PROVIDER UPDATE
VOLUME 9, NUMBER 1
FEBRUARY 1992
Unisys Name Change
Unisys/LA. Medicaid is now operating under the name Paramax
Systems Corporation, a Unisys company. Paramax
Systems Corporation, headquartered in McLean, Virginia, is a $2 billion
information systems company with 17,000 employees.
A subsidiary of Unisys Corporation, Blue Bell, Pennsylvania, Paramax is
an experienced leader in complex systems integration, custom electronic
products, and related professional services for civil and defense agencies of
the U.S. Government, Canada, and nations on five continents.
Our recent name change, however, need not concern the
Medicaid provider community in Louisiana. Now,
more than ever, we are dedicated to meeting our customer's needs and
expectations. Paramax has a long
history of proven performance and a long list of satisfied customers.
Paramax is market-driven and technology-enabled.
Simply put, we develop and apply leading-edge technologies to meet our
customer's needs and requirements. We
blend our technical substance with a corporate style that stresses quality,
cost-effectiveness, program performance, and partnership with our customers.
Ultimately, what makes Paramax special is the proud
reputation we've achieved among our customers for being a responsible
contractor, for keeping promises, for getting the job done.
Our promise to the provider community of Louisiana is to
build on our core strengths and to forge new partnerships in the years to come.
The PE-50 Form
When completing the Provider Enrollment Form (PE-50),
providers should submit a one-page form (front and back).
In other words, providers should not submit the form on two separate
pages.
In addition, providers should ensure that the PE-50 has an
original signature. Stamped or
copied signatures are not accepted.
Provider Relations
The Provider Relations inquiry staff strives to respond to
provider inquiries quickly and efficiently.
However, due to the number of incoming calls for other departments that
must be transferred out of Provider Relations, the inquiry staff is having
difficulty responding to Provider Relations related inquiries in a timely
manner. Thus, to help us serve the
provider community better, we are requesting that providers telephone Provider
Relations only when they have questions concerning printed policy, claims
processing problems, or the status of particular claims.
NOTE:
We request that providers review and reconcile their Remittance Advices
before they call Provider Relations for the status of a claim.
Providers who have questions concerning EMC may telephone (504)
924-7051.
Providers who have questions concerning Prior Authorization
may telephone (504) 928-5263 or
1-800-488-6334.
NOTE:
PA claims billing problems, however, should be addressed to Provider
Relations.
Providers requesting check amounts, eligibility
information, and the number of remaining recipient days or visits may call our
VIPS line at 1-800-776-6323.
NOTE:
Effective immediately, we are no longer able to transfer providers out of
Provider Relations to other departments.
HCFA 1500 Billers and the Prior Authorization Number
Providers billing on the HCFA 1500 form with a Prior
Authorization number will not be paid if they simply attach the PA form to the
claim form and do not enter the PA number in the correct block on the claim
form. The PA number must be entered
in Block #23B and the PA form must be attached to the claim form in order for
the claim to be paid.
EMC Submitters
Reminder
Providers have been mailing or submitting claims directly
to the EMC Unit rather than mailing them to the correct EMC Post Office Box.
Using the EMC label with the appropriate box number will decrease the
processing turnaround time.
KIDMED Providers
New Management and New Services
Birch & Davis Health Management Corporation, Inc. (BDHMC),
under contract to DHH will begin administering the KIDMED (EPSDT) Program on
February 17, 1992. Effective March
1, 1992, a new KIDMED screening claim form must be used for all KIDMED medical,
vision, and hearing screening claims. During
the month of February, providers were trained on the administrative aspects of
KIDMED.
KIDMED will offer various services to support providers,
including linking eligibles with providers, Denver II Developmental Screening
Test training, review and authorization of screening claims, and assistance with
denied claims. Also, at the
provider's request, KIDMED is available to schedule screening appointments for
children 12 months of age and older and to arrange transportation.
