RA Messages for June 10, 2008

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 HEMODIALYSIS AND HOSPITAL PROVIDERS

UPDATED UB-04 BILLING INSTRUCTIONS, INCLUDING INFORMATION FOR BILLING REQUIRED NDC DATA FOR BOTH HEMODIALYSIS CENTERS AND HOSPITAL PROVIDERS, ARE NOW LOCATED ON THE LA MEDICAID WEB SITE TO ASSIST YOU IN SUBMITTING NDC/HCPCS CODE INFORMATION FOR PHYSICIAN-ADMINISTERED DRUGS ON THE 837I (INSTITUTIONAL TRANSACTION) AND THE UB-04 CLAIM FORM. THIS REQUIREMENT IS EFFECTIVE WITH PROCESSING DATE MAY 23, 2008 (RA DATE 5/27/08) FOR DATES OF SERVICE MARCH 1, 2008 AND AFTER FOR OUTPATIENT HOSPITAL CLAIMS AND LICENSED HEMODIALYSIS CENTER CLAIMS. THESE INSTRUCTIONS ARE LOCATED UNDER THE BILLING INFORMATION LINK AND THE NEW MEDICAID INFORMATION LINK. THE REVISED EDI COMPANION GUIDE FOR THE 837I IS AVAILABLE ON THE WEB SITE. THE NDC INFORMATION MUST BE ENTERED ON THE CLAIM SUBMISSION EXACTLY AS INDICATED IN THE BILLING INSTRUCTIONS TO PREVENT FUTURE CLAIM DENIALS. EFFECTIVE WITH DATE OF PROCESSING JULY 1, 2008, CLAIMS THAT DO NOT CONTAIN THE REQUIRED, ACCURATE NDC INFORMATION SUBMITTED WILL DENY.

ATTENTION HOSPITAL PROVIDERS

HCPC CODES REQUIRED FOR OUTPATIENT CLAIMS/OUTPATIENT HOSPITAL SERVICES FEE SCHEDULE - EFFECTIVE FOR DATES OF SERVICE ON OR AFTER JUNE 1, 2008, IN KEEPING WITH THE NATIONAL UNIFORM BILLING STANDARDS, HOSPITALS ARE REQUIRED TO REPORT THE CORRESPONDING HCPC CODE WITH REVENUE CODES FOR SERVICES AS REQUIRED BY NUBC. INDIVIDUAL CLAIM LINES THAT ARE BILLED WITHOUT THE REQUIRED HCPC CODE WILL DENY WITH ERROR CODE 513 "HCPC REQUIRED." THIS APPLIES TO BOTH ELECTRONIC AND HARD COPY CLAIMS. IN ADDITION, THE OUTPATIENT HOSPITAL SERVICES FEE SCHEDULE WILL BE POSTED ON THE LA MEDICAID WEB SITE BY JUNE 1, 2008. PAYMENT METHODOLOGY WILL NOT CHANGE.

RE: IMMUNIZATION ADMINISTRATION CODES 90465-90468 AND 90473-90474

TO CORRECT CLAIMS PROCESSING OF THESE CPT CODES FROM DATES OF SERVICE JANUARY 1, 2006 THROUGH SEPTEMBER 30, 2007, A RECYCLE OF DENIED CLAIMS IS PLANNED FOR JUNE 10, 2008. A SUBSEQUENT RECYCLE PLANNED FOR JUNE 17, 2008 WILL CORRECT A SMALL NUMBER OF DENIALS THAT OCCURRED IN NOVEMBER 2007. PLEASE VISIT WWW.LAMEDICAID.COM TO VIEW A DETAILED NOTICE CONTAINING INFORMATION ABOUT THESE RECYCLES AND OTHER IMMUNIZATION INFORMATION.

CLARIFICATION OF COMMUNITYCARE POLICY RELATIVE TO OUTPATIENT VISIT

LIMITS: MEDICAID ENROLLEES AGE 21 AND OLDER ARE LIMITED TO 12 MEDICALLY NECESSARY PHYSICIAN/CLINIC VISITS PER CALENDAR YEAR. IF A CC ENROLLEE WHO HAS USED ALL 12 ANNUAL VISITS IS IN NEED OF NON-EMERGENT CARE, THE PCP CAN EITHER TREAT THE ENROLLEE AND NOT BILL MEDICAID OR OFFER TO SEE THE ENROLLEE AS A PRIVATE PAY AGENT (ENROLLEE PAYS OUT OF POCKET). IF THE PCP FEELS THE ENROLLEE'S TREATMENT WOULD BE LIFE SAVING OR SUSTAINING, HE/SHE MAY PROVIDE CARE TO THE ENROLLEE AND REQUEST AN EXTENSION OF VISITS; OR IF THE PCP DOES NOT FEEL THAT TREATMENT MEETS CRITERIA FOR AN EXTENSION, AND THE ENROLLEE IS UNWILLING/UNABLE TO PAY OUT OF POCKET, THE PCP CAN ISSUE A REFERRAL/AUTHORIZATION SO THE ENROLLEE MAY RECEIVE CARE FROM ANOTHER PROVIDER WHO MAY BE WILLING EVEN THOUGH ALL 12 VISITS ARE USED. QUESTIONS REGARDING CC POLICY SHOULD BE DIRECTED TO UNISYS PROVIDER RELATIONS AT (800)473-2783, OR CC HOTLINE (800)259-4444.

