RA Messages for February 15, 2011

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 www.lamedicaid.com. 

ATTENION PHARMACISTS AND PRESCRIBING PROVIATTENTION PHARMACISTS AND PRESCRIBING PROVIDERS

 Sumatriptan generic oral tablets will be moved to the PDL. Effective February 1, 2011, Sumatriptan generic oral tablets will no longer require Prior Authorization.   

ATTENTION LABORATORY AND RADIOLOGY (NON-HOSPITAL) PROVIDERS SYSTEMATIC CLAIMS ADJUSTMENT FOR RATE REDUCTIONS EFFECTIVE JAN 1, 2011

The effective date for the 2% rate reduction for laboratory and radiology services has been changed from December 1, 2010 to January 1, 2011. Refer to the LA Medicaid website (www.lamedicaid.com)and the Office of the State Register's website at http://doa.louisiana.gov/osr/ for published rules detailing these reductions. The system has been updated to reflect this change. Claims for dates of services Dec 1, 2010-Dec 31, 2010 that were adjudicated prior to the new Jan 1, 2011 effective date will be systematically adjusted on the RA of Feb 15, 2011. Providers should reference the "Fee Schedules" link on the homepage of the LA Medicaid website (www.lamedicaid.com) for the most current fees. Contact the Provider Relations unit at (800) 473-2783 or (225) 924-5040 with questions related to the implementation of the rate reductions or adjustment of claims.

ATTENTION HOSPITAL PROVIDERS: RE: REIMBURSEMENT OF VAGUS NERVICE STIMULATORS (VNS)

Effective June 14, 2010, a PA-01 Form is no longer required for hospital providers for the VNS device. However, reimbursement of the device continues to be dependent upon approval of the surgeon to perform the procedure. Hospitals should confirm that the surgeon has received an authorization for the procedure prior to submitting their claim in order to prevent denials. The hospital will bill their VNS claim using HCPCS procedure code C1767 (VNS generator) and/or C1778 (VNS leads) to Molina on a CMS 1500 claim form with the words DME written in red on the top of the form. The claim will pend to the Molina Medical Review Department for review of the surgeon's approved PA request. If approved, the hospital claim will be allowed to process for payment; if there is no valid authori- zation, the hospital claim will deny with edit 191 (PA required).

IMMUNIZATION PAY-FOR-PERFORMANCE

Effective immediately, CommunityCARE PCPs participating in the Immunization Pay-for-Performance (P4P) initiative are encouraged to enter the Medicaid ID numbers of children linked to their practice into the 'Demographics' page of the LINKS Immunization Registry. The Medicaid ID number along with the currently used Social Security Number (if present), name and date of birth will assist Medicaid in ensuring Medicaid eligible children are matched with their corresponding LINKS immunization record (if present) for use in the P4P incentive payment calculation. For assistance with questions related to the LINKS registry, contact the OPH Immunization Consultant for your region (see https://linksweb.oph.dhh.louisiana.gov/linksweb/main.jsp) or call the OPH Immunization Office at (504) 838-5300. For assistance with questions not related to LINKS, contact Molina Provider Relations at (800) 473- 2783 or (225) 924-5040.

IMPORTANT NOTICE TO ALL MEDICAID PROVIDERS

The Department of Health and Hospitals will align with the Centers for Medicare and Medicaid Services (CMS) when a recipient wishes to re-elect hospice services after revocation or discharge. Therefore, effective February 1, 2011, when a hospice patient either revokes hospice services or is discharged from hospice services during an election period, the patient will lose the remaining days in that election period, but may re-elect hospice services at any time other than the same day of revocation or discharge. For example, if the third election period for a hospice patient is from January 1, 2011 through February 28, 2011, and the patient chooses to revoke their hospice services or is discharged from hospice services on January 15, 2011, the patient will lose the remaining days in the third election period, but may re-elect hospice services on January 16, 2011, as the first day of their fourth election period. In this scenario, should the patient re-elect hospice services on January 16, 2011, the hospice provider is required to submit up-to-date Notice of Election (NOE) and Certification of Terminal Illness forms in addition to a prior authorization (PA) packet within ten (10) days of the patient's or legal representative's signature on the NOE.

ATTENTION PROVIDERS

The Bureau of Appeals has transferred to the Division of Administrative Law effective January 1, 2011. When initiating a formal appeal, the request should be sent to:

Division of Administrative Law/HH Section
P.O. Box 4189
Baton Rouge, LA 70821

Any appeal requests that have already been submitted to the old Bureau of Appeals address will be forwarded to the Division of Administrative Law.

ATTENTION PHARMACY PROVIDERS LOUISIANA MEDICAID REIMBURSEMENT OF TAMIFLU� SUSPENSION

Louisiana Medicaid does not pay for compounded prescriptions, nor has the billing process been established to allow the submission of compounded prescriptions. Due to the shortage of commercially manufactured oseltamivir (Tamiflu�) suspension, Louisiana Medicaid will only allow pharmacies to bill the quantity of Tamiflu� capsules utilized in the mixing of the suspension as ordered by a prescribing provider's prescription. This will be allowed as long as the shortage of the manufactured Tamiflu� exists. Pharmacies may receive letters from the Louisiana Medicaid Pharmacy Audit Section which is verifying the quantity of Tamiflu� capsules dispensed. In some instances, pharmacies have submitted billed quantities for the final compounded quantity and not the total number of capsules used in the mixing of the suspension. Following the instructions above will avoid the overbilling of quantities and/or charges. When a pharmacy is attempting to bill Medicaid as the secondary payor, the claim must be submitted to Medicaid on the NCPDP paper Universal Claim Form.