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 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.

ATTENTION ALL PROVIDERS

The diagnosis code 3051 (Tobacco Use Disorder) will be paid under Medicaid Managed Care (Bayou Health) for health plan recipients and by Molina for legacy Medicaid recipients. This diagnosis is not paid under LBHP through Magellan. Claims will be recycled on the 11/22/13 RA.

Please submit claims with a primary diagnosis of 3051 to the appropriate Bayou Health Plan or Molina for processing. Please refer to the Informational Bulletin 12-18 at www.makingmedicaidbetter.com for the complete list of behavioral health Diagnosis Codes that are excluded from payment by Magellan.

Attention LTC, ICF-DD, ADHC and Hospice Room & Board Providers
INFORMATION RELATED TO BILLING FOR SEPTEMBER AND OCTOBER, 2013

We have made revisions to the LTC regular and supplemental payment schedule for October 2013 to clarify when providers may receive payment in the month of October depending on the date of service on the claim(s).

FOR ALL PROVIDER TYPES LISTED: Any claims billed and processed prior to the October 10th and October 17th cutoff with dates of service prior to September 2013 for private facilities will appear on the Remittance Advices/check writes of either 10/15/2013 and/or 10/22/2013.

FOR STATE OPERATED FACILITIES: The check write dates of either 10/15/2013 and/or 10/22/2013 will include payments to State Operated Facilities.

FOR ADHC PROVIDERS: The system generated claims for September dates of service were paid at a reduced rate in error on the RA of 09/26/2013. These incorrectly paid claims will be voided on the 10/22/13 RA. Providers must get their 'regular' billing for September 2013 dates to Molina for processing no later than Noon on Thursday, October 17th, in order to have these claims processed for corrected payment on the RA of 10/22/2013. Providers that do not meet this deadline (the regular supplemental billing cutoff) will have the corrected claims processed in the regular LTC check write of 11/12/2013.

FOR PROVIDERS OTHER THAN ADHC PROVIDERS: The check write dated 10/29/2013 will include the processing of the MOLINA system generated Adjustments/Voids to make needed adjustments to the provider submitted claims for payment of September 2013 claims which were made on the RA dated 09/26/2013. This check write will also include any other September claims submitted by providers for the regular supplemental billing cycle.

Please be sure that you submit bills for all of your September services prior to the October 17th cut-off date or your 09/26/13 payments will be voided. Providers should submit original claims for September services, not adjustments.

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

Attention Providers That Submit Professional Crossover Claims
Paper Crossover Claims Paid In Error

Claims for recipients who have Medicare and Medicaid coverage must be filed with the Medicare fiscal intermediary within 12 months of the date of service in order to meet Medicaid's timely filing regulations. Claims which fail to cross over electronically from Medicare must be submitted hard copy to Medicaid within six months from the date on the Medicare Explanation of Medicare Benefits (EOMB), provided that they were filed with Medicare within one year from the date of service. This policy is stated in the General Information and Administration Provider Manual - General Claims Filing Section, found at www.lamedicaid.com, directory link - Provider Manuals.

Due to a system calculation error, the dates for this timely filing edit (971 - Claim Exceeds Filing Limit Coins/Deduct) were not being correctly edited for Professional Crossover Claims that were submitted to Medicaid as paper claims. Claims that did not meet the filing requirement based on the Medicare EOB that was submitted with the claim that paid, but were paid due to this calculation error, have been identified and are being systematically voided on the 10/22/13 RA.

Providers should not resubmit any of these claims unless appropriate documentation supporting timely filing can be submitted with the claim. The documentation originally submitted with the claim DOES NOT support timely filing. If providers have claims for which they can produce documentation that supports timely filing, they should resubmit (1) the claim, (2) the Medicare EOB, (3) the Molina RA that supports the claim being filed timely (within 1 year from date of service and/or 6 months from the Medicare EOB payment date), (4) the Molina RA with the voided claim, and (5) a letter of explanation to: Molina Provider Relations. Attn: Correspondence Unit, P.O. Box 91024, Baton Rouge, LA 70821. If the dates of service are over two years old, any reconsideration of these claims will be sent from Molina to DHH for approval.

Attention Providers Regarding Edit 971

We are giving authorization for Molina to override the two (2) year timely filing edit on the related claims from this specific project. The provider will be responsible for documenting timely filing on those claims that are over two years old. If documentation of timely filing is not provided, the claims will deny with instructions not to resubmit.