PLEASE MAKE THE FOLLOWING CHANGES TO THE 1/01/02 VERSION OF APPENDIX A:

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

NOTICE TO ALL PROVIDERS

THE DEPARTMENT OF HEALTH AND HOSPITALS IS CURRENTLY IN THE PROCESS OF UPDATING MEDICAID PROVIDER FILES. THE RECORDS OF PROVIDERS WHO HAVE NOT PARTICIPATED, BILLED OR BEEN PAID BY LOUISIANA MEDICAID SINCE PRIOR TO JUNE 30, 2001 WILL BE CLOSED. ANY PROVIDER CLOSED IN THIS AUTOMATIC UPDATE WILL BE REQUIRED TO RE-ENROLL IF THEY WISH TO PARTICIPATE IN THE LOUISIANA MEDICAID PROGRAM. 

COMMUNITY CARE PROVIDERS

REFERRAL AUTHORIZATIONS 

WHEN REVIEWING REQUESTS FOR REFERRAL AUTHORIZATIONS FOR EMERGENCY ROOM SERVICES, COMMUNITYCARE PCP'S SHOULD CAREFULLY REVIEW THE EMERGENCY ROOM
FACE SHEET AND ISSUE OR DENY THE REFERRAL BASED ON WHETHER OR NOT THE PRESENTING SYMPTOMS MEET THE "PRUDENT LAYPERSON STANDARD." 

THE LINKED PCP SHOULD PROVIDE THE ENROLLEE WITH A TWO MONTH TRANSITION REFERRAL TO A NEW PCP IF THE ENROLLEE IS LINKED TO THE WRONG PCP DUE TO AN ADMINISTRATIVE ERROR OR A CHANGE IN PCP HAS BEEN APPROVED, AND IT IS NOT YET REFLECTED ON THE REVS/MEVS SYSTEM. APPROVED PCP CHANGES SHOULD TAKE UP TO 60 DAYS TO BE SHOWN CORRECTLY ON REVS/MEVS. 

EXEMPTIONS FOR MEDICALLY HIGH RISK RECIPIENTS 

UNDER CERTAIN CIRCUMSTANCES, AN ENROLLEE'S MEDICAL CONDITION MAY WARRANT THE DIRECT CARE AND SUPERVISION OF A NON-PRIMARY CARE SPECIALIST. EXEMPTIONS ARE RESERVED FOR PATIENTS WHOSE TOTAL MEDICAL CARE REVOLVES AROUND THEIR PREDOMINANT MEDICAL PROBLEM. IN SOME INSTANCES THE SPECIALIST MAY BE ACTING AS THE ENROLLEE'S PRIMARY CARE PHYSICIAN PRIOR TO COMMUNITYCARE ENROLLMENT.

EXEMPTIONS FOR MEDICALLY HIGH RISK RECIPIENTS SUBMITTED IN WRITING BY THE REQUESTING PHYSICIAN SHOULD DOCUMENT THE PATIENT'S SPECIFIC MEDICAL CONDITION, RATIONALE FOR THE EXEMPTION, AND MEDICAID NUMBER. UPON BHSF APPROