RA Messages for September 27, 2011

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 www.lamedicaid.com. 

 ATTENTION PROFESSIONAL SERVICES PROVIDERS
PROVIDING SERVICES PHASE IV LaCHIP (SCHIP) ELIGIBLES

It has been brought to the Department's attention that clarification is needed regarding the eligibility period of Phase IV LaChip recipients. This program provides prenatal care services, from conception to birth, for low income uninsured mothers who are not otherwise eligible for other Medicaid programs. This certification period begins with the first month of eligibility and continues without interruption until the pregnancy ends. There is no post partum eligibility period in this program.

Medicaid payments received by providers for inappropriate services are subject to review, recoupment and sanction.

ATTENTION PROFESSIONAL SERVICES PROVIDERS
PROCEDURE CODES PAYABLE TO OPTOMETRISTS

Programming logic related to procedure codes payable to optometrists has been updated effective for dates January 1, 2010, forward. Claims that previously denied with errors 210, "PROVIDER NOT CERTIFIED FOR THIS PROCEDURE," 298, "INVALID PROCEDURE CODE FOR DATE OF SERVICE," and 299, "PROC/DRUG NOT COVERED BY MEDICAID," will be systematically adjusted and will appear on the RA of September 13, 2011. No action is required by providers.  

ATTENTION PHYSICIAN AND HOSPITAL PROVIDERS: EFFECTIVE OCTOBER 15, 2011
CHANGE IN OBSTETRIC ULTRASOUND SERVICE LIMITS

DHH is changing the policy related to the number of obstetric ultrasounds allowed per pregnancy without a medical review. Currently, three ultrasounds per pregnancy without medical review are allowed. The policy change reduces the number of ultrasounds allowed per pregnancy without a medical review to two ultrasounds per pregnancy. If greater than two ultrasounds are medically necessary, the physician provider and the hospital provider can be reimbursed. The provider must submit the bill with documentation supporting the clinical rationale for performing ultrasounds beyond the first two. The decision to approve any ultrasound exceeding two will be based on medical necessity. DHH has researched other states' policies and this change is in line with the current practices of other states and commercial carriers. This change does not inhibit women's access to ultrasound services. Please visit www.lamedicaid.com for the complete notice. If you have any questions, contact Molina Provider Relations at (800) 473-2783 or (225) 924-5040.

ATTENTION PROVIDERS OF OPHTHALMOLOGY/OPTOMETRY PROFESSIONAL SERVICES

Revisions have been made to Louisiana Medicaid's claims processing system that will now allow modifiers -24 (Unrelated evaluation and management service by the same physician during a postoperative period) and -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to be applied to the procedure codes related to the general ophthalmological services for examination and evaluation of new and established patients. Providers are reminded that discovery of improper use of any modifier solely to circumvent valid claim editing to maximize reimbursement will subject the provider to administrative sanctions. Documentation in the recipient's record must clinically substantiate the use of the modifier in each instance.

Claims for these ophthalmological services (CPT procedure codes 92002, 92004, 92012, and 92014) that received denial error code 092 (Invalid or missing modifier) when either of these modifiers were present on the claim will be recycled, and therefore no action is required by the provider. This change is applicable to claims with dates of processing May 1, 2010 forward. Providers may see that some claims continue to deny for a different reason. The recycle is anticipated to occur on the remittance of September 20, 2011. Please contact Molina Provider Relations at (800) 473-2783 or (225) 924-5040 if there are questions related to this matter.

ATTENTION PROVIDERS

The Centers for Medicare & Medicaid Services (CMS) is hosting a PERM Provider education webinar/Listening Session to provide an opportunity for the providers of the Medicaid and Children's Health Insurance Program (CHIP) communities in the States of Louisiana, South Dakota, and Alaska. The webinar will be held Wednesday, October 5, 2011, at 2:00pm to 3:00pm CST. Details are below.

To join the Webinar/Conference Call: Details for joining the webinar/conference call may be found at: http://www.cms.gov/PERM/07_Providers.asp#TopOfPage. 

Access the "Cycle 3 Provider Education Webinar" link.

There will be time available for Q&A's through the webinar, however, CMS encourages you to submit questions in advance to our designated PERM Provider email address at PERMProviders@cms.hhs.gov.