RA Messages for February 1, 2000 Print

RA Messages for February 1, 2000

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                                   

ATTENTION PHARMACY PROVIDERS:  

 AS A RESULT OF A BUDGETARY SHORTFALL, THE DEPARTMENT, THROUGH AN EMERGENCY RULE, WILL CHANGE ESTIMATED ACQUISITION COST REIMBURSEMENT FOR PRESCRIPTION DRUGS TO:                                                 

    * AVERAGE WHOLESALE MINUS 15% FOR INDEPENDENT PHARMACIES AND AVERAGE WHOLESALE PRICE MINUS 16.5% FOR CHAIN PHARMACIES FOR ALL SINGLE SOURCE DRUGS (BRAND NAME), MULTIPLE SOURCE DRUGS WHICH DO NOT HAVE A STATE MAXIMUM ALLOWABLE COST OR FEDERAL UPPER LIMIT AND THOSE PRESCRIPTIONS WHICH ARE SUBJECT TO MAC OVERRIDES BASED ON THE PHYSICIAN'S CERTIFICATION THAT A BRAND NAME PRODUCT IS MEDICALLY NECESSARY FOR A PARTICULAR RECIPIENT. THIS REIMBURSEMENT CHANGE IS EFFECTIVE FOR SERVICES BEGINNING FEBRUARY 1, 2000. CHAIN PHARMACIES ARE DEFINED AS MORE THAN FIFTEEN MEDICAID ENROLLED PHARMACIES UNDER COMMON OWNERSHIP. ALL OTHER MEDICAID ENROLLED PHARMACIES ARE DEFINED AS INDEPENDENT PHARMACIES.

EFFECTIVE FOR DATES OF SERVICE BEGINNING FEBRUARY 1, 2000, LOUISIANA MEDICAID WILL LIMIT PAYMENTS FOR PRESCRIPTION DRUGS TO THE LOWER OF:   

   * ESTIMATED ACQUISITION COST WHICH IS DEFINED AS AVERAGE WHOLESALE PRICE MINUS 15% FOR INDEPENDENT PHARMACIES AND AVERAGE WHOLESALE PRICE MINUS 16.5% FOR CHAIN PHARMACIES FOR ALL SINGLE SOURCE DRUGS (BRAND NAME), MULTIPLE SOURCE DRUGS WHICH DO NOT HAVE A STATE MAXIMUM ALLOWABLE COST OR FEDERAL UPPER LIMIT AND THOSE PRESCRIPTIONS WHICH ARE SUBJECT TO MAC OVERRIDES BASED ON THE PHYSICIAN'S CERTIFICATION THAT A BRAND NAME PRODUCT IS MEDICALLY NECESSARY FOR A PARTICULAR RECIPIENT PLUS THE MAXIMUM ALLOWABLE OVERHEAD COST (DISPENSING FEE);                                                 

   * LOUISIANA MAXIMUM ALLOWABLE COST LIMITATION PLUS THE MAXIMUM ALLOWABLE OVERHEAD COST;                                               

   * FEDERAL UPPER LIMIT PLUS THE MAXIMUM ALLOWABLE OVERHEAD COST; OR  

   * PROVIDER'S USUAL AND CUSTOMARY CHARGE TO THE GENERAL PUBLIC.      

PLEASE MAKE THE FOLLOWING CHANGES TO THE 8/15/98 VERSION OF APPENDIX A: 

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

MEVS

HEALTHCARE DATA EXCHANGE (HDX) HAS BEEN APPROVED AS A MEVS VENDOR FOR LOUISIANA MEDICAID EFFECTIVE 1/8/00, AND HAS BEEN ADDED TO THE LIST OF CERTIFIED MEVS VENDORS. THE CONTACT IS BRIAN GILL, HEALTHCARE DATA EXCHANGE, PHONE:610/219-1859, E-MAIL: BRAIN.GILL@HDX.COM, WEB SITE: WWW.HDX.COM. 

ATTENTION EPSDT HEALTH SERVICES PROVIDERS

PLEASE NOTE THE FOLLOWING CORRECTIONS TO THE EPSDT HEALTH SERVICES TRAINING, MEDICAID ISSUES FOR 1999: 
1) ON P. 2, PROCEDURE CODE 92251 SHOULD BE PROCEDURE CODE 92551. THE REIMBURSEMENT IS $3.60. 
2) ON P. 3, PROCEDURE CODE 92585 IS REIMBURSED AT $180.00, NOT $65.00. 
3) ON P. 3, PROCEDURE CODE X0412 IS REIMBURSED AT $45.00, NOT $48.60. 
PLEASE MAKE THESE CORRECTIONS TO YOUR 1999 EPSDT HEALTH SERVICES TRAINING PACKET. IF YOU WISH TO REQUEST A NEW, CORRECTED TRAINING  PACKET, PLEASE CONTACT UNISYS PROVIDER RELATIONS AT (800) 473-2783 OR (225) 924-5040. EPSDT HEALTH SERVICES PROVIDERS WHO HAVE BILLED AND BEEN PAID FOR PROCEDURE CODE 92585 AT A RATE LESS THAN $180.00 FOR 1999 DATES OF SERVICE MAY FILE ADJUSTMENTS FOR SUCH CLAIMS. 

LOUISIANA DEDUCTIBLE AND COINSURANCE OVERPAYMENT PROJECT

CLAIMS WERE RECOVERED IN 01-08-2000 AS THE RESULT OF THE "LOUISIANA DEDUCTIBLE AND COINSURANCE/OVERPAYMENTS PROJECT. WE HAVE LEARNED THAT, DUE TO A PROGRAMMING MISINTERPRETATION, THE PRIVATE CONTRACTOR FOR THIS PROJECT INCLUDED CLAIMS WHICH SHOULD HAVE BEEN ADJUSTED RATHER THAN VOIDED. THE STATE AND UNISYS ARE IN THE PROCESS OF RESOLVING THE PORTIONS RECOVERED IN ERROR IN ORDER TO REIMBURSE THE APPROPRIATE FUNDS TO PROVIDERS. A PROCESSING ERROR FOR REMITTANCE DATE 01-25-2000 COMPOUNDED THE PROBLEM AS A DUPLICATED RECOVERY OF THE 01-18-2000 CLAIMS OCCURRED. IN ORDER TO RECTIFY THE 01-25-2000 ERROR, ON APPROXIMATELY 02-08-2000 PROVIDERS WILL RECEIVE A REIMBURSEMENT CHECK (AUDIT PAYOUT) EQUAL TO THE AMOUNT RECOVERED ON 01-25-2000. PLEASE REFER TO YOUR 01-25-2000 RA FOR CLAIMS DETAIL TO RECONCILE THIS AUDIT PAYOUT.