Provider Update

Volume 19, Issue 4 

August/September 2002

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Implementation of Hospice Program
RA Message - 7/2/02, 7/9/02, 7/16/02, and 7/23/02
(FIMS # 6602)

The Louisiana Medicaid Program announces that effective July 1, 2002, a Hospice Program was implemented to provide services to terminally ill recipients. 

This program may have significant impact on your reimbursement for services rendered to Medicaid recipients. Once a recipient elects to receive hospice services, the hospice agency is responsible for either providing or paying for all covered services related to the treatment of the recipient�s terminal condition. Therefore, any claims for services related to the terminal illness submitted by a provider, other than the elected hospice agency, will be denied for error edit code 493 - �non hospice provider/submit justification for 
services.� If the claim is not related to the terminal illness the provider should submit the claim with attached justification sufficient to establish that the service was medically necessary and was not related to the terminal condition. 

Claims for prescription drugs, and home and community based waiver services will not be subject to error edit code 493. However, these services will be subject to post-payment review and recoupment may be imposed if it is determined that the service was related to the treatment of the terminal illness. 

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106 Denials
RA Message 9/17/02 and 9/24/02
(FIMS #6646)

Anesthesia providers who are receiving 106 denials (billing provider not primary care providers or service not authorized by primary care provider) on their claims for delivery should resubmit their claims using the same pregnancy-related diagnosis code as that used by the Obstetrician for the delivery.

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Discontinued CPT Codes
RA Message 9/17/02 and 9/24/02
(FIMS #6644)

The CPT codes which were discontinued in the YEAR 2002 issuance of the Current Procedural Terminology will be placed in non-pay status on our files effective with date of service October 1, 2002.

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Dental Program Policy Regarding Radiographs
RA Message 7/8/02, 7/15/02, and 7/23/02
(FIMS #6589)

Post-payment reviews have shown that a number of providers are routinely taking upper and lower anterior periapical radiographs at the time of examination. Medicaid Dental Program policy states that anterior periapical or occlusal radiographs taken routinely at the time of examination are not covered. If a routine practice of taking such radiographs is discovered during post-payment review, treatment records may be reviewed and recoupment of money paid for all such radiographs will be initiated. Anterior periapical radiographs are payable when their purpose is to obtain information in regard to a specific pathological condition other than caries; when serious doubt is entertained in regard to the presence of the permanent dentition, prior to extraction.

Post-payment reviews have shown that a number of providers are billing for the extraction of primary teeth in the advanced stages of natural exfoliation, with little or no therapeutic indication or benefit. Primary teeth that are being lost naturally should not be billed to Medicaid as an extraction. If a 
practice is noted during post-payment review of billing for the extraction of primary teeth that are shown radiographically to be in the advanced stages of root absorption (more than 3/4 of the root is resorbed), i.e., exfoliating naturally, there will be a recoupment of money paid for all such 
therapeutically unnecessary extractions. If the extraction is warranted due to therapeutically indicated circumstances indicated circumstances such as prolonged retention, blocking out of erupting 
permanent teeth, severe decay, abscess with bone loss, or other specifically identifiable indications, a preoperative periapical radiograph should be taken as a diagnostic aid and as a means of documentation. This radiograph must be maintained in the recipient�s record, and must be furnished to 
post-payment review if requested. Written documentation of the reason for the extraction must be noted in the dental treatment record.

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PROVIDER REMINDERS

As part of our contract with DHH, Unisys is required to visually screen claims for critical information necessary for processing. If these items are missing on the claim, they will be returned for correction.

Over the past several years our reporting system has shown us that over 200,000 claims per year are returned before even making it into the system. Our statistics show many of the same errors occur repeatedly. The most common errors are:

1. RECIPIENT ID NUMBER (13 DIGITS) MISSING OR INCOMPLETE FROM ITEM (the correct field on the claim form). 

The 16-digit card control number (CNN) found on the plastic ID cards may not be used to submit claims. The purpose of this number is to access the recipient�s eligibility information through either the Medicaid Eligibility Verification System (MEVS) or Recipient Eligibility Verification System (REVS).

REVS Access Methods (1-800-776-6323) or (225) 216-7387 in Baton Rouge

In order to access REVS, the caller must have a valid 7-digit provider and 13-digit recipient numbers. Without this information the request cannot be processed. Eight digits must be used for all date entries (MMDDYYYY).

At the REVS prompt, enter the 7-digit provider number.

*1 Recipient eligibility

        *1 Enter recipient ID #
        *2 Enter Card Control Number (16-digits) and date of birth, OR
        *3 Enter Card Control Number (16-digits) and Social Security #
        *9 End Call

*3 Last check amount (service gives amount and date of last check)

*9 Ends call

If you do not have access to a touch tone phone, call Provider Relations at 1-800-473-2783 or (225) 924-5040 in Baton Rouge, option 3.

MEVS Eligibility Access Methods (SWIPE CARD ACCESS)

Inquirers may select which way to access the MEVS system according to the information available. Options are listed below. Eight digits must be used for all date entries.

13-DIGIT RECIPIENT ID + DOB (MMDDYYYY)
13-DIGIT RECIPIENT ID + SSN
13-DIGIT RECIPIENT ID + FIRST AND LAST NAME

OR
16-DIGIT CARD CONTROL # + DOB (plus issue date if keyed vs. swiped)
16-DIGIT CARD CONTROL # + SSN (plus issue date if keyed vs. swiped)

OR
RECIPIENT NAME + DOB
RECIPIENT NAME + SSN

OR
DOB + SSN

Incorrect entry of verifying pieces of information will result in a �Not on File� response.