A provider representative is available in the Baton Rouge
KIDMED office to assist providers and may be reached at 1-800-259-8000 or (504) 928-9683 in Baton Rouge.
Hospitals and Physicians
Therapeutic Passes
Medicaid of Louisiana is aware of the importance of
temporary leave of absence or therapeutic pass from the hospital in the
treatment of psychiatric and rehabilitative patients. However, it would be contradictory to our policy to pay the
per diem rate for a day of service when the patient was not in the facility to
receive any services. Consequently,
therapeutic pass days are not considered covered days under our program and
should be reflected as non-covered days on the UB-92 claim form regardless of
the length of absence.
In addition, providers should note that the medical
necessity for the therapeutic pass must be documented in the patient's chart by
the attending physician, and any pass exceeding 72 hours must be considered a
discharge.
Providers may consult pages 11-7 and 11-8 of the Hospital
Services Provider Manual for instructions on how pass days should be
recorded on the claim form.
NOTE:
Only one leave of absence may be included on a claim form.
Hospitalized Nursing Home Residents
When a nursing home resident is admitted to a Distinct Part
Psychiatric Unit of an acute care hospital, Medicaid of Louisiana will pay to
reserve the recipient's nursing home bed for 10 days per hospitalization just as
it does for an acute care admission. In
the event of the hospitalization exceeding 10 days, the recipient or his family
may pay the nursing home to continue to reserve a bed.
The practice of discharging the patient for 24 hours and
then readmitting him in order to "protect" his nursing home bed is
contrary to policy for both the Long Term Care program, as well as the Hospital
program.
Form 152-N
Form 152-N (Title XIX Medical Assistance Medical
Eligibility Inquiry for Newborns) is the form used to verify a child's birth to
a Medicaid recipient. This form
serves as documentation of the child's name, date of birth, race, and
enumeration. Provided below is
information concerning the requisition, completion, routing, and processing of
the Form 152-N.
Requisitioning Forms
Supplies of the Form 152-N must be requested in writing.
Providers should send their requests to Paramax Systems Corporation at
the following address:
Paramax Systems Corporation
8591 United Plaza Blvd.
Baton Rouge, LA 70809
Attention: Forms Distribution
Paramax Systems Corporation will then route the request to
the State Division of Administration warehouse, which will be responsible for
filling the request. The
Eligibility Operations Section, which handles the deeming of eligibility
process, cannot order forms, verify the order, or check on the status of the
order. Providers
should ensure that the return address for the order is a street address, not a
box number.
Completing the Form
Providers should type or print all
information on the form. If
printing the information, providers should use a hard tipped pen and bear down
hard enough so the third carbon is legible.
Providers should not
attach proof of birth or acknowledgement of paternity to the form.
The Form 152-N serves as proof of birth and/or relationship to the
mother. Acknowledgements of
Paternity should be sent to the parish Office of Family Support.
Providers should
complete every block on the form. They
should provide full names -- first name, middle name or initial, and last name
-- for the mother, father (if appropriate), and the newborn.
We cannot assume that the child and the mother have the same last name,
so the provider must specify the newborn's last name.
The entries labeled Mother's Phone
Number, Medical Record Number, and
Patient Account Number are the only optional entries on the form.
However, it is important to include a phone number to assist in making
referrals for KIDMED services.
Full addresses for the physicians to whom forms must be
sent must be provided, and zip codes must
be included on each form. Stamps
may be used for the addresses.
For provider groups, the group name and address should be
used on the forms, so that mailing may be consolidated to one mailing per day to
the group. We recommend that the
group stamp be used in the address portion of the form.
A form will be sent to each provider listed on the form.
It is not necessary for each provider (the hospital and each physician)
to complete a separate form. If the
doctor's name and address are provided on the form completed by the hospital, it
is not necessary for the doctor(s) to complete another request.
Redundant requests will be completed but will slow the process.
