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 HOSPITAL PROVIDERS:
POLICY CLARIFICATION- HOSPITAL OWNED CLINICS AND PROVIDER BASED BILLING

In late June, a notice was published to hospitals addressing the appropriate use of Revenue Code 761 and claims related to the issues identified in the notice were systematically voided. Since that notice, we have received inquiries from several hospitals concerning services provided at hospital ‘satellite’ locations and the use of HR761. Medicaid has issued a policy clarification statement to assist providers with understanding Medicaid policy for hospital satellite locations/clinics and provider based billing. This statement is available in its entirety for all providers via web posting on the LaMedicaid.com homepage.

Please contact Molina Provider Relations (800) 473-2783 or (225) 924-5040 if you have any questions regarding this matter.

Attention Fee for Service (FFS) Louisiana Medicaid Providers:

Effective November 17, 2015, clinical pre-authorization will be required on pharmacy claims for all behavioral health medication prescriptions for recipients <6 years old. Please refer to www.lamedicaid.com for specifics.

Attention Fee for Service (FFS) Louisiana Medicaid Providers:

Effective November 17, 2015, the La. Medicaid FFS Pharmacy Program has implemented a new maximum dosage for Saphris® and a new diagnosis for Humira® . Please refer to www.lamedicaid.com for specifics.

ATTENTION WAIVER AND PCS PROVIDERS
AUDIT PAYOUTS
FOR CLAIMS THAT WERE UNDERPAID ON THE 11/10/15 RA

During the systematic recycle of Waiver and PCS claims that were denied in error on the 11/3/15 RA, some claims pending for pre-payment review were not captured and were underpaid on this week’s RA (11/10/15). Those claims have been identified and an audit payout is being done to pay providers the additional amounts owed on these claims. This check write will be dated Wednesday, 11/11/15 with EFT deposits occurring on Thursday, 11/12/15 or Friday, 11/13/15 depending on the Provider’s bank. A special RA dated 11/11/15 will be posted for providers.

An audit recovery will be created on the 11/17/15 check write to offset the audit payout and those claims that were used to create the audit payout will be adjusted.

No action is required by providers and we apologize for any inconvenience this has caused.

ATTENTION PROFESSIONAL PROVIDERS OF LABORATORY SERVICES CLIA Waived Tests

Clinical Laboratory Improvement Amendments (CLIA) claim edits are applied to all claims for laboratory services that require CLIA certification. Those claims that do not meet the required criteria will deny. Providers with waiver or provider-performed microscopy (PPM) certificate types may be paid only for those waiver and/or PPM codes approved for billing by CMS. These providers are to add the 'QW' modifier to the procedure code for all CLIA waived tests they submit for reimbursement.

Please note that the claims processing system has been updated and the following Current Procedural Technology (CPT) codes have been added to the codes that require a “QW” modifier for dates of service on or after the associated effective date. Please visit http://www.cms.gov for a complete listing of effective dates for the recently added codes. For more CLIA information, please see Appendix A in the Professional Services Provider Manual.

82962 83861 86308 86803 87806
83036 83986 86386 87389 87809
83516 84450 86780 87502  

Please contact Molina Provider Relations (800) 473-2783 or (225) 924-5040 if you have any questions regarding this matter.

ATTENTION PHYSICIAN AND OUTPATIENT HOSPITAL PROVIDERS
CALCULATING OBSTETRIC ULTRASOUND SERVICE LIMITS:

Effective with date of processing November 2, 2015, fee-for-service (FFS) Medicaid claims processing logic has been updated to reflect the intent of policy related to obstetrical ultrasound procedures. The intent of Obstetrics ultrasound policy in the Professional Services manual for those providers who are not maternal-fetal medicine specialists, is to allow two complete OB ultrasounds to be performed per pregnancy without the need for hard copy documentation.

Under this policy:

  • When professional providers perform the entire service in their office (the OB ultrasound and interpretation), the service counts as 1 ultrasound.
  • When the ultrasound itself is done in an outpatient hospital setting and the professional provider (not employed by the outpatient hospital) performs the interpretation, each provider’s component counts as one half (i.e. the claim from the outpatient hospital and the claim for the professional interpretation together count as 1 ultrasound). In these cases, both providers (outpatient hospital and professional) are expected to bill their portion of the service and are expected to bill the same procedure code for the same date of service. The procedure codes must match to be reimbursed.
  • If the complete procedure (OB ultrasound and interpretation) is provided by the outpatient hospital, the service counts as one ultrasound.

Please contact Molina Provider Relations (800) 473-2783 or (225) 924-5040 if you have any questions regarding this matter.

ATTENTION WAIVER AND PCS PROVIDERS
ADDITIONAL INFORMATION CONCERNING
THE SPECIAL AUDIT PAYOUTS OF 11/11/15

A notice was published on 11/10/15 concerning a special Audit Payout that was done on 11/11/15 due to the underpayment of some claims appearing on the 11/10/15 RA. This Audit Payout created a special RA dated 11/11/15 which contained only a financial transaction for the additional payment made to you. No claims associated with the payout were presented on this special RA.

On your RA of 11/17/15, systematic adjustments for each affected claim will appear. Since these adjustments will be included with all other claim adjustments on the RA, you will be able to identify these systematic adjustments through the ICN Julian Day of 5312 (i.e., the first 4 digits of the claim ICN). You must post the money received through the special Audit Payout of 11/11/15 to your accounts for these recipients’ claims included in the systematic adjustments.

In order to offset the systematic adjustments, and to keep from making duplicate payments on these claims, a financial transaction for an Audit Recovery will also be posted on the RA of 11/17/15. This will appear as a negative amount that equals the Audit Payout. This information was indicated in the original message.

Please ensure that you pull your RAs for 11/11/15 and 11/17/15 and post your accounts accordingly. Again, we apologize for any inconvenience this has caused.