RA Messages for January 30, 2001

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 MAKE THE FOLLOWING CHANGES TO THE 12/9/00 VERSION OF APPENDIX C:

PLEASE FILE ADJUSTMENTS FOR CLAIMS WHICH MAY HAVE BEEN INCORRECTLY PAID.

NOTICE TO ALL OPTICAL SUPPLIERS

THIS NOTICE IS TO PROVIDE CLARIFICATION OF EXISTING POLICIES AND PROCEDURES FOR PRIOR AUTHORIZATION REQUESTS FOR SPECIALTY EYEWEAR WHICH ARE BILLED UNDER THE PROCEDURE CODE X0089 FOR MEDICAID RECIPIENTS UNDER THE AGE OF 21.  CONTACT LENSES WILL NOT BE APPROVED UNLESS MEDICALLY NECESSARY. ALONG WITH THE FORM PA-01, YOU MUST ALSO SUBMIT A PRESCRIPTION, DOCUMENTATION OF MEDICAL NECESSITY WHICH ALSO STATES THAT NO OTHER MEANS CAN RESTORE VISION.  WE WILL CONTINUE TO PAY 85% OF THE BILLED CHARGES FOR THIS PROCEDURE NOT TO EXCEED $250.00. SPECIALTY LENSES, SUCH AS LENSES WITH A HIGHER INDEX THAN THOSE LISTED IN THE VISION SERVICES MANUAL WILL CONTINUE TO PAY AT 85% OF THE BILLED CHARGES NOT TO EXCEED $100.00.  POLYCARBONATE LENSES WILL NOT BE APPROVED UNLESS THEY ARE MEDICALLY NECESSARY.  THE FORM PA-01 SHOULD BE SUBMITTED ALONG WITH THE PRESCRIPTION AND A STATEMENT OF MEDICAL NECESSITY.  WE WILL CONTINUE TO PAY 85% OF THE BILLED CHARGES FOR THIS PROCEDURE NOT TO EXCEED $100.00.  THE FEE FOR SPECIALTY LENSES INCLUDE A STANDARD METAL OR PLASTIC FRAME.  THE PROCEDURE  CODE X0089 IS ALL INCLUSIVE, THEREFORE, PROVIDERS SHOULD NOT BILL ANY FRAME IN ORDER TO FIT A CHILD WHO HAS A CERTAIN MEDICAL CONDITION OR IS TOO SMALL OR LARGE TO ACCOMMODATE A STANDARD FRAME WILL BE CONSIDERED.  THE FORM PA-01 SHOULD BE SUBMITTED ALONG WITH THE PRESCRIPTION AND A STATEMENT PROVIDING THE REASON FOR THE NECESSITY OF THE SPECIAL FRAMES.  THE ONLY TIME THAT A FRAME SHOULD BE LISTED ON THE FORM PA-01 IS IF A SPECIALTY FRAME IS BEING REQUESTED.  WE WILL CONTINUE TO PAY 85% OF THE  BILLED CHARGES NOT TO EXCEED $100.00.  PLEASE NOTE THAT ALL DOCUMENTATION REGARDING MEDICAL NECESSITY MUST BE FROM THE EYECARE PROVIDER WHO WROTE THE PRESCRIPTION AND MUST CONTAIN INFORMATION SPECIFIC TO THE NEEDS OF THE EACH INDIVIDUAL RECIPIENT.  IF YOU ARE REQUESTING MORE THAN ONE ITEM LISTED ABOVE FOR A SINGLE PAIR OF EYEGLASSES, YOU MUST LIST EACH ITEM SEPARATELY ON THE FORM PA-01.  A PRIOR AUTHORIZATION REQUEST WHICH CONTAINS ALL THE REQUIRED DOCUMENTATION SHOULD NOT TAKE LONGER THAN 30 DAYS TO PROCESS.  SHOULD YOU HAVE ANY QUESTIONS REGARDING THE PRIOR AUTHORIZATION ON PROCESS FOR EYEWEAR, PLEASE CONTACT UNISYS PRIOR AUTHORIZATION UNIT BY CALLING 1-800-488-6334.

NOTICE TO PROVIDERS OF PROFESSIONAL SERVICES

EFFECTIVE WITH DATE OF SERVICE 10/01/00, CPT CODE 58660 (ELECTRICAL CARDIOVERSION) WAS GIVEN ANESTHESIA BASE UNITS OF 05.