PHARMACY PROVIDERS, PLEASE NOTE!!!

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 http://exclusions.oig.hhs.gov and the System for Award Management (SAM) website at https://sam.gov/portal/SAM#1 for 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 https://adverseactions.dhh.la.gov 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:

DHH.Medicaid.State.Exclusion@la.gov or

Department of Health and Hospitals
Program Integrity
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 BEHAVOIR 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 via 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 H2018HM. This is only needed when H2019HN is requested.

If you have questions or concerns, please contact Rene' Huff at (225) 342-3935 or rene.huff@la.gov

ATTENTION LOUISIANA APPLIED BEHAVOIR ANALYSIS PROVIDERS

H2019/H2019HM are both to be used to provide one on one ABA services to Medicaid clients. Under the current constraints of the Medicaid ABA program group therapy is not to be provided.

If you have questions or concerns, please contact Rene' Huff at (225) 342-3935 or rene.huff@la.gov

Attention Pharmacists and Prescribing Providers of Louisiana Medicaid Shared Plans and Legacy Medicaid:

Effective October 26, 2014, Pharmacy claims for recipients with Third Party Liability (TPL) must be submitted with the sales tax amount identified in NCPDP field 431-DV and NCPDP field 342-HC must contain the value 10, to indicate sales tax. Effective December 9, 2014, Pharmacy claims without this information submitted will deny with EOB 283, Sales Tax Not Present on Rx Claim with TPL. See www.lamedicaid.com.

Attention Pharmacists and Prescribing Providers of Louisiana Medicaid Shared Plans and Legacy Medicaid:

Pharmacy claims for Lamivudine (Epivir® Epivir HBV®) will no longer require a diagnosis code to be submitted at Point of Sale (POS). Also, hydrocodone combination prescription refills with an original prescription date before 10/06/2014 should now process up to 6 months from the original date. These changes are effective October 16, 2014.

Attention Pharmacists and Prescribing Providers of Louisiana Medicaid Shared Plans and Legacy Medicaid:

Effective October 28, 2014, diagnosis codes will be required on pharmacy claims for ADHD/ADD medication prescriptions. Please refer to www.lamedicaid.com for the complete list with appropriate diagnosis codes.

Attention Pharmacists and Prescribing Providers of Louisiana Medicaid Shared Plans and Legacy Medicaid:

Effective November 1, 2014 clinical pre-authorization will be required for Synagis® (Palivizumab). These claims will deny with EOB code 066 Clinical Pre-Authorization Required. For more information please refer to www.lamedicaid.com.

ATTENTION HOSPITAL PROVIDERS
CORRECTION TO HOSPITAL INPATIENT CLAIMS DENIED WITH EDIT 048

An error occurred in processing inpatient hospital claims that included an ICD-9 surgical procedure(s). These claims were incorrectly denied on the RAs of 10/21/14 and 10/28/14 with edit 048 (Missing/Invalid Surgical Procedure Code). This error has been corrected and the denied claims are being recycled on the RA of 10/28/14. Provider may see claims that were submitted from 10/17/14 - 10/23/14 listed as both denied and paid on the RA of 10/28/14. We apologize for any inconvenience this has caused.

For questions related to this information, please contact Molina Medicaid Solutions Provider Services at (800) 473-2783 or (225) 924-5040.

Attention Nursing Home Providers

The provider fee for ICF/DD providers was recently increased by $1.85. Subsequently, the Medicaid rates for the ICF/DD providers also increased by $1.85 as a "pass thru" for this increase. While implementing these changes, the nursing home payments for leave days were inadvertently increased by $1.85 in error. Molina is aware of the issue and are working to correct their system. They plan to re-cycle all affected nursing homes claims with a target date of 11/11/14. Providers will not have to do anything. We apologize for this error and if you have any questions, please call Lana Ryland at 225-342-9488 or lana.ryland@la.gov.