RA Messages for November 27, 2012


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 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.


Effective for dates of service August 1, 2012, the inpatient and out-patient rates paid to acute care hospitals (excluding small rural) were reduced by 3.7% of the rate on file as of July 31, 2012. Also effective for dates of service on or after August 1, 2012, the inpatient and out-patient rates paid to state-owned acute care hospitals, excluding Villa Feliciana and inpatient psychiatric services were reduced by 10% of the rate on file as of July 31, 2012. These reimbursement rate reductions have been implemented.                                           

Claims for dates of service August 1, 2012-September 25, 2012 that were adjudicated prior to September 25, 2012 will be systematically adjusted on the RA of November 20, 2012. Providers should contact the Provider Relations unit at (800) 473-2783 or (225) 924-5040 with billing or policy questions.      


Providers that submitted claims for services with a diagnosis of behavioral health during the month of February 2012, after the implementation of Bayou Health and before the implementation of the Louisiana Behavioral Health Program (LBHP) received erroneous claim denials.  System edits were changed for the implementation of Bayou Health that prevented these claims from being paid by Molina. The editing has been corrected and the claims denied in error are recycled for payment by Molina on the RA of 11/06/12.  We apologize for any inconvenience this may have caused providers.        


Medicaid pays Ambulatory Surgery Centers a facility fee, and policy allows ASC providers to bill one procedure per recipient per day, even when multiple procedures are performed.  Through logic changes and the implementation of Bayou Health, ASC providers began billing claims with an attending provider included on the claim.   This caused these claims to process differently and by-pass the duplicate logic that denies multiple procedures billed on the same date of service for the same recipient.  Thus, multiple procedures were paid to providers in some instances.

The inclusion of the attending provider number on ASC claims also allowed these claims to process through ClaimCheck editing and cause the denial of the claims submitted by the attending physician for his/her services related to the surgical procedure.

New edit 077 (Attending Provider Must Be Billing Provider) has been added to deny ASC claims that include an attending provider number.  When ASC claims are billed correctly without an attending provider number, the system will deny claim lines for multiple procedures done on the same day for the same recipient.  It will also eliminate the ClaimCheck editing issues between the ASC and physician claims.

Claims paid to ASCs that indicated an attending provider number are being systematically voided on the RA of 11/13/12 and must be resubmitted correctly for one procedure with no attending provider.  Physicians that received claim denials for their services related to ASC procedures may resubmit these claims for processing.  Questions may be directed to Molina Provider Relations at (800) 473-2783 or (225) 924-5040.