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: ICF/IID FACILITIES

The USC, CFR, and La Medicaid State Plan require that the claim. defined as a single document line identifying the services and/or charges for services for a single recipient from a single provider, be submitted to Louisiana Medicaid for payment within 12 months from the date of service and that the claim be paid no later than 12 months from the date of receipt of the claim. Failure to bill within the allotted period will result in the nonpayment of claims.

In addition, the Louisiana Department of Health strongly encourages providers to bill monthly and to attempt to clear any denials received within two billing periods.

Attention Louisiana Medicaid Providers:

Effective October 24, 2018, the Louisiana Medicaid Fee for Service (FFS) Pharmacy Program will implement Point of Sale (POS) quantity limits for epinephrine injection (Generic, EpiPen®, and EpiPen Jr®). Please refer to www.lamedicaid.com for more information.

Attention Providers - Claims Adjustment/Recycle
Reimbursement Changes for Physician-Administered Drugs

Louisiana Medicaid has recently revised the reimbursement methodology for physician-administered drugs in a physician office setting effective with dates of service July 1, 2018 forward.

Fee-for-service (FFS) claims previously processed and paid for physician-administered drugs (J-codes) or payable vaccines beginning with a July 1, 2018 date of service have been adjusted/recycled as appropriate based on the updated reimbursement rate. Providers can expect to see the results of this process on the remittance advice of October 23, 2018. Crossover claims impacted by this change will be addressed separately in the near future.

This action will affect Professional Services, Take Charge Plus and applicable Immunization claims.

Please contact Molina Provider Relations at (800) 473-2783 or (225) 924-5040 if there are questions related to this matter for FFS claims. Questions related to the Healthy Louisiana managed care organizations' updates should be directed to the specific health plan.

Attention Professional, and Independent Laboratory, Providers

Reimbursement for Lynch Syndrome and Familial Adenomatous Polyposis (FAP) Genetic Testing
Effective with dates of service January 1, 2019 and forward, Louisiana Medicaid will reimburse genetic testing for Lynch Syndrome and FAP.

In fee for service (FFS) Medicaid Genetic testing for Lynch Syndrome and FAP must be approved by the fiscal intermediary’s Prior Authorization Unit (PAU). Information regarding this policy, medical necessity criteria for coverage and the required documentation is forthcoming, and will be found at www.lamedicaid.com under the Provider Manuals link within the Professional Services Manual.

Please contact the appropriate Managed care Organization if there are questions concerning their policies and prior authorization process. In addition, questions regarding FFS Medicaid should be directed to Molina Provider Relations at (800) 473-2783 or (225) 924-5040.

Attention FQHCs and RHC Providers
Amendment to Medicaid Methodology of Reimbursement for Long- Acting Reversible Contraceptives to FQHCs and RHCs

Effective January 1, 2019 Louisiana Medicaid will reimburse for long-acting reversible contraceptives (LARCs) separate from the prospective payment system (PPS) rate to FQHCs and RHCs.

Reimbursement shall be separate from the FQHC and RHC PPS rate and will be the lesser of the Durable Medical Equipment fee for service rate on file or the actual acquisition cost (AAC), for entities participating in the 340B program.

Questions regarding this message and fee for service claims should be directed to Molina Provider Relations at (800) 473-2783 or (225) 924-5040.

Updates to Healthy Louisiana related policy, systems and claims processing changes are plan specific and are the responsibility of each health plan. For questions regarding Healthy Louisiana updates and prior authorization requirements, please contact the appropriate health plan.

Attention Durable Medical Equipment Providers

Durable Medical Equipment (DME) Coverage of Breast Pumps

Effective for dates of service January 1, 2019, double electric breast pumps will be covered equipment without prior authorization. Recipients must present with a prescription for the breast pump and documentation of infant delivery to a DME provider. Louisiana Medicaid will only provide coverage for the personal-use, double electric breast pumps. Hospital grade, manual, or single breast pumps will not be covered. Nursing mothers will be eligible for one breast pump per delivery within a three (3) year period.

Additionally, Medicaid will cover the appropriate breast pump supplies once every 180 days. A prescription for the supplies will be required.

Medicaid will allow replacement of breast pumps purchased within the past three (3) years from the date of request and after expiration of manufacturer's warranty. Replacement and warranty is subject to policy in the Durable Medical Equipment provider manual.

Questions regarding this message and fee for service claims should be directed to Molina Provider Relations at (800) 473-2783 or (225) 924-5040.

Questions regarding managed care claims should be directed to the appropriate managed care organization.

Attention Durable Medical Equipment Providers

Long-Term Continuous Glucose Monitoring Device

Effective January 1, 2019, Louisiana Medicaid will reimburse for long-term continuous glucose monitoring devices through the durable medical equipment program. Prior authorization is required and recipients must meet one of the following eligibility criteria:

  • Diagnosis of type I diabetes with recurrent, unexplained, severe hypoglycemia (glucose levels <50 mg/dl), or impaired hypoglycemia awareness that puts the recipient at risk or
  • Pregnant recipient with poorly controlled type 1 diabetes evident by recurrent, unexplained hypoglycemic episodes, hypoglycemic unawareness, or postprandial hyperglycemia, or recurrent diabetic ketoacidosis.

NOTE: Louisiana Medicaid will not consider short term CGMs as a covered device.

Updates to the Durable Medical Equipment provider manual are forthcoming.

Questions regarding fee for service Medicaid should be directed to Molina Provider Relations at (800) 473- 2783 or (225) 924-5040.

Questions regarding managed care claims should be directed to the appropriate Managed Care Organization.

Reimbursement Changes for Physician-Administered Drugs
Medicare Crossover Claim Adjustments

Louisiana Medicaid has recently revised the reimbursement methodology for physician-administered drugs in a physician office setting effective with dates of service July 1, 2018.

Fee-for-service (FFS) Medicare crossover claims previously processed for physician-administered drugs(J­codes) or payable vaccines beginning with date of service July 1, 2018 have been adjusted/recycled as appropriate based on the updated reimbursement rate.

Providers can expect to see the results of this process as it applies to Medicare crossover claims on the remittance advice of October 30, 2018.

This action will affect Professional Services, Take Charge Plus and applicable Immunization claims.

Please contact Molina Provider Relations at (800) 473-2783 or (225) 924-5040 if there are questions related to this matter for FFS claims. Questions related to the Healthy Louisiana managed care organizations' updates should be directed to the specific health plan.

Changes for Providers Using Facility Notification System

The implementation of the state’s new Medicaid eligibility and enrollment (E&E) system, is scheduled to go-live in mid-November 2018. The E&E system includes a Provider Portal, which replaces the current Facility Notification System (FNS) and allows provider, hospital and support coordination agency (SCA) representatives to submit forms for Medicaid to process. All current representatives authorized to submit forms in FNS will be required to re-register in the new system.

Training videos are available to providers that show how to register with the new system and introduce the basics of how to operate in the new Provider Portal. To learn how to manage information from a personal account or provider’s profile, visit: http://ldh.la.gov/LaMEDSAccessProviderPortal. To learn how to submit, finish or view forms, visit: http://ldh.la.gov/LaMEDSProviderFormEntry.