RA Messages for March 21, 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                                   

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

KIDMED

SCHOOL BOARDS MAY NOT BILL MEDICAID FOR THE ADMINISTRATION OF MEDICATION.  THIS DUTY IS WITHIN THE SCOPE OF THE SCHOOL BOARD'S RESPONSIBILITY.  NEITHER X0187, NOR 992211 SHOULD BE BILLED FOR MEDICATION ADMINISTRATION BY A SCHOOL NURSE.

ALL PROVIDERS

CONTRACT ARRANGEMENTS WITH PRIVATE INSURANCE

SOME PROVIDERS CONTRACT WITH PRIVATE INSURANCE COMPANIES TO PROVIDE SERVICES AT A REDUCED RATE.  POLICY HAS BEEN CLARIFIED REGARDING THESE SITUATIONS.  MEDICAID IS INTENDED TO MAKE PAYMENTS ONLY WHERE THERE IS A RECIPIENT OBLIGATION TO PAY.  THIS MEANS THAT THE DISCOUNTS ESTABLISHED WITH THE INSURANCE COMPANY MUST BE PASSED ALONG TO MEDICAID, AND MEDICAID IS NOT RESPONSIBLE FOR PAYING ON CHARGES OVER AND ABOVE THE CONTRACTED RATE.  PLEASE MAKE SURE YOUR MEDICAID BILLING METHOD INCLUDES THESE DISCOUNTS.

ALL PROVIDERS

WE HAVE BEGIN RECEIVING CALLS FROM PROVIDERS ASKING IF IT IS ACCEPTABLE TO REFUSE TO ACCEPT MEDICAID WHEN A PATIENT HAS BOTH MEDICARE AND MEDICAID.  A PROVIDER MAY NOT REFUSE TO ACCEPT MEDICAID IN THESE CIRCUMSTANCES.  HCFA, THROUGH AN OBRA 89 PROVISION, MANDATES ACCEPTANCE OF ASSIGNMENT UNDER MEDICARE FOR INDIVIDUALS WHO ARE ELIGIBLE FOR BOTH MEDICARE AND MEDICAID.  ADDITIONALLY, SOME, IF NOT ALL MEDICARE PROVIDER  MANUALS ALSO INDICATE THAT IF A MEDICARE BENEFICIARY IS ALSO A RECIPIENT OF MEDICAID, THE PROVIDER MUST ACCEPT ASSIGNMENT ON CLAIMS FOR SERVICES RENDERED, REGARDLESS OF THE PROVIDER'S PARTICIPATION STATUS IN THE MEDICARE PROGRAM. 

PHYSICIANS AND LABORATORIES

ONLY ONE OF CODES 81000 THROUGH 81003 WILL BE PAYABLE PER PREGNANCY PEr RECIPIENT PER BILLING PROVIDER UNLESS THE PRIMARY DIAGNOSIS CODE FOR 
SUBSEQUENT BILLINGS OF 81000-81003 IS WITHIN THE 590-599 RANGE OR CODE 646.6 (INFECTIONS OF GENITOURINARY TRACT IN PREGNANCY). PROVIDERS WHO  HAVE BEEN PAID FOR A Z9005 OR Z9006 FOR A PARTICULAR DATE OF SERVICE FOR A PARTICULAR RECIPIENT WILL NOT ALSO RECEIVE PAYMENT FOR CODE 81002 OR 81003 RENDERED ON THE SAME DATE OF SERVICE FOR THE SAME RECIPIENT. THE OPPOSITE IS TRUE AS WELL: IF YOU'VE BEEN PAID FOR CODE 81002 OR 81003 ON RECIPIENT A FOR A PARTICULAR DATE OF SERVICE, YOUR CLAIM FOR Z9005 OR Z9006 FOR THE SAME DATE FOR RECIPIENT A WILL DENY. 

CLAIMS RECOVERY

CLAIMS WERE RECOVERED ON 01-08-2000 AS THE RESULT OF THE LOUISIANA DEDUCTIBLE AND COINSURANCE/OVERPAYMENTS PROJECT. DUE TO A PROGRAMMING MISINTERPRETATION, THE PRIVATE CONTRACTOR FOR THIS PROJECT INCLUDED CLAIMS WHICH SHOULD HAVE BEEN ADJUSTED RATHER THAN VOIDED. IF YOUR CLAIMS WERE PART OF THIS PROJECT, YOUR 03-14-2000 REMITTANCE ADVICE  REFLECTED AN AUDIT PAYMENT AMOUNT WHICH REPRESENTS A REFUND FOR THE DIFFERENCE BETWEEN THE AMOUNT RECOVERED AND THE AMOUNT WHICH SHOULD HAVE BEEN RECOVERED. YOU MUST REFER TO THE PRINTOUTS ORIGINALLY SENT TO YOU BY THE DHH CONTRACTOR, HEALTH MANAGEMENT SYSTEMS, INC. IN ORDER TO IDENTIFY THE CLAIMS THAT SHOULD HAVE BEEN ADJUSTED.