PROVIDER UPDATE
Volume 17, Issue 2
April 2000
General Medicaid Information
The Louisiana Medicaid Program strives to make all providers aware of the range and scope of services available to recipients through its program. This knowledge enables providers to provide medically necessary services, make referrals for needed services, or assist recipients in obtaining medically necessary
services.
Medicaid Services and Access
In an effort to assist providers with general information concerning Medicaid services and access, included in this issue of the Provider Update is a listing of services available, eligibility limitations, and access information. The listing appears on the colored insert of this newsletter.
Additionally, providers should be aware that Unisys Provider Relations Field Analysts are available to visit providers upon request and to provide training to new providers and their office staff. Providers are encouraged to request analyst assistance in training staff to bill Medicaid claims, resolving complicated billing issues, and increasing awareness of other programs and services
offered.
EPSDT Recipient Eligibility
The newest eligibility category covering EPSDT Medicaid eligible children up to 19 years of age, which became effective November 1, 1998, is called LaCHIP (Louisiana Children�s Health Insurance Program).
LaCHIP, an expansion of Medicaid for children who do not qualify under other eligibility categories, provides coverage to additional needy children residing in the state. Children who are eligible through this expansion program are reffered to as �optional targeted low-income children.� These children cannot be eligible for Medicaid under any other eligibility group, including CHAMP, LIFC, or the regular Medically Needy Program. Also, children eligible through this category do not have health
insurance.
Provider Workshops
The 2000 annual provider training workshops will include a new informational session covering LaCHIP and Medicaid services available to EPSDT recipients to age 21. If you are a provider who services or refers EPSDT recipients for services, please plan to attend this informative workshop. The 2000 annual workshops will begin in mid-September. Please watch for upcoming information concerning the workshop schedule.
Provider Required to Accept Medicaid
(RA Message 3/14/2000, 3/21/2000, 3/28/2000)
We have begun receiving calls asking if it is acceptable to refuse to accept Medicaid when a patient has both Medicare and Medicaid. A provider may not refuse to accept Medicaid in this circumstance. HCFA, through an OBRA 89 provision, mandates acceptance of assignment under Medicare for individuals who are eligible for both Medicare and Medicaid. Additionally, some, if not all Medicare Provider Manuals also indicate that if a Medicare beneficiary is also a recipient of Medicaid, the provider must accept assignment on claims for services rendered, regardless of the provider�s participation status in the Medicare program.
Providers Must Notify Medicaid of Area Code Change
Providers whose telephone area code is changing from 318 to 337 should be aware that their Medicaid provider records will not be updated automatically to show the correct area code. Providers MUST notify the DHH Provider Enrollment Unit of the change as soon as possible. Please submit the change in writing to DHH Provider Enrollment at P.O. Box 91030, Baton Rouge, LA 70821, or by fax to (225) 342-3893. These requests must include the provider�s name and seven-digit Medicaid provider number to ensure the appropriate files are updated.
Contract Arrangements with Private Insurance
(RA Message 3/14/2000, 3/21/2000, 3/28/2000)
Some providers contract with private insurance companies to provide services at a reduced rate. Policy has been clarified regarding these situations. Medicaid is intended to make payment only where there is a recipient legal obligation to pay. This means that the discounts established with the insurance company must be passed along to Medicaid, and Medicaid is not responsible for paying on charges over and above the contracted rate. Please make sure your Medicaid billing method includes these discounts.
Funding for Intrathecal Baclofen Announced
The Bureau of Health Services Financing is pleased to announce funding, effective with date of service November 1, 1999, for intrathecal baclofen therapy for the treatment of severe spasticity of spinal cord or cerebral origin and for the surgical implantation of the programmable infusion pump by which ITB is delivered. All claims for chronic infusion with ITB must be
PRIOR AUTHORIZED.
Age Restriction
Four years of age or older
Place of Service Restriction
Hospital inpatient, only. Hospitals may obtain pre-certification for the stay by following the inpatient hospital precertification
process.
Diagnoses Covered
The following diagnoses are considered appropriate for ITB treatment and infusion pump
implantation:
A. Meningitis
B. Encephalitis
C. Dystonia
D. Multiple Sclerosis
E. Spastic Hemiplegia
F. Infantile Cerebral Palsy
G. Other Specified Paralytic Syndromes
H. Acute, but Ill-Defined, Cerebrovascular Disease
I. Closed Fracture of Base of Skull
J. Open Fracture of Base of Skull
K. Closed Skull Fracture
L. Fracture of Vertebral Column w/Spinal Cord Injury
M. Intracranial Injury of Other and Unspecified Nature
N. Spinal Cord Injury w/o Evidence of Spinal Cord Injury
Criteria for Patient Selection
Consideration shall be given for Medicaid reimbursement for implantation of an ITB infusion pump if the treatment is considered medically necessary, the candidate is four years of age or older with a body mass sufficient to support the implanted system, and any one or more of the following criteria is
met:
A. Inclusive Criteria for Candidates with Spasticity of Cerebral Origin:
1. There is severe spasticity of cerebral origin with no more than mild athetosis;
2. The injury is older than one year;
3. There has been a drop in Ashworth scale of 1 or more;
4. Spasticity of cerebral origin is resistant to conservative management;
5. The candidate has a positive response to test dose of intrathecal baclofen.
B. Inclusive Criteria for Candidates with Spasticity of Spinal Cord Origin:
1. Spasticity of spinal cord that is resistant to oral antispasmodics or side effects unacceptable in effective doses;
2. There has been a drop in Ashworth scale of 2 or more; or
3. The candidate has a positive response to test dose of intrathecal
baclofen.
