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 Gainwell Technologies at (800) 473-2783 or (225) 924-5040.

For information regarding the medication policy and/or criteria associated with this denial, providers may access the Louisiana Medicaid Preferred Drug List (PDL) / Non-Preferred Drug List at http://ldh.la.gov/assets/HealthyLa/Pharmacy/PDL.pdf.

ATTENTION PROVIDERS
PAYMENT ERROR RATE MEASUREMENT (PERM) 2024 IS IN PROGRESS

The Centers for Medicare and Medicaid (CMS) conducts a Payment Error Rate Measurement (PERM) review program on Louisiana Medicaid every three years. PERM is a review developed by CMS to identify payments in the Medicaid and Children’s Health Insurance (CHIP) programs that did not comply with policies and statutory requirements. PERM does not investigate fraud in Medicaid and CHIP, and is not a fraud rate.

PERM Reporting Year (RY) 2024 will sample from Medicaid and CHIP payments dated from July 1, 2022 through June 30, 2023. CMS contractors will review randomly selected claims to verify provider service documentation is complete, supports the service billed, and is compliant with Medicaid and CHIP policies and documentation requirements.

If your claims are selected for PERM review, your office will receive a medical records request letter and telephone outreach from the CMS review contractor Empower AI. All selected providers must cooperate with the CMS review contractor.

Providers can reach EmpowerAI at PERMRC_ProviderInquiries@empower.ai or 1-800-393-3068. Please visit www.lamedicaid.com, Provider Tools, Payment Error Rate Measurement (PERM) for more information on securely sending records.

Failure to produce documentation of services provided to Medicaid beneficiaries will result in monetary recoveries for undocumented services. Providers must maintain all medical, fiscal, professional and business records for services provided to Medicaid recipients for at least five years from the date of service, even if the provider has closed.

Upon closure, providers must maintain all records, including electronic records, according to applicable laws, regulations and retention requirements. The closing provider must notify LDH of the location records will be stored, and contact information of the records custodian. Providers can report agency closure to Gainwell Provider Enrollment at LouisianaProvEnroll@gainwelltechnologies.com or 225-216-6370.

For questions about PERM, providers may contact Toni Prine, project manager for Louisiana Medicaid’s PERM program, with Myers and Stauffer LC at tprine@mslc.com or 512-770-4237.

SFY23 Recycle of NCCI Outpatient Hospital and DME Claims

Louisiana Medicaid will recycle outpatient hospital (OPH) and durable medical equipment (DME) claims processed from July 1, 2022 through March 31, 2023 to assure correct processing based on the National Correct Coding Initiative edits. Claims affected will be processed in the June 27, 2023 claims cycle.

For more information regarding “The Medicaid National Correct Coding Initiative,” please visit the CMS website below: https://www.cms.gov/medicare-medicaid-coordination/national-correct-coding-initiative-ncci/ncci-medicaid

Questions regarding this message and fee-for-service claims are to be directed to Gainwell Technologies Provider Relations at (800) 473-2783 or (225) 924-5040.

Attention Durable Medical Equipment (DME) Providers

Medicaid has made updates to the Custom Wheelchair Evaluation Form that was mandatory for Fee-For-Service (FFS) custom wheelchair requests effective May 1, 2023. The additional changes were made to streamline the prior authorization process and make the form more user friendly. The new revision date for the current form is June 23, 2023.

Durable Medical Equipment providers must download the PDF form www.lamedicaid.com. Providers MAY NOT convert the form to Word or make any changes to the form prior to completion.

There will be a 30-day grace period to allow providers to become accustomed to the new form. For evaluations performed on or prior to July 31, 2023, the old Custom Wheelchair Evaluation form (effective date of April 1, 2023) will be accepted. Evaluations performed on or after August 1, 2023 will require the new Custom Wheelchair Evaluation Form dated June 23, 2023 and available at the link above.

For questions related to this information as it pertains to Medicaid FFS claims processing, please contact Irma Gauthier via email at Irma.Gauthier2@la.gov.

COVID-19 laboratory tests: Update of HCPCS codes U0003, U0004 and U0005

Effective for dates of service on or after May 12, 2023, Louisiana Medicaid will no longer cover Healthcare Common Procedure Coding System (HCPCS) codes U0003, U0004, and U0005 for COVID-19 laboratory tests.

Claims inadvertently paid with dates of service May 12, 2023 and after will be recycled to assure a proper denial is provided.

For questions related to this information as it pertains to fee-for-service Medicaid claims processing, please contact Gainwell Technologies Provider Services at (800) 473-2783 or (225) 924-5040.

Attention Durable Medical Equipment (DME) Providers

Effective with dates of service on or after October 1, 2023, the below diabetic supplies and equipment will be reimbursable as a pharmacy benefit, as well as a durable medical equipment service. For dates of service on or after December 1, 2023, diabetic supplies and equipment will be reimbursed as a pharmacy benefit ONLY. Durable Medical Equipment (DME) claims will deny.

  • Diabetes Glucose Meters
  • Diabetic Test Strips
  • Continuous Glucose meters
  • Transmitters and Sensors
  • External Insulin Pumps i.e. Omnipod and V-Go
  • Control Solution
  • Ketone test strips
  • Lancets and Devices
  • Pen Needles
  • Re-usable insulin pens
  • Syringes

The Pharmacy and DME provider manuals will be updated to reflect this change, as well as the DMEPOS fee schedule and the Single PDL.

Questions regarding this message and fee for service claims should be directed to Gainwell Technologies Provider Relations at (800) 473-2783 or (225) 924-5040.

Questions regarding managed care claims should be directed to the appropriate managed care organization.