2. PROVIDER SIGNATURE OR HANDWRITTEN INITIALS MISSING. STAMPED OR COMPUTER GENERATED SIGNATURE REQUIRE HANDWRITTEN INITIALS.

3. PROVIDER ID NUMBER (7-DIGITS) MISSING OR INCOMPLETE FROM ITEM (the correct field on the claim form)

4. PROVIDER NUMBER INVALID. PLEASE RESUBMIT WITH THE CORRECT 7- DIGIT PROVIDER NUMBER.

5. PROOF OF TIMELY FILING MISSING.

6. DENIED TURNAROUND DOCUMENT (DTA) EXCEEDS 30 DAYS FROM DATE ON DTA AND RA. RESUBMIT A COPY OF THE CLAIM.

7. THIRD PARTY LIABILITY (TPL) 6-DIGIT CODE(S) MISSING FROM ITEM (the correct field on the claim form)

8. THE ENTIRE EOB MUST BE SUBMITTED TO PROCESS CROSSOVER CLAIM.

9. CHARGES ON THE EOB DO NOT MATCH CHARGES ON THE CLAIM.

Our goal is to process your claims as quickly and efficiently as possible. To expedite payment, please review your claims prior to submission for the presence of all information required, including, but not limited to, the items listed above.

With your cooperation, the payment process will be smoother and decrease the number of paper claims returned to you. If you submit a large volume of paper claims, perhaps you should consider submitting your claims through the electronic media claims process (EMC). This process can decrease your turnaround time from 30 days to 7-14 days. For more information, please contact 225-237-3239.

Unisys has a staff of Field Analysts who are available to help providers with billing problems, clarify state policy, or to train new provider staff members. To schedule an appointment with one of our Field Analysts, please call our Provider Relations Department at 1-800-473-2783 or 225-924-5040.

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Louisiana Medicaid Paper Claim Form Submission Procedures

A new and improved claims data capture technology has been implemented to better serve the Louisiana Medicaid Provider Community. All Louisiana Medicaid paper claims are now scanned and stored on-line.

This process allows the Unisys Provider Relations Department to respond more efficiently to claim inquiries by facilitating the retrieval and research of submitted claims.

If you cannot submit claims electronically, please prepare your paper claim forms according to the following instructions to ensure appropriate and timely processing.

� Submit an original claim form whenever possible. Do not submit carbon copies under any  
   circumstance. If you must submit a photocopy, ensure that it is legible and not too light or too 
   dark.

� Enter information within the appropriate boxes and align forms in your printer to ensure the 
  correct horizontal and vertical placement of data elements within the appropriate boxes.

� Use high quality printer ribbons or cartridges-black ink only.

� Use 10-12 point font sizes. We recommend font styles Courier 12, Arial 11 and Times New 
   Roman 11. Do not use italic, bold, or underline features.

� Do not use a marking pen to omit claim line entries. Use a black ballpoint pen (medium point).

Note 1. We currently return illegible claims. The criteria for legible claims are that all information is readable for the normal eye and that essential information not be blocked out. 

Note 2. Electronic submission of claims is most efficient and gives the provider a quicker 
turnaround on payment.

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Reminders to All Providers

� Please submit only one-sided operative reports and documentation with your claims.

� Louisiana Medicaid does not pay for any procedures that are done for cosmetic purposes.

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Changes to the Pre-Admission Screening Process (PASARR) for Persons with Mental Illness

The DHH Health Standards Section will no longer make the final determination regarding appropriateness of placement. The Office of Mental Health (OMH) has assumed this responsibility. The Level II assessment will be completed by a Health Standards consultant psychologist or psychiatrist who will then forward the information to the OMH Prior Authorization Unit for the final determination regarding placement will be made. OMH will also review for the need for specialized services. Specialized services will usually be either evaluation and follow-up by one of the local mental health clinics or one of the services covered under the Medicaid Mental Health Rehab program.

In addition, the Level 1 Pre-Admission/Readmission Screening (PAS/RAS) form has been revised. This form must be submitted to the DHH Health Standards Section along with Form 90L for all nursing home admissions. Providers can download the revised form from the following two web sites:

Internet: http://www.dhh.state.la.us/hss/ltc_publications.htm

MDS Intranet: login to CMS MDS Submission web site, click on Resources link, click on Forms link, click on Item 2 PAS/RAS link. 

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Louisiana Medicaid Policy on Keloid Treatment

When an injection into the keloid or the surgical removal of a keloid is not paid, any follow-up office visits, the pathology, anesthesia, surgical suite, and any radiation resulting from the above mentioned procedures will not be paid.

An initial visit when a keloid is examined and diagnosed will be paid.

All claims involving a keloid are reviewed on a case-by-case basis.

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Correct Information on the Provider File

The Provider Enrollment Unit wishes to remind you of the importance of maintaining correct information on your Louisiana Medicaid provider file. The information on the provider file must be correct to ensure that payments are made to the correct individual or entity. 

The following information has been compiled after review of common errors seen by the Provider Enrollment Unit:

1. Provider Requests 

� Requests for provider information must be submitted by the provider or an authorized agent employed by the provider. 

� Due to reports and concerns of provider identity theft, the Provider Enrollment Unit is not authorized to disclose any provider information to any third party. Third parties include billing companies and/or clearinghouses, management companies, attorneys, accountants, and credentialing companies or other entities not directly associated with the provider. Requests for release of provider information to a third party must be submitted in writing with the provider's original SIGNATURE (NO STAMPS OR INITIALS).

� Unsolicited faxed requests are not accepted. All original requests must be submitted via mail.

2. Completion of Form BHSF PE-50

� The PE-50 is the main document used for enrollment purposes. Provider Enrollment is not authorized to make any changes to this document. Therefore, it is imperative that it be completed accurately.