C. Caution should be exercised when considering ITB infusion pump implantation for candidates who: have a history of autonomic dysreflexia; suffer from psychotic disorders; have other implanted devices; or utilize spasticity to increase function such as in posture, balance, and
locomotion.
D. Exclusive Criteria. Consideration for an implantation of an ITB infusion pump shall not be made if the candidate:
1. Fails to meet any of the inclusion criteria;
2. Is pregnant, or refuses or fails to use adequate methods of birth control;
3. Has a severely impaired renal or hepatic function;
4. Has a traumatic brain injury of less than one year pre-existent to the date of the screening dose;
5. Has a history of hypersensitivity to oral baclofen;
6. Has a systematic or localized infection which could infect the implanted pump; or
7. Does not respond positively to a 50, 75, or 100 mcg intrathecal bolus of Lioresal during the screening trial
procedure.
Billing for the Bolus Injections
The Medicaid Program will reimburse providers for the cost of the OUTPATIENT bolus injections given to candidates for ITB infusion treatment even if the patient fails the screening trial procedure. Professional providers may bill for these injections by submitting HCPCS code J0476 (Injection, Baclofen, 50 mcg for intrathecal trail) on a HCFA 1500 to Unisys Corporation for each date on which an injection was given. These injections do not have to be prior authorized. The fee for code J0476 is $55.13 ($51.27 effective date of service
2-1-2000).
Prior Authorization
Prior Authorization for chronic infusion of ITB shall be requested after the screening trial procedure has been completed but
prior to pump implantation.
The request to initiate chronic infusion shall come from the multidisciplinary team which evaluates the patient. On this multidisciplinary team should be a neurosurgeon or an orthopedic surgeon, a physiatrist and or neurologist, the patient�s attending physician, a nurse, a social worker and allied professionals (physical therapist, occupational therapist, etc.).
These professionals shall have expertise in the evaluation, management, and treatment of spasticity of cerebral and spinal cord origin and shall have undergone training in infusion therapy and pump implantation by Medtronic or an equally recognized product supplier with expertise in intrathecal baclofen.
The following documentation shall be labeled Unisys Prior Authorization Unit - Request for ITB Therapy
and shall be submitted in one package by the multidisciplinary team to Box 14919, Baton Rouge, LA
70898-4919:
1.) A recent history with documentation of assessments in the following areas:
- Medical and Physical
- Neurological
- Functional
- Psychosocial
2.) Ashworth scores taken before and after the administration of the ITB test
dose(s).
3.) Documentation of any other findings about the patient�s condition which would be of interest to or would assist the Medical Review team in making a decision regarding the patient�s need for chronic infusion, i.e., a videotape of the trial
dosage.
Billing for the Cost of the Infusion Pump
Hospitals will be reimbursed by Medicaid for their purchase of the infusion pump but must request prior authorization for it by submitting a Form PA-01 to the Prior Authorization Unit at Unisys. The PA-01 should be submitted as part of the multidisciplinary team�s packet. Hospitals will not be given a PA number for the pump until a prior authorization request for surgery has been received from the surgeon who will perform the procedure. If the surgeon�s request is approved, the hospital will then be given a PA number for the pump. To be reimbursed for the device, hospitals shall submit HCPCS procedure code E0783 (Implantable programmable infusion pump) to Unisys on a HCFA 1500 claim form with the words DME written in red on the top of the form and the PA number written in Item 23. Reimbursement for the pump, the catheter, and the catheter passer shall be $7, 870.59 ($6, 824.07 effective date of service
2-1-2000).
Billing for the Implantation of the Infusion Pump and Catheter
Implantation of the infusion pump must be prior authorized. The surgeon who implants the pump shall submit a Form PA-01 to the Prior Authorization Unit as part of the disciplinary team�s packet. The surgeon must use his/her individual, rather than group, provider number on the PA-01. The provider shall bill for the implantation of the intraspinal catheter by submitting either CPT procedure code 62350 or code 62351 (Implantation, revision, or repositioning of intrathecal or epidural catheter, for implantable reservoir or implantable infusion pump; without or with laminectomy) on a HCFA 1500 to Unisys Corporation. Code 62350 is reimbursed at $405.09 ($376.73 effective with date of service 2-1-2000), and code 62351 is reimbursed at $598.99 ($557.06 effective with date of service 2-1-2000). The PA number given to the surgeon must be written in Item 23 on the HCFA 1500 in order for payment to be claimed.
