RA Messages for December 13, 2011

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 PHARMACY PROVIDERS

The deadline for being compliant with NCPDP D.0 is fast approaching. Please be sure that any software changes needed for interface with your telecommunications switch vendor are complete and will be ready for use no later than January 01, 2010. If you have any questions or concerns about readiness for submitting claims using the new transaction, be sure and contact your software vendor and your telecommunications switch vendor as soon as possible. These vendors provider pharmacies with the ability to test electronic claims for compliance with D.0 transaction standards. Visit lamedicaid.com for additional information on NCPDP D.0 implementation using the 5010v of the the HIPAA Electronic Transactions 11/7/11 link. Specifications for Medicaid vendor point of sale (POS) adjudication, as well the appendices, are available on the website.

UPDATE AND CLARIFICATION OF OBSTETRICAL SERVICES AND
POSTPARTUM CARE POLICY

It has come to the attention of DHH that some providers are continuing to submit claims for CPT code 59430 (Postpartum care only [separate procedure]) when they have also submitted and been paid for one of the delivery codes that include postpartum care. It has been the intent of DHH that when the delivery codes that include postpartum care were made payable, separate reimbursement for postpartum care was no longer valid if those inclusive codes were used. Providers who perform both the OB delivery services and the postpartum care should use the code that describes these services and not unbundle the services by use of individual procedure codes. As with all claim submissions, providers are to use the most inclusive code available. Only when there is not a more appropriate code available should providers use the separate code for the postpartum service. At no time does Louisiana Medicaid intend to reimburse more than once for postpartum care. Providers should refer to the Current Procedural Terminology manual for additional coding guidance related to these services. Providers are urged to review their billing practices and take action as needed to be in compliance with Medicaid policy. Overpayments and abusive billing are subject to recoupment and/or sanction.

ATTENTION HOSPITAL, PHYSICIAN AND OUTPATIENT RADIOLOGY PROVIDERS
EFFECTIVE JANUARY 1, 2012, FOR THE RADIOLOGY UTILIZATION MANAGEMENT PROGRAM (RUM)

One new CPT code has been established for Computed Tomographic Angiography (CTA) study of the abdomen and pelvis. The code is 74174. This code becomes effective January 1, 2012, and is included in the Radiology Utilization Management (RUM) program. This code will require prior authorization (PA). The code description is listed below:

- 74174 Computed tomographic angiography; abdomen and pelvis; with contrast material(s), including noncontrast images, if performed, and image postprocessing

If prior authorization (PA) is not obtained for this procedure per the current RUM guidelines, then the procedure will not be payable by Louisiana Medicaid. For further information regarding RUM policy and procedure please visit www.lamedicaid.com.

ATTENTION PROFESSIONAL SERVICE PROVIDERS

Effective December 1, 2011, Louisiana Medicaid will provider coverage for fluoride varnish. For coverage details and policy information please refer to www.lamedicaid.com. Providers should contact the Provider Relations unit at (800) 473-2783 or (225) 924-5040 with billing or policy questions.

ATTENTION ALL PROVIDERS SUBMITTING OR RECEIVING
5010 CLAIM TRANSACTIONS (820, 835, 837D, 837I, and 837P)

In order to allow additional time for providers to test, Molina will continue to accept Version 4010 electronic claims transactions after January 1, 2012. CMS has announced that they will not initiate enforcement action with respect to any HIPAA covered entity that is not in compliance with the implementation date for the ASC X12 VERSION 5010 STANDARDS until March 31, 2012.

In preparation for 5010 implementation, providers should continue to work with their billing entities to ensure that they will be ready for submittal prior to March 31, 2012.

For more detailed information, the revised 5010 EDI Companion Guides are published on the Louisiana Medicaid Website, under the 5010 link on the main page.

Access the website on a regular basis for 5010 implementation updates and reminders.

ORGANIZATIONAL VS INDIVIDUAL NPI IN 5010 CLAIM TRANSACTIONS

With the transition to 5010 specifications, when submitting the 837 claim transactions, an individual billing provider that is incorporated must enter the organizational NPI as the Billing Provider identification number and the individual NPI as the Rendering Provider identification number. Individual billing providers that are incorporated and have not previously obtained both an organization (business entity) NPI and an individual NPI should apply for an organization NPI as well as an individual NPI at this time. Both NPIs must be reported to the Molina Provider Enrollment Department. Claim denials may result if this information is not reported to us and properly entered in the transactions. This clarification has been added into the 5010 837 Professional Companion Guide.

NOTE: THIS CHANGE DOES NOT APPLY IF THE INDIVIDUAL IS UNINCORPORATED.

ATTENTION GREATER NEW ORLEANS COMMUNITY HEALTH CONNECTION (GNOCHC)
PROVIDERS: EDIT 904 AND CLAIMS DENIAL

Due to a system error, some claims that received edit 904 (Service Performed Beyond the Required Time Specification) were not denied but posted the edit and continued to process for payment. This edit is posted for any claim that was received after the deadline of November 14, 2011, for Dates of Service prior to October 1, 2011. Those claims that have been paid that should have denied for the edit 904 are being systematically voided on 12/13/11. We apologize for the inconvenience this may have caused providers.