RA Messages for September 17, 2013

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 Pharmacists and Prescribing Providers:

Effective September 1, 2013 Louisiana Medicaid will reimburse enrolled pharmacies for the 2013-2014 influenza vaccines and administration of the vaccines for recipients who are nineteen years and older when the administering pharmacist is an enrolled Medicaid provider. The cost of the vaccine will not be reimbursed for recipients under the age of nineteen as these vaccines are available through the Louisiana Vaccines for Children (VFC) program. Only the administration fee will be reimbursed for these recipients. See http://www.lamedicaid.com/.

ATTENTION PROVIDERS: PAYMENT ERROR RATE MEASUREMENT (PERM) TO BEGIN 10/01/2013

LA Medicaid is mandated to participate in the Centers for Medicare and Medicaid (CMS) Payment Error Rate Measurement (PERM) program which will assess our payment accuracy rate for the Medicaid and LACHIP programs. The results of these reviews will be used to produce a national error rate which will be reported to Congress. If chosen in a random sample, your organization will soon receive a Medical Records Request from the review contractor, A+ Government Solutions. A period of 75 days from the date of receipt of the request will be given to submit the requested documentation. If no documentation or incomplete documentation is submitted, the claim(s) will be considered to be an error and is subject to a payment recovery through withholding of payment, and/or a possible fine. REMINDER: Providers who are no longer doing business with Louisiana Medicaid are obligated to retain recipient records for 5 years, under the terms of the Provider Enrollment Agreement. FOR MORE PERM INFORMATION: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/PERM/Providers.html.

Attention Electronic Billers/Submitters of Institutional Claims

We want to remind providers and submitters that the following Bill Type codes are the only codes that are acceptable for the Louisiana Medicaid Program, including Bayou Health claims and encounters. The file extension of the electronic claim file is also very important in combination with the Bill Type codes.

For file extension 837I � UB9 the acceptable Bill Type codes are: 11X, 12X, 13X, 14X, 18X, 71X, 72X, 76X, 81X, 82X, 83X, 85X, 86X; 89X

For file extension 837I � HOM (Home Health) the only acceptable Bill Type code is 33x. When billing Home Health claims electronically you must use the file extension 837I � HOM.

For file extension 837I � LTC (Long Term Care) the only acceptable Bill Type codes are: 21X, 65X, 66X. These codes are ONLY acceptable for Long Term Care billing. Hospitals may not use these codes.

Electronic 837I billing files that are submitted with Bill Type codes not included in those listed above will be rejected and not entered into the claims processing system. One of the most common errors identified for file rejections is the use of Bill Type 33x with file extension 837I- UB9.

Providers must review the billing instructions for their provider type to ensure use of acceptable Bill Types for their program. Providers using a Bill Type from the list above that is not acceptable for the specific provider type/medical program will receive a denial of 042 � Invalid UB Bill Type.

ATTENTION PROVIDERS: CONTINUED ACA ENHANCED REIMBURSEMENT CLAIMS RECYCLES AND IMPLEMENTATION OF ENHANCED PAYMENTS FOR APRNS

Pursuant to the claims payment logic implemented in June 2013, Molina will recycle previously paid specified primary care service claims provided by Designated Physicians and eligible Physician Assistants in order to allow the enhanced payments as directed by the Patient Protection and Affordable Care Act. The recycles will cover the following:

  • Providers whose Designated Physician forms were processed in late June but eligible for enhanced payments for dates of service beginning 01/01/2013. These providers did not have their claims recycled during July to receive the enhanced rate.
  • Additional claims with dates of service 01/01/2013-02/19/2013 which were paid at the incorrect facility rate.

In addition, new claims payment logic was implemented in mid-August to allow Advanced Practice Registered Nurses to receive enhanced rates. However, the majority of claims that are potentially eligible for enhanced payment did not have a referring provider ID on the claim. DHH will post ACA enhanced reimbursement information to the provider manual in the near future. To help facilitate providers receiving the enhanced rates, please note the following:

  • Claims submitted via CMS 1500 (paper) require that a valid Designated Physician's NPI be listed on item 17b - Referring Provider
  • Claims submitted via v5010 837P (electronic) require that the Designated Physician's NPI be listed in a NM1 segment with the Qualifier DN. The NMl segment may be billed at either the Claim level 2310A or the Line l evel 2420F.

Claims for APRNs that do not have the Designated Physician listed as the referring provider on their claims will not receive the enhanced rate, nor will previously paid claims be recycled without this critical piece of information.

Providers should submit an adjustment for APRN claims that did not have the required Designated Physician's NPI included in the appropriate location on the previously paid claim. This can be done by paper using the 213 Adjustment Form or electronically via the 837P adjustment format. The Designated Physician's NPI must be entered correctly on the adjustment as indicated above for either paper or EDI adjustments in order to receive the enhanced payment.

Update to �ClaimCheck� Product Editing

Effective with the Remittance Advice of September 3, 2013:

McKesson�s �ClaimCheck� product is routinely updated by the 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, and/or provider specialty society updates. The �ClaimCheck� product�s procedure code edits are guided by these widely accepted industry standards. The edit changes will affect claims processed beginning with the remittance advice of September 3, 2013. Providers may notice some differences in claims editing as most claims will continue to edit in the same manner but when applicable, claims may now pay or deny for a different reason. Providers will continue to be notified when routine updates are made in the future.

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