To receive reimbursement for the implantation of the infusion pump, code 62362 (Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming) shall be submitted. The fee for this code is $407.36 ($378.84 effective with date of service 2-1-2000.
Codes 62350, 62351, and 62362 are also payable to assistant surgeons, anesthesiologists, and non-anesthesiologists-directed
CRNAs. Assistant surgeons will receive 20% of the flat fee for their services, and anesthesiologists and non-anesthesiologists-directed CRNAs will receive base units plus X the coefficient of $13.50 ($12.56 per unit effective with date of service 2-1-1000). If anesthesia is administered concurrently with that of another or other procedures, reimbursement for the supervising anesthesiologist and the CRNA shall be made according to the policy stated on page 10-8 of the
Physician Services manual. These professionals will not be reimbursed for their services unless/until the surgeon has received approval from the PA Unit to perform the
surgery.
Billing for Replacement Pumps and Catheters
Replacement pumps (HCPCS code E0783) shall be billed on a HCFA 1500 claim form just like the recipient�s original pump was billed; i.e., with the letters �DME� written in red on the top.
Replacement catheters shall be billed in like manner by use of HCPCS code E0785 ($345.04 until date of service 2-1-2000 and then $320.89). A copy of Prior Authorization�s original approval letter must be attached to the claim form in addition to documentation explaining the reason(s) a new and/or catheter is/was
needed.
Billing for Reservoir Refills and Pump Maintenance
CPT procedure codes 62367 ($39.61, then decreasing to $36.84 on date of service 2-1-2000), 62368 ($59.46, then decreasing to $55.30 on date of service 2-1-2000) and 96530 ($29.61 (this code exempted from reductions implemented on date of service 2-1-00)) shall be billed on a HCFA 1500 to claim reimbursement for reservoir refills, pump analysis and maintenance, and reprogramming.
Codes 62367 and 62368 are payable only to physicians with specialties in anesthesiology and neurological surgery.
New Forms for Reporting Abuse, Neglect, and Misappropriation
Administrators of nursing homes and intermediate care facilities for the mentally retarded were informed in a letter dated November 5, 1999 that effective November 29, 1999 new forms would be required for reporting abuse, neglect and misappropriation. Effective 2/23/00 providers will be able to access the forms and instructions via the internet at:
http://www.dhh.state.la.us/HSS/index.htm.
The HSS-AB-01 form (24 hour report) must be completed on each client/resident allegedly victimized as a result of abuse, neglect, misappropriation, injuries of unknown origin (which could possibly be due to abuse) and unexpected deaths. The form must be completed legibly and in its entirety. Note: The time the incident occurred needs to be included in the report. It should be sent to the Health Standards Section at fax # (225) 342-5292 or mailed to P.O. Box 3767, Baton Rouge, LA 70821-3767. It is due within 24 hours of occurrence or discovery of the incident. In cases involving unknown origin or unexpected deaths, the report is due within 5 working days of occurrence or discovery. If the investigation of an incident involving unknown origin or unexpected death reveals there was no abuse or neglect, do not report to Health Standards. For example, incidents determined to be accidental, non-intentional or related to a diagnosed medical or psychiatric condition which results in no injury or minor injury, that is addressed by the facility should not be submitted to Health Standards. These incidents should be documented in the medical record.
Form HSS-AB-02 should be completed as a follow-up to the HSS-AB-01 to report the outcome of the investigation and the determination in regard to the allegation(s) of abuse, neglect, misappropriation, injuries of unknown origin and unexpected deaths. This form is to be submitted only to report the results of a pending investigation and is due within 5 working days of submission of the initial report to Health Standards. Providers who do not have access to the internet and need copies of the forms or have additional questions concerning completion, may call (225) 342-5779 for nursing home and (225) 342-0253 for
ICF/MR.
School Nurse Cannot Bill for Medication Administration
(RA Message 3/14/2000, 3/21/2000, 3/28/2000)
School Boards may not bill Medicaid for the administration of medication. This duty is within the scope of the School Board�s responsibility. Neither X0187, nor 99211 should be billed for medication administration by a school nurse.
Billing on the UB92 Claim Form
When billing on the UB92 claim form for a dosage of 10,000 units or above of Epotin, the medical justification form must be attached to each claim. Also, the most recent hematocrit and the date of that hematocrit are required for review of payment. The absence of the correct justification form, the most recent hematocrit and the date of that hematocrit will cause the claim to be denied with a 772 error code (Send notes justifying number of units billed).
Reimbursement of Outpatient Surgical Procedures
Certain surgical procedures are covered by the Louisiana Medicaid Program if they are performed as outpatient. Reimbursement to hospitals for the performance of these outpatient surgical procedures is made on a flat-fee per service basis, not to exceed the Medicare payment rate.
Hospitals must bill outpatient surgery charges with revenue code 490 (HR490)for an ambulatory surgery from the Outpatient Surgery List. These same surgical procedures may be provided on an inpatient basis only under particular circumstances and only if prior authorization for the procedure is obtained before the procedure is performed.
