RA Messages for December 28, 2010
PROVIDERS, PLEASE NOTE!!!
If you are unsure
about the coverage of a drug product, please contact the PBM help desk
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
HOSPITAL, PHYSICIAN AND OUTPATIENT RADIOLOGY PROVIDERS
New CPT codes become
effective January 1, 2011. These CPT codes will require prior
authorization (PA) and are included in the Radiology Utilization
Management (RUM) program. The codes are part of the diagnostic CT set
and are listed below:
- 74176 Computed
tomography; abdomen and pelvis; without contrast material
- 74177 Computed tomography; abdomen and pelvis; with contrast
- 74178 Computed tomography; abdomen and pelvis; without contrast
material in one or both body regions, followed by contrast material(s)
and further sections in one or both body regions
If PA is not obtained
for these procedures per the current RUM guidelines, then the procedure
will not be payable by Louisiana Medicaid. For further information
regarding RUM policy and Procedure please visit
NEWS AND EDITING UPDATE MESSAGE
Providers impacted by 'ClaimCheck'
editing are directed to the message entitled "'ClaimCheck' News and Editing
Updates" on the Louisiana Medicaid website homepage at www.lamedicaid.com and/or under the blue
ClaimCheck' icon there for the latest information related to modifications to claims editing via 'ClaimCheck.' Providers may note
updates in the following areas effective with processing reflected on
the RA of December 21, 2010: Allergy immunotherapy, CPT code age
restrictions based on the code definition, new visit frequency, pre and
post-op editing for obstetrical delivery services, and inclusion of
pertinent procedures from the Medicine section of CPT in multiple
surgery reduction processing.
ATTENTION PROVIDERS OF IMMUNIZATIONS
Effective with dates of service January 1, 2011 and forward, providers should no longer use procedure codes 90465, 90466, 90467 and 90468 to
report immunization administration services as they have been deleted from the 2011 Current Procedural Terminology (CPT) manual and therefore these codes will be in non-payable status. Providers should continue
to use procedure codes 90471, 90472, 90473 and 90474 per current Louisiana Medicaid policy to report all immunization administration services.
At this time Louisiana Medicaid will not be using new immunization administration CPT codes 90460 & 90461 and these two new procedure codes
will be in non-payable status.
ATTENTION PROVIDERS THAT SUBMIT MEDICARE PART B CROSSOVER CLAIM
Effective January 1, 2011, LA Medicaid will begin processing Medicare
Part B claim adjustments that electronically cross to Medicaid from the
Medicare carrier through GHI (the coordination of Benefits
Administrator). It will no longer be necessary for providers to
routinely initiate submission of Medicare adjustments as paper claims
with EOMBs attached. Of course, if for any reason an adjustment does
not electronically cross to Medicaid through GHI, providers must submit
them for processing using the process previously in place. As always,
providers should allow ample time for Medicare claims, including
adjustment claims, to be processed by Medicare and electronically
cross to Medicaid before taking action to submit a claim.
ATTENTION PROFESSIONAL SERVICES PROVIDERS
PROCEDURE CODES PAYABLE TO OPTOMETRISTS
Programming logic related to procedure codes payable to optometrists has
been updated effective for dates of service January 1, 2007 forward.
Claims that previously denied with errors 210 "PROVIDER NOT CERTIFIED
FOR THIS PROCEDURE," 298 "INVALID PROCEDURE CODE FOR DATE OF SERVICE"
and 299 "PROC/DRUG NOT COVERED BY MEDICAID" will be systematically
adjusted and will appear on the RA of December 21, 2010. No action is
required by providers.
ATTENTION ANESTHESIA PROVIDERS
A correction was made to the claims processing logic for anesthesia
claims that denied incorrectly for edit 748 (only 1 delivery allowed in
6 months). Claims affected by this change will be recycled on the RA of
December 21, 2010. Please see the Louisiana Medicaid provider website
ATTENTION ALL PROVIDERS
IMPLEMENTATION OF DEC 1, 2010 RATE REDUCTIONS
Due to a funding deficit in Medicaid caused by unfunded increases in
utilization, the Department of Health and Hospitals has implemented a
budget reduction effective December 1, 2010. A portion of this reduction
will come from adjustments to current provider reimbursement rates. The
reimbursement rates for the following provider types have been reduced
by 2% effective for dates of services on or after December 1, 2010:
Early Steps direct services (OT, PT, ST, Audiology & Psychology)
Extended Home Health Nursing Services
Free Standing ESRD Facilities
These rate reductions have been loaded in the system. These rate
reductions began appearing on the RA of December 7, 2010.
