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 ALL PROVIDERS
CLAIMS VOIDED DUE TO TIMELY FILING ERROR

Based on extensive review, DHH has identified specific fee-for-service claims where the one (1) year timely filing limit was incorrectly applied during claims processing, and determined that some claims were paid in error. The review period covers fee-for-service claims received from December 2012 to September 2014.

In April 2015, Providers were notified by RA messages and by direct mail-outs that they were identified as being paid for inappropriately timely filed claims. Providers whose claim totals were less than one-thousand ($1,000) dollars were voided during the months of April and May 2015.

Providers whose claim total was one-thousand ($1,000) dollars and greater were given three options to address their claims, and if no choice was made, were informed that claims would be systematically voided within 30 days of the notice.

DHH has delayed the voiding of identified claims to allow for a secondary review of this issue. Based on this re-review, it was determined that all initial findings were correct, except for approximately thirty-six (36) claims. Therefore, affected providers will receive corrected notification by direct mail-out.

Providers originally identified who responded by choosing a specific option and those providers who did not chose an option as previously notified, your claims will be systematically voided on the RA of April 26, 2016. These actions will be based on the original letters of notification. No further notification will be transmitted.

Voided claims can be identified on the RA by the Internal Control Number (ICN) of the claim line, which will have a Julian date (the first 4 digits of the ICN) of 6108 (Sunday, April 17, 2016).

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 regarding this notice.

Attention Fee for Service (FFS) Louisiana Medicaid Providers:

Effective April 1, 2016 the Centers for Medicare and Medicaid Services (CMS) will begin updating the Federal Upper Limits (FUL) on a monthly basis to be in compliance with the Affordable Care Act. Since FFS Medicaid pharmacy claims reimburse on a “lesser of” methodology including the FUL some pharmacy claims may reimburse at a different rate.

Implementation of the National Correct Coding Initiative (NCCI), Medically Unlikely Edits (MUE) for Practitioner and Ambulatory Surgical Center (ASC) Services

The NCCI MUE processing will be implemented for practitioner and ASC services effective for claims processed on and after the remittance date of April 19, 2016 for fee for service claims.

MUEs are applied separately to each line of a claim, not to the total number of units for a procedure code on a single date of service. If the units of service (UOS) submitted exceeds the MUE value for the code on a claim line, the entire line will be denied. Practitioners and ASC providers may see new edit message, “809” that pertains specifically to NCCI MUE edits: 809 - ‘CCI: Units of service exceeds medically unlikely edit’

Providers can expect to see denials due to MUE’s on procedures that may have previously paid when billed in the same manner. With the implementation of MUEs, fee for service duplicate edits have been enhanced; therefore, claims that previously denied as duplicates may now deny via MUE or may deny as maximum services exceeded.

For some procedures (e.g. cholecystectomy), the MUE is an absolute limit. However, for other procedures, providers may occasionally report UOS in excess of the MUE value by reporting the same code on more than one line of the claim. Modifier usage is acceptable when medically necessary and supported by clinical documentation; however, appending a modifier will not override MUE denials.

The MUE value for applicable procedure codes is determined by the Centers of Medicare and Medicaid Services (CMS). These edits are updated quarterly by CMS. For more information, please refer to the prior NCCI MUE notice on www.lamedicaid.com dated March 29, 2016 or visit the CMS Medicaid website, www.medicaid.gov.

Each Bayou Health plan is required to administer NCCI editing, but may have slightly different implementation schedules and/or billing policies related to the mandate. Please contact each plan for information specific to that plan.

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

Attention Fee for Service (FFS) Louisiana Medicaid Providers:

Effective April 22, 2016 recipients with a breast and cervical cancer type case will be exempt from copay on Fee for Service pharmacy claims.

Attention Fee for Service (FFS) Louisiana Medicaid Providers:

Effective April 26, 2016, buprenorphine/naloxone products will have updated quantity and dosage limits at Point of Sale (POS). Botox® and Xeomin® will have updated diagnosis codes at Point of Sale (POS). Please refer to www.lamedicaid.com for specifics.