The hospital training packet issued for annual provider workshops in the fall of 1999 ("Hospital/Distinct Part Psychiatric Unit/Free Standing Psychiatric Hospital Medicaid Issues for 1999") includes a list of surgical procedures on pp. 27-34. For each surgical code subject to the flat fee pricing, the list contains the ICD-9 procedure code, a description of the code, the procedure's surgical grouping, and the reimbursement for the procedure. The following surgical codes were inadvertently excluded from the published list.
Please add the following codes to those published in the 1999 hospital training packet. Providers who wish to request a 1999 training packet may do so by contacting Unisys Provider Relations at (800) 473-2783 or (225)
924-5040.
ICD-9 Surgical Procedures and Outpatient Surgical Groupings
| ICD-9 Code |
Description |
Surgical Grouping |
Reimbursement |
| 8050 |
IV DISC EXCS / DSTRUCT NOS |
3 |
282.40 |
| 806 |
EXCISION OF SEMILUNAR CARTILAGE OF KNEE |
4 |
320.56 |
| 8073 |
SYNOVECTOMY OF WRIST |
4 |
320.56 |
| 8074 |
SYNOVECTOMY OF HAND AND FINGER |
4 |
320.56 |
| 8078 |
SYNOVECTOMY OF FOOT AND TOE |
4 |
320.56 |
| 8087 |
OTHER LOCAL EXCISION OR DESTRUCTION OF L |
3 |
282.40 |
| 809 |
OTHER EXCISION OF JOINT |
4 |
320.56 |
| 8094 |
OTHER EXCISION OF JOINT OF HAND AND FING |
3 |
282.40 |
| 8116 |
METATARSOPHALANGEAL FUSION |
4 |
320.56 |
| 8118 |
OTHER FUSION OF TOE |
4 |
320.56 |
| 8128 |
INTERPHALANGEAL FUSION |
4 |
320.56 |
| 8131 |
ARTHROPLASTY OF FOOT AND TOE WITH SYNTHE |
4 |
320.56 |
| 8139 |
OTHER ARTHROPLASTY OF FOOT AND TOE |
4 |
320.56 |
| 8171 |
ARTHROPLASTY OF HAND AND FINGER WITH SYN |
4 |
320.56 |
| 8179 |
OTHER REPAIR OF HAND AND FINGER |
4 |
320.56 |
| 8186 |
ARTHROPLASTY OF CARPALS WITH SYNTHETIC P |
4 |
320.56 |
| 8201 |
EXPLORATION OF TENDON SHEATH OF HAND |
1 |
220.39 |
| 8203 |
BURSOTOMY OF HAND |
1 |
220.39 |
| 8209 |
OTHER INCISION OF SOFT TISSUE OF HAND |
2 |
262.36 |
| 8211 |
TENOTOMY OF HAND |
1 |
220.39 |
| 8212 |
FASCIOTOMY OF HAND |
4 |
320.56 |
| 8221 |
EXCISION OF LESION OF TENDON SHEATH OF H |
3 |
282.40 |
| 8232 |
EXCISION OF TENDON OF HAND FOR GRAFT |
3 |
282.40 |
| 8233 |
OTHER TENONECTOMY OF HAND |
4 |
320.56 |
| 8235 |
OTHER FASCIECTOMY OF HAND |
4 |
320.56 |
| 8251 |
ADVANCEMENT OF TENDON OF HAND |
3 |
282.40 |
| 8279 |
PLASTIC OPERATION ON HAND WITH OTHER GRA |
4 |
320.56 |
| 8284 |
REPAIR OF MALLET FINGER |
3 |
282.40 |
| 8285 |
OTHER TENODESIS OF HAND |
3 |
282.40 |
| 8286 |
OTHER TENOPLASTY OF HAND |
3 |
282.40 |
| 8289 |
OTHER PLASTIC OPERATIONS ON HAND |
4 |
320.56 |
| 8291 |
LYSIS OF ADHESIONS OF HAND |
3 |
282.40 |
| 8301 |
EXPLORATION OF TENDON SHEATH |
2 |
262.36 |
| 8303 |
BURSOTOMY |
2 |
262.36 |
| 8309 |
OTHER INCISION OF SOFT TISSUE |
2 |
262.36 |
| 8314 |
FASCIOTOMY |
4 |
320.56 |
| 8321 |
BIOPSY OF SOFT TISSUE |
2 |
262.36 |
| 8331 |
EXCISION OF LESION OF TENDON SHEATH |
3 |
282.40 |
| 8339 |
EXCISION OF LESION OF OTHER SOFT TISSUE |
3 |
282.40 |
| 8341 |
EXCISION OF TENDON FOR GRAFT |
4 |
320.56 |
| 8342 |
OTHER TENONECTOMY |
4 |
320.56 |
| 8345 |
OTHER MYECTOMY |
4 |
320.56 |
| 835 |
BURSECTOMY |
3 |
282.40 |
| 8361 |
SUTURE OF TENDON SHEATH |
3 |
282.40 |
| 8364 |
OTHER SUTURE OF TENDON |
3 |
282.40 |
| 8387 |
OTHER PLASTIC OPERATIONS ON MUSCLE |
3 |
282.40 |
| 8388 |
OTHER PLASTIC OPERATIONS ON TENDON |
3 |
282.40 |
| 8391 |
LYSIS OF ADHESIONS OF MUSCLE, TENDON, FA |
3 |
282.40 |
| 8411 |
AMPUTATION OF TOE |
2 |
262.36 |
| 8412 |
AMPUTATION THROUGH FOOT |
2 |
262.36 |
| 850 |
MASTOTOMY |
3 |
282.40 |
If an outpatient hospital claim includes any ICD-9 procedure having the first two digits in the range of "01" through "86," the claim must be billed using revenue code 490 (HR490). If any of the procedures billed are on the Outpatient Surgery List, the claim will be reimbursed as in the past, depending upon the procedure's surgical grouping:
Group 1 - $ 220.39
Group 3 - $ 282.40
Group 2 - $ 262.36
Group 4 - $ 320.56
Insert
|
Medicaid
Services
|
|
Service
|
How to Access Services
|
Eligibility
|
Covered Services
|
Comments
|
Contact Person
|
|