COMMUNITYCARE POLICY REVISION:

CC POLICY REQUIRES POST-AUTHORIZATION FROM THE PCP FOR THE TWO LOWEST LEVELS OF EMERGENCY ROOM (CPT CODES 99281 AND 99282) AND ASSOCIATED SERVICES. CURRENTLY, REQUESTS FOR POST AUTHORIZATION MUST BE SUBMITTED TO THE PCP, ALONG WITH DOCUMENTATION OF PRESENTING SYMPTOMS, THE NEXT BUSINESS DAY FOLLOWING DATE OF SERVICE. EFFECTIVE FOR DATE OF SERVICE 07-01-2008, THE TIME FRAME FOR SUBMITTING REQUESTING FOR POST-AUTHORIZATION OF ER VISITS HAS BEEN EXTENDED TO 10 CALENDER DAYS FOLLOWING DOS. FOR QUESTIONS ABOUT CC POLICY, CALL UNISYS PROVIDER RELATIONS AT (800)473-2783, OR CC HOTLINE (800)259-4444.

ATTENTION PROFESSIONAL SERVICES PROVIDERS:

CLAIMS AFFECTED BY THE PROFESSIONAL SERVICES RATE INCREASES EFFECTIVE WITH DOS 10-04-06 FORWARD FOR SELECT GROUPS OF CPT CODES (SEE RA'S FROM JUNE 2007 FOR DETAILS) WERE SYSTEMATICALLY ADJUSTED IN 2007. IT HAS BEEN NOTED THAT CLAIMS PAID ON THE 5-29-2007 RA WERE NOT INCLUDED. THE ADJUSTMENT OF THE PAYMENT FOR THOSE CLAIMS IS NOW INCLUDED IN THE 06-10-2008 RA.

ATTENTION PROFESSIONAL SERVICES PROVIDERS:

PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT SERVICES FOR ADULTS BECAME REIMBURSABLE WITH DOS 07-1-06 (SEE AUGUST-SEPT. 2007 RA'S FOR DETAILS). IT HAS BEEN NOTED THAT SOME CLAIMS ERRONEOUSLY DENIED FOR ERROR CODE 517 (CLAIM MUST BE SUBMITTED IN KIDMED FORMAT). THIS ISSUE HAS BEEN RESOLVED AND THE ADJUSTMENT OF THE PAYMENT FOR THOSE CLAIMS IS NOW INCLUDED IN THE 6-10-08 RA.

ATTENTION PROFESSIONAL SERVICES PROVIDERS: "PSYCHIATRIC SERVICES"

EFFECTIVE WITH DOS 10-01-07, LOUISIANA MEDICAID REIMBURSES FOR SELECT PROCEDURE CODES SPECIFIC TO OUTPATIENT PSYCHIATRIC SERVICES. THESE SERVICES ARE INCLUDED IN THE OUTPATIENT VISIT SERVICE LIMIT ALLOWED PER CALENDAR YEAR FOR ADULT RECIPIENTS (AGE 21 AND UP). RHC/FQHC PROVIDERS SHOULD ENTER THESE PSYCHIATRIC PROCEDURE CODES AS ENCOUNTER DETAIL LINES WHEN APPLICABLE. PROVIDERS ARE RESPONSIBLE FOR ADHERENCE TO THE PSYCHIATRIC SERVICES POLICY WHICH IS LOCATED ON WWW.LAMEDICAID.COM UNDER 'NEW MEDICAID INFORMATION' AS WELL AS THE 'LA MEDICAID PROVIDER UPDATE.' PROGRAMMING IS FINISHED AND PROVIDERS MAY NOW SUBMIT CLAIMS FOR REIMBURSEMENT FOR DOS ON OR AFTER 10-01-07. PREVIOUSLY DENIED CLAIMS NOW ELIGIBLE FOR REIMBURSEMENT WILL BE SYSTEMATICALLY ADJUSTED IN THE 6-17-08 RA.