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.
UPDATE TO 'CLAIMCHECK' PRODUCT EDITING
Effective with the Remittance Advice of April 26,
2011:
McKesson's 'ClaimCheck' product is routinely updated by McKesson
Corporation based on changes made to the resources used, such as Current
Procedural Terminology (CPT) and Healthcare Common Procedure Coding
System (HCPCS) coding guidelines, the Centers for Medicare & Medicaid
Services (CMS) Physician Fee Schedule database, and/or provider
specialty society updates. The 'ClaimCheck' product's procedure code
edits are guided by these widely accepted industry standards. These edit
changes will affect claims processed beginning with the remittance
advice of April 26, 2011 forward. Providers may notice some differences
in claims editing that includes Pre/Post-op Days, Incidental Mutually
Exclusive, Rebundling and Multiple Surgery Reductions. Providers should
expect that some claims will continue to deny for the same error, but
when applicable, claims may now pay or deny for a different reason.
Providers will continue to be notified when these routine updates are
made in the future. For questions related to this information, please
contact Molina Provider Services at (800)-473-2783 or (225)-924-5040.
ATTENTION HOSPITAL PROVIDERS
Effective for DOS on/after 3/1/2011, methodology for
Outlier payments for under age 1 and 6 has been changed. Refer to the
emergency rule published by the Office of the State Registrar in the
3/20/2011, LA Reg:
http://www.doa.louisiana.gov/OSR/reg/regs2011.htm. Outlier cases
with DOS before 3/1/2011 will pay as they have in the past, EXCEPT that
submissions MUST BE RECEIVED AT DHH NO LATER THAN 5/31/2011. Cases with
covered charges of less than $150,000 before 3/1/2011 may qualify for
outlier payments if a patient is still in the hospital on/after
3/1/2011, and covered charges for the entire inpatient stay reaches/
exceeds $150,000. Regardless of any existing billing/payment issue for
DOS claims prior to 3/1/2011, if a hospital feels they are owed Outlier
payment, THEY SHOULD SUBMIT CLAIMS NO LATER THAN 5/31/2011.