Appointment Scheduling Assistance�See
KIDMED
|
|
|
|
|
|
|
Audiological
Services�See
KIDMED, EPSDT
Health Services,
Rehabilitation
Clinic Services, Hospital Outpatient Services, Physician/
Professional Services
|
|
|
|
|
|
|
Case Management Services-Elderly and Disabled Adult Waiver
|
Parish Councils on Aging
|
Medicaid
recipient must be in the Elderly Waiver
|
Coordination
of Medicaid and other services. The Case Manager helps to identify
needs, access services and coordinate care.
|
Services
must be prior authorized by DHH, Division of Home and Community-Based
Waivers. The provider will
submit requests for the Prior Authorization.
|
Janith Miller
225/342-9535
|
|
Case Management Services-EPSDT Targeted Populations
|
Office of
Citizens with Develop-mental Disabilities
Regional Offices
|
All Medicaid
Recipient ages
0 to 21
Must be on the MR/DD
waiver WAITING LIST
To
get on the waiting list, call OCDD Regional Office
|
Coordination
of Medicaid and other services. The
Case Manager helps to identify needs, access services and coordinate
care.
|
Services
must be prior authorized by DHH, Division of Home and Community-Based
Waivers. The provider will
submit requests for the Prior Authorization.
|
Janith Miller
225/342-9535
|
|
Case Management Services-High Risk Pregnant Women
|
Office of Public Health
|
Medicaid
recipients residing in the New Orleans area (Orleans, Jefferson, St.
Charles, St. John, and St Tammany parishes)
|
Coordination
of Medicaid and other services. The
Case Manager helps to identify needs, access services and coordinate
care.
|
Services
must be prior authorized by DHH, Division of Home and Community-Based
Waivers. The provider will
submit requests for the Prior Authorization.
|
Janith
Miller 225/342-9535
|
|
Case Management Services-HIV
|
Office of Public
Health-HIV/Aids
and
HIV Case Management Agencies
|
Medicaid
recipient must have HIV as determined by a physician
|
Coordination
of Medicaid and other services. The
Case Manager helps to identify needs, access services and coordinate
care.
|
Services
must be prior authorized by DHH, Division of Home and Community-Based
Waivers. The provider will
submit requests for the Prior Authorization.
|
Janith Miller
225/342-9535
|
|
Case Management Services-Infants and Toddlers
|
Child Search Coordinator in the local education agency
|
Medicaid
recipients must be 0 to 3 years of age and have documented and
established medical condition
|
Coordination
of Medicaid and other services. The
Case Manager helps to identify needs, access services and coordinate
care.
|
Services
must be prior authorized by DHH, Division of Home and Community-Based
Waivers. The provider will
submit requests for the Prior Authorization.
|
Janith Miller
225/342-9535
|
|
Case Management
Services-Mentally Retarded/
Developmentally Delayed
|
Office of
Citizens with Develop-mental Disabilities
Regional Offices
|
Medicaid recipients
0 to 21 years of age
Recipient must be
in the MR/DD WAIVER
Currently
there is a waiting list to be included the Waiver. Contact OCDD Regional Office to get on waiting list.
|
Coordination
of Medicaid and other services. The
Case Manager helps to identify needs, access services and coordinate
care. Some services
available through the Waiver are: Respite Services; Substitute Family
Care Services; Supervised Independent Living; and Habilitation/Supported
Employment.
|
Services
must be prior authorized by DHH, Division of Home and Community-Based
Waivers. The provider will
submit requests for the Prior Authorization.
|
Janith Miller
225/342-9535
|
|
Chemotherapy Services�See
Hospital Services-Outpatient
|
|
|
|
|
|
|
Chiropractic Services
|
KIDMED Medical Screening Provider
|
Medicaid
recipients 0 to 21years of age
|
Spinal
manipulations
|
Medically
necessary manual manipulations of the spine when the service is provided
as a result of a referral from a KIDMED medical screening provider.
|
Kandis Whittington
225/342-9490
|
|
Dental Care Services
|
Dentist
|
Medicaid recipients
0 to 21 years of age
Medically Needy
(Type case 20, 21, and 25) recipients are not eligible for dental care
services.
