RA Messages for July 8, 2014

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 PROVIDERS:

PAYMENT ERROR RATE MEASUREMENT (PERM) 2014 PROVIDER EDUCATION WEBINARS

The Centers for Medicare & Medicaid Services (CMS) will be hosting PERM Provider Education Conference Calls/Webinars this summer, to provide interactive sessions for providers of Medicaid and Children's Health Insurance Program (CHIP) services. Providers will be informed about PERM updates, trends and responsibilities. There will be opportunities to ask questions and provide feedback to CMS and your state representatives.

For Webinar details, refer to the March/April, 2014 Provider Update Article, located in the Provider portal at www.lamedicaid.com.

Oncotype DX Breast Cancer Assay Coverage:

Effective with date of service, July 1, 2014, Oncotype DX Breast Cancer Assay via Genomic Health, Inc. will be reimbursed by the Louisiana Medicaid program. This assay provides a prediction of chemotherapy benefit in women with certain early stage breast cancers.

Please see www.lamedicaid.com for complete details related to coverage and billing information for Oncotype DX Breast Cancer Assay.

Attention Professional Service, DME, and Pharmacy Providers: Revision of Insulin Pump Criteria

Payment for a continuous subcutaneous insulin external infusion pump and related supplies will be authorized for treatment of Type I diabetes when Medicaid recipients meet certain criteria. Effective with date of service June 1, 2014, Louisiana Medicaid has revised their Insulin Pump medical criteria guidelines to reflect current industry standards.

Please visit www.lamedicaid.com to view the web posting for complete details.

Attention Providers: Reject CommunityCARE/KlDMED Claim Submissions

Louisiana Medicaid will no longer accept CommunityCARE/KIDMED claim submissions beginning July 1, 2014 and thereafter. The KIDMED program name for EPSDT Screening for Medicaid recipients and the administration of that function through traditional Medicaid Program was discontinued effective May 31, 2012.

Please visit www.lamedicaid.com to view the web posting for complete details.

Attention Personal Care Services Providers:

Effective with dates of service on or after June 1, 2014, Louisiana Medicaid will no longer require the parent or guardian to be present in the home for minor children receiving EPSDT � Personal Care Services.

For questions related to this information, please contact Molina Provider Services at (800) 473-2783 or (225) 924-5040.

ATIENTION DENTAL PROVIDERS

MCNA will administer the dental benefits to most Medicaid enrollees beginning July 1, 2014. Please continue to verify eligibility using MEVS/eMEVS. Effective for dates of service on or after July 1, 2014, MCNA will pay claims. MCNA will honor all existing Medicaid approved prior authorizations during the month of July. For any questions related to MCNA visit their website at www.mcnala.net or call the provider hotline at 1-855-701-6262. Visit www.lamedicaid.com for more information on those enrollees that will continue to receive dental benefits through the Fee-For-Service Medicaid Dental Program or call Molina Provider Relations at (800) 473-2783.

Attention DME Providers: Coverage of Compression Garments and Related Items

Louisiana Medicaid is updating the DMEPOS fee schedule effective May 1, 2014 to include coverage of the full range of procedure codes for custom ordered/fitted compression garments (e.g., stocking/burn garment/gradient pressure aid garment/sleeve) and the necessary pneumatic compressors and appliances. The HCPCS code range currently includes A6501-A6538, S8420-S8427, and E0650-E0675.

There are no established fees for most of the items; therefore when necessary, the reimbursement rates will be manually priced in the usual manner. Because most of the procedure codes represent items that are custom made, the following manual pricing methodology is to be used: where there is a manufacturer's suggested retail price (MSRP), the reimbursement will be MSRP minus (-) 23.7%. If there is no MSRP, the reimbursement shall be the documented provider invoice fee plus (+) 6.3%.

For questions related to this information as it pertains to legacy Medicaid or Bayou Health Shared Savings Plans claims processing, please contact Molina Medicaid Solutions Provider Services at (800) 473-2783 or (225) 924-5040.

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

Effective July 1, 2014 clinical pre-authorization will be required for the non-preferred direct-acting Hepatitis C agents: Incivek® (telaprevir), Sovaldi® (sofosbuvir), and Olysio® (simeprevir). These claims will deny with EOB code 066 Clinical PreAuthorization Required. The form and worksheet are available at www.lamedicaid.com.

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

Effective July 15, 2014, pharmacy claims for hydrocodone containing drugs will deny when there is an active prescription on file and a new claim is submitted with a different prescriber. See www.lamedicaid.com.

RECYCLE OF UHC SHARED PLAN CLAIMS BILLED WITH 22 MODIFIER

DHH Staff, in conjunction with UHC Staff, have completed review of claims billed to UHC which denied when a 22 modifier was appended to procedure codes. UHC has reviewed all prior submitted denied claims to determine which should be paid the 125% payment and which should not. These denied claims will be recycled for appropriate payment or subsequent appropriate denial. The recycled claims appear on the RA of 7/8/14.

For these claims, as well as future claims billed to Shared Plans with a 22 modifier:

  • If the service does not meet the criteria for use of the 22 modifier, claims will pay at 100% of the fee on file and indicate edit 034 (22 modifier not justified).


  • If the service does meet the criteria for use of the 22 modifier, the claim will pay at 125% of the fee on file.


Providers are reminded that these claims must be submitted hard copy with documentation justifying use of the 22 modifier.

In instances where providers resubmitted claims without the 22 modifier in order to receive payment for services, the recycled claims will deny as duplicates. Providers may submit paper adjustments to Shared Plans for these paid claims; append the 22 modifier to the procedure code; and include documentation to justify the 22 modifier.