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 of Bayou Health Shared and Legacy Plans:

Effective October 1, 2013 short-acting beta2 agonist inhalers (albuterol, levalbuterol, and pirbuterol) will have a quantity limit of six inhalers per calendar year. Pharmacy claims for omalizunab (Xolair �) will require a valid ICD-9-CM diagnosis code and a minimum age of 12 years. See http://www.lamedicaid.com/ for more information.

ATTENTION LOUISIANA BEHAVIORAL HEALTH PROVIDERS UPDATE TO THE NOTICE DATED 8/15/13 CONCERNING NEW EDIT 133 FOR BEHAVIORAL HEALTH CROSSOVER CLAIMS

In July, you were notified that effective 8/6/2013 (date of payment), Medicare crossover claims for Behavioral Health services would be denied with new Edit 133 and the claims would automatically be sent to Magellan for processing. In August, you were notified of a delay in the automatic transfer of these claims until late August or September.

This notice is to convey another delay in this transfer process. DHH and Magellan are working to resolve the outstanding issues to allow these claims to be processed by Magellan in a timely manner.

Providers will continue to see Edit 133 denials in Molina's processing system, and all of these claims (with payment date 8/6/2013 and after) will be appropriately processed by Magellan as quickly as possible. As before, no action is required on the part of the provider.

We apologize for any inconvenience this may continue to cause as we work to through the final steps in this new process.

ATTENTION PHARMACISTS AND PRESCRIBING PROVIDERS

OF BAYOU HEALTH SHARED AND LEGACY PLANS

Effective October 15, 2013 pharmacy claims billed for omalizumab (Xolair �) for shared health plans or legacy recipients will require a prior authorization (PA). Claims billed without a PA will deny with EOB code 485 (PA required). See www.lamedicaid.com for more information.

ATTENTION PHARMACISTS AND PRESCRIBING PROVIDERS

Effective October 1, 2013 pharmacy claims for concurrent use of different Short-Acting Beta2 Agonis inhalers (SABAs) will deny with a therapeutic duplication (EOB 482).See www.lamedicaid.com for more information.

ATTENTION BILATERAL PROCEDURES

As indicated in the Remittance Advice messages dated July 24-August 7, 2012, when billing for bilateral procedures performed during the same session (unless otherwise directed in CPT), providers are to use the-50 modifier (Bilateral procedure) with the appropriate CPT code and place a "1" in the units field of the claim. The site specific modifiers 'LT' (Left side) or 'RT' (Right side) may be used on appropriate CPT codes only when services are performed on either the right OR the left side. Providers should not use the 'LT'and 'RT' modifiers on the same procedure code instead of the -50 modifier.

Claims processing is being updated to look for and deny inappropriately billed bilateral procedures. Providers can soon expect to see claims denied with error codes 707 and 710 when billed incorrectly.

707- Bilateral-Resubmit with modifier 50-One Unit

710- Bilateral-Void Paid Claim-Resubmit with Modifier-50

Overpayments due to fragmented claim submissions are subject to review and recovery of the overpayment.

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

OB Providers: New NCCI Edits on Codes H0049 and H0050 (Alcohol and/or Drug Screening/Brief Intervention)

The next update to the National Correct Coding Initiative (NCCI) edits may result in the denial of HCPCS codes H0049 (Alcohol and/or Drug Screening) and H0050 (Alcohol and/or drug services, brief intervention per 15 minutes). NCCI editing considers them to be incidental to Evaluation and Management services.

It is the intent and policy of Louisiana Medicaid to continue to reimburse for H0049 and H0050. When these services are appropriately performed on the same date of service as Evaluation and Management services (E/M), the E/M service may be submitted with modifier 25. Documentation in the clinical record must substantiate each service.

There has been no change in policy regarding the use and frequency of H0049 and H0050. These codes are only reimbursable when billed with modifier -TH and reimbursement for these services is restricted to once per pregnancy.

ATTENTION LTC-PCS PROVIDERS

Due to programming changes implemented October 1, 2013, claims for procedure codes T1019, TOS 19 with modifiers UB, UN & UP were incorrectly denied with error code edit 210 (PROVIDER NOTCERTIFIED FOR THIS PROCEDURE) claims.

These claims will be systematically corrected, recycled and paid by October 22, 2013.

Claim denials with error code edits 210 (PROVIDER NOTCERTIFIED FOR THIS PROCEDURE) will receive an override for edit 241 (CLAIM HELD FOR PRE-PAYMENT REVIEW) in order to allow those claims to be recycled and paid by the October 22, 2013 Remittance Advice. NO ACTION IS REQUIRED ON THE PART OF THE PROVIDER. We apologize for any inconvenience this may have caused.