RA Messages for May 4, 2010

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. 

ATTENTION PHARMACISTS AND PRESCRIBING PROVIDERS

The FDA has determined that the following active Exocrine Pancreatic Insufficiency NDCs are unapproved new drugs within the meaning of section 201(p) of the Federal Food, Drug and Cosmetic Act, subject to enforcement action, and cannot be marketed without appropriate FDA approval. According to the FDA, these products do not have approved applications; therefore, CMS has determined that the NDCs do not meet the definition of a covered outpatient drug as defined in Section 1927(k) of the Social Security Act and are subsequently no longer eligible for inclusion in the rebate program. These drugs will be non-payable by the Louisiana Medicaid Pharmacy Benefits Management Unit.
 
 NDC                     PRODUCT NAME
 
00032-1205         CREON5 CAPSULES
00032-1210         CREON10 CAPSULES
00032-1220         CREON20 CAPSULES
00091-4175         KUTRASE CAPSULES RX
10267-2737         PANCRELIPASE 8,000 TABLETS
39822-9045         PANCRLIPASE 4,500
39822-9100         PANCRELIPASE 10,000
39822-9160         PANCRELIPASE 16,000
39822-9200         PANCRELIPASE 20,000
58177-0028         PANGESTYME MT 16 CAPSULES
58177-0029         PANGESTYME CN 10 (PANCRELIPASE) DELAYED RELEASE CAP
58177-0030         PANGESTYME CN 20 (PANCRELIPASE) DELAYED RELEASE CAP
58177-0031         PANGESTYME EC CAPSULES
58177-0048         PANGESTYME UL 12 CAPSULES
58177-0049         PANGESTYME UL 18 CAPSULES
58177-0050         PANGESTYME UL 20 CAPSULES
58177-0416         PLARETASE
58914-0002         ULTRASE MT 12
58914-0004         ULTRASE MT 20
58914-0018         ULTRASE MT 18
58914-0045         ULTRASE MS 4
58914-0111         VIOKASE
58914-0115         VIOKASE 8OZ POWDER
58914-0116         VIOKASE 16000
59767-0001         PANCRECARB MS-8
59767-0002         PANCRECARB MS-4
59767-0003         PANCRECARB MS-16

ATTENTION: IMMUNIZATION PAY-FOR-PERFORMANCE ENROLLED PROVIDERS

The Department of Health and Hospitals has determined that to avoid a budget deficit, a change in the Immunization Pay-For-Performance Initiative (P4P) is necessary. Effective with P4P payments for April 2010 and thereafter, the initial benchmark measurement to receive a payment will be that 60% to 74% of the recipients linked to the participating CommunityCARE PCP must be up to date by age 24 months to be eligible to receive an incentive payment. No changes are being made to the second or third level benchmark or payments. Detailed information on the P4P incentive payment initiative can be found on the www.lamedicaid.com website, following the link for Pay-For-Performance. For details regarding the Emergency Rule associated with this change, please go to the Emergency Rule section of the Louisiana Register at the Office of the State Register's website (http://doa.louisiana.gov/osr/). Contact Unisys Provider Relations at (800) 473-2783 or (225) 924-5040 with any questions.

IMPORTANT NOTICE TO ALL MEDICAID HOSPICE PROVIDERS

The Department of Health and Hospitals will partner with Automated Health Systems (AHS) to administer the Medicaid Hospice Program. Effective May 1, 2010, Hospice providers are to appropriately submit all hospice related forms and prior authorization requests to:


Automated Health Systems
10101 Siegen Lane
Baton Rouge, LA 70810
Attention: Hospice Manager

Fax: (225) 757-4360

ATTENTION MENTAL HEALTH CLINIC (MHC) PROVIDERS

A new Medicaid Provider Manual for Mental Health Clinics is currently available at www.lamedicaid.com.

ATTENTION DENTAL PROVIDERS

Medicaid recently identified a problem that caused duplicate payments of dental procedure codes when submitted more than once by the provider. This problem affected only those dental claims which were processed from February 22, 2010, through April 19, 2010. Program changes have been implemented to correct this problem and all duplicate claims that were processed within the time period mentioned will be automatically recycled by Medicaid and appear on a future remittance advice. Please keep in mind that all claims recycled will consist of recouped payments of these duplicate claims. Should you have any questions, you may contact Provider Relations at (225) 924-5040.

