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.

Attention Durable Medical Equipment Prosthetics and Orthotics (DMEPOS) Providers

The DMEPOS Fee Schedule on the Louisiana Medicaid website, www.lamedicaid.com, have been updated to reflect the deleted and new 2015 HCPCS codes. The deleted codes removed from the DMEPOS Fee Schedule with the termination date of December 31, 2014:

  • A-7043: Vacuum drainage bottle and tubing for use with implanted catheter
  • L-7260: Electronic wrist rotator, Otto Bock or equal.
  • L-7261: Electronic wrist rotator, for Utah arm.

Effective with date of service January 1, 2015, Louisiana Medicaid will cover the following CPT procedure codes:

  • A4459: Manual pump-operated enema system, includes balloon, catheter and all accessories, reusable, any type
  • A4602: Replacement battery for external infusion pump owned by patient, lithium, 1.5 volt, each
  • A7048: Vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit change, for use with implanted catheter, each
  • K0901: Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated
  • K0902: Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated
  • L3981: Upper extremity fracture orthosis, humeral, prefabricated, includes shoulder cap design, with or without joints, forearm section, may include soft interface, straps, includes fitting and adjustments.
  • L6026: Transcarpametacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s).
  • L7259: Electronic wrist rotator, any type.
  • L8696: Antenna (external) for use with implantable diaphragmatic/phrenic nerve stimulation device, replacement, each

ATTENTION HOSPITAL PROVIDERS
BILLING LEGACY MEDICAID NEWBORN CLAIMS

Following the elimination of Inpatient Hospital Pre Certification requirements for Legacy FFS Medicaid claims, claims billed with Revenue Codes 172-175 for newborn babies have been identified as being incorrectly paid at a $0 amount. This issue has been resolved to provide appropriate payments, and all claims previously billed with these revenue codes will be recycled on the April 7th, 2015 RA.ulation

If you have questions about the contents of this RA, you may contact Molina Provider Relations at (800) 473-2783 or refer to www.lamedicaid.com.

Attention Pharmacists and Prescribing Providers of Louisiana Medicaid Shared Plans and Legacy Medicaid:

Effective April 8, 2015 clinical pre-authorization will be required for Androgenic Agents (excluding oxandrolone), lvacaftor (Kalydeco®), and Roflumilast (Daliresp®). These claims will deny with EOB code 066 (Clinical Pre-Authorization Required). For more information please refer to www.lamedicaid.com.

ATTENTION HOSPITAL PROVIDERS:

It was recently noted that code G0379 (Direct Refer Hospital Observation) was not included in recent changes to claims processing logic for observation services resulting in unintended claim denials. The claims processing logic has been corrected. Claims will systematically be recycled without any action required on behalf of the provider. Providers will see this on the April 7th RA

Providers should also note that the service limit for G0379 is 1(one) unit. The actual number of hours in observation is reported under a separate CPT (Current Procedural Technology) code.

Please contact Molina Provider Relations (800)473-2783 or (225) 924-5040 for questions.

New Healthcare Common Procedure Coding System (HCPCS) Modifiers: XE, XP, XS and XU

Four new HCPCS modifiers have been established to provide greater reporting specificity than modifier -59 on claims with dates of service on or after January 1, 2015. They are:

  • XE - Separate encounter: a service that is distinct because it occurred during a separate encounter
  • XP - Separate practitioner: a service that is distinct because it was performed by a different practitioner
  • XS - Separate structure: a service that is distinct because it was performed on a separate organ / structure
  • XU - Unusual non-overlapping service: the use of a service that is distinct because it does not overlap usual components of the main service

Modifier -59 will remain a valid modifier. Use of the new XE, XP, XS and XU modifiers is currently optional. However, providers may choose to use them to specify more clearly the clinical situations in which modifier -59 is now reported.

These modifiers may be used for clinical situations in which two HCPCS/CPT codes are reported by the same provider on the same date of service and that are currently indicated by appending modifier -59 “Distinct Procedural Service” to a HCPCS/CPT code.

