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.

ATTENTION PROFESSIONAL PROVIDERS OF LABORATORY SERVICES
CLIA Waived Tests

Clinical Laboratory Improvement Amendments (CLIA) claim edits are applied to all claims for laboratory services that require CLIA certification. Those claims that do not meet the required criteria will deny. Providers with waiver or provider-performed microscopy (PPM) certificate types may be paid only for those waiver and/or PPM codes approved for billing by CMS. These providers are to add the 'QW' modifier to the procedure code for all CLIA waived tests they submit for reimbursement.

Please note that the claims processing system has been updated and the following Current Procedural Technology (CPT) codes have been added to the codes that require a “QW” modifier for dates of service on or after the associated effective date. Please visit http://www.cms.gov for a complete listing of effective dates for the recently added codes. For more CLIA information, please see Appendix A in the Professional Services Provider Manual.

82962 83861 86308 86803 87806
83036 83986 86386 87389 87809
83516 84450 86780 87502  

Please contact Molina Provider Relations (800) 473-2783 or (225) 924-5040 if you have any questions regarding this matter.

ATTENTION PHYSICIAN AND OUTPATIENT HOSPITAL PROVIDERS
CALCULATING OBSTETRIC ULTRASOUND SERVICE LIMITS:

Effective with date of processing November 2, 2015, fee-for-service (FFS) Medicaid claims processing logic has been updated to reflect the intent of policy related to obstetrical ultrasound procedures. The intent of Obstetrics ultrasound policy in the Professional Services manual for those providers who are not maternal-fetal medicine specialists, is to allow two complete OB ultrasounds to be performed per pregnancy without the need for hard copy documentation.

Under this policy:

  • When professional providers perform the entire service in their office (the OB ultrasound and interpretation), the service counts as 1 ultrasound.
  • When the ultrasound itself is done in an outpatient hospital setting and the professional provider (not employed by the outpatient hospital) performs the interpretation, each provider’s component counts as one half (i.e. the claim from the outpatient hospital and the claim for the professional interpretation together count as 1 ultrasound). In these cases, both providers (outpatient hospital and professional) are expected to bill their portion of the service and are expected to bill the same procedure code for the same date of service. The procedure codes must match to be reimbursed.
  • If the complete procedure (OB ultrasound and interpretation) is provided by the outpatient hospital, the service counts as one ultrasound.

Please contact Molina Provider Relations (800) 473-2783 or (225) 924-5040 if you have any questions regarding this matter.

ATTENTION ALL PROVIDERS

Molina is experiencing greater volumes of hard copy claims in which providers use of liquid paper for corrections is causing the pages of the claims to stick together. This practice creates two problems:

(1) The pages are not readable after being pulled apart; and

(2) Pages that are stuck together cause scanning equipment to jam.

Therefore, we request that providers not use liquid correction products to make corrections on claims. Please use either a 'tape-type' product or mark through the error and rewrite the corrected information. All information on the claim form must be clear and readable in order for the claim to be processed correctly.

ATTENTION ALL PROVIDERS SUBMITTING FEE FOR SERVICE
LOUISIANA MEDICAID CLAIMS TO MOLINA

Louisiana Medicaid's 7-digit provider number is required on all claim forms. Each week, Molina rejects and returns paper claims because the 7-digit Louisiana Medicaid provider number is not present on the claim form in the appropriate field. Providers must be enrolled in Louisiana Medicaid and receive a 7-digit provider number in order to bill services to Louisiana Medicaid. If you are an enrolled provider, please ensure the Louisiana Medicaid Provider number is on the claims before mailing. If you are a provider not enrolled in Louisiana Medicaid (whether in-or out-of-state) and you have provided services to a Louisiana Medicaid recipient, you must enroll as a Louisiana Medicaid provider in order to be reimbursed for services rendered.