� Complete the form in its entirety. Do not complete sections with word "Same".

� Must be submitted as one-page document, front and back. Two-page PE-50 forms will be returned for correction.

� Section A requests information on the physical location.

� The Provider Name should be the name in which the business is doing business.

� If the desired provider type is a licensed entity, the name in Section A must match the license name EXACTLY.

� Section B requests information on the Pay-To location. The Pay-To Name must match the IRS preprinted document EXACTLY. 

� Parish information in Section B should be the parish of the physical location, not the Pay-To location.

� If a specific effective date is desired, please indicate the date at the top of the PE-50. If a provider is eligible for enrollment on the effective date, the request can be accommodated, pending approval of the Department of Health and Hospitals. If license is required, a copy of the license covering the effective date requested must be attached.

� The PE-50 form must have an original signature of the individual provider or the authorized agent of the entity. No stamped signatures or initials are accepted. Also, the individual must date the form once signed.

3. Change in Business / Practice Physical or Pay-To Address

� Submit updates to the Provider Enrollment Unit in writing and identify whether the physical location, the Pay-To location, or both have been changed. (For long-term care providers, this would also include the TAD address). Each request must include the Louisiana Medicaid provider number and must include the original signature of the provider (no stamps or initials are accepted).

� Post Office boxes are not accepted for physical address (except in the case of long-term care providers who use a post-office box address for TADs.)

� All correspondence is mailed to the Pay-To Name on file.

4. Change in Pay-To Name

� For entities, this may signal a change of ownership (CHOW). A complete enrollment packet will be required to update the provider file. Additionally, a new provider number may be issued.

� For individuals, this may indicate a move of the business/practice. It is a good idea to review the direct deposit information to ensure that it is correct. If the direct deposit information is not updated, claims payments may be sent to the wrong account.

� If the Pay-To Name has changed, a copy of a preprinted IRS document showing the taxpayer identification number and business name must be submitted with requests to update name. Form W-9 is not accepted.

� The Pay-To Name must match the IRS preprinted document EXACTLY. Any variations will cause the request to be returned for correction.

5. Changes in Direct Deposit Information 

� Only one checking or savings account may be loaded to the Medicaid files for claims payments.

� All Direct Deposit requests MUST be signed by the individual provider even if the Pay-To Name on file is a group or other entity. Signatures of group or entity authorized agents are not acceptable.

� A copy of a voided check must be submitted with the request. Copies of deposit slips are not accepted. A letter on bank letterhead identifying the bank routing number, account number and type of account may be substituted for a voided check.

� Because of processing time, requests to update direct deposit information should be submitted before the account on file is closed. If the information is not updated prior to closing the account, unnecessary delays may be encountered. 

6. Form HCFA 1513 - Disclosure of Ownership

� Section III must be completed in its entirety. Supplied information should include a list of all owners, Board of Directors names, and senior management names. 

� Section III (d) should include ALL Louisiana Medicaid provider numbers issued to any person identified on the list of owners, Board of Directors or senior management.

7. Miscellaneous Items

� Provider numbers are NEVER given to any provider over the telephone. New enrollees receive correspondence of new enrollment, including provider number, at the Pay-To address on file.

� All claims activity submitted under a given provider number is the responsibility of the individual to whom the number was issued even if the claims are submitted by another individual or entity.

Requests should be submitted in writing to the following address:

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QUESTION CORNER

Durable Medical Equipment (DME) Questions

1. Will DME providers be affected by statewide implementation of the CommunityCARE Program?

Yes. If a recipient is participating in the CommunityCARE Program, the DME claims will require a referral from the recipient�s primary care physician that includes the Referral Authorization Number. The Referral Authorization Number will be used when submitting their claims for payment. The DME provider will need to include this number in item 17A of the hardcopy HCFA-1500 claim form or as data element 33 in electronic claims.

2. If a recipient is eligible at the time a DME item is approved by the Unisys Prior Authorization Unit, but the recipient is no longer eligible on the date of delivery of this DME item, will Medicaid still reimburse us for this item?

No. The date of delivery for a DME item is to be used as the date of service when filing the claim. If the recipient loses Medicaid eligibility prior to the date of delivery, the provider is not eligible to receive payment. Medicaid does not pay for services delivered to individuals who are not Medicaid eligible.

3. Does Medicaid reimburse for breast or mammary prostheses?

Medicaid will approve payment for breast or mammary prostheses only after breast removal. Only one prosthesis will be approved for each breast removed. Replacement of a prosthesis may be approved if medical need is established and documented.

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Louisiana Drug Utilization Review (LADUR) Education

Pediatric Drug Dosing

By: Ahmad Khalil, Pharm.D. and C. David Matthews, Pharm.D. 

ISSUES...

• The medical community and the pharmaceutical industry must plan to provide pharmaceutical care to the pediatric population.

 

• Clinicians need to incorporate racial, cultural, socioeconomic, developmental and physiologic differences resulting from growth and maturation when making plans for pharmaceutical care of this population.
  

If we look at the report from the US Census Bureau, it shows that there were 68 million children living in the USA in 1995. This percentage makes pediatrics about 25% of the United States population. Twenty million of these children were under the age of 5 years. Over the next few decades this percentage is not likely to change substantially. The medical community and the pharmaceutical industry need to make plans to provide pharmaceutical care for this large population segment based on these figures.

Although less than a quarter (25%) of currently available drugs carry an approved Food and Drug Administration (FDA) indication for use in pediatric populations, more than three quarters of them have been used for patients younger than 18 years of age. Pediatric health care providers find themselves forced to use drugs off-label (without FDA approval) in pediatric patients. These pediatric practitioners often rely on case reports, personal experience, small clinical trials, and case series for information regarding pediatric pharmacotherapy acceptability and pediatric dosing.

