RA Messages for May 23, 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.

NOTICE TO HOSPITALS AND HOME HEALTH AGENCIES

WE REALIZE, DUE TO THE EVERGREEN VS. DHH CASE, WE HAVE NOTIFIED HOSPITALS OF DIFFERENT SPLIT-BILLING PROCEDURES FOR DATES OF SERVICE MARCH 1, 8, AND 23 OF 2000, AS WELL AS NOTIFYING HOME HEALTH AGENCIES OF DIFFERENT PROCEDURES FOR REQUESTING PA AND BILLING OF HOME HEALTH SERVICES BEGINNING WITH DATES OF SERVICE 2/1/00.  DUE TO RECENT DEVELOPMENTS IN THIS CASE, UPON RECEIPT OF THIS NOTICE, BILLING PROCEDURES ARE AS FOLLOWS:

ALL LONG TERM CARE HOSPITALS AND ALL PRIVATE AND PUBLIC PSYCHIATRIC HOSPITALS, INCLUDING PSYCHIATRIC UNITS WITHIN PRIVATE AND PUBLIC ACUTE CARE HOSPITALS (EXCEPT CHARITY HOSPITALS) WILL BE REQUIRED TO SPLIT-BILL MEDICAID INPATIENT CLAIMS CASED ON DOS EFFECTIVE MARCH 8 AND 23, 2000. HOME HEALTH AGENCIES - FOR DOS 2/1/00 THROUGH 3/22/00, THE PROCEDURES FOR REQUESTING PA AND BILLING ARE THOSE OUTLINES IN OUR PROVIDER NOTICE DATED 1/24/2000. IN SHORT, DURING THESE DOS ONLY, THE FIRST HOUR OF EXTENDED CARE MUST BE INCLUDED IN THE PA REQUEST FOR EXTENDED CARE FOR RECIPIENTS TO AGE 21. THE FEES DURING THOSE DOS ARE ALSO INCLUDED IN THIS NOTICE. FOR DOS 3/23/00 FORWARD, THE PROCEDURES FOR REQUESTING PA AND BILLING FOR THE 1ST HOUR OF EXTENDED ARE REMAINS THE SAME AS THOSE IN PLACE PRIOR TO 2/1/00, WHEN SERVICES ARE PROVIDED BY A PHYSICAL THERAPIST ASSISTANT OR AN LPN, THESE SERVICES ARE TO BE INDENTIFIED BY USING THE NEW CODES WHEN REQUESTING PA AND IN BILLING.

WE ARE SORRY  FOR THE INCONVEINEINCE. CONTACT UNISYS PROVIDER RELATIONS AT (800) 473-2783 OR (225) 924-5040 IF FURTHER ASSISTANCE IS REQUIRED.

POLICY REMINDER FOR ALL DENTAL PROVIDERS

THE FOLLOWING IS NA UPDATE TO REMIND ALL DENTAL PROVIDERS OF SPECIFIC MEDICAID POLICIES, WHICH IF FOLLOWED, MAY RELIEVE THE PROVIDER OF POSSIBLE SANCTIONS WHEN THEIR RECORDS ARE REVIEWED.  MEDICAID DENTAL PROGRAM POLICY STATES THAT A CLAIM FOR PAYMENT OF SERVICE IS PROVIDED. SHOULD THE BILLED DATE OF SERVICE BE PRIOR TO THE ACTUAL DATE THAT THE SERVICE IS PROVIDED. SHOULD THE BILLED DATE OF SERVICE BE PRIOR TO THE ACTUAL DATE THAT THE SERVICE WAS PERFORMED OR BEFORE THE DATE OF FINAL DELIVERY OF A SERVICE AS NOTED IN THE PATIENT'S RECORD, THE PROVIDER WILL BE SANCTIONED. MEDICAID DENTAL PROGRAM POLICY STATES THAT HOSPITALIZATION SOLEY FOR THE CONVENIENCE OF THE PATIENT OR THE DENTIST IS NOT ALLOWED. HOSPITALIZATION MUST BE JUSTIFIED BY THE PHYSICAL CONDITION OF THE PATIENT, THE AGE OF THE PATIENT, OR THE SEVERITY OF THE PROCEDURE PERFORMED. HOSPITAL DENTAL SERVICES SHOULD BE RENDERED ON AN OUTPATIENT BASIS AN SHOULD CONSIST OF  THOSE SERVICES COVERED UNDER THE EPSDT DENTAL PROGRAM. ALL REQUESTS FOR HOSPITALIZATION MUST BE PRIOR AUTHORIZED AND MUST INCLUDE DETAILED JUSTIFICATION DOCUMENTATION. THE TREATMENT PLAN SHOULD ALSO BE SUBMITTED WITH THE PRIOR AUTHORIZATION (PA) REQUEST. USUALLY, HOSPITALIZATION OF PATIENTS OVER THE AGE OF FIVE WILL BE DENIED, UNLESS THE REASON FOR THE HOSPITALIZATION IS EXTENSIVELY DOCUMENTED. CONSIDERATIONS WILL BE GIVEN TO THE EXTENT OF TREATMENT REQUESTED. SERVICES FOR WHICH AN X-RAY IS REQUIRED (BUT THE X-RAY IS MEDICALLY CONTRAINDICATED), BEHAVIOR MANAGEMENT, AND HOSPITALIZATION SERVICES REQUIRE DETAILED DOCUMENTATION IN THE PATIENT'S RECORD AND IN THE  "REMARKS" SECTION OF THE ADA CLAIM FORM WHEN SUBMITTING FOR PA. TWO  IDENTICAL COPIES OF EACH PA REQUEST MUST BE SUBMITTED TO THE DENTAL CONSULTANTS AT THE LSU DENTAL PA UNIT. THE DENTAL PA UNIT WILL NOT  CONSIDER A PA REQUEST THAT DOES NOT CONTAIN THE REQUIRED DOCUMENTATION  UNDOCUMENTED REQUESTS WILL BE RETURNED THE THE PROVIDER FOR COMPLETION.  UPON RENDERING A PA DETERMINATION, THE DENTAL PA UNIT WILL RETURN ONE  COPY OF THE REQUEST TO THE PROVIDER. A PA DISPOSITION LETTER WILL ALSO  GENERATED TO THE PROVIDER AND TO THE PROVIDER. A PA DISPOSITION LETTER  WILL ALSO BE GENERATED TO THE PROVIDER AND TO THE RECIPIENT. BOTH OF  THESE PROVIDER COPIES SHOULD BE RETAINED IN THE PATIENT'S RECORD. SHOULD THESE DOCUMENTS AND/OR DOCUMENTATION NOT BE LOCATED IN THE PATIENT'S RECORD, AND/OR SHOULD THEY NOT INCLUDE THE PROPER DOCUMENTATION, THE  PROVIDER WILL BE SANCTIONED. PLEASE NOTE THAT FOR BEHAVIOR MANAGEMENT, THE WORD PREMEDICATION AS  DOCUMENTATION IS NOT SUFFICIENT. ANY PA REQUESTS THAT ONLY CONTAIN THE WORD PREMEDICATION WILL BE RETURNED TO THE PROVIDER WITH A REQUEST THAT LANGUAGE SPECIFYING THE NEED FOR ADDITIONAL TREATMENT TIME BE INCLUDED. IN ORDER TO RECEIVE REIMBURSEMENT FOR BEHAVIOR MANAGEMENT, THE  DOCUMENTATION FOR BEHAVIOR MANAGEMENT MUST SPECIFICALLY STATE WHAT MANAGEMENT EFFORTS WERE REQUIRED.