RA Messages for September 9, 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 LOUISIANA APPLIED BEHAVIOR ANALYSIS PROVIDERS

Provider Type BI is only to be used for billing purposes and should never be used for prior authorization purposes. All claims for ABA services should be submitted directly to Molina.

H2019 is used when enrolled provider provides direct service.

H2019HM is used when services are delivered by line staff (not the enrolled provider providing direct service)

G9012 is the supervisions code and should be used when the enrolled provider is supervising staff who are providing services under code H2019HM. This is only needed when H2019HM is requested.

If you have questions or concerns, please contact Rene' Huff at (225) 342-3935 or rene.huff@la.gov.

Update to 'ClaimCheck' Editing- August 2014

McKesson's 'ClaimCheck' product is routinely updated by McKesson Corporation based on changes made to the resources used, such as Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) coding guidelines, the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule database, National Correct Coding Initiative (NCCI) edits, and/or provider specialty society updates. The 'ClaimCheck' product's procedure code edits are guided by these widely accepted industry standards.

The latest product update will affect claims beginning with the date of processing August 19, 2014 forward. Providers may notice some differences in claims editing that may include NCCI, pre/post-op days, incidental, mutually exclusive, rebundling, add-on and multiple surgery reductions. Providers should expect that some claims will continue to deny for the same error, but when applicable, claims may now pay or deny for a different reason.

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 September 9, 2014, pharmacy claims for all antipsychotic medication prescriptions will require specific diagnosis codes and Latuda® (Lurasidone), Fanapt® (Iloperidone), and Saphris® (Asenapine) will have age and dosage limits. Please refer to www.lamedicaid.com for specifics.

ATTENTION PROFESSIONAL SERVICES PROVIDERS:

Effective for dates of service June 1, 2014 and forward, DHH has revised policy to remove the three Emergency Department visit limit per calendar year. Emergency Department visits will no longer be included in the 12 outpatient visit limit. All impacted claims with date of service on or after June 1, 2014 will be recycled for adjustment of funds and removal of emergency room visits from inclusion with the 12 outpatient visit limit. 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.

Guidelines for Teaching Facilities and Billing for Physician Services Updated August 2014*

Teaching physicians may bill for the services performed by residents in teaching facilities if the following criteria are met and the services are covered by the Medicaid Program.

Emergency Services

If there is on-site supervision or retrospective supervision within 24 hours of the services being rendered and the teaching physician signs or initials approval/concurrence with the treatment/services, the service may be billed. Emergency services include, but are not limited to:

  • Emergency Department visits
  • Surgical procedures
  • Laboratory procedures
  • Radiology procedures

Planned Surgical Services

If the teaching physician is present and available in the suite, on call or otherwise available in the event intervention is necessary, the service may be billed. The teaching physician must document supervision by signing, initialing, or initialing a signature stamp on the operative notes and the pre- and post-surgery evaluations. Planned surgical services include, but are not limited to:

  • Primary surgery
  • Assistant surgery
  • Anesthesiology, and
  • Other physician specialty services necessary to the primary surgery.

Non-Surgical Hospital Admissions and Subsequent Visits

If the admission and discharge summaries are signed or initialed, non-surgical admissions may be billed for services rendered by a resident. A signature stamp which has been initialed by the teaching physician may also be used to indicate approval of services. If the hospital stay is routine and exceeds seven days, the teaching physician should sign or initial the progress notes at least once a week. In acute care or serious illness situations, the teaching physician's signature or initials should appear on the daily notes.

Obstetrical Care/Delivery

If the progress notes for each prenatal visit are signed or initialed by the teaching physicians, the teaching physician may bill for prenatal visits and other services associated with prenatal care. Deliveries may be billed by the teaching physician if the record documents his/her presence in the suite or participation in the delivery or if he/she is on call in the facility or on call at a reasonable distance. Reasonable distance is defined as a distance of no more than twenty minutes from the delivery suite. Signature or initials should appear on the chart within 12-14 hours of delivery if the teaching physicians' presence was not necessary in the delivery room.

*All Other Services

The teaching physician may bill for services such as interpretation of x-rays, laboratory services, etc., by signing and initialing the appropriate report and charts. Sign off of resident notes should be done at the time of service or within a maximum of one week to assure supervision of the resident and to allow a reasonable time to sign off on the electronic and/or hard copy record. This time allowance for record sign off does not negate the obligation of standard oversight/supervision in real time. Residents must have faculty supervision for all direct patient care in accordance with national Residency Review Committee (RRC) requirements. Residents cannot be enrolled as participating providers if practicing in a teaching facility. They can be enrolled as participating providers for services rendered outside of the teaching facility.

Remember, only the professional component of pathology and laboratory services performed in inpatient and outpatient hospital settings may be billed to Louisiana Medicaid by the teaching or supervising physician. One must own, rent, or lease laboratory or x-ray equipment in order to bill full service.

Attention Hospital Providers and Physicians Performing OB Delivery Services RE: Deliveries Prior to 39 Weeks

Babies born prior to 39 weeks gestation for reasons that are not medically necessary have a high risk of spending their first days in the NICU unnecessarily. This unnecessary NICU admission is detrimental to the baby and also very costly for taxpayers. It is the intent of the Department of Health and Hospitals to not pay for deliveries prior to 39 weeks that are not medically necessary. This is a joint endeavor between Louisiana Medicaid and Blue Cross Blue Shield of Louisiana.

Effective with date of service September 1, 2014 forward, the Department intends to deny hospital and physician claims for the delivery of a baby prior to 39 weeks that is not medically necessary. Claims for the anesthesia related to the delivery will not be impacted by this policy.

The Department will use the Louisiana Electronic Event Registration System (LEERS) data from the Office of Public Health Vital Records to validate that the delivery was not prior to 39 weeks or if prior to 39 weeks, that it was medically necessary. Currently, LEERS creates a file on a monthly basis with the birth records and sends this data to Molina. The LEERS data will be changing to a weekly process so claims can be validated and processed more timely. Claims from the hospital, delivering physician (and assistant surgeon if applicable) for a delivery will be held within the Molina claims processing system until LEERS updates the birth record information for those claims. After the claims and LEERS are matched up, all claims will be allowed to continue processing unless LEERS indicates the delivery was prior to 39 weeks and not medically indicated.

Instructions for Delivering Physicians and Hospitals:

  • Following delivery, please select the corresponding medical reason from the LEERS Singleton Births Below 39 Weeks Gestation Worksheet
  • If there was no medical reason, select the �None, No medical reason� check box.

If a provider feels a claim has been denied inappropriately, please follow these steps:

  • The physician will need to log into LEERS to review the data they certified on the birth record.
  • The physician will then need to speak to the birth clerk at the facility to determine what data was entered on the birth record and whether an amendment needs to be requested if the data is not correct.
  • If what is on the birth record does not correspond with the file, the birth clerk may contact Vital Records LEERS Hotline at 504-593-5101. It is recommended that the birth clerk from the facility contact the hotline since they are more familiar with the birth record process.
  • If a facility needs to correct the data on the birth file, they may request an amendment form through the Vital Records LEERS Hotline at 504-593-5101. The completed form should be returned to Vital Records by the facility for processing. Vital Records will provide verification of this amendment to the hospital provider. This form will need to be attached to the claim and resubmitted via hard copy for payment to Molina.

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