RA Messages for September 16, 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.

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.

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

Effective October 1, 2014, Makena� (Hydroxyprogesterone Caproate) will now be covered as a pharmacy benefit in addition to the existing medical benefit coverage. Makena� prescriptions will require a diagnosis code to be submitted at Point of Sale (POS). Please refer to www.lamedicaid.com for specifics.

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

Louisiana Medicaid will reimburse enrolled pharmacies for influenza vaccines and the administration of the vaccines per program policy effective September 15, 2014. If you submit a pharmacy claim for a flu vaccine online through the Point of Sale (POS) system the Professional Service Code Medication Administration (MA) is required in the NCPDP field 440-ES. The following fields are also required as part of the POS claim: vaccine NDC, ingredient cost, incentive amount (administration fee), DUR/PPS Code Counter (value of 1), Prescriber ID, Provider ID, and Provider ID qualifier. See www.lamedicaid.com for more information and definitions of the POS fields.

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.gov 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.