RA Messages for June 17, 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 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
BOTHELECTRONIC 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 CALENDAR 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: "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 ELIGIBLEFOR REIMBURSEMENT WILL BE SYSTEMATICALLY
ADJUSTED IN THE 6-17-08 RA.
PREVENTIVE MEDICINE SERVICES (INCLUDING KIDMED), 2007 REIMBURSEMENT
CHANGES:
AS PART OF THE REIMBURSEMENT CHANGES FUNDED IN THE
2007 LEGISLATIVE SESSION AND APPROVED BY CMS, EFFECTIVE WITH DATE OF
SERVICE OCTOBER 15, 2007 FORWARD, THE REIMBURSEMENT FOR PREVENTIVE
MEDICINE SERVICES (CPT CODES 99381-99387 AND 99391-99397) HAS BEEN
INCREASED TO 90% OF THE 2007 MEDICARE REGION 99 RATE. THE PROFESSIONAL
SERVICES FEE SCHEDULE ON WWW.LAMEDICAID.COM HAS BEEN UPDATED TO REFLECT
THIS CHANGE. KIDMED PROVIDERS ARE DIRECTED TO THE RECENTLY ADDED KIDMED
PROGRAM FEE SCHEDULE ALSO ON THE WEBSITE. THOSE SERVICES IMPACTED BY THE
RATE CHANGE WILL BE SYSTEMATICALLY ADJUSTED AND SCHEDULED TO APPEAR ON
JUNE 17, 2008'S RA.
ALERT! PREVENTIVE MEDICINE/KIDMED REIMBURSEMENT CHANGES
REIMBURSEMENT RATES FOR PREVENTIVE MEDICINE
SERVICES, INCLUDING KIDMED MEDICAL SCREENINGS, HAVE BEEN INCREASED
EFFECTIVE WITH DOS 10/15/07 AS PART OF THE 2007 REIMBURSEMENT CHANGES.
CLAIMS WHERE PROVIDERS DID NOT BILL THEIR USUAL AND CUSTOMARY FEE AS
INSTRUCTED WILL NOT PAY MORE THAN THE ORIGINAL PAYMENT BECAUSE THE FEE
ON FILE WAS ENTERED FOR BILLED CHARGES. THESE CLAIMS CANNOT BE PART OF
THE SYSTEMATIC ADJUSTMENT OF PREVENTIVE MEDICINE SERVICES. PROVIDERS
MUST SUBMIT ADJUSTMENTS FOLLOWING CURRENT POLICY IN ORDER TO RECEIVE THE
INCREASED FEES. CONTACT UNISYS PROVIDER RELATIONS AT (800)473-2783 WITH
ANY QUESTIONS. ONCE AGAIN, DHH ENCOURAGES THE USE OF USUAL AND CUSTOMARY
FEES FOR BILLING.