PHARMACY PROVIDERS, PLEASE NOTE!!!

If you are unsure about the coverage of a drug product, please contact the PBM help desk at 1-800-648-0790.

Please file adjustments for claims that may have been incorrectly paid. Only those products of the manufacturers which participate in the Federal Rebate Program will be covered by the Medicaid program. Participation may be verified in Appendix C, available at http://www.lamedicaid.com. 

Should you have any questions regarding any of the following messages, please contact Gainwell Technologies at (800) 473-2783 or (225) 924-5040.

For information regarding the medication policy and/or criteria associated with this denial, providers may access the Louisiana Medicaid Preferred Drug List (PDL) / Non-Preferred Drug List at http://ldh.la.gov/assets/HealthyLa/Pharmacy/PDL.pdf.

Attention Local Education Agency (LEA) Providers

Federal regulations require states to screen and enroll all Medicaid providers that order, prescribe, or refer items or services for Medicaid beneficiaries. Participating LEAs should expect claim denials on interim claims submitted for reimbursement if ordering provider enrollment requirements are not complete by December 30, 2023. To fulfill requirements, physicians and non-physician practitioners whose order results in health care services being provided by an LEA must enroll as a fully participating fee-for-service provider or an Ordering, Prescribing, Referring (OPR) provider type. The ordering provider’s name, their Type 1 (individual) NPI and DK qualifier must be on all claims,with exception of nursing evaluations and preventative screenings. The ordering provider may be an individual physician or other licensed practitioner associated with the student’s plan of care or may be the actual provider performing the service if they have licensing authority within their defined scope of practice to order health care services. LEA employees and contracted practitioners currently enrolled as participating LA Medicaid fee-for-service providers are not required to enroll separately as an OPR provider. Please refer to the home page of www.lamedicaid.com to review policy notice: ‘School-Based Provider Enrollment Requirements’ for additional details. Providers who are unsure of their fee-for-service enrollment status or require enrollment assistance should contact Gainwell Technologies at 225-216-6370 or email louisianaprovenroll@gainwelltechnologies.com.

SFY23 Voids of NCCI MUE OPH and DME Claims in December 19, 2023 claim cycle

Louisiana Medicaid has processed administrative voids in the December 19, 2023 payment cycle for fee-for-service outpatient hospital (OPH) and DME claims that originally paid from July 1, 2022 through March 31, 2023 because they were not edited with the National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUE).

The voided OPH and DME claims were included in the June 27, 2023 recycle where they were reprocessed with EOB 809 (CCI: Units of service exceeds medically unlikely edit). However, the recycle did not correctly offset the original payment.

Questions regarding this message and fee-for-service claims are to be directed to Gainwell Technologies Provider Relations at (800) 473-2783 or (225) 924-5040.