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.

Prescribing Providers and Pharmacists

As affirmed in the April 2012 issue of the Louisiana Board of Pharmacy quarterly newsletter, be advised that pharmacy-generated refill authorization documents that are received via fax from a prescriber represent a new prescription. As such, these prescription documents must be signed by the prescriber. They cannot be signed by the prescriber's agent.

Attention All Providers regarding Credit Balance Audits:

Effective January 1, 2013, responsibility for credit balance audits was shifted from Medicaid Recovery and Premium Assistance to Medicaid Program Integrity. The Recovery Audit Contractor (RAC) for Program Integrity credit balance audits is Health Integrity, LLC, 9240 Centreville Road, Easton, MD 21601. Health Integrity contacts are Bill Warner, warnerw@healthintegrity.org, 214-548-5148 (office direct) - 518-527-6477 (cell), and Mike Fiore, fiorem@healthintegrity.org, 443-286-1577. HMS will wrap up audits in process as of December 31, 2012.

National Correct Coding Initiative Edits 2013

The Centers for Medicare and Medicaid Services (CMS) has recently released the 2013 quarter one procedure to procedure edits as a part of the mandated National Correct Coding Initiative (NCCI) editing. Included are edits that pair immunization administration codes with preventive medicine codes billed on the same date of service by the same provider. This can result in the preventive medicine code being denied. NCCI long-standing policy and methodology allows payment of both codes in this scenario IF significant, separately identifiable E & M service is provided on the same day and the -25 modifier is appended to the E & M code.

As a result of comments received from the American Academy of Pediatrics and some state Medicaid agencies, CMS has decided to permit states to deactivate these edits should they choose to do so. Per CMS on February 7, 2013, "It is understood that immunizations are commonly administered in conjunction with a comprehensive preventive medicine evaluation and that, when this occurs, both services are payable." It would be expected that all services provided are medically necessary and appropriately documented in the patient record.

Louisiana Medicaid (for fee for service and shared plan claims that process through the Molina claims processing system) will soon be implementing the 2013 quarter one NCCI edits; however, the code pairs specific to preventive services and immunization administration will be deactivated as CMS permits. Doing so aligns with our intent and expectations that appropriate immunizations are to be given at the time of the preventive visit to avoid missed opportunities in both preventive care and immunizations.

Each Bayou Health prepaid plan is required to implement NCCI editing, but may have slightly different implementation schedules and billing policy related to the mandate. It is understood that the prepaid plans will allow appropriate use of modifier-25 if they have activated the code pairs in question. Please contact the plans directly for information specific to their implementation, policies, and any billing instructions.

For questions related to this information as it pertains to legacy Medicaid or Bayou Health shared plans, please contact Molina Medicaid Solutions Provider Services at (800) 473-2783 or (225) 924-5040.