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
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: ICF/IID FACILITIES
The USC, CFR, and La Medicaid State Plan require that the claim, defined as a single document line identifying the services and/or charges for services for a single recipient
from a single provider, be submitted to Louisiana Medicaid for payment within 12 months from the date of service and that the claim be paid no later than 12 months from the date
of receipt of the claim. Failure to bill within the allotted period will result in the nonpayment of claims.
In addition, the Louisiana Department of Health strongly encourages providers to bill monthly and to attempt to clear any denials received within two billing periods.
Attention Professional, and Independent Laboratory, Providers
Reimbursement for Lynch Syndrome and Familial Adenomatous Polyposis (FAP) Genetic Testing
Effective with dates of service January 1, 2019 and forward, Louisiana Medicaid will reimburse genetic testing for Lynch Syndrome and FAP.
In fee for service (FFS) Medicaid Genetic testing for Lynch Syndrome and FAP must be approved by the fiscal intermediary’s Prior Authorization Unit (PAU). Information regarding this policy, medical necessity criteria for coverage and the required documentation is forthcoming, and will be found at www.lamedicaid.com under the Provider Manuals link within the Professional Services Manual.
Please contact the appropriate Managed care Organization if there are questions concerning their policies and prior authorization process. In addition, questions regarding FFS Medicaid should be directed to Molina Provider Relations at (800) 473-2783 or (225) 924-5040.
Attention FQHCs and RHC Providers
Amendment to Medicaid Methodology of Reimbursement for Long- Acting Reversible Contraceptives to FQHCs and RHCs
Effective January 1, 2019 Louisiana Medicaid will reimburse for long-acting
reversible contraceptives (LARCs) separate from the prospective payment system
(PPS) rate to FQHCs and RHCs.
Reimbursement shall be separate from the FQHC and RHC PPS rate and will be the
lesser of the Durable Medical Equipment fee for service rate on file or the actual
acquisition cost (AAC), for entities participating in the 340B program.
Questions regarding this message and fee for service claims should be directed to
Molina Provider Relations at (800) 473-2783 or (225) 924-5040.
Updates to Healthy Louisiana related policy, systems and claims processing changes
are plan specific and are the responsibility of each health plan. For questions
regarding Healthy Louisiana updates and prior authorization requirements, please
contact the appropriate health plan.
Attention Durable Medical Equipment Providers
Durable Medical Equipment (DME) Coverage of Breast Pumps
Effective for dates of service January 1, 2019, double electric breast pumps will be covered equipment without prior authorization. Recipients must present with a prescription for the breast pump and documentation of infant delivery to a DME provider. Louisiana Medicaid will only provide coverage for the personal-use, double electric breast pumps. Hospital grade, manual, or single breast pumps will not be covered. Nursing mothers will be eligible for one breast pump per delivery within a three (3) year period.
Additionally, Medicaid will cover the appropriate breast pump supplies once every 180 days. A prescription for the supplies will be required.
Medicaid will allow replacement of breast pumps purchased within the past three (3) years from the date of request and after expiration of manufacturer's warranty. Replacement and warranty is subject to policy in the Durable Medical Equipment provider manual.
Questions regarding this message and fee for service claims should be directed to Molina Provider Relations at (800) 473-2783 or (225) 924-5040.
Questions regarding managed care claims should be directed to the appropriate managed care organization.
Attention Durable Medical Equipment Providers
Long-Term Continuous Glucose Monitoring Device
Effective January 1, 2019, Louisiana Medicaid will reimburse for long-term continuous glucose monitoring devices through the durable medical equipment program. Prior authorization is required and recipients must meet one of the following eligibility criteria:
- Diagnosis of type I diabetes with recurrent, unexplained, severe hypoglycemia (glucose levels <50 mg/dl), or impaired hypoglycemia awareness that puts the recipient at risk or
- Pregnant recipient with poorly controlled type 1 diabetes evident by recurrent, unexplained hypoglycemic episodes, hypoglycemic unawareness, or postprandial hyperglycemia, or recurrent diabetic ketoacidosis.
NOTE: Louisiana Medicaid will not consider short term CGMs as a covered device.
Updates to the Durable Medical Equipment provider manual are forthcoming.
Questions regarding fee for service Medicaid should be directed to Molina Provider Relations at (800) 473- 2783 or (225) 924-5040.
Questions regarding managed care claims should be directed to the appropriate Managed Care Organization.
Reimbursement Changes for Physician-Administered Drugs
Medicare Crossover Claim Adjustments
Louisiana Medicaid has recently revised the reimbursement methodology for physician-administered drugs in a physician office setting effective with dates of service July 1, 2018.
Fee-for-service (FFS) Medicare crossover claims previously processed for physician-administered drugs(Jcodes) or payable vaccines beginning with date of service July 1, 2018 have been adjusted/recycled as appropriate based on the updated reimbursement rate.
Providers can expect to see the results of this process as it applies to Medicare crossover claims on the remittance advice of October 30, 2018.
This action will affect Professional Services, Take Charge Plus and applicable Immunization claims.
Please contact Molina Provider Relations at (800) 473-2783 or (225) 924-5040 if there are questions related to this matter for FFS claims. Questions related to the Healthy Louisiana managed care organizations' updates should be directed to the specific health plan.
Attention Providers of Preventive Medicine Visits
Amendment to Louisiana Medicaid policy
Effective for dates of service on or after December 1, 2018, Louisiana Medicaid will reimburse for one well-woman gynecological examination per calendar year for women aged 21 and over, when performed by a primary care provider or gynecologist. This is in addition to the current service provision of one preventive medicine visit for adults aged 21 years and older.
These service changes are in effect to allow women to receive the necessary primary care and gynecological components of their annual preventive screening visits. This additional component is not to facilitate duplicative services. Providers should continue to bill with the appropriate preventive medicine CPT codes, with the visit reflecting the specific medical nature of the service.
Questions regarding this message and fee-for-service claims should be directed to Molina Provider Relations at (800) 473-2783 or (225) 924-5040.
Questions related to managed care claims should be directed to the appropriate Managed Care Organization (MCO).
ATTENTION PROVIDERS OF HOME HEALTH SERVICES
Louisiana Medicaid has implemented changes required by The Centers for Medicare and Medicaid Services (CMS) in accordance with 42 CFR 440.70 for home health services, and in line with Medicaid State Plan updates.
Effective December 1, 2018 Louisiana Medicaid Fee for Service beneficiaries aged 21 and over will now require Prior Authorization (PA) for skilled nursing and home health aide services.
For further in formation see web notice title “ATTENTION PROVIDERS OF HOME HEALTH
SERVICES” located on www.lamedicaid.com.
PHYSICIAN REQUIREMENTS FOR ORDERING HOME HEALTH SERVICES
The Centers for Medicare and Medicaid Services (CMS) requires a face-to-face encounter between a beneficiary and their certifying physician, or an allowed non-physician practitioner, to occur no sooner than 90 days prior to the start of home health services, or no later than 30 days after the start of home health services.
It is the responsibility of the home health agency to acquire the face-to-face encounter documentation and submit it to Molina, as soon as possible for both emergent and non-emergent home health services requests.
For further information see web notice title “PHYSICIAN REQUIREMENTS FOR ORDERING HOME HEALTH SERVICES” located on www.lamedicaid.com.