These modifiers should not be used unless the proper criteria for use of the modifier are met. Documentation in the medical record must support the use of any modifier that is used.

Provider use of these modifiers will be monitored for abuse and when appropriate, referred to Program Integrity for detailed review and potential recovery of overpayments.

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

ATTENTION HOSPITAL PROVIDERS
Diabetes Self Management Training Payments:

It was recently noted that hospital outpatient claims containing codes G0108 (Diabetes outpatient self-management training-individual) and G0109 (Diabetes outpatient self-management training-group) have been processing and paying incorrectly at Cost-to Charge Ratio rather than Fee-For Service, which lead to both claims that were over paid and claims that were underpaid. Changes to the claims processing system have been made to correct this error. Claims for dates of service 2/5/2013 through 2/5/2015 will be systematically recycled/adjusted on the remittance of 4/21/2015 without any action required on behalf of the provider .

Please contact Molina Provider Relations (800)473-2783 or (225) 924-5040 for questions.

ATTENTION PROFESSIONAL AND LABORATORY SERVICE PROVIDERS:
NEW PROCEDURE CODES

Effective with date of service May 1, 2015, previously designated HCPCS codes for the reimbursement of Oncotype DX and Fluoride Varnish Application, S3854 and D1206, respectively will no longer be allowed.

Providers should bill the following procedures with their newly designated Current Procedural Terminology (CPT) codes beginning with date of service May 1, 2015:

  • 81519 (Oncology mRNA gene expression profiling by real-time RT-PTC of 21-genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score)
  • 99188 (Application of topical fluoride varnish by a physician or other qualified health care professional)

Please contact Molina Provider Relations (800)473-2783 or (225) 924-5040 for questions.

Attention Providers of Obstetrical Services
'Obstetrics' Policy Billing Changes

Effective with date of service June 1, 2015 legacy Medicaid will no longer reimburse obstetrical delivery CPT codes that include antepartum and/or postpartum care. These codes will be made non-payable on the procedure file.

Prenatal care billing should continue to use outpatient visit ‘evaluation and management’ CPT codes (new and established patient) modified with 'TH'. The most appropriate 'delivery-only' CPT code is to be submitted for the delivery itself. The specific postpartum care CPT code may be used for billing that service when the postpartum visit occurs.

When these changes are implemented in June, the revised 'Obstetrics' policy in the Professional Services provider manual on www.lamedicaid.com related to these and other updates will be published.

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

ATTENTION MID-LEVEL PROVIDERS:
ADJUSTMENT OF PHYSICIAN ADMINISTERED DRUG CLAIMS

Reimbursement methodology for physician administered drugs related to mid-level providers has been revised. Claims impacted will be adjusted on the RA of April 21, 2015. No action is required by providers.

For questions related to this adjustment, please contact Molina Provider Relations at (800)473-2783 or (225) 924-5040.

ATTENTION ALL PROVIDERS
CLAIMS VOIDED DUE TO TIMELY FILING ERROR

We have identified instances where the 1 year timely filing edit (272) was not correctly applied during claims processing, and some claims submitted after the 1-year filing limit were paid when submitted even though they were not initially filed timely. These claims go back to 2013 dates of service and this issue impacts only a small number of providers.

Providers that have less than $1000 in overpayments will see these claims voided on the 04/14/2015 RA. These voids will appear with the EOB edit code 272 and the Internal Control Number (ICN) of the void claim line will have a Julian day of 5095 (Sunday, April 05, 2015). The first 4 digits of the ICN are the Julian day.

Providers that have $1000 or more in overpayments will receive a letter regarding the recoupment of the overpayments. Please watch your mail for this letter from DHH.

We apologize for this error and for any inconvenience this may cause. Please contact Molina Provider Relations at (800) 473-2783 or (225) 924-5040 should you have questions in reference to these voided claims.