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 Molina Medicaid Solutions at (800) 473-2783 or (225) 924-5040.

New and Revised Place of Service Codes (POS) for Outpatient Hospital
Implementation Date 01-01-2016

The Centers for Medicare and Medicaid Services (CMS) made changes to the existing place of service code set by creating a new place of service (POS) code, code 19 (Off Campus-Outpatient Hospital), and revised the POS Code 22 (On Campus-Outpatient Hospital).

Louisiana Medicaid will accept POS 19 for any claims processed on or after January 1, 2016. That is, POS code 19 is valid for any claim, regardless of the date of service, when it is processed on or after January 1, 2016. The payment policies that currently apply to POS 22 will continue to apply to this POS, and will now also apply to POS 19.

CMS also issued minor corrections to POS codes 17 (Walk-in Retail Health Clinic) and 26 (Military Treatment Facility).

To access the CMS POS code set go to: https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html.

Should you have questions related to the place of service codes changes, please contact Molina Providers Relations at 1-800-473-2783. Questions regarding submission of claims to/payment by the correct entity should be directed to the MCO.

Attention Fee for Service (FFS) Louisiana Medicaid Providers:

Effective January 12, 2016, Fee for Service pharmacy claims for Ombitasvir/paritaprevir/ritonavir (Technivie®) and Daclatasvir (Daklinza®) will have edits at Point of Sale (POS) similar to the other Hepatitis C direct acting antiviral agents. Please refer to www.lamedicaid.com for specifics.

Attention Durable Medical Equipment Prosthetics and Orthotics (DMEPOS) Providers 2016 HCPCS Update

HCPCS codes E0463 (Pressure Support Ventilator, Used with Invasive Interface) and E0464 (Pressure Support Ventilator, Used with Non-invasive Interface) will be removed from the Louisiana Medicaid DMEPOS fee schedule effective for date of service January 1, 2016. The codes have been discontinued by CMS.

Effective with date of service January 1, 2016, HCPCS code E0463 will be replaced with E0465 (Home Ventilator, Any Type, Used with Invasive Interface) and E0464 will be replaced with E0466 (Home Ventilator, Any Type, Used for Non-Invasive Interface). Reimbursement will be the same as the prior code.

The on-line fee schedule will be updated in the next few weeks. If you have questions regarding this matter contact Molina Provider Relation at 800-473-2783.

Attention ICF Providers, Nursing Home Providers and Hospice Providers
CMS required billing changes

Transaction standards updated under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) with regard to ASC X12 Version 5010 require an attending provider be submitted on all institutional (format UB-04) claims. By definition the attending provider is an individual. In addition, CMS is also requiring the billing provider NPI information must also be identified on the claim form. An additional edit will be put into the system to deny claims missing the billing provider's information.

Please visit www.lamedicaid.com for detailed provider notices concerning these changes.

Attention Home Health Providers
2016 HCPCS Update

HCPCS code G0154 (Direct skilled nursing services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes) will be removed from the Louisiana Medicaid Home Health fee schedule effective for date of service January 1, 2016. The code has been discontinued by CMS.

Effective with date of service January 1, 2016, HCPCS code G0154 will be replaced with G0299 (Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes) and G0300 (Direct skilled nursing services of a license practical nurse (LPN) in the home health or hospice setting, each 15 minutes). Reimbursement will be the same as the prior code.

The on-line fee schedule will be updated in the next few weeks. If you have questions regarding this matter contact Molina Provider Relation at 800-473-2783.

ATTENTION PROVIDERS: REMOVAL OF THE TWELVE (12) VISIT LIMIT:

Effective with dates of Service January 1, 2016 and forward, the twelve (12) visit limit per year in legacy Medicaid on outpatient professional services for adult recipients age twenty-one (21) years and older has been removed. This includes professional services provided in emergency rooms, outpatient hospital clinics, physician’s offices, Federally Qualified Health Centers (FQHC’s) and Rural Health Centers (RHC’s). All visits and services provided must be medically necessary but do not require authorization for reimbursement

Please contact Molina Provider Relations at (800) 473-2783 or (225) 924-5040 if you have any questions regarding this matter.

Attention Residential Options Waiver Providers of Nursing Services
2016 HCPCS Update

HCPCS code G0154 (Direct skilled nursing services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes) will be removed from the Louisiana Medicaid Home Health fee schedule effective for date of service January 1, 2016. The code has been discontinued by CMS.

Effective with date of service January 1, 2016, HCPCS code G0154 will be replaced with G0299 (Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes) and G0300 (Direct skilled nursing services of a license practical nurse (LPN) in the home health or hospice setting, each 15 minutes). Reimbursement will be the same as the prior code. The modifiers TD and TE will no longer be required. The modifier TT will continue to be an option for both G0299 and G0300.

The on-line fee schedule will be updated in the next few weeks. If you have questions regarding this matter contact Tracy Barker at 225-342-8156.

2015 Annual 1099 Notice for Providers

Louisiana Medicaid 2015 1099s will be distributed by U.S. Mail on or before January 31, 2016. Electronic copies are now available for download by going to the Louisiana Medicaid web site, www.lamedicaid.com, Secure Portal, application link, Online 1099. If replacement copies or additional copies are needed, providers must print them from the web site. If you feel there is an error on your 1099, please contact Molina Provider Enrollment at 225-216-6370. Prior year 1099’s will be stored in the archive on www.LaMedicaid.com.

Attention Fee for Service (FFS) Louisiana Medicaid Providers:

Effective January 22, 2016, FFS pharmacy claims for Xyrem® (Sodium Oxybate) will have Point of Sale (POS) edits and require clinical pre-authorization. Please refer to www.lamedicaid.com for specifics.

ATTENTION LT-PCS and PCA Waiver Providers
Claims Recycle of Edit 194 Denials

Several claims billed by LT-PCS and Waiver PCA providers with Dates of Service from 1/1/16 through 1/14/16, have denied in error for Edit 194 (Claim Exceeds Prior Authorized Limits). Research revealed that a processing error occurred which resulted in errors to prior authorized service units issued to providers, thus causing the 194 denials.

The error has been determined to be an isolated event due to changes in SRI’s LAST software. Since the old software version is no longer being used and the transition completed, it is not expected that this error would occur again. In order to remedy this, these claims denied with edit 194 will be recycled. Edit 241(pre-payment review) will be bypassed on these claims so that providers may receive payment at the expected date of 1/26/16.