Usually, physicians other than the pediatrician and the OB/GYN
should not be included on the form. The
names and addresses of the specialists should be included only when services
have been provided by a specialist and the Medicaid number for the newborn is
needed for billing services that have already been provided.
Mothers will be issued monthly medical cards.
For future care, providers should have the client present the monthly
medical card.
Routing the Form
Providers should route the form to the state Eligibility
Operations Section in Baton Rouge only when the mother is already eligible and
is already receiving Medicaid on the date of the child's birth.
The Eligibility Operations Section cannot determine the eligibility of
the mother or complete a pending application.
If the mother has an application pending for Medicaid, the Form 152-N
should be sent to the Office of Family Support in the parish in which the mother
is a resident. The Form 152-N may
be used by the parish office as proof of the birth.
If the mother has not applied for Medicaid prior to the
birth, she should be referred to the parish Office of Family Support, and the
provider should give her some proof of birth for the baby because she will need
to present proof at the time of application.
Processing at BHSF
The Eligibility Operations staff will process the Form
152-Ns in the date order of receipt.
When the forms arrive, they are date stamped and logged in
for processing in order of receipt, and the Eligibility Operations staff makes
every effort to meet the 10-day turnaround timeframe on the forms.
The 10-day timeframe starts on the date of receipt; the timeframe does
not begin on the date of birth or the date the form was mailed from the
provider's office.
Forms which do not include all identifying information for
the mother or the child will be returned to the hospital/physician for
completion.
When forms are completed with only the physician's last
name, e.g., Dr. Black, a copy of the form cannot be provided to the physician
unless there is complete address provided for the physician.
The Eligibility Operations staff will not conduct research to determine
the provider name and address.
Forms on which the hospital's/doctor's name is complete but
on which there is no address or there is an incomplete address will be mailed
but will be delayed until the name and/or address can be researched.
Researching addresses will not be given priority over regular processing.
Hospitals Only
Exhausted Medicare Part A Benefits Claims
It has come to our attention that hospitals are
experiencing difficulty in receiving reimbursement for Medicare/Medicaid claims
when the Part A benefits have been exhausted.
To facilitate the reimbursement of such claims, we request that providers
submit these crossover claims with documentation of the Part A benefits being
exhausted, such as a notice of Medicare Claim Determination or a Medicare Part A
EOB. A copy of the Medicare Part B
EOB must also be attached to the
claim.
In addition, for bill type 111, the dates of service on the
notice of Medicare Claims Determination or the Part A EOB must match the date of
service on the claim in order for the exhaustion of the Part A benefits to be
verified.
NOTE:
Providers should note that all such claims should be submitted to the
attention of Peggy Misner at the Unisys Post Office Box for crossover claims, P.
O. Box 91023.
Correct Procedures for Claims Resolution
It has come to our attention that there is a
misunderstanding among providers regarding the correct procedure for claims
resolution. If a claim is over one
year old, then it must be submitted to Unisys Provider Relations with a request
for an override of the timely filing limitations and documentation which
reflects that the claim was originally timely filed.
Documentation of timely filing may be a remittance advice or
correspondence from either Unisys or the Bureau of Health Services Financing
which identifies the claim and reflects that it was filed within one year of the
date of service.
If a claim is over two years old, then it must be submitted
to the Hospital Program with a request for an override of the timely filing
limitation, documentation of timely filing, and documentation of the provider's
attempt to resolve the billing problem. If
the provider does not have documentation of timely filing because the patient
became eligible for Medicaid retroactively, then the claim must be submitted to
the MMIS Section with documentation of retroactive eligibility.
Documentation of retroactive eligibility may be either a copy of the
patient's Medicaid eligibility card or correspondence from the local Office of
Family Support which identifies the period of retroactive eligibility.
NOTE:
Claims involving retroactive eligibility must be submitted to MMIS within
one year of the patient becoming Medicaid eligible.
