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.

Update to 'CiaimCheck' Product Editing - January 2013
'Clear Claim Connection' Information

McKesson's 'ClaimCheck' product, used in claims processing, is routinely updated by McKesson Corporation. The most recent update is based on changes made to key industry mandates as well as enhanced modifier processing functionality. This update will affect claims processed beginning with the remittance advice of January 22, 2013, forward. Due to the enhancement, providers may notice minor differences in the clinical claims editing that include National Correct Coding Initiative (NCCI) and Outpatient Hospital edits. Providers should expect that most claims will continue to be edited in the same manner; but when applicable, claims may now pay or deny differently.

'Clear Claim Connection' is the related web-based reference tool that enables providers to access the editing rules and clinical rationale for some of the 'ClaimCheck' edits. This reference is in the process of being aligned with the updates to the editing product described above. Providers may see temporary differences when they use this tool until the corresponding update is made. Please keep in mind that 'Clear Claim Connection' is for reference only and the results are not a guarantee of how claims will finalize in the claims processing system.

For questions related to this information, please contact Molina Medicaid Solutions Provider Services at (800)473-2783 or (225)924-5040.

ATTENTION FREE-STANDING REHABILITATION CENTER PROVIDERS

Effective with dates of service on or after February 1, 2013, Rehabilitation Clinics (Provider Type 65) which are private/free-standing clinics will no longer receive reimbursement for rehabilitation services for Medicaid recipients age 21 and older.

This does not include rehabilitation services provided by hospital-based providers and home health agencies. This only applies to Providers Type 65 who provided services to recipients over 21.

In cases where Medicaid is the secondary coverage to private insurance, Medicaid shall no longer be billed for the recipient responsibility and therefore, the recipient may be billed for the co-payments. In instances where Medicare is the primary payer, Medicaid shall only be billed when the recipient is certified as a Qualified Medicare Beneficiary (QMB). Providers may bill all other Medicare recipients the co-insurance and deductible amounts.

There are no changes of any kind for Medicaid rehabilitation services for recipients under the age of 21.

ATTENTION PROFESSIONAL PROVIDERS PERFORMING BEHAVIORAL HEALTH SERVICES
FOR LEGACY OR SHARED HEALTH PLAN RECIPIENTS

With the March 1, 2012 implementation of the Louisiana Behavioral Health Partnership (LBHP), some claims submitted to Molina for payment were processed incorrectly and are being systematically reprocessed on this RA (2/11/13). These claims fall into one of the following categories:

  • Claims for behavioral health services performed in an emergency room setting that were paid in error and are being systematically voided on this RA:
    Providers receiving voided claims should resubmit these claims to Magellan/LBHP for consideration of payment.
  • Claims for basic behavioral health services in an outpatient setting that were denied in error with edit 555 and are now denying for the correct edit/reason code on this RA:
    Providers receiving denials with correct edit/reason codes should review these claims and resubmit correctly if a resubmission of the claim is appropriate.
  • Claims for basic behavioral health services in an outpatient setting that were denied in error with edit 555 and are now paying on this RA.

Please direct questions related to this recycling of claims to Molina Provider Relations at (800) 473-2783 or (225) 924-5040.