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.

New Louisiana Department of Health and Hospitals Adverse Actions Web Search:

As a condition of participation in the Louisiana Medicaid Program, providers are responsible for ensuring current and potential employees, contractors and other agents and affiliates have not been excluded from participation in the Medicaid, or Medicare Program by Louisiana Medicaid, or the Department of Health and Human Services' Office of Inspector General. Providers who employ or contract with excluded individuals or entities may be subject to penalties of $10,000 for each item or services the excluded individual or entity furnished.

Providers have been previously instructed to check the websites of the Department of Health and Human Services' Office of Inspector General at http://exclusions.oig.hhs/search.aspx and the System for Award Management (SAM) website at https://sam.gov/portal/SAM#1 for any exclusion imposed at the federal level upon hire and monthly thereafter for employees and/or subcontractors that perform services that are compensated with Medicaid/Medicare funds. Please be reminded that the SAM site is only for entities, and providers do not need to check employees on the SAM site.

Effective immediately, providers should check the Louisiana Department of Health and Hospitals Adverse Actions website at https://adverseactions.dhh.la.gov upon hire and monthly thereafter for individuals and entities that have had adverse actions imposed. This is a user friendly site that allows single and multiple searches of individuals and entities. The user may also choose to export the database and have it available in an Excel spreadsheet. Providers are required to maintain proof in their records that checks were done for employees and/or subcontractors. This may be done by printing out the result of the search.

All current and previous names used such as first, middle, maiden, married or hyphenated names and aliases for all owners, employees and contractors should be checked. If an individual's or entity's name appears on these websites, this person or entity is considered excluded and is barred from working with Medicare and/or the Louisiana Medicaid Program in any capacity. If the exclusion is learned prior to employment the provider should not employ the person or entity. If the provider learns of the exclusion after hiring the provider must notify the Department of Health and Hospitals within ten working days of discovering the exclusion with the following information:

  • Name of the excluded individual or entity and

  • Status of the individual or entity (applicant or employee/contractor).

If the individual or entity is an employee or contractor, the provider should also include the following information:

  • Beginning and ending dates of the individual's or entity's employment or contract with the agency,

  • Documentation of termination of employment or contract, and

  • Type of service(s) provided by the excluded individual or entity.

These findings should be reported to:
DHH.Medicaid.State.Exclusion@la.gov or
Department of Health and Hospitals
Program Integrity
P.O. Box 91030
Baton Rouge, LA 70821-9030

This new adverse actions web search tool does not replace the Nurse Aide Registry/Direct Service Worker Registry found at www.labenfa.com. Providers that employee Certified Nursing Assistants (CNA) and Direct Service Workers (DSW) are still required to check these registries upon hire and every six months thereafter.

These requirements are identified in the Provider Enrollment Agreements, the Medical Assistance Program Integrity Law (MAPIL) cited as Louisiana Revised Statute 46:437, referenced in the Louisiana Administrative Code (LAC) Title 50 and the Code of Federal Regulations 42 CFR § 455.436.

All excluded individuals must request reinstatement after the minimum excluded period has been served. There is no automatic reinstatement at either the federal or state level.

ATTENTION ALL PROVIDERS

DHH has identified paid claims associated with administration corrections of member linkages into Bayou Health Plans. These linkage corrections were necessary to ensure compliance with internal policies, approved Medicaid State Plan and maintaining audit controls. Member linkages from February 1, 2012 through June 30, 2014 were evaluated and claims paid by an incorrect entity (CHS, UHC or Molina) have been identified. On August 11, 2014 Molina will systematically void all identified paid claims with a denial reason code 999 Administrative Correction, which will be 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 hard copy 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 prior payment and 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.

For this clean-up only, the Making Medicaid Better website (www.makingmedicaidbetter.com) contains a list of affected providers, which includes the provider name, a partial Medicaid Provider ID (to protect privacy), the number of claims, number of recipients and total of payments to be voided. Questions may be sent to Bayou Health at (bayouhealth@la.gov) with the subject line addressed to "Retro Claims".

Beginning September 2014, the process of voiding identified paid claims will be repeated on a monthly basis, to occur around mid-month, for administrative corrections made to member linkages in the prior month.

CLAIM ADJUSTMENT - CAS SEGMENTS IN LOOPS 2100/2110 OF THE 5010 835 TRANSACTION

Effective with the August 5, 2014 check write, the 835 Transaction you receive from Molina will have the "impact amount" reported for claims processed as secondary in the CAS segment with reason code 23 (payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments) as well as any other CAS segments as necessary to balance. Prior to this change, Louisiana Medicaid was reporting only the prior payer's payment amount in the CAS segment with reason code 23. The claim status code in CLP02 identifies whether the claim is being processed as primary, secondary or tertiary.

Please refer to the previous article on this topic dated 6/16/14.

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

A provider notice has been posted to clarify the quantity limit override procedure for anxiolytics that was implemented on April 2, 2014. See www.lamedicaid.com.

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

Effective August 1, 2014, the Louisiana Medicaid Pharmacy Program has posted revised RXPA forms at www.lamedicaid.com. The new forms should be utilized for any new RXPA request.

ATTENTION PROFESSIONAL SERVICES PROVIDERS:

It has been brought to the attention of DHH that the assistant surgeon fee on file for Current Procedural Terminology (CPT) code 59514 (Cesarean delivery only;) of $137.44 was inadvertently not included in the July 1, 2012 and February 1, 2013 budget cuts. The reimbursement amounts effective on or after the dates of those budget cuts have been corrected as of July 15, 2014. The Professional Services Fee Schedules will be updated to reflect those changes. All impacted claims will be recycled for potential recoupment and/or adjustment of funds. No action is required by providers.

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