RA Messages for October 5, 2010

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
UPDATE REGARDING RATE REDUCTIONS AND CLAIM ADJUSTMENTS

Providers affected by the claim adjustments for the Aug 4, 2009 and January 22, 2010 rate reductions will see their remaining adjustments on one midweek RA, either on September 22 or October 6. Refer to the memorandum published 8/25/10 on www.lamedicaid.com. Please note that one of the following two scenarios will occur unless an alternative payment plan is requested: 1) If the balance due is less than $500, the full amount will be withheld from the normal weekly RAs following the midweek adjustment RA. 2) If the balance due is greater than $500, it will be divided and applied in equal amounts to the normal weekly RAs following the midweek adjustment RA & continue through June 7, 2011.

Providers interested in an alternative payment plan, send an email as soon as possible to medicaidprofessionalservices@la.gov detailing your request. Please enter "Alternative Payment Plan" in the subject line.

ATTENTION COMMUNITYCARE PROVIDERS
COMMUNITYCARE ENHANCED FEES ENDING

Effective August 1, 2010, the CommunityCare enhanced reimbursement rates for select primary care services ended. CommunityCare providers will be reimbursed based on the applicable fee on Professional Services Fee Schedule. The CommunityCare monthly management fee remains in place. Providers will see these changes on the RA of September 28, 2010. Refer to the Office of the State Register's website at http://doa.louisiana.gov/osr/ for published rules detailing these reductions. Providers should visit the LA Medicaid website (www.lamedicaid.com) for updates to the Professional Services Fee Schedule.

Claims for dates of service August 1, 2010-September 21, 2010 that were adjudicated prior to September 21, 2010 are currently being assessed to determine an approach to a systematic adjustment. No action is required by providers. Continue to monitor future RAs for details regarding when the recycle of these claims will take place. Should you have questions concerning this change, please contact Provider Relations at (800) 473-2783 or (225) 924-5040.

ATTENTION FREE STANDING END STAGE RENAL DISEASE (ESRD) FACILITIES
IMPLEMENTATION OF JANUARY 22, 2010 RATE REDUCTIONS

Effective with dates of service on or after January 22, 2010, the reimbursement rates for Free Standing ESRD Facilities are reduced by 5%. Complex system changes initially resulted in delayed implementation of these reductions, but they have now been implemented. Providers will begin seeing these reductions on the RA of September 28, 2010. Refer to the Office of State Register's website at http://doa.louisiana.gov/osr/ for published rules detailing these reductions. Claims that were adjudicated prior to September 21, 2010 are currently being assessed to determine an approach to a systematic adjustment. No action is required by providers. Continue to monitor future RAs for details regarding when the recycle of these claims will take place. Contact the Provider Relations unit at (800) 473-2783 or (225) 924-5040 with questions related to the implementation of the rate reductions.

ATTENTION FREE STANDING ESRD FACILITIES
DELAYED IMPLEMENTATION OF AUG 2010 RATE REDUCTIONS

Effective with dates of service on or after August 1, 2010, the reimbursement rates for Free Standing ESRD Facilities are further reduced by 4.6%. For details regarding these reductions, please refer to the rules published on the Office of the State Register's website (http://doa.louisiana.gov/osr). Complex system changes have resulted in delayed implementation of these reductions. Claims adjudicated prior to implementation of the reductions will be assessed to determine an approach to systematic adjustment. No action is required by providers. Continue to monitor RA's and www.lamedicaid.com for status updates. Contact the Provider Relations unit at (800) 473-2783 or (225) 924-5040 with questions related to the implementation of the rate reductions.

SPECIAL NOTICE: ALL MEDICAID PROVIDERS
CMS MANDATE-NATIONAL CORRECT CODING INITIATIVE (NCCI) EDITING FOR
MEDICAID SERVICES

Under new federal regulations signed into law earlier this year, State Medicaid Agencies must incorporate and apply editing methodologies of the National Correct Coding Initiative (NCCI) for claims filed on or after October 1, 2010. This CMS program was originally developed to control improper payments in Medicare Part B claims in 1996. Based on the fact that states were just provided details related to this requirement on September 1, 2010, and the complexities involved in entirely incorporating these edits into the claims processing systems, CMS has granted some flexibility to the States to fully implement the editing into their systems until April 1, 2011. However, claims filed on or after October 1, 2010, will be subject to the mandate and be required to be reprocessed, if necessary, to assure compliance with the NCCI mandate.

For more detailed information related to this CMS mandate, including provider types affected and further explanation of the edits, providers are directed to the Louisiana Medicaid website at www.lamedicaid.com.

ATTENTION HOSPITAL PROVIDERS
PROVIDER NOTICE FOR RETROSPECTIVE REVIEW PROCESS

Effective October 18, 2010, hospitals must submit documentation for retrospective reviews per the clarification posted on the Louisiana Medicaid website. Please visit www.lamedicaid.com and click on the yellow "Acute Precert" button on the left side of the homepage. This will bring you to the detailed provider notice concerning this clarification.

ATTENTION HOSPITAL AND PHYSICIAN PROVIDERS
PROVIDER NOTICE FOR PRECERTIFICATION FOR OB CARE AND DELIVERY

The precertification edit for OB Care and Delivery that went into effect August 30, 2010, was implemented to remove the administrative burden placed on the providers to obtain approval of days that are mandated by federal law. The 2 days approved for a vaginal delivery and 4 days approved for a cesarean section are in accordance with federal guidelines pertaining to the Newborn Protection Act. Days beyond the 2 and 4 days that are approved in accordance with the Newborn Protection Act via the precertification edit are to account for admissions or deliveries late in the evening. Any days approved via the claims processing edit that are greater than the 2 and 4 days mandated by federal guidelines may be subject to medical necessity review retrospectively. Facility specific length of stay reports are generated monthly to compare delivery LOS data pre and post implementation of this policy. Medical necessity should guide the physician decision making process related to discharge and patients should be kept in the hospital for medical necessity only. The precertification edit is not intended to provide approval of hospital days where medical necessity does not exist for continued hospitalization.

ATTENTION: PROVIDERS OF INFLUENZA VACCINE

The 2010-2011 seasonal influenza vaccine includes as one of its three components the same H1N1 vaccine used for the 2009-2010 H1N1 pandemic. Also, as of 09/16/2010, the only remaining available 2009-2010 monovalent H1N1 vaccine inventory in circulation reached its expiration and should no longer be used. Therefore, effective 09/16/2010, procedure code 90663 (influenza virus vaccine, pandemic formulation) will be in non-payable status and claims submitted with dates of service 09/16/2010 and after will deny. Providers submitting claims for the 2010-2011 seasonal influenza vaccine should use the appropriate CPT procedure code for the vaccine formulation administered following current immunization billing policy. Detailed information on the 2010-2011 seasonal influenza vaccine can be found at www.cdc.gov/flu. Contact Molina Medicaid Solutions Provider Relations at (800) 473-2783 or (225) 924-5040 if you should have any questions.

DIAGNOSIS CODE UPDATE

Effective with DOS October 1, 2010, the 2010 ICD-9 diagnosis codes and operation codes have been added to our files. The files have also been updated to deny those codes now considered invalid. Providers should use the most complete and appropriate diagnosis and operation codes when submitting claims to Louisiana Medicaid.