RHC/FQHC PROVIDERS
"Adjunct Services"

Effective with DOS 10-21-07, Louisiana Medicaid reimburses for select adjunct services (currently CPT codes 99050-99051). RHC/FQHC providers were notified through remittance advices published in July 2008 to begin submitting claims to preserve timely filing, but to initially expect denials until programming was finalized.

Programming is now complete and providers will no longer receive denials due to the adjunct services not being payable to RHC/FQHCs. Updated billing instructions can be found on the homepage of www.lamedicaid.com. Claims with proof of timely filing that previously denied due to the adjunct services not being reimbursable to RHC/FQHCs will be systematically adjusted and no action is required by providers. Providers should continue to monitor future RAs.

ATTENTION PROVIDERS BILLING TPL CLAIMS

It has come to our attention that many claims for dates of service January 1, 2010 forward, involving TPL insurance payments, have paid the full Medicaid allowable amount in error. The logic allowing these claims to incorrectly overpay has been corrected, and affected claims will be systematically adjusted to recoup the overpayments previously made. We apologize for any inconvenience this may have caused. If you had any of these claims that were processed incorrectly we will recycle the claims during the month of May.

ATTENTION PROFESSIONAL SERVICES ANESTHESIA PROVIDERS
Implementation of Reimbursement Changes to Formula Based
Anesthesia Services

Effective with dates of service on and after January 22, 2010, the reimbursement for formula based anesthesia services performed by physicians and CRNAs is 75% of the 2009 Louisiana Medicare Region 99 allowable for services rendered to Medicaid recipients ages 16 and older, and 90% of the 2009 Louisiana Medicare Region 99 allowable for services rendered to Medicaid recipients under the age of 16. For further details, refer to the Office of the State Register's website (http://doa.louisiana.gov/osr/) for the emergency rule published on January 22, 2010. Providers began seeing these reimbursement changes on the RA of February 2, 2010, and are responsible for adherence to the policy entitled, "Reimbursement for Formula Based Anesthesia Services," located on the homepage of www.lamedicaid.com. The reimbursement change was implemented in a timely fashion and a systematic adjustment of claims was not necessary.

ATTENTION COMMUNITYCARE PROVIDERS

Effective with date of service June 1, 2010, the Department will no longer pay CommunityCARE PCP management fees (procedure code CC001) for linked enrollees after the month of the enrollee's death. Recent audit findings have revealed that on occasion deceased enrollees have remained active in CommunityCARE prior to Medicaid being informed of their death. In the future, payments after the month of death will be automatically calculated and recouped, regardless of the current status of the PCP's CommunityCARE participation. Management fee recoupments will be identified on the Remittance Advice by error edit 364 - RECIPIENT DECEASED.

ATTENTION ALL MEDICAID PROVIDERS
DELAYED IMPLEMENTATION & CLAIM ADJUSTMENTS FOR RATE REDUCTIONS

The implementation of reimbursement rate reductions for the following programs has occurred, but was initially delayed: (1) Anesthesia Services effective with DOS August 4, 2009; (2) ASC (Non-Hospital) effective with DOS February 4, 2010; and (3) Lab & Radiology services effective with DOS January 22, 2010. Previously paid claims will be systematically adjusted in the very near future with no action required by providers. Continue to monitor future RA's for these adjustments.

The implementation of reimbursement rate reductions for the following programs has been delayed and will occur in the very near future: (1) Professional Services-Physician Services effective with DOS August 4, 2009; (2) Professional Services-Physician Services effective with DOS January 22, 2010; and (3) Free Standing ESRD Facilities effective with DOS January 22, 2010. Providers should continue to monitor RA's and www.lamedicaid.com for status updates. For details regarding what services are affected by these reductions, please refer to the emergency rules on the Office of the State Register's website (http://doa.louisiana.gov/osr/). Providers should continue to contact the Provider Relations unit at (800) 473-2783 or (225) 924-5040 with questions related to the implementation of the rate reductions.

ATTENTION KIDMED PROVIDERS

With the implementation of ClaimCheck on DATE OF PROCESSING May 17, 2010, a change is being made that may directly impact you. In circumstances where a child has a KIDMED screening, a suspected condition is identified, and the child must be referred in-house for a 'sick' visit on the same date of service, the 'sick' visit procedure code 99211 or 99212 MUST be accompanied by the 25 modifier. Following ClaimCheck implementation, absence of the 25 modifier will cause your claim to deny. Please take the necessary steps within your system or procedures to ensure that the 25 modifier can be appropriately placed on these claims.