Presumptive
Eligible (Type case 12) recipients are not eligible for dental care
services.
|
Annual dental
screening consisting of an examination, radiographs, prophylaxis,
topical fluoride application and oral hygiene instruction
Preventive
procedures
Certain surgical and
restorative services (extractions, fillings, etc.)
Dental prosthetics
(dentures, partial dentures, etc.)
Orthodontics
require Prior Authorization and are paid only when there is a cranio-facial
deformity, such as cleft pallette, resulting in a handicapping
malocclusion. The recipient
should see a Medicaid enrolled orthodontist to determine if the child
meets the criteria of a handicapping malocclusion.
|
Some services must
be Prior Authorized and the dental provider will arrange for the request
of Prior Authorization in those situations.
|
Terri Norwood
225/342-9403
|
|
Durable Medical Equipment (DME)
|
Physician
|
All
Medicaid recipients
|
Medical equipment
and appliances such as wheelchairs, leg braces, hearing aids, etc.
Medical
supplies such as ostomy supplies, etc.
|
All services must be
prescribed by a physician and must be Prior Authorized.
DME providers will
arrange for the Prior Authorization request.
|
Gene King
225/342-3930
|
|
Eyeglass
Services�See Optical
Services
|
|
|
|
|
|
|
EPSDT Health Services-Early Intervention Centers
|
Early Intervention Centers
or Childnet
|
All
Medicaid recipients 0 to 3 years of age.
|
Audiological
Services
Occupational Therapy
Physical Therapy
Speech &
Language Therapy
Psychological
Therapy
|
All
EPSDT Health Services through EICs must be included in the
infant/toddlers Individualized Family Services Plan (IFSP)
|
Randy Davidson
225/342-3935
|
|
EPSDT Health Services-School Board
|
School
|
All
Medicaid recipients 3 to 21 years of age
|
Audiological
Evaluation and Therapy
Occupational
Evaluation and Therapy
Physical Evaluation
and Therapy
Speech &
Language Evaluation and Therapy
Psychological
Evaluation including a battery of tests, interviews, and behavioral
evaluations that appraise cognitive, emotional, social, and behavioral
functioning and self-concept.
Psychological
Therapy includes diagnosis and psychological counseling for children and
their parents.
|
Services are
performed by the School Board
All
EPSDT Health Services must be included in the child�s Individualized
Education Program (IEP).
|
Randy Davidson
225/342-3935
|
|
EPSDT Personal Care Services
|
Physician and
Personal Care Attendant Agencies
|
All
Medicaid recipients 0 to 21not receiving Personal Care Attendant
waiver services. However, once a recipient receiving Personal Care
Attendant waiver services has exhausted those services they are then
eligible for EPSDT Personal Care Services
|
Basic personal
care-toileting & grooming activities.
Assistance with
bladder and/or bowel requirements or problems
Assistance with
eating and food preparation
Performance of
incidental household chores, only for the recipient
Accompanying,
not transporting, recipient to medical appointments
|
The Personal Care
Agency must submit the prior authorization request.
Recipients receiving
Personal Care Services must have physician�s prescription and meet
medical criteria
Does not
include medical tasks
Provided
by providers enrolled in Medicaid to provide Personal Care Attendant
waiver services.
|
Randy Davidson
225/342-3935
|
|
Family Planning Clinic Services
|
Family Planning
Clinics
Office of Public Health
|
Female
Medicaid recipients between the ages of 10 and 60
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Doctor
visits to assess the patient�s physical status and contraceptive
practices; nurse visits; physician counseling regarding sterilization;
nutrition counseling; social services counseling regarding the
medical/family planning needs of the patient; family planning EPSDT
screenings; contraceptives; and certain lab services
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Medicaid will
reimburse for routine family planning services for family planning
purposes only and not treatment of other medical conditions.
Referrals should be made for other medical problems as indicated.
Family Planning
Clinics
do not provide services to pregnant women.
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Terri Norwood
225/342-9403
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Hearing Aids� See
Durable Medical Equipment
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Hemodialysis Services�See
Hospital-Outpatient Services
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Home Health
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Physician
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All Medicaid
recipients
Medically
Needy (Type Case 20 & 21) recipients are not eligible for Aide
Visits or Physical Therapy.
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Intermittent/part-time
nursing services including skilled nurse visits
Aide Visits
Physical
Therapy Services
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Recipients receiving
Home Health must have physician�s prescription and meet
�Homebound� criteria.