As we enter the 21st century, pediatric pharmacotherapy embarks on a period of considerable growth. The information age has benefited pediatric practice as a specialty. In the past, there has been little attention paid to this important segment of our patient population. This has previously resulted in a lack of information to guide the health care professional in making competent decisions in pediatric pharmacotherapy. 

The pediatric clinician encounters several limitations of information in pediatric pharmacotherapy. Some of which include small numbers on patients with rare diseases, small size studies, and huge inter-patient variability among this population. Previously, the FDA did not require pediatric data about new drugs. Recently, more readily available computer technology has eased the access of the pediatric clinician to pediatric information by facilitating rapid scanning of all available information published over the years. Regulatory agencies have also helped. For example, the FDA is now requiring pediatric labeling for many new medications. All of these advances have resulted in a greater wealth of information on pharmacotherapy for the pediatric population.

With ages of pediatric patients ranging from 23-24 weeks gestation up to young adolescents, the diversity of the pediatric population presents a huge challenge to the neonatal clinician. One particularly problematic segment of the pediatric population includes premature neonates. The physiology, pharmacokinetics, and the pharmacodynamics of medications are highly variable among the patient groups in this age span. In order to simplify this variation as much as possible, the age of the pediatric patient has been described by placing them into groups that describe trends in development and maturation. These arbitrary groupings do not always recognize the real differences in growing children.

These groupings are as follows: preterm newborn (a baby who did not complete 36 weeks in gestation), term newborn (a baby who had 36 weeks or more of gestation), neonate (a baby who is less than 1 month old), infant (a baby who is less than 1 year old but older than 1 month), child (a person who is 1 to 11 years of age), and adolescent (a person who is 12 to 16 years of age).

Clinicians need to incorporate racial, cultural, socioeconomic, developmental, and physiologic differences resulting from growth and maturation when making plans for pharmaceutical care of this population.

Pharmacokinetic Differences
Huge variabilities in pharmacokinetics and pharmacodynamics are observed among the pediatric populations. Body size, proportion, organ development and function affect the pharmacokinetic behavior of many drugs. In addition, variability of maturation within the pediatric population imposes an extra challenge to the pediatric health care provider. Age and weight are the two maturation endpoints used in clinical decisions for dosage calculation. They can properly be used as general guides in patients; however, they should be considered only as rough indicators.

Absorption
Gastrointestinal (GI) absorption of drugs is greatly affected in the first two years of life. Gastric acid production is transiently decreased, which results in basic drugs having better absorption in the newborn and acidic drugs having reduced absorption. The transit time is prolonged in the GI tract, with gastric emptying time changing to a value that is closer to an adult by the end of the first week of life. However, the emptying time for the entire intestinal tract takes up to 6 months to mature and reach adult values. Similarly gastric acid production takes up to 3 years to mature to adult levels. Neonates have a smaller gut surface area and more erratic gastric blood flow which may reduce the absorption of drugs that undergo passive absorption. The enzymes of digestion, such as bile acid and pancreatic enzymes, are also lacking at birth and may affect the absorption of acid sensitive agents. All of these variables make it difficult to predict how the GI absorption of a certain drug will be affected. That is why clinical experience, actual absorption, and clinical studies are important sources of information for the rational dosing of young pediatric patients.

Studies are sorely lacking on the drug-dosing of the neonate subject. However, one of the best studied areas is the use of anticonvulsants in the neonatal population. Phenobarbital is found to be well absorbed which is the reason it is considered the first line therapy for neonatal seizures. Phenytoin is the second drug of choice. The maintenance dose of phenytoin in neonates should be 20 mg/kg/day to account for the reduced GI absorption in neonates. As the baby is growing and maturing, doses should be monitored and may need to be changed regularly for several weeks due to increasing patient weight and gradually improving absorption from the GI tract.

Due to concerns that some oral medications which are hypertonic in nature may cause damage to the GI, it was suggested that premature neonates should be able to receive at least one-half of their total daily fluid intake by the enteral route before starting oral medications. This serves as an end point for maturation of the GI function and, at the same time, dilutes the drug so that it can be better tolerated.

Infants and neonates have limited muscle mass and/or fat stores, and their blood circulation is not always mature. All of these factors limit absorption by the intramuscular and subcutaneous routes. However, this variability loses clinical significance by the end of the first month of life. The volume of injection to be injected intramuscularly is limited in infants and neonates to 0.5 ml per dose in the lateral aspect of the thigh; grade school age should not be given more than 1 ml intramuscularly. Children more than 11 years can receive up to 5 ml per dose.

Percutaneous absorption of drugs is magnified in neonates and infants. This is a direct result of thinner, more hydrated stratum, corneum and greater skin surface area to body size ratio. This high absorption capacity results in potential toxicities from different cleaning and antiseptic agents such as povidone iodine which is used as a topical disinfectant. Povidine iodine has been shown to cause thyroid dysfunction in several infants being prepped for surgery. Another example of toxicity is suppression of the pituitary-hypothalamus-adrenal axis after prolonged use of topical steroid containing creams for diaper rash. Thus topical application of hydrocortisone for diaper rash should be limited to no longer than 2 weeks and only with creams containing 0.5% cortisone or less. This mode of absorption is so effective that it was considered for use as a route of administration for therapeutic agents in premature neonates to treat apnea using topical theophylline or caffeine. However, this was not practical as this route was found too variable and erratic for routine use in such patients.

