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 Pharmacists and Prescribing Providers of Louisiana Legacy Medicaid:

Effective April 27, 2015, there will be changes in the Point of Sale (POS) response for Fee for Service pharmacy claims. NCPDP field 506-F6 (ingredient cost paid) will now only contain the ingredient cost, NCPDP field 507-F7 (dispensing fee paid) will include the dispensing fee and provider fee, and NCPDP field 509-F9 (total amount paid) will contain the total amount paid for the claim.

ATTENTION PROVIDERS
REGARDING BAYOU HEALTH ADMINISTRATIVE CORRECTIONS FOR RETROACTIVE ENROLLMENT AND RETROACTIVE DISENROLLMENT DENIAL CODE 999

Claims were voided on the Remittance Advice of 03/17/2015, but the denial code was not appended. The Remittance Advice of 03/17/2015 has been regenerated for providers to append denial code 999 for these voided claims. We apologize for any inconvenience this has caused providers.

Bayou Health Administrative Corrections for Retroactive Enrollment and Retroactive Disenrollment Monthly Process

DHH identified paid claims associated with administrative corrections of member's linkages into Bayou Health Plans. These linkage corrections were necessary to ensure compliance with internal policies, approved Medicaid State Plan and maintaining audit controls.

Beginning March 17, 2015, the process of voiding identified paid claims by an incorrect entity (Shared Plans: CHS & UHC, and Legacy Medicaid) will be repeated on a monthly basis to occur mid-month for administrative corrections made to member linkages in the prior month. Molina will void all identified paid claims with a denial reason code 999 Administrative Correction which is shown on the Remittance Advice.

In order to rebill, providers must verify the correct entity based on the date of service by using either MEVS or REVS. To obtain consideration for payment, providers are required to submit claims to the correct entity no later than 6 months from the date the claim is voided. If PA or Pre-Cert was obtained on the original claim, providers will not be required to obtain additional authorization when submitting these specific prior-paid claims to the correct entity. Documentation must accompany claims verifying the void.

This documentation of prior payment will also support the authorization of the service. Claims submitted within 6 months of the void date will not be denied based on timely filing.

NOTE: Pharmacy claims should not be resubmitted through the Molina POS. All Pharmacy claims should be submitted using the NCPDP universal claim form accompanied by documentation verifying the void.

For more information, please visit www.makingmedicaidbetter.com or lamedicaid.com "Attention All Providers: Bayou Health Administrative Corrections for Retroactive Enrollment and Retroactive Disenrollment-Monthly void process will begin March 17, 2015".

Questions may be sent to Bayou Health at bayouhealth@la.gov, with the subject lined addressed to "Retro Claims".

Attention ICF Providers, Nursing Home Providers and Hospice Providers
CMS required billing changes

Transaction standards updated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) with regard to ASC Xl2 Version 5010 require an attending provider be submitted on all institutional (format UB-04) claims. Effective July 1, 2015, all claims submitted for payment must identify the attending physician and all appropriate blocks on the claim form must be completed with the attending physician's identifying information. There will be no exceptions to this change. An edit will be put into the system to deny/reject any and all claim forms with missing required information.

Please visit www.lamedicaid.com for detailed provider notices concerning these changes.

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

Effective May 20, 2015, pharmacy claims for Ombita/Paritap/Riton/Dasabuvir (Viekira®) will have edits at Point of Sale (POS). Please refer to www.lamedicaid.com for specifics.

ATTENTION RADIATION ONCOLOGY PROVIDERS:
REIMBURSEMENT RATE CHANGE AND ADJUSTMENT OF CLAIMS

The Department has made an administrative decision to adjust reimbursement rates for the following 2015 procedure codes related to Radiation Oncology Services: 77385 (Intensity modulated radiation treatment delivery….simple), 77386 (Intensity modulated radiation treatment delivery….complex), and 77387 (Guidance for localization of target volume…) . This change in reimbursement rates is effective January 1, 2015.

  • For CPT code 77385 , the reimbursement rate changed from $130.42 to $266.51.
  • For CPT code 77386, the reimbursement rate changed from $151.65 to $265.54.
  • For CPT code 77387, the reimbursement rate changed from $80.95 to $51.39.

Claims that paid at the lower rate beginning with date of service January 1, 2015 were systematically adjusted on the RA of 04/28. No action was required by the provider.

The Laboratory and Radiology Fee Schedule has been updated on the Louisiana Medicaid website at www.lamedicaid.com to reflect the recent change in the reimbursement rate for these procedure codes.

It is not the intent of the Department to reimburse the new G codes related to Radiation Oncology services.

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

Attention Hospital and Independent Lab Providers
Coverage and Reimbursement Guidelines for CPT code 81220:

Effective for dates of service January 1, 2012 and forward, CPT (Current Procedural Terminology) code 81220 CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; common variants) will be reimbursed by Louisiana Medicaid. Previously denied claims due to the procedure code not being on file will be systematically recycled without any action required by the provider on the RA of May 26, 2015.

The reimbursement for any lab testing that occurs during a recipient’s inpatient hospitalization (at a recipient’s birth or if hospitalized at a later date) is included in the per diem rate paid to the hospital by Medicaid. This includes CPT code 81220 when performed on hospitalized newborns immediately after birth. If a hospital contracts the services of an independent lab to perform lab services during a member’s inpatient hospitalization, the hospital is responsible for payment of these services to the independent lab. The independent lab may not bill Medicaid directly for payment of these services.

Hospitals are allowed by Medicaid to contract with an independent laboratory for performance of outpatient laboratory services including CPT code 81220 when performed as a repeat screening for a newborn. When a hospital contracts with a freestanding laboratory for the performance of the technical service only, it is the responsibility of the hospital to pay the laboratory.