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Derek Stafford
225/342-2495
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Home Health�
Extended
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Physician
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Medicaid
recipients 0 to 21 years of age
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Intermittent/part-time
nursing services including skilled nurse visits
Aide Visits
Physical Therapy
Services
Recipients
0 to 3 must receive physical therapy through an Early Intervention
Center. See EPSDT Health
Services-School Board
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Recipients receiving
Home Health must have physician�s prescription and meet
�Homebound� criteria.
Recipients 0 to 21
receive unlimited services.
Extended
Home Health requires Prior Authorization.
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Derek Stafford
225/342-2495
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Hospice Services
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Nursing Home
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Medicaid
recipients also receiving Medicare in Nursing Homes
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Medicare
allowable services
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Willene Mire
225/342-2604
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Hospital�
Inpatient
Services
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Physician/
Hospital
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All Medicaid
recipients.
Medically
Needy (Type Case 20 & 21) under age 22 are not eligible for
Inpatient Psychiatric Services.
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Inpatient hospital
care needed for the treatment of an illness or injury which can only be
provided safely & adequately in a hospital setting
Includes
those basic services that a hospital is expected to provide
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Inpatient
hospitalization requires Pre-certification and Length of Stay
assignment. Hospitals are
aware of this and will submit the request to the Prior Certification
Unit.
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Derek Stafford
225/342-2495
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Hospital�
Outpatient Services
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Physician/
Hospital
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All
medicaid recipients
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Diagnostic &
therapeutic outpatient services, including outpatient surgery and
rehabilitation services
Therapeutic and
diagnostic radiology services
Chemotherapy
Hemodialysis
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Outpatient
rehabilitation services require Prior Authorization.
Provider will submit request for Prior Authorization.
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Derek Stafford
225/342-2495
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Hospital�
Emergency Room Services
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Physician/
Hospital
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All
medicaid recipients
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Emergency
Room services
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Recipients 0 to
21 years�No service limits
Recipients 21 and older�Limited
to 3 emergency room visits per calendar year (January 1 - December 31)
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Derek Stafford
225/342-2495
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Immunizations
See KIDMED
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KIDMED�
EPSDT Services
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Louisiana KIDMED
Birch
& Davis Health Management Corporation
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All
Medicaid recipients 0 to 21 years of age
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Medical Screenings
(including immunizations and certain lab services)
Vision Screenings
Hearing Screenings
Dental
Screenings
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Recipients are
linked to KIDMED providers for screening services
KIDMED providers
identify suspected conditions and make necessary referrals for treatment
KIDMED
will link recipients to providers
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KIDMED (Birch &
Davis)
(800) 259-4444
Janis Souvestre
225/342-9496
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Laboratory Tests
and
X-Ray Services
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Physician
Hospital
Independent Labs
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All
Medicaid recipients
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Diagnostic
testing and X-Ray services ordered by the attending or consulting
physician
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Portable
x-rays are paid only for recipients who meet homebound criteria
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Gail Williams
225/342-1417
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Medical
Transportation
Emergency
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Emergency ambulance providers
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All
Medicaid recipients
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Hospital-based
emergency ambulance services may be reimbursed if circumstances exist
that make the use of any conveyance other than an ambulance medically
inadvisable for transport of the patient.
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Carroll Davis
225/342-9485
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Medical
Transportation
Non-Emergency
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Regional Dispatch
Offices
Dispatch Office
Phone Numbers:
Alexandria
800-446-3490
Baton Rouge
800-259-1944
Lafayette/
Lake Charles
800-864-6034
Monroe
800-259-1835
New Orleans
800-836-9587
Shreveport
800-259-7235
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All
Medicaid recipients
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Transportation to
and from medical appointments
The
medical provider the recipient is being transported to does not have to
be a Medicaid enrolled provider but the services do have to be Medicaid
covered services. Dispatch
office will make this determination.
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Recipients should
call dispatch offices 48 hours before the appointment.
Transportation
to out-of-state appointments can be arranged but requires Prior Authorization
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Carroll Davis
225/342-9485
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Mental Health Rehabilitation Services
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Office of Mental Health Local Office
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All Medicaid
recipients except some who are Medicare/
Medicaid
eligible
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Clinical and Medical
Management
Individual and
Parent/Family Intervention
Supportive and Group
Counseling
Individual &
Group Psycho-social Skills Training
Behavior
Intervention Plan Development
Service
Integration
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All
services must be Prior Authorized.
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Mary Norris
225/342-1247
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Midwife Services
(Certified Nurse Midwife)�See
Physician/
Professional Services
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Occupational and Physical Therapy Services
See EPSDT Health Services, Rehabilitation Clinic Services,
Hospital-Outpatient Services, Home Health-Extended
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Optical Services
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Optometrist or Ophthal-mologist
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All Medicaid
recipients
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Recipients 0 to
21
Examinations and
treatment of eye conditions, including examinations for vision
correction, refraction error.
Regular eyeglasses
or medically necessary specialty eyewear and contact lenses if
prior approved.
Other related
services, if necessary
Recipients 21 and
over
Examinations and
treatment of eye conditions, such as infections, cataracts, etc.
Examinations for vision correction, refraction error, are not
covered.