Claims requiring resolution should be sent to one of the
following addresses:
One Year Old:
Paramax Systems Corporation
P. O. Box 91024
Baton Rouge, LA 70821
Attention: Provider Relations
Two Years Old:
B.H.S.F.
P. O. Box 91030
Baton Rouge, LA 70821
Attention: Sandra Victor, Hospital
Program
Retroactive
Eligibility:
B.H.S.F.
P. O. Box 91030
Baton Rouge, LA 70821
Attention: Cathy Troy, MMIS Claims
Resolution
Providers should note that compliance with these guidelines
for claims resolution will facilitate the processing of claims.
Physicians Only
Electrocardiograms for Medicare/Medicaid Recipients
Effective with date of service January 1, 1992, for
Medicare/Medicaid recipients only, reimbursement for the interpretation of
electrocardiograms, procedure codes 93000, 93010, 93040, and 93042, will be
included in the provider's fee for the office, hospital, or consultation visit.
However, these procedure codes will remain payable for straight Medicaid
recipients.
Pharmacists & Prescribers
Desipramine HCL
Effective for services beginning December 11, 1991, the
Federal Upper Limits on Desipramine HCL (generic name), 10 mg. tablets, have been
suspended.
Pharmacy Program Revisions
The pharmacy program has revised the requirement that
prescriptions be filled initially within 10 days of the date prescribed and the
requirement that prescriptions for Schedule II narcotic analgesics be filled
within 24 hours. The new
requirements state that prescriptions should be filled within six months of the
date prescribed and the
prescriptions for Schedule II narcotic analgesics should be filled within 5 days
of the date prescribed. Transfer of a prescription from one pharmacy to another is
allowed if less than 6 months has passed since the date prescribed, and in
accordance with the Louisiana Board of Pharmacy regulations. The
effective date of these revisions is January 21, 1992.
Amendments to Appendix C
Providers should make the following corrections to the
10/18/91 printing of Appendix C:
|
Manuf.
Code
|
Pharmaceutical
Company
|
Amendment
|
Eff.
Date
|
|
00117
|
Cord Laboratories,
Inc.
|
Off Prog.
|
01/01/92
|
|
00165
|
Blaine Company, Inc.
|
Add
|
01/01/92
|
|
00224
|
Konsyl Pharmaceuticals
|
Add
|
01/01/92
|
|
00477
|
Obetrol
Pharmaceuticals
|
Add
|
01/01/92
|
|
00478
|
Rexar Pharmaceutical
Corp.
|
Add
|
01/01/92
|
|
00538
|
Landry
Pharmaceuticals, Inc.
|
Add
|
01/01/92
|
|
11763
|
Perry Medical-Hall
Laboratories
|
Add
|
01/01/92
|
|
15398
|
Hydromag Int. Ltd.
|
Off Prog.
|
01/01/92
|
|
38137
|
Spectrum Chemical Mfr.
Corp.
|
Add
|
01/01/92
|
|
48017
|
Hermal Pharmaceutical
Labs
|
Add
|
01/01/92
|
|
49452
|
Spectrum Chemical Mfr.
Corp.
|
Add
|
01/01/92
|
|
50962
|
Xactdose, Inc.
|
Off Prog.
|
01/01/92
|
|
51201
|
American Dermal
Corporation
|
Add
|
01/01/92
|
|
55081
|
Clinical
Pharmaceutical, Inc.
|
Add
|
01/01/92
|
|
58118
|
Johnson Laboratories,
Inc.
|
Add
|
01/01/92
|
|
58194
|
Scandipharm, Inc.
|
Add
|
01/01/92
|
|
58605
|
American
Pharmaceuticals
|
Add
|
01/01/92
|
|
58634
|
American Generics,
Inc.
|
Add
|
01/01/92
|
|
58607
|
Martin Elwealor Pharm.,
Inc.
