RA Messages for February 20, 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 A:

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.

DME

DME PROVIDERS OF BREATHING EQUIPMENT, SUCH AS OXYGEN CONCENTRATORS, MAY REQUEST REPAIRS FOR THESE EQUIPMENT ITEMS WHEN A RECIPIENT REQUESTS THE PROVIDER TO INSPECT AND FIX A BROKEN OR MALFUNCTIONING MACHINE. MEDICAID HOWEVER, DOES NOT PROVIDE FOR COVERAGE IN THE DME PROGRAM FOR PREVENTIVE MAINTENANCE SERVICES FOR THESE EQUIPMENT ITEMS. WHEN THESE SERVICES ARE DONE ON A ROUTINE, PERIODIC BASIS AND INVOLVE FILTER REPLACEMENTS, FITTINGS, MINOR ADJUSTMENTS, ETC., WE WILL CONSIDER THESE SERVICES TO BE PREVENTIVE MAINTENANCE. TO BE CONSIDERED AS REPAIRS, REQUESTS FOR PRIOR AUTHORIZATION SHOULD DOCUMENT THAT THE REQUESTED SERVICES WERE DONE AS A CONSEQUENCE OF A REQUEST BY PHONE, OR OTHERWISE, TO THE PROVIDER, FROM THE RECIPIENT, TO COME TO THE HOME TO INSPECT AND FIX A BROKEN OR MALFUNCTIONING MACHINE. REPAIRS NEEDED ON EQUIPMENT BROUGHT TO THE PROVIDER BY THE RECIPIENT BECAUSE OF A BROKEN OR MALFUNCTIONING MACHINE MAY ALSO BE CONSIDERED WHEN THE PROVIDER DOCUMENTS THAT THIS WAS THE SITUATION. 
DOCUMENTATION THAT THE REPAIRS WERE REQUESTED BY THE RECIPIENT TO FIX BROKEN OR MALFUNCTIONING EQUIPMENT MAY BE NOTED ON THE DELIVERY OR  INVOICE FORMS, OR OTHERWISE STATED IN WRITING TO THE PRIOR AUTHORIZATION UNIT. 

DENTAL PROVIDERS

EFFECTIVE JANUARY 21, 2001, THE REIMBURSEMENT RATES FOR THE FOLLOWING  PROCEDURE CODES WILL BE CHANGED TO THE FOLLOWING RATES: EPSDT DENTAL  PROGRAM - 02930-$78.00; 02931-$78.00. EPSDT DENTAL AND ADULT DENTAL PROGRAMS - 05110-$470.00; 05120-$470.00; 05130-$470.00; 05140-$470.00; 05211-$425.00; 05212-$425.00; 05750-$200.00; 05751-$200.00;05760-$175.00 AND 05761-$175.00. 
 IN ADDITION, EFFECTIVE JANUARY 21, 2001, ALL NEW ROUTINE REMOVABLE DENTAL PROSTHETICS REIMBURSED UNDER THE MEDICAID EPSDT DENTAL PROGRAM AND THE ADULT DENTURE PROGRAM MUST HAVE THE FOLLOWING UNIQUE IDENTIFICATION INFORMATION PROCESSED INTO ITS ACRYLIC BASE; THE RECIPIENT'S LAST NAME AND FIRST INITIAL, THE MONTH AND YEAR, AND THE MEDICAID PROVIDER NUMBER. THIS CRITERIA WOULD APPLY TO THE FOLLOWING SERIES: 
EPSDT AND ADULT - UPPER FULL DENTURE (05110),LOWER FULL DENTURE (05120), IMMEDIATE FULL UPPER DENTURE (05130), IMMEDIATE FULL LOWER DENTURE  (05140), UPPER ACRYLIC PARTIAL W/CLASP (05211), AND LOWER ACRYLIC PARTIAL W/CLASP (05212). EPSDT - UPPER CAST PARTIAL/ACRYLIC (05213) AND  LOWER CAST PARTIAL/ACRYLIC (05214). 
A LETTER REGARDING THIS MATTER AND A REVISED FEE SCHEDULE, APPENDIX A IN THE DENTAL SERVICES MANUAL, WILL BE MAILED TO YOU AS SOON AS POSSIBLE. SHOULD YOU HAVE ANY FURTHER QUESTIONS, YOU MAY CONTACT TERRI NORWOOD BY CALLING 225-342-9403. 

PROFESSIONAL SERVICE PROVIDERS

EFFECTIVE WITH DATE OF SERVICE MARCH 1, 2001, LOUISIANA MEDICAID'S POLICY ON REIMBURSEMENT FOR OBSTETRIC SONOGRAMS WILL BECOME THE FOLLOWING: 
ONE COMPLETE SONOGRAM (EITHER CODE 76805 OR CODE 76810) AND TWO FOLLOW UP SONOGRAMS (EITHER TWO 76815S, TWO 76818S OR A COMBINATION OF 76815 AND 76816) WILL BE REIMBURSED PER RECIPIENT PER 270 DAYS PER PROVIDER. 
THIRD AND SUCCEEDING CLAIMS FOR 76815 OR 76816 WITH A DIAGNOSIS CODE OF V22, V22.0, V22.1, OR V22.2 FROM ANY PROVIDER WILL BE DENIED. 
THIRD AND SUCCEEDING CLAIMS FOR 76815 OR 76816 WITH A DIAGNOSIS CODE OTHER THAN THOSE ABOVE WILL BE DENIED UNLESS ACCOMPANIED BY DATED NOTES WHICH JUSTIFY MEDICAL NECESSITY, AS THESE CLAIMS WILL PEND FOR REVIEW.