RA Messages for December 28, 2010

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 HOSPITAL, PHYSICIAN AND OUTPATIENT RADIOLOGY PROVIDERS

New CPT codes become effective January 1, 2011. These CPT codes will require prior authorization (PA) and are included in the Radiology Utilization Management (RUM) program. The codes are part of the diagnostic CT set and are listed below:

- 74176 Computed tomography; abdomen and pelvis; without contrast material
- 74177 Computed tomography; abdomen and pelvis; with contrast material(s)
- 74178 Computed tomography; abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions

If PA is not obtained for these procedures 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.

'CLAIM CHECK' NEWS AND EDITING UPDATE MESSAGE

Providers impacted by 'ClaimCheck' editing are directed to the message entitled "'ClaimCheck' News and Editing Updates" on the Louisiana Medicaid website homepage at www.lamedicaid.com and/or under the blue ClaimCheck' icon there for the latest information related to modifications to claims editing via 'ClaimCheck.' Providers may note updates in the following areas effective with processing reflected on the RA of December 21, 2010: Allergy immunotherapy, CPT code age restrictions based on the code definition, new visit frequency, pre and post-op editing for obstetrical delivery services, and inclusion of  pertinent procedures from the Medicine section of CPT in multiple surgery reduction processing.

ATTENTION PROVIDERS OF IMMUNIZATIONS

Effective with dates of service January 1, 2011 and forward, providers should no longer use procedure codes 90465, 90466, 90467 and 90468 to report immunization administration services as they have been deleted from the 2011 Current Procedural Terminology (CPT) manual and therefore these codes will be in non-payable status. Providers should continue to use procedure codes 90471, 90472, 90473 and 90474 per current Louisiana Medicaid policy to report all immunization administration services. At this time Louisiana Medicaid will not be using new immunization administration CPT codes 90460 & 90461 and these two new procedure codes will be in non-payable status.

ATTENTION PROVIDERS THAT SUBMIT MEDICARE PART B CROSSOVER CLAIM

Effective January 1, 2011, LA Medicaid will begin processing Medicare Part B claim adjustments that electronically cross to Medicaid from the Medicare carrier through GHI (the coordination of Benefits Administrator). It will no longer be necessary for providers to routinely initiate submission of Medicare adjustments as paper claims with EOMBs attached. Of course, if for any reason an adjustment does not electronically cross to Medicaid through GHI, providers must submit them for processing using the process previously in place. As always, providers should allow ample time for Medicare claims, including adjustment claims, to be processed by Medicare and electronically cross to Medicaid before taking action to submit a claim.

ATTENTION PROFESSIONAL SERVICES PROVIDERS PROCEDURE CODES PAYABLE TO OPTOMETRISTS

Programming logic related to procedure codes payable to optometrists has been updated effective for dates of service January 1, 2007 forward. Claims that previously denied with errors 210 "PROVIDER NOT CERTIFIED FOR THIS PROCEDURE," 298 "INVALID PROCEDURE CODE FOR DATE OF SERVICE" and 299 "PROC/DRUG NOT COVERED BY MEDICAID" will be systematically adjusted and will appear on the RA of December 21, 2010. No action is required by providers.

ATTENTION ANESTHESIA PROVIDERS

A correction was made to the claims processing logic for anesthesia claims that denied incorrectly for edit 748 (only 1 delivery allowed in 6 months). Claims affected by this change will be recycled on the RA of December 21, 2010. Please see the Louisiana Medicaid provider website for details.

ATTENTION ALL PROVIDERS IMPLEMENTATION OF DEC 1, 2010 RATE REDUCTIONS

Due to a funding deficit in Medicaid caused by unfunded increases in utilization, the Department of Health and Hospitals has implemented a budget reduction effective December 1, 2010. A portion of this reduction will come from adjustments to current provider reimbursement rates. The reimbursement rates for the following provider types have been reduced by 2% effective for dates of services on or after December 1, 2010:

  • Laboratory/radiology

  • ASC (Non-Hospital)

  • Early Steps direct services (OT, PT, ST, Audiology & Psychology)

  • Extended Home Health Nursing Services

  • Free Standing ESRD Facilities

These rate reductions have been loaded in the system. These rate reductions began appearing on the RA of December 7, 2010.