|
Add
|
01/01/92
|
|
58940
|
Reliable Drugs
|
Add
|
01/01/92
|
|
59010
|
Medi-Plex Pharm., Inc.
|
Add
|
01/01/92
|
|
70074
|
Ross Laboratories
|
Delete
|
|
LADUR Provider Education: Anti-Anxiety
Drugs (H2F)
Program Statistics:
Drug expenditures for this therapeutic class represents
2.0% ($3,066,631) of the total drug program expenditures during the last fiscal
year (7/1/90 to 6/30/91). During
the first five months of the current fiscal year, 2.4% of payments were for
anti-anxiety agents. In addition,
172,224 anti-anxiety prescriptions were filled fiscal year 1990/91.
Expenditure examples include the following:
|
|
|
Average
Payment/Rx
($)
|
Total
Paid*
($)
|
|
Buspar
|
10mg
5mg
|
54.33
32.86
|
788,053
179,397
|
|
Xanax
|
1mg
.5mg
.25mg
|
37.31
27.37
23.27
|
284,480
538,159
391,442
|
|
Diazepam
|
10mg
5mg
2mg
|
6.37
7.89
7.12
|
|
|
Lorazepam
|
2mg
1mg
.5mg
|
12.93
9.25
8.44
|
|
*
Reflects ingredient cost +
dispensing fee (7/1/90 to 6/30/91). Generics
not totaled.
Combination Use of
Anti-Anxiety Agents:
Currently, there are several anti-anxiety agents available
for use in the treatment of acute anxiety.
Most are classified chemically as benzodiazepines.
In addition to these, there are older agents, e.g., meprobamate, and
newer agents, e.g., buspirone, in common use.
Although all the benzodiazepines are thought to act primarily through
similar mechanisms of action, it is clear that slight differences in these
agents may justify the selection of a unique agent for a particular indication.
Based on duration of action, the anti-anxiety agents may be
broadly classified as either short, intermediate, or long acting.
These differences in duration of action are largely due to differences in
absorption, distribution, metabolism, and/or elimination.
The unique characteristics of each agent may cause a physician to prefer
one benzodiazepine over another. However,
there is not documentation to the added value of the use of multiple anxiolytics
in a single patient when the agent is used solely for the treatment of
anxiety in individual patients.
Short-Term Use of
Combinations of Anti-Anxiety Agents:
While combinations of anti-anxiety agents are not
considered useful in the treatment of anxiety, there may be circumstances where
the use of combinations of anti-anxiety agents for short periods of time might
be expected. One use might be the
continuation of benzodiazepine anti-anxiety agent. Generally, this switch can be accomplished by the combined
use of buspirone with a benzodiazepine for two to four weeks during the
initiation of busipirone therapy. Such
a switch presupposes an intention to discontinue appropriately the
benzodiazepine after a period of concomitant therapy.
Another circumstance where the use of combinations of anti-anxiety agents
might occur is when attempts are made to switch a patient from a shorter-acting
benzodiazepine to a longer-acting agent from the same class.
A third situation would be the prolonged use of a single benzodiazepine
during the withdrawal process while slowly tapering dosages.
While tapering guidelines generally suggest a period as short as four
weeks, experience dictates the need for tapering benzodiazepine dosages over
periods as long as twelve weeks. Benzodiazepine
withdrawal syndrome is a medically debilitating latrogenic situation that
requires careful monitoring by a physician.
Tapering Schedules:
Tapering of benzodiazepine dosages in patients
addicted/tolerant to the benzodiazepines has become accepted therapy.
Without an adequate period of tapering, the patient may be subject to a
variety of usually successful but potentially serious adverse reactions.
Therefore, the clinical literature is strongly supportive of the need for
tapering benzodiazepine withdrawal or at least monitoring the risks associated
with benzodiazepine withdrawal. Currently
accepted protocols include, but are not limited to, a 10% reduction in dosage at
weekly intervals. Generally, a
period of six of twelve weeks is required in such tapering programs.