If
Medicare/Medicaid, cataract glasses are covered.
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Recipient 0 to 21
Specialty eyewear
and contact lenses, if medically necessary for EPSDT eligibles requires
Prior Authorization. The
provider will submit requests for the Prior Authorization.
Prescriptions are
required for all glasses/contacts.
After a prescription is obtained, the recipient may see an
optical supplier to receive the glasses/contacts.
Recipient 21 and
over
Eyeglasses
are not covered.
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Terri Norwood
225/342-9403
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Orthodontic Services�See
Dental Care Services
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Nurse
Practitioners�
See Physician/
Professional Services
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Personal Care
Attendant Waiver Services
See Case
Management Services-Mentally Retarded/
Develop-
mentally Delayed
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Personal Care Services�See
EPSDT Personal Care Services
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Pharmacy Services
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Pharmacies
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All Medicaid
recipients except some who are Medicare/
Medicaid
eligible
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Covers prescription
drugs except:
Cosmetic drugs
Cough & cold preparations
Diet Aids
Fertility drugs
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Co-payments
($0.50-$3.00) are required except for some recipient categories
Recipients
under age 21 pay NO co-payments
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M.J. Terrebonne
225/342-9768
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Physical Therapy �See
EPSDT Health Services, Rehabilitation Clinic Services,
Hospital-Outpatient Services, Home Health-Extended
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Physician/
Professional Services
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Physician or
Healthcare
Professional
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All
Medicaid recipients
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Professional
medical services including physician, nurse midwife, nurse practitioner,
chiropractic, audiology and other services.
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Some services
require Prior Authorization. Providers
will submit request for Prior Authorization.
Services are subject
to limitations and exclusions. Your
physician or healthcare professional can help you with this.
Recipients 21and
over are limited to 12 outpatient visits per state fiscal year (July 1 -
June 30) unless an extension is granted.
Your physician or healthcare professional must request an
extension if deemed necessary.
Recipients
under 21 are not limited to the number of outpatient visits.
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Kandis Whittington
225/342-9490
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Podiatry Services
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Podiatrist
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All
Medicaid recipients
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Office visits
Certain
radiology & lab procedures and other diagnostic procedures
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Some
prior authorization, exclusions, and restrictions apply.
Providers will submit request for Prior Authorization.
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Kandis Whittington
225/342-9490
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Pre-Natal Care Services
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Physicians & Certified Registered Nurse Midwives
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Female
Medicaid recipients of child bearing age
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Office visits
Other pre- &
post-natal care and delivery
Lab
services
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Some
limitations apply
|
Kandis Whittington
225/342-9490
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Psychiatric Hospital Care Services�See
Hospital-Inpatient Services
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Psychological Evaluation and Therapy Services
See EPSDT Health Services
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Rehabilitation Clinic Services
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Physician
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All
Medicaid recipients
|
Occupational Therapy
Physical Therapy
Speech,
Language and Hearing Therapy
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All services must be
Prior Authorized
The
provider of services will submit the request for Prior Authorization
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Gail Williams
225/342-1417
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Residential
Institutional Care or Home and Community Based Waiver Services
Adult Day Care
Personal Care
Attendant
Elderly and
Disabled Adult
Mentally
Retarded/
Develop-mentally
Delayed
(MR/DD)
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Adult Day Care
Centers
Independent
Living Centers
Parish Councils
on Aging
Office of
Citizens with Develop-mental Disabilities Regional Offices
(OCCD)
|
Medicaid recipients
21 years of age and older who meet SSI Disability criteria and
Institutional Admission criteria
Medicaid recipient
under the age of 65 who meet SSI Disability criteria and Institutional
Admission criteria
Medicaid recipients
21 years of age and older who meet SSI Disability criteria and
Institutional Admission criteria
Individuals
disabled during the developmental period who meet SSI Disability
criteria and Institutional Admission criteria
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Adult Day Healthcare
Case Management
Services
Personal Care
Attendant Services
Case Management
Services
Personal Care home
modifications
Case Management
Services
Person Emergency
Response Systems
An array of services
to provide support to maintain persons in the community
An
alternative to ICF/MR (Group Homes)
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Waiver Unit
225/219-4280
Lynn Nicholson
225/925-1860
Lynn Nicholson
225/925-1860
Waiver Unit
225/219-4280
|
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Speech and Language Evaluation and Therapy�See
EPSDT Health Services, Rehabilitation Clinic Services,
Hospital-Outpatient Services
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Substance Abuse Clinic Services
|
Office of
Addictive Disorders
or
Physician
|
Medicaid
recipient 0 to 21 years of age
|
Individual, Group
and Family Counseling
Medical treatment
Medical injections
Pyschosocial,
Psychiatric, Medical, and other evaluations
|
Services are
provided by the Office of Addictive Disorders
Recipients
must be diagnosed with an addictive disorder prior to receiving services
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Gail Williams
225/342-1417
|
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Transportation
See Medical
Transportation
|
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X-Ray Services�See
Laboratory Tests and X-Ray Services
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