RA Messages for May 11, 2004

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 DME AND PHARMACY PROVIDERS

OUR PROGRAM INTEGRITY STAFF HAVE BEEN CONDUCTING FIELD AUDITS ON DURABLE MEDICAL EQUIPMENT PROVIDERS AND HAS FOUND IN SOME CASES, THE PROVIDER IS NOT MAINTAINING A COPY OF THE PRIMARY CARE PHYSICIAN'S REFERRAL. THIS IS A REQUIREMENT UNDER THE COMMUNITYCARE PROGRAM. FAILURE TO MAINTAIN A COPY OF A REFERRAL IS GROUNDS FOR RECOUPMENT OF MONEY PAID FOR SERVICES, EQUIPMENT AND SUPPLIES, AS WELL AS IMPOSITION OF OTHER SANCTIONS AS A RESULT OF THE PROVIDER NOT ADHERING TO MEDICAID POLICY. 

IT IS NOT NECESSARY TO HAVE A REFERRAL FROM THE PRIMARY CARE PHYSICIAN PRIOR TO SUBMITTING A REQUEST FOR AUTHORIZATION OF PAYMENT TO THE PRIOR AUTHORIZATION UNIT (PAU). HOWEVER, A REFERRAL MUST BE OBTAINED AND MAINTAINED ON FILE PRIOR TO BILLING, SINCE ALL CONDITIONS REQUIRED FOR PAYMENT MUST BE MET PRIOR TO BILLING.

NOTICE TO PROVIDER OF PROFESSIONAL SERVICES

EFFECTIVE WITH DATE OF SERVICE JULY 1, 2003.  THE FOLLOWING CPT CODES WILL BE ADDED TO THE LIST OF CODES PAYABLE TO AUDIOLOGISTS.

92541 92543 92544 92545 92547

ATTENTION DENTAL PROVIDERS

MEDICAID POLICY STATES THAT DENTAL SERVICES WILL BE REIMBURSED AT THE LOWER OF THE BILLED CHARGES OR THE MEDICAID ESTABLISHED RATE. AN EDITING PROBLEM HAS OCCURRED WHICH CAUSED CLAIMS FOR THE AMALGAM PROCEDURE CODES D2140, D2150 AND D2160, FOR PRIMARY TEETH ONLY, TO PAY AT THE MEDICAID RATE ALTHOUGH THE BILLED CHARGES WERE LESS. MEDICAID WILL AUTOMATICALLY RECYCLE THESE CLAIMS IN THE NEAR FUTURE IN ORDER TO RECOVER THE OVERPAYMENTS AND THESE TRANSACTIONS WILL APPEAR ON YOUR REMITTANCE ADVICE. IF YOU HAVE ANY QUESTIONS REGARDING THIS MATTER, YOU MAY CONTACT UNISYS PROVIDER RELATIONS BY CALLING 1-800-473-2783 OR 225-924-5040. 

ATTENTION OPTHAMOLOGISTS AND OPTOMETRISTS

OPTHAMOLOGISTS AND OPTOMETRISTS THAT HAVE RECEIVED A 690 DENIAL (PAYMENT INCLUDED IN SURGERY FEE) WHEN BILLING PROCEDURE CODE 99211 (FOLLOW-UP EXAM) ON THE SAME DATE OF SERVICE AS THE INITIAL EYE EXAM AND GLASSES SHOULD REBILL PROCEDURE CODE 99211. A ONE DAY GLOBAL SURGERY PERIOD WAS INADVERTENTLY ADDED TO THE INITIAL EYE EXAM PROCEDURE CODE, CAUSING THESE DENIALS.