Rectal administration of drugs is a valuable route for pediatric patients. It has a predictable absorption for important medications that may be needed in times when oral administration is contraindicated or not practical. Oral preparations of valproic acid, carbamazepine, and some benzodiazepines can be given rectally in seizing or vomiting patients with a high degree of success. 

Distribution:
Growth and maturation from infancy to adulthood changes many factors that affect distribution. These factors are water content, fat content, hemodynamics, plasma protein concentration, organ size, and tissue perfusion. Perhaps the best examples for discussion about the differences in pediatric distribution are the aminoglycosides. Gentamicin has been extensively studied in the pediatric population. The volume of distribution in adults is 0.2-0.3 L/kg while it is about 0.5-0.7 L/kg in the premature neonate. It is about 0.4 L/kg in children falling into the age range of 1-5 years. This is probably due to changes in body water content through life. This also may infer that highly water-soluble substances may have higher volumes of distribution in premature neonates and young infants.

Metabolism:
The liver is the primary site for most metabolic activities. Growth and maturation changes affect the liver as an organ by changing the blood circulation to the liver and the hepatic enzyme systems themselves. During the last few years, there was a lot of research examining the cytochrome (CYP) P450 enzyme system. Various researchers have shown the different CYP enzyme systems mature at different rates from gestation up to early childhood ages.

There are two types of drug metabolism that occur in the liver. Type one reactions include oxidation, reduction, hydroxylation, and hydrolysis. Type II reactions include conjugation that converts compounds to more soluble forms. The total CYP content in the fetal liver is estimated to be half that of the adult. The CYP 1A family has been extensively studied because of its activity on theophylline and caffeine metabolism in mature and premature neonates. It has been found that the activity of CYP1A2 is almost nonexistent in the neonate, and this explains the very long half-life of caffeine and theophylline in this group of patients. CYP matures by 4-6 months of age and, by that time, it may exceed the activity of that of adults on a mg per kg basis. This CYP1A2 then starts to decline to adult values around puberty.

CYP 2D6, CYP 2C19, and CYP 2C8 are severely depressed during the neonatal stage. The most important class in drug metabolism is the CYP 3A enzymes. Neonates predominantly have CYP 3A5 and CYP 3A7 which are similar to CYP 3A4, but they have a relatively minor role in the adult liver. CYP 3A4 is not highly expressed in neonates.

The alcohol dehydrogenase enzyme is also suppressed during premature and mature neonate stages. This directly impacts the ability to administer benzyl alcohol for these babies. Neonates have less than 5% of alcohol dehydrogenase adult activity, and administration of benzyl alcohol containing preparations has resulted in many acidosis cases and gasping baby syndromes. Therefore, the FDA recommends using preservative free products for neonates.

Gray baby syndrome has been caused by administration of chloramphenicol within the recommended dosage range. This has been shown to be due to the deficiency of glucouronidation in neonates and infants. Although they are immature during the infanthood and neonate stages, phase II reactions, mainly conjugation, mature during childhood.

Elimination:
In neonates and infants, glomerular filtration rate, tubular secretion, and the ability to reabsorb substances are all reduced. This results in impaired drug and metabolite elimination. The glomerular filtration rate starts dramatic maturation at the gestational age of 35 weeks. Premature neonates experience GFR improvement at birth, but it is less than that seen in term neonates. Renal elimination of medication stays premature during the first week of life; however, by the end of the first week, doses should be adjusted to match improving renal function. For example, the ampicillin dose in the first week of life is 50 mg/kg every 12 hours, but after the first week, it should be adjusted to 50 mg every 8 hours.

The renal function parameters used in adult dosing of renally excreted medications are not as useful in neonates and infants. A premature infant's serum creatinine is reflective more of fluid status than of renal function. For older children, the serum creatinine is useful for renal function evaluation; however, the traditional adult renal status calculation equations are not useful. Several equations have been developed to estimate renal function of the pediatric population based on serum creatinine values which are easily obtainable. The Traub and Johnson equation is the most widely used: 
CrCl (ml/min/1.73 m2) = (0.48) (Ht)/S Cr 
CrCl =creatinine clearance Ht = height in centimeters SCr =serum creatinine. 

Renal function steadily matures in the first year of life, and at the end of this period, total function actually exceeds that of adults. At this age, many drugs may need to be dosed more frequently than the standard adult frequency of administration due to the greater renal function of children older than one year. A clear example of this phenomenon is gentamycin administration in leukemia patients, which should properly be dosed every 6 hours to optimize therapy. 

Pharmacodynamic differences in pediatric population:
There has been little work done on the drug receptor differences in pediatrics. Based on animal studies, it has been suggested that receptor function begins to develop in the fetal stage and matures to full function long after birth. More research in this area is warranted.

In summary, pediatric pharmacotherapy presents a lot of challenges to health care providers. We have primarily discussed dosing issues in this article; however, there are many other factors that need to be addressed. Tailoring the therapy for children according to their developmental stage, as well as chronological age, will include selecting the appropriate dosage regimen, the availability of dosage forms, the fluid volumes in neonates, and the development of new delivery devices used for application. Age specific ways to prevent medication errors and enhance compliance of pediatric patients are both significant problems that must be further addressed as we move forward in pediatric therapy. The limited amount of information about existing drugs in pediatric populations presents another challenge for the health care provider; however, with the recent changes in FDA requirements, this body of information is growing in pediatric pharmacotherapy. The great need to prevent pharmaceutical misadventures in pediatric patients presents opportunities for pharmacists to participate in the provision of pharmaceutical care for pediatrics.