An evaluation of patient profiles usually shows some evidence of the
tapering of dosages.
New uses of benzodiazepine in the treatment of panic
disorders often result in the use of higher than usual doses of anti-anxiety
agents, which may result in situations where patients become dependent upon
higher dosages of these agents. Caution
should be exercised during implementation of withdrawal programs in these
patients because of the increased potential for serious withdrawal symptoms.
A longer tapering schedule may need to be employed.
References available upon request.
Transportation Providers
Rate Increase for Emergency Ambulance Providers
According to the new Louisiana state law passed last July,
1990, Medicaid is required to pay the same amount as Medicare for emergency
ambulance services. Consequently,
effective January 1, 1992, a rate increase for Medicaid Emergency Ambulance
services has been approved. The new
rates, as well as the old rates, the corresponding codes, and their descriptions
are listed below.
NOTE:
Providers will be paid only for a maximum of one emergency base rate
and/or one emergency transfer rate service per recipient per day.
Emergency Ambulance
Transportation Rates (Eff. 1/1/92)
|
Description
of Procedure Code
|
Code
|
Old
Amount
$
|
New
Amount
$
|
|
Base Rate Basic Life
Support
|
A0010
|
148.69
|
155.68
|
|
Base Rate Advanced
Life Support
|
A0220
|
275.36
|
288.30
|
|
Transfer Rate (BLS)
|
Z5100
|
148.69
|
155.68
|
|
Transfer Rate (ALS)
|
Z5101
|
275.36
|
288.30
|
|
Vehicle Miles,
Advanced Life Support
|
A0221
|
3.43
|
3.59
|
|
Vehicle Miles, Basic
Life Support
|
A0020
|
3.43
|
3.59
|
|
Base rate Advanced
Life Support, where non-reusable supplies are billed separately (For use
only with Medicare crossovers; the payment amount equals the Medicare and
Medicaid combined payments.)
|
A0223
|
143.18
|
149.92
|
NEMT Insurance Requirements
Medicaid policy requires that each provider maintain
insurance coverage on all vehicles. This
means that the insurance polices must be in the provider's name, not in the
driver's. In addition, the Bureau
of Health Services Financing must be listed as the party to be notified in the
event of cancellation. Coverage
maintained must provide, at a minimum, liability insurance for the amounts of
$100,000 per person and $300,000 per accident, or a $300,000 combined service
limits. The liability service
policy must cover specifically described autos, hired autos, and non-owned autos.
Analysis of DME Denials
Due to the high denial rate of DME claims, we decided to
analyze the first four checkwrites of December, 1991, to determine the reason
why so many DME claims are being denied.
Our analysis showed that 1443 claim lines were denied
during this period. Then, we broke
down the reasons for the denials into eight categories.
The results of our analysis are as follows:
Categories and
Percentages of DME Denials
|
Error Category
|
Percentage (%)
|
|
1.
Recipient
|
09.42
|
|
2.
Provider
|
00.97
|
|
3.
Procedure Code
|
02.98
|
|
4.
Diagnosis Code
|
3.95
|
|
5.
TPL or Medicare Coverage
|
10.12
|
|
6.
Duplicate Claim
|
12.54
|
|
7.
Other, i.e., invalid dates
|
14.28
|
|
8.
Prior Authorization Related Denials
|
45.74
|
The Prior Authorization related denials were analyzed
further. We found that the largest
number were denied for "Procedure Requires PA."
The second largest category was for "Date of Service Not Covered by
PA." Also, there were quite a
few denials for "Claim Exceeds PA Limit."
The remaining categories were less than 1.5%.
Paramax Systems Corporation wants providers to get their
claims paid on the first submission; therefore, we would like to assist
providers with billing problems. Providers
who have billing problems should contact our Provider Relations Department to
schedule a visit from one of our field analysts.
They are available to train providers' billing personnel in billing for
Medicaid claims of all types.