ATTENTION HOSPITAL PROVIDERS IMPLEMENTATION OF DECEMBER 1, 2010 RATE REDUCTIONS

The December 1, 2010 rate reductions for inpatient and outpatient hospital services have been implemented. Providers will begin seeing these reductions on their remittance advices beginning with December 14, 2010. Claims for dates of service after December 1,2010 that have already been adjudicated will be systematically adjusted on the remittance advice dated December 23,2010 and no action will be required by providers. The exception to this is if an inpatient stay spans the December 1,2010 date, these claims then would have to be voided and split-billed in order to be paid correctly. Refer to the Office of the State Register's website at http://doa.louisiana.gov/osr/ for published rules detailing these reductions.


ATTENTION ALL NON-PHYSICIAN PROVIDERS

DHH has scheduled an additional claims processing cycle for all non-physician providers for the last week of December. The remittance advice dates for that week are: Tuesday 12/28/10 and Thursday 12/30/10. Please alert your staff, your accounting department, and any impacted business partner, including submitters and billing agents, of this addition. All claims submitted by physicians will be processed during the regular cycles of 12/28/10 and 01/04/11. It is important to note that the EDI deadlines for the last 2 weeks of December are:

  • 12/23 (Thursday) at 3PM for the 12/28 processing cycle;

  • 12/28 (Tuesday) at noon for the 12/30 processing cycle; and

  • 12/30 (Thursday) at noon for the 01/04/11 processing cycle.

The Molina office will be closed on Friday, December 24 and Friday, December 31.

ATTENTION DENTAL PROVIDERS

Effective for dates of service on or after January 1, 2011, the dental procedure code D0272 will be reimbursable by Medicaid in the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Dental Program only once a year. Complete details can be located on the www.lamedicaid.com website under the "Dental Providers" link. Contact the LSU Dental Medicaid Unit at 504-941-8206 or 1-866-263-6534 (toll-free) with any questions.

ATTENTION HOSPITAL PROVIDERS: REIMBURSEMENT OF VAGUS
NERVE STIMULATORS

Effective June 14, 2010, a PA-01 Form is no longer required for hospital providers for the VNS device. However, reimbursement of the device continues to be dependent upon approval of the surgeon to perform the procedure. Hospitals should confirm that the surgeon has received an authorization for the procedure prior to submitting their claim in order to prevent denials.

The hospital will bill their VNS claim using HCPCS procedure code C1767 (VNS generator) and/or C1778 (VNS leads) to Molina on a CMS 1500 claim form with the words DME written in red on the top of the form and the PA number written in Item 23 or through the electronic claims submission.

The claim will pend to the Molina Medical Review Department for review of the surgeon's approved PA request. If approved, the hospital claim will be allowed to process for payment; if there is no valid authorization, the hospital claim will deny with edit 191 (PA required).

If the recipient is Chisholm, the authorization for the device will be referred to PAL to assist the recipient in obtaining the necessary documentation to process the request. This may include identifying the surgeon to contact in order to assist with the submission of his/her prior authorization request.

ATTENTION ALL PROVIDERS (EXCEPT ATYPICAL)

In order to comply with federal requirements to include the National Provider Identifier (NPI) on all claims. Changes to current claims processing will be made over the next two months. Providers using the Molina Form 213 for Physician Crossover Adjustments, Professional Crossover Adjustments, Durable Medical Equipment Adjustments, Durable Medical Equipment TPL Adjustments, and Physician Adjustments will need to begin using the CMS-1500 claim form; providers using the Rehabilitation forms for claims and adjustments (102, 202) will instead be required to use the CMS-1500 form. Over the coming months, changes to Dental (209, 210), Pharmacy (211), and KIDMED (KM-3) claim forms will also be introduced to accommodate these federal requirements. Providers who have software vendors must alert their vendors of the changes. Please monitor the Louisiana Medicaid website, www.lamedicaid.com, for an implementation schedule and more details.
 

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Contact Molina Medicaid Solutions Provider Relations at (800) 473-2783 or (225) 924-5040 should you have any questions related to the implementation of the rate reductions in any of the previous messages..