edits have been put into place to ensure payment of only the medications covered under the TCP program when billed with HR codes 250 and 636. As a result, previously denied claims for TCP recipients containing HR 636 will be recycled for payment if a payable procedure code is present. Claims containing HR 250 for TCP recipients that were previously paid without a payable procedure code will be voided. Previously paid claims containing HR 250 and HR 636 will be adjusted if necessary. These actions will occur on the remittance advice of November 1, 2016 without any action required on behalf of the provider.

Questions regarding this message should be directed to Molina Provider Relations at (800) 473-2783 or (225) 924-5040.

Updates to Healthy Louisiana related systems and claims processing changes are plan specific and are the responsibility of each health plan. For questions regarding Healthy Louisiana updates, please contact the appropriate health plan.

Billing Immunization Administration Code 90472

The Centers for Medicare and Medicaid Services has a claim line limit edit via the National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUE) that will deny CPT code 90472 (Immunization administration; each additional vaccine), when more than five is entered in the units field on a single claim line. This procedure code is billed in addition to the primary administration code, 90471 (Immunization administration…1 vaccine).

For Medicaid fee for service processing, to ensure proper reimbursement when more than six vaccines are administered on a single date, providers should bill the 90471 as the primary procedure, 90472 with five units on one claim line, and any additional injections with 90472 on a separate claim line. There is no change to the general immunization billing instructions.

Louisiana Medicaid supports ensuring our children are up to date with their immunizations and understands that on rare occasions a provider may find it necessary to administer more than this single claim line limit. Combination vaccines are encouraged in order to maximize the opportunity to immunize and to reduce the number of injections a child receives in one day. Documentation in the patient’s medical record must support the services billed.

Please contact the appropriate Managed Care Organization if there are any questions concerning their billing policies. For questions related to this information as it pertains to fee-for-service Medicaid claims processing, please contact Molina Medicaid Solutions Provider Services at (800) 473-2783 or (225) 924-5040.