ATTENTION HOSPITAL PROVIDERS
IMPLEMENTATION OF DECEMBER 1, 2010 RATE REDUCTIONS
The December 1, 2010 rate reductions for inpatient and outpatient
hospital services have been implemented. Providers will begin seeing
these reductions on their remittance advices beginning with
December 14, 2010. Claims for dates of service after December 1,2010
that have already been adjudicated will be systematically adjusted on
the remittance advice dated December 23,2010 and no action will be
required by providers. The exception to this is if an inpatient stay
spans the December 1,2010 date, these claims then would have to be
voided and split-billed in order to be paid correctly. Refer to the
Office of the State Register's website at
for published rules detailing these reductions.
ATTENTION ALL NON-PHYSICIAN PROVIDERS
DHH has scheduled an additional claims processing cycle for all
non-physician providers for the last week of December. The remittance
advice dates for that week are: Tuesday 12/28/10 and Thursday 12/30/10.
Please alert your staff, your accounting department, and any impacted
business partner, including submitters and billing agents, of this
addition. All claims submitted by physicians will be processed during
the regular cycles of 12/28/10 and 01/04/11. It is important to note
that the EDI deadlines for the last 2 weeks of December are:
12/23 (Thursday) at 3PM for the 12/28 processing cycle;
12/28 (Tuesday) at noon for the 12/30 processing cycle; and
12/30 (Thursday) at noon for the 01/04/11 processing cycle.
The Molina office will be closed on Friday, December 24 and
Friday, December 31.
for dates of service on or after January 1, 2011, the dental procedure
code D0272 will be reimbursable by Medicaid in the Early Periodic
Screening, Diagnosis, and Treatment (EPSDT) Dental Program only once a
year. Complete details can be located on the www.lamedicaid.com website
under the "Dental Providers" link. Contact the LSU Dental Medicaid Unit
at 504-941-8206 or 1-866-263-6534 (toll-free) with any questions.
HOSPITAL PROVIDERS: REIMBURSEMENT OF VAGUS
June 14, 2010, a PA-01 Form is no longer required for hospital providers
for the VNS device. However, reimbursement of the device continues to be
dependent upon approval of the surgeon to perform the procedure.
Hospitals should confirm that the surgeon has received an authorization
for the procedure prior to submitting their claim in order to prevent
The hospital will bill their VNS claim using HCPCS procedure
code C1767 (VNS generator) and/or C1778 (VNS leads) to Molina on a CMS
1500 claim form with the words DME written in red on the top of the form
and the PA number written in Item 23 or through the electronic claims
The claim will pend to the Molina Medical Review Department
for review of the surgeon's approved PA request. If approved, the
hospital claim will be allowed to process for payment; if there is no
valid authorization, the hospital claim will deny with edit 191 (PA
If the recipient is Chisholm, the authorization for the
device will be referred to PAL to assist the recipient in obtaining the
necessary documentation to process the request. This may include
identifying the surgeon to contact in order to assist with the
submission of his/her prior authorization request.
PROVIDERS (EXCEPT ATYPICAL)
to comply with federal requirements to include the National Provider
Identifier (NPI) on all claims. Changes to current claims processing
will be made over the next two months. Providers using the Molina Form
213 for Physician Crossover Adjustments, Professional Crossover
Adjustments, Durable Medical Equipment Adjustments, Durable Medical
Equipment TPL Adjustments, and Physician Adjustments will need to begin
using the CMS-1500 claim form; providers using the Rehabilitation forms
for claims and adjustments (102, 202) will instead be required to use
the CMS-1500 form. Over the coming months, changes to Dental (209, 210),
Pharmacy (211), and KIDMED (KM-3) claim forms will also be introduced to
accommodate these federal requirements. Providers who have software
vendors must alert their vendors of the changes. Please monitor the
Louisiana Medicaid website, www.lamedicaid.com, for an implementation
schedule and more details.
Molina Medicaid Solutions Provider Relations at (800) 473-2783 or (225)
924-5040 should you have any questions related to the implementation of
the rate reductions in any of the previous messages..