References

1. Stewart CF, Hampton EM. Effect of maturation on drug disposition in pediatric patients. Clinical Pharmacy 6:548-64, 1987

2. Hakkola J, Tanaka E, Pelkonen O. Developmental expression of cytochrome P450 enzymes in human liver. Pharmacology and Toxicology 82:209-17, 1998

3. Murphy JE, Austin ML, Frye RF. Evaluation of Gentamicin pharmacokinetics and dosing protocols on 195 neonates. American Journal of Health System Pharmacists 55:2280-8, 1998

4. Nahata MC. Pediatrics. In Dipiro JT, Talbert RL, Yee GC et al., eds. Pharmacotherapy: A Pathophysiologic approach. 4th edition. Stamford, Connecticut; Appleton&Lange, 1999:44-51 

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Insert - Provider Training Information and Schedules

!!!! NOTICE !!!!

CHANGES IN FALL 2002 PROVIDER WORKSHOP SCHEDULE

PLEASE MAKE NOTE OF THE FOLLOWING CHANGES IN THE FALL 2002 PROVIDER TRAINING WORKSHOPS PRESENTED IN THE JUNE/JULY 2002 EDITION OF THE MEDICAID PROVIDER UPDATE.

(1) ALL NEW ORLEANS PROVIDER WORKSHOPS ARE BEING MOVED FROM THE JOHN ALARIO CENTER TO THE HOLIDAY INN DOWNTOWN-SUPERDOME, 330 LOYOLA AVENUE, NEW ORLEANS, LA.

(2) TRAINING WORKSHOPS FOR RHC/FQHCs HAS BEEN CANCELLED COMPLETELY. TRAINING FOR THESE PROVIDERS WILL BE SCHEDULED AT A LATER DATE.

(3) THE WORKSHOP LISTED AS PHARMACY PA IS ACTUALLY THE PHARMACY PROVIDER WORKSHOP. ONLY PHARMACY PROVIDERS SHOULD ATTEND THIS WORKSHOP. PHARMACY PA WILL BE DISCUSSED IN THE APPROPRIATE PROGRAM SPECIFIC WORKSHOPS.

(4) THIS YEAR'S LONG TERM CARE (LTC) WORKSHOP IS FOR ICF-MR FACILITIES ONLY. ADULT DAY PROVIDERS SHOULD NOT ATTEND THIS WORKSHOP AS PREVIOUSLY STATED.

(5) PCS SERVICES PROVIDERS SHOULD ATTEND THE PCS SEGMENT OF THE EPSDT/PCS WORKSHOP (last 30 minutes).

(6) ALL PRECERTIFICATION WORKSHOPS HAVE BEEN CANCELLED.

PLEASE CONTACT UNISYS PROVIDER RELATIONS AT 800/473-2783 IF YOU HAVE ANY QUESTIONS ABOUT THE SCHEDULE OR THESE CHANGES!!

2002 Unisys Provider Workshops

Following is the schedule for the 2002 Unisys Provider Workshops. The annual Unisys Provider Workshops focus on presenting vital policy and billing information to our Medicaid provider community. With that in mind, our intent is to create a neutral atmosphere for delivery of the educational materials to the providers in attendance. The Department of Health and Hospitals has asked Unisys Provider Relations to address questions relating to recent policy and procedure changes. HIPAA updates will be provided at each workshop.

Our training format separates basic information from specific program information. The Basic Medicaid information workshops will cover general Medicaid policy such as standards for participation, recipient eligibility/ID cards, third party liability, how to obtain assistance from Unisys, etc. This information will be presented ONLY in the Basic sessions and will not be repeated in specific program workshops. All Basic workshop sessions will be identical in content.

THIS YEAR, BECAUSE OF THE STATEWIDE CommunityCARE EXPANSION, CommunityCARE WILL BE COVERED IN A SEPARATE CommunityCARE WORKSHOP. CommunityCARE will not be discussed in detail in any other workshops. These workshops will also be identical in content and will cover all aspects of the CommunityCARE Program. We encourage you to attend one of these workshops.

In each specific program workshop, Unisys staff will discuss recent policy or procedure changes for that specific program. Basic information such as eligibility, third party liability, CommunityCARE, etc. WILL NOT be presented in the specific program workshops.

Providers may choose to attend any of the basic sessions and any of the CommunityCARE sessions, in addition to their specific program session, or they may choose to attend only the specific program session for their provider type.

An Eligibility workshop geared toward the LaCHIP eligibility category, Medicare Buy-In, and EPSDT services availability and access is being offered again this year. Anyone who services EPSDT recipients is encouraged to attend.

Hospital training and Precertification training are being held as separate sessions. Personnel from the Utilization Review Department of each hospital and those involved in precertification for inpatient admissions, including hospital case managers who do precertification, should attend the Precertification workshop, which will contain information specifically for precertification. The Hospital workshop will focus on hospital policy in general and on billing policies and procedures.

Hemodialysis policy and billing information for free-standing hemodialysis centers will be presented in the hospital training session.

Pharmacy workshops will focus on Pharmacy Prior Authorization and Peer Based Profiling. Pharmacy providers who also provide services through the DME program may wish to attend the DME workshop, also.

RHC/FQHC, Case Management, Waiver, and Mental Health Rehabilitation program workshops WILL NOT be held this year. Providers of these services will be notified of other arrangements for training as that information becomes available.

ONLY ICF-MR providers should attend the Long Term Care workshop. Training for nursing homes will be held independently at a later date. Nursing home providers will be notified of other arrangements for training as that information becomes available. Adult Day providers should not attend this workshop as previously stated.

Due to space limitations in all workshops, please limit attendees to two (2) persons per provider. Attendees should arrive 15 - 20 minutes early to register. Remember, each person MUST have his or her provider name and Medicaid provider ID number in order to register and attend, and providers are required to have a valid Medicaid provider ID number for each specific program workshop attended.

