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.

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.

ATTENTION: HOSPICE PROVIDERS
Service Intensity Add-On Reimbursement Rates Effective January 1, 2016

CMS has implemented a new reimbursement rate for more intensive services provided by registered nurses (RNs) or social workers in the final seven days of a hospice patient’s life.

Effective for dates of service on and after January 1, 2016, a service intensity add-on (SIA) payment will be reimbursable for a visit by an RN or a social worker, when provided during routine home care in the last seven days of a patient’s life. The SIA payment is in addition to the routine home care rate.

The fee schedule has been updated with the current rates according to each metropolitan service area (MSA) for SIA services and the required hospital revenue code (HR659). The claim for SIA services must be billed in units. Each unit is equal to 15 minutes. The maximum number of reimbursable units per day is 16 units. The seven day maximum number of reimbursable units is 112 units. All claims must be submitted with documentation demonstrating the necessity of the services provided. Documentation submitted should reflect the arrival and departure time of the professional providing the services.

Please contact Molina Provider Relations (800) 473-2783 or (225) 924-5040 if you have any questions regarding this matter.

Updates to Bayou Health-related systems and claims processing changes are plan specific and are the responsibility of each health plan. For questions regarding Bayou Health updates, please contact the appropriate health plan.