RA Messages for June 13, 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 5/15/00 VERSION OF APPENDIX A:

PLEASE MAKE THE FOLLOWING CHANGES TO THE 5/15/00 VERSION OF APPENDIX C:  

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

PHARMACISTS AND PRESCRIBING PROVIDERS  

RECENTLY, THE APPENDICES FOR PROVIDER MANUALS WERE MAILED TO YOU. APPENDIX A INCLUDED ADDITIONS, DELETIONS AND REVISIONS TO THE FEDERAL UPPER LIMITS WHICH BECOME EFFECTIVE ON JUNE 1, 2000. WE HAVE RECEIVED NOTIFICATION FROM THE HEALTH CARE FINANCING ADMINISTRATION TO DELAY THE IMPLEMENTATION OF THE JUNE 1 FEDERAL UPPER LIMITS TO AUGUST 1, 2000.  THEREFORE, THE GENERIC DESCRIPTIONS WITH JUNE 1 PRICES LISTED IN  APPENDIX A WILL NOT BE IMPLEMENTED UNTIL AUGUST 1 OR OTHERWISE DIRECTED BY HCFA.                                                               

PHARMACY PROVIDERS

PLEASE BE ADVISED THAT THE POS SYSTEM WILL NOT BE AVAILABLE ON 6/16/00 (FRIDAY) FROM 10:30 PM TO 1:30 AM AND ON 6/17/00 (SATURDAY) FROM 8 PM  TO 5 AM DUE TO SYSTEM ENHANCEMENTS.       

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.