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 Gainwell Technologies at (800) 473-2783 or (225) 924-5040.

For information regarding the medication policy and/or criteria associated with this denial, providers may access the Louisiana Medicaid Preferred Drug List (PDL) / Non-Preferred Drug List at http://ldh.la.gov/assets/HealthyLa/Pharmacy/PDL.pdf.

ATTENTION PROVIDERS
PAYMENT ERROR RATE MEASUREMENT (PERM) 2024 IS IN PROGRESS

The Centers for Medicare and Medicaid (CMS) conducts a Payment Error Rate Measurement (PERM) review program on Louisiana Medicaid every three years. PERM is a review developed by CMS to identify payments in the Medicaid and Children’s Health Insurance (CHIP) programs that did not comply with policies and statutory requirements. PERM does not investigate fraud in Medicaid and CHIP, and is not a fraud rate.

PERM Reporting Year (RY) 2024 will sample from Medicaid and CHIP payments dated from July 1, 2022 through June 30, 2023. CMS contractors will review randomly selected claims to verify provider service documentation is complete, supports the service billed, and is compliant with Medicaid and CHIP policies and documentation requirements.

If your claims are selected for PERM review, your office will receive a medical records request letter and telephone outreach from the CMS review contractor Empower AI. All selected providers must cooperate with the CMS review contractor.

Providers can reach EmpowerAI at PERMRC_ProviderInquiries@empower.ai or 1-800-393-3068. Please visit www.lamedicaid.com, Provider Tools, Payment Error Rate Measurement (PERM) for more information on securely sending records.

Failure to produce documentation of services provided to Medicaid beneficiaries will result in monetary recoveries for undocumented services. Providers must maintain all medical, fiscal, professional and business records for services provided to Medicaid recipients for at least five years from the date of service, even if the provider has closed.

Upon closure, providers must maintain all records, including electronic records, according to applicable laws, regulations and retention requirements. The closing provider must notify LDH of the location records will be stored, and contact information of the records custodian. Providers can report agency closure to Gainwell Provider Enrollment at LouisianaProvEnroll@gainwelltechnologies.com or 225-216-6370.

For questions about PERM, providers may contact Toni Prine, project manager for Louisiana Medicaid’s PERM program, with Myers and Stauffer LC at tprine@mslc.com or 512-770-4237.

Attention Local Education Agency (LEA) Providers

Federal regulations require states to screen and enroll all Medicaid providers that order, prescribe, or refer items or services for Medicaid beneficiaries. Participating LEAs should expect claim denials on interim claims submitted for reimbursement if ordering provider enrollment requirements are not complete by December 30, 2023. To fulfill requirements, physicians and non-physician practitioners whose order results in health care services being provided by an LEA must enroll as a fully participating fee-for-service provider or an Ordering, Prescribing, Referring (OPR) provider type. The ordering provider’s name, their Type 1 (individual) NPI and DK qualifier must be on all claims,with exception of nursing evaluations and preventative screenings. The ordering provider may be an individual physician or other licensed practitioner associated with the student’s plan of care or may be the actual provider performing the service if they have licensing authority within their defined scope of practice to order health care services. LEA employees and contracted practitioners currently enrolled as participating LA Medicaid fee-for-service providers are not required to enroll separately as an OPR provider. Please refer to the home page of www.lamedicaid.com to review policy notice: ‘School-Based Provider Enrollment Requirements’ for additional details. Providers who are unsure of their fee-for-service enrollment status or require enrollment assistance should contact Gainwell Technologies at 225-216-6370 or email louisianaprovenroll@gainwelltechnologies.com.