ATTENTION ALL PROVIDERS
RESUBMISSION OF PAPER CLAIMS TO MOLINA FOR BAYOU HEALTH
SHARED PLAN (UHC OR CHS) MEMBERS

Shared Plan claims received by Molina after the initial one year timely filing limit cannot be processed unless the provider is able to furnish the Shared Plans EOB or Payment Register showing the original claim was filed timely. Molina has received Shared Plan claims where only the private insurance EOB is attached and no Shared Plan EOB or Molina EOB is present. A private insurance EOB does not support proof of timely filing with Medicaid. All outstanding claims over 1 year old must be submitted with either the Shared Plan or Molina EOB indicating proof of timely filing. If a situation involves private insurance, that TPL EOB must also be submitted with the claim, however, it does not replace the EOB required from either the Shared Plan or Molina in providing proof of filing.

Update to ‘ClaimCheck’ Product Editing

McKesson’s ‘ClaimCheck’ product is routinely updated by the McKesson Corporation based on changes made to the 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, CMS National Correct Coding Initiative (NCCI) and/or provider specialty society updates. The ‘ClaimCheck’ product’s procedure code edits are guided by these widely accepted industry standards.

These edit changes went into effect for claims processed beginning with the remittance advice of October 6, 2015. Providers may notice some differences in claims editing; however, most claims will continue to edit in the same manner, but when applicable, claims may now pay or deny for a different reason.

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

ATTENTION HOME HEALTH PROVIDERS
RECOVERY OF OVERPAYMENTS MADE ON THE 11/10/15 RA

A problem was encountered during claims processing, and some home health claims billed with appropriate modifiers were not processed correctly on the 11/10/15 RA. Impacted claims were overpaid at the non-modified rate. The processing problem has been corrected, and all affected claims are being systematically adjusted on the RA of 11/24/15 to recover the overpayments.

No action is required by providers, and we apologize for any inconvenience this has caused.

If you have questions about the contents of this RA, you may contact Molina Provider Relations at 1-800-473-2783 or refer to www.lamedicaid.com.

Attention "Local" Medicaid Pharmacy Providers:

Effective December 1, 2015, the Department of Health and Hospitals will initiate a Managed Care Organization (MCO) claims reimbursement dispute process for "local" pharmacies in accordance with Act 399 of the 2015 Regular Legislative Session. Please see http://www.lamedicaid.com/provweb1/Pharmacy/pharmacyindex.htm for more information.

ATTENTION DENTAL-ORAL SURGEON - PROVIDERS

DHH has identified Dental Services claims (for Provider Type 27-Dentist: Provider Specialty 67-0ral Surgeon) that were inappropriately paid by Legacy Medicaid beginning with date of service 2/1/2015. These claims became the responsibility of the Managed Care Organizations (MCOs) effective 2/1/2015. Therefore, on Remittance Advice 12/01/2015, Molina will void these inappropriately paid claims with edit 507 - submit claim to BYU Health Plan. Providers are required to verify linkage thru e-MEVS or REVS and submit these claims to the recipients' MCO for payment.

Should you have questions related to the voids, please contact Molina Providers Relations at 1-800-473-2783. Questions regarding submission of claims to/payment by the correct entity should be directed to the MCO.

ATTENTION MEDICAL PROVIDERS SUBMITTING SHARED PLAN CLAIMS
THAT DENIED WITH EDIT 625

DHH has directed Molina to systematically recycle all medical claims that denied with edit 625 during Bayou Health Contract Year 1 because the patient was in hospice. The claim dates of service are 2/1/2012 through 1/31/2015, and they will be processed as Legacy (traditional) Medicaid claims through Molina. These recycled claims appear on the 11/24/15 RA.

Some of these claims will pay and others will deny for another, legitimate reason. In circumstances where claims deny and a corrected claim must be resubmitted, the resubmitted claims should be sent to the Molina Provider Relations Correspondence Unit with a request to reprocess the claim. Proof of timely filing and any required supporting documentation must be included.

Should you have any questions regarding these recycled claims, please contact Molina Provider Relations at 1-800-473-2783.