RA Messages for July 23, 2002

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 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 1/1/02 VERSION OF APPENDIX C:

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

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ATTENTION ALL PROVIDERS

THE LOUISIANA MEDICAID PROGRAM ANNOUNCES THAT EFFECTIVE JULY 1, 2002, A HOSPICE PROGRAM WILL BE IMPLEMENTED TO PROVIDE SERVICES TO TERMINALLY ILL RECIPIENTS. 
ONCE A RECIPIENT ELECTS TO RECEIVE HOSPICE SERVICES, THE HOSPICE AGENCY IS RESPONSIBLE FOR EITHER PROVIDING OR PAYING FOR ALL COVERED SERVICES RELATED TO THE TREATMENT OF THE RECIPIENT'S TERMINAL CONDITION.  THEREFORE, ANY CLAIMS FOR SERVICES RELATED TO THE TERMINAL ILLNESS SUBMITTED BY A PROVIDER, OTHER THAN THE ELECTED HOSPICE AGENCY, WILL BE DENIED FOR ERROR EDIT CODE 493 - "NON-HOSPICE PROVIDER/SUBMIT JUSTIFICATION FOR SERVICES." IF THE CLAIM IS NOT RELATED TO THE  TERMINAL ILLNESS THE PROVIDER SHOULD SUBMIT THE CLAIM WITH ATTACHED JUSTIFICATION SUFFICIENT TO ESTABLISH THAT THE SERVICE WAS MEDICALLY NECESSARY AND WAS NOT RELATED TO THE TERMINAL CONDITION. CLAIMS FOR PRESCRIPTION DRUGS AND HOME AND COMMUNITY BASED WAIVER SERVICES WILL NOT BE SUBJECT TO ERROR EDIT CODE 493. HOWEVER, THESE SERVICES WILL BE SUBJECT TO POST-PAYMENT REVIEW AND RECOUPMENT MAY BE IMPOSED IF IT IS DETERMINED THAT THE SERVICE WAS RELATED TO THE TREATMENT OF THE TERMINAL ILLNESS.

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INFORMATION FOR EPSDT DENTAL PROGRAM PROVIDERS

POST-PAYMENT REVIEWS HAVE SHOWN THAT A NUMBER OF PROVIDER ARE ROUTINELY TAKING UPPER AND LOWER ANTERIOR PERIPAPICAL RADIOGRAPHS AT THE TIME OF EXAMINATIONS. MEDICAID DENTAL PROGRAM POLICY STATES THAT ANTERIOR PERIAPICAL OR OCCLUSAL RADIOGRAPHS TAKEN ROUTINELY AT THE TIME OF EXAMINATION ARE NOT COVERED. IF A ROUTINE PRACTICE OF TAKING SUCH RADIOGRAPHS IS DISCOVERED DURING POST-PAYMENT REVIEW, TREATMENT RECORDS MAY BE REVIEWED AND RECOUPMENT OF MONEY PAID FOR ALL SUCH RADIOGRAPHS WILL BE INITIATED. ANTERIOR PERIAPICAL RADIOGRAPHS ARE PAYABLE WHEN THEIR PURPOSE IS TO OBTAIN INFORMATION IN REGARD TO A SPECIFIC PATHOLOGICAL CONDITION OTHER THAN CARIES; WHEN SERIOUS DOUBT IS ENTERTAINED IN REGARD TO THE PRESENCE OF THE PERMANENT DENTITION; PRIOR TO EXTRACTION. 

POST-PAYMENT REVIEWS HAVE SHOWN THAT A NUMBER OF PROVIDERS ARE BILLING 
FOR THE EXTRACTION OF PRIMARY TEETH IN THE ADVANCED STAGES OF NATURAL EXFOLIATION, WITH LITTLE OR NO THERAPEUTIC INDICATION OR BENEFIT. PRIMARY TEETH THAT ARE BEING LOST NATURALLY SHOULD NOT BE BILLED TO MEDICAID AS AN EXTRACTION. IF A PRACTICE IS NOTED DURING POST-PAYMENT REVIEW OF BILLING FOR THE EXTRACTION OF PRIMARY TEETH THAT ARE SHOWN RADIOGRAPHICALLY TO BE IN THE ADVANCED STAGES OF ROOT RESORPTION 
(MORE THAN 3/4 OF THE ROOT IS RESORBED), I.E., EXFOLIATING NATURALLY, THERE WILL BE A RECOUPMENT OF MONEY PAID FOR ALL SUCH THERAPEUTICALLY UNNECESSARY EXTRACTIONS. IF THE EXTRACTION IS WARRANTED DUE TO THERAPEUTICALLY INDICATED CIRCUMSTANCES SUCH AS PROLONGED RETENTION, BLOCKING OUT OF ERUPTING PERMANENT TEETH, SEVERE DECAY, ABCESS WITH BONE LOSS, OR OTHER SPECIFICALLY IDENTIFIABLE INDICATIONS, A PREOPERATIVE PERIAPICAL RADIOGRAPH SHOULD BE TAKEN AS A DIAGNOSTIC 
AID AS A MEANS OF DOCUMENTATION. THIS RADIOGRAPH MUST BE MAINTAINED IN THE RECIPIENT'S RECORD, AND MUST BE FURNISHED TO POST-PAYMENT REVIEW IF REQUESTED. WRITTEN DOCUMENTATION OF THE REASON FOR THE EXTRACTION MUST BE NOTED IN THE DENTAL TREATMENT RECORD.

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2002 PROVIDER TRAINING SESSIONS

PROVIDER TRAINING SESSIONS WILL BE HELD ON THE FOLLOWING DATES: 

BATON ROUGE - OCTOBER 1,2,3 
COVINGTON - OCTOBER 4 
BOSSIER CITY - OCTOBER 7,8,9 
LAFAYETTE - OCTOBER 14,15,16 
NEW ORLEANS - OCTOBER 21,22,23 
HOUMA - OCTOBER 24 
ALEXANDRIA - NOVEMBER 4,5,6 
LAKE CHARLES - NOVEMBER 7,8 
MONROE - NOVEMBER 12,13,14 

WATCH FOR A COMPLETE SCHEDULE OF LOCATIONS AND DATES IN THE JUNE/JULY AND AUGUST/SEPTEMBER EDITIONS OF THE PROVIDER UPDATE.