Medicaid programs for discussion at the workshops include:

1. Basic Medicaid Information: All providers may attend. Basic Medicaid information will be presented, including standards for participation, recipient eligibility and ID cards, third party liability, remittance advice review, how to obtain assistance from Unisys, Provider Relations information, common generic denial reasons and methods of correction, etc. This information will not be repeated in any of the specific program workshops listed below.

2. Eligibility: Includes LaChip, Medicare Buy-In, and EPSDT services. All providers may attend.

3. Professional: Physicians, Labs, Optometrists, Chiropractors, Ambulatory Surgery Centers, Optical Suppliers, Nurse Practitioners, Audiologists, Nurse Midwives, CRNAs, Hemodialysis (supervision ONLY), and Mental Health Clinics.

4. Hospital/Hemodialysis: Acute, Rehabilitation, Long Term, Free-standing Psych, Distinct Part Psych hospitals, AND Free-Standing Hemodialysis Centers. Hospital policy and billing issues and Hemodialysis policy and billing issues will be presented. 

5. Precertification (Precert): Hospital Utilization Review or other personnel involved in obtaining precertification. Precertification workshops will include policy and procedures specific to precertification (not billing). THIS SESSION IS FOR HOSPITAL CASE MANAGERS/UTILIZATION REVIEW STAFF.

6. Long Term Care: ONLY ICF/MR Facilities. (Hospice is offered in a separate workshop.) This program will be held in all locations EXCEPT Houma and Covington. (Nursing homes will be notified of other arrangements for training as that information becomes available. Adult Day providers should not attend this workshop.

7. Hospice: Hospice providers. This program will be held in all locations EXCEPT Houma and Covington.

8. Home Health Agencies: Home Health providers who are also DME providers should attend both the Home Health and DME sessions.

9. Durable Medical Equipment (DME) Suppliers. Pharmacists who also provide services through the DME program providers may wish to attend this workshop.

10. Free-Standing Rehabilitation Centers: This session is for free-standing centers ONLY � it does not include hospital rehabilitation providers. (Hospital providers should attend the hospital workshop.) This program will be held in all locations EXCEPT Houma and Covington.

11. Dental: EPSDT and Adult and Oral Surgery. Presentation of specific HIPAA information is planned. Dental training will be offered at all locations except Houma and Covington.

12. Ambulance Transportation: Ambulance providers only�does not include non-emergency non-ambulance transportation. This session will be held in New Orleans, Shreveport/Bossier City, and Lafayette.

13. Non-emergency Medical Transportation: Non-emergency non-ambulance providers only�does not include ambulance transportation. This session will be held in New Orleans, Shreveport/Bossier City, and Lafayette.

14. EPSDT/PCS Services: EPSDT Health Services (school boards and Early Intervention Centers ONLY)and PCS Services providers. This program will be held in all locations EXCEPT Houma and Covington.

15. KIDMED: This program will be held in all locations EXCEPT Houma and Covington.

16. Pharmacy: This program will be held in all locations EXCEPT Houma and Covington.

Please refer to the following list for dates (Day 1, Day 2, and Day 3) and times at each workshop location. Note that there may be more than one session held at the same time. There is no pre-registration required. Please direct any questions concerning the workshops to Unisys Provider Relations at 800/473-2783 or 225/924-5040. Meeting sites should be contacted for directions or sleeping accommodations ONLY! DO NOT contact the meeting sites with questions related to the workshops!

CITY	DAY, DATE, TIME, AND SESSION
Baton Rouge	Tuesday, October 1		Wednesday, October 2			Thursday, October 3
Room Name	Auditorium	Classroom 3	Main Auditorium		Classroom 3	Classroom 3
LA State Police Training Academy 7901 Independence Blvd Baton Rouge, LA	Basic � 8:00 � 9:30 CommunityCare � 9:45 - 12:00 Eligibility � 1:00 � 2:00 Professional � 2:15 - 4:15 KIDMED � 4:30 - 5:45	Hospital � 1:30 - 3:15 Precert � 3:30 � 5:00 Pharmacy � 5:15 - 6:30	EPSDT/PCS � 8:30 � 9:30 Eligibility � 11:30 - 12:30 Basic � 1:30 � 3:00 CommunityCare � 3:15 � 5:15		DME � 8:30 � 10:00 Home Health � 10:15 � 11:45 Rehab � 12:00 � 1:00	LTC � 8:30 � 9:45 Hospice � 10:00 - 11:30 Dental � 11:45 � 1:45
Covington	Friday, October 4
Room Name	Ballroom 1	Ballroom 3
Holiday Inn 501 N Hwy 190 Covington, LA	Basic - 8:00 - 9:30 CommunityCARE - 9:45 - 12:00 Eligibility - 1:30 � 2:30 Professional - 2:45 � 4:45	Hospital - 1:30 - 3:15 Precert - 3:30 - 5:00
Bossier City	Monday, October 7		Tuesday, October 8				Wednesday, October 9
Bossier Civic Center 620 Benton Rd Bossier City, LA	Basic � 8:00 � 9:30 CommunityCare � 9:45 - 12:00 Eligibility � 1:00 � 2:00 Professional � 2:15 - 4:15 KIDMED � 4:30 - 5:45	Hospital � 1:30 - 3:15 Precert � 3:30 � 5:00 Pharmacy PA � 5:15 - 6:30	EPSDT/PCS � 8:30 � 9:30 Eligibility � 11:30 - 12:30 Basic � 1:30 � 3:00 CommunityCare � 3:15 � 5:15		DME � 8:30 � 10:00 Home Health � 10:15 � 11:45 Rehab �12:00 � 1:00     NEMT � 5:30 - 6:30		LTC � 8:00 � 9:15 Hospice � 9:30 - 11:00 Ambulance � 11:15 - 12:15 Dental � 12:30 � 2:30
Lafayette	Monday, October 14		Tuesday, October 15				Wednesday, October 16
Room Name	Pink Perfection	Purple Dawn	Pink Perfection		Purple Dawn		Purple Dawn
Holiday Inn Holidome 2032 N Evangeline Thru Lafayette, LA	Basic � 8:00 � 9:30 CommunityCare � 9:45-12:00 Eligibility � 1:00 � 2:00 Professional � 2:15- 4:15 KIDMED � 4:30 - 5:45	Hospital � 1:30-3:15 Precert � 3:30 � 5:00 Pharmacy � 5:15-6:30	EPSDT/PCS � 8:30 � 9:30 Eligibility � 11:30 - 12:30 Basic � 1:30 � 3:00 CommunityCare � 3:15 � 5:15		DME � 8:30 � 10:00 Home Health� 10:15 � 11:45 Rehab � 12:00 � 1:00     NEMT � 5:30 � 6:30		LTC � 8:00 � 9:15 Hospice � 9:30 -  11:00 Ambulance � 11:15 - 12:15 Dental � 12:30 - 2:30
New Orleans	Monday, October 21		Tuesday, October 22				Wednesday, October 23
Room Name	Hall A	Meeting Rooms 1&2	Hall A	Meeting Rooms 1&2			Meeting Rooms 1&2
John A. Alario Center 2000 Segnette Blvd Westwego, LA	Basic � 8:00 � 9:30 CommunityCare � 9:45 - 12:00 Eligibility � 1:00 � 2:00 Professional � 2:15- 4:15 KIDMED � 4:30 - 5:45	Hospital � 1:30 - 3:15 Precert � 3:30 � 5:00 Pharmacy � 5:15-6:30	EPSDT/PCS � 8:30 � 9:30 Eligibility � 11:30 - 12:30 Basic � 1:30 � 3:00 CommunityCare � 3:15 � 5:15	DME � 8:30 � 10:00 Home Health � 10:15 �11:45 Rehab � 12:00 � 1:00     NEMT � 5:30 - 6:30			LTC � 8:00 � 9:15 Hospice � 9:30 - 11:00 Ambulance � 11:15 - 12:15 Dental � 12:30 - 2:30
Houma	Thursday, October 24
Houma-Terrebonne Civic Center 346 Civic Center Blvd Houma, LA	Basic - 8:00 - 9:30 CommunityCARE - 9:45 - 12:00 Eligibility - 1:30 � 2:30 Professional - 2:45 - 4:45	Hospital - 1:30 - 3:15 Precert - 3:30 - 5:00
Alexandria	Monday, November 4		Tuesday, November 5					Wednesday, November 6
Room Name	Magnolia/Camellia	Wisteria/Gardenia	Magnolia/Camellia	Wisteria/Gardenia				Wisteria/Gardenia
Best Western Inn- Suites & Conference Ctr 2720 West MacArthur Dr Alexandria, LA	Basic � 8:00 � 9:30 CommunityCare � 9:45 - 12:00 Eligibility � 1:00 � 2:00 Professional � 2:15 - 4:15 KIDMED � 4:30 - 5:45	Hospital � 1:30 - 3:15 Precert � 3:30 � 5:00 Pharmacy  � 5:15-6:30	EPSDT/PCS � 8:30 � 9:30 Eligibility � 11:30 - 12:30 Basic � 1:30 � 3:00 CommunityCare � 3:15 � 5:15	DME � 8:30 � 10:00 Home Health � 10:15 � 11:45 Rehab � 12:00 � 1:00				LTC � 8:00 � 9:15 Hospice � 9:30 - 11:00 Dental � 11:15 - 1:15
Lake Charles	Thursday, November 7		Friday, November 8
Lake Charles Civic Center 900 Lakeshore Dr Lake Charles, LA	Basic � 8:00 � 9:30 CommunityCare � 9:45 - 12:00 Eligibility � 1:00 � 2:00 Professional � 2:15 - 4:15 KIDMED � 4:30 - 5:45	Hospital � 1:30 - 3:15 Precert � 3:30 � 5:00 Pharmacy � 5:15 - 6:30	EPSDT/PCS � 8:00 � 9:00 Eligibility � 11:00 - 12:00 Rehab � 12:15 - 1:15 Basic � 1:30 � 3:00 CommunityCare � 3:15 � 5:15	DME � 8:00 � 9:30 Home Health � 9:45 � 11:15 LTC � 11:30 � 12:45 Hospice � 1:00 - 2:30 Dental � 2:45 - 4:45
Monroe	Tuesday, November 12		Wednesday, November 13					Thursday, November 14
Room Name	Jackson/Lafitte	Bonaparte	Jackson/Lafitte	Bonaparte				Bonaparte
Holiday Inn Holidome 1051 Hwy 165 Bypass Monroe, LA	Basic � 8:00 � 9:30 CommunityCare � 9:45-12:00 Eligibility � 1:00 � 2:00 Professional � 2:15 - 4:15 KIDMED � 4:30 - 5:45	Hospital � 1:30 - 3:15 Precert � 3:30 � 5:00 Pharmacy � 5:15 - 6:30	EPSDT/PCS � 8:30 � 9:30 Eligibility � 11:30 - 12:30 Basic � 1:30 � 3:00 CommunityCare � 3:15 � 5:15	DME � 8:30 � 10:00 Home Health � 10:15 � 11:45 Rehab � 12:00 � 1:00				LTC � 8:00 � 9:15 Hospice � 9:30 - 11:00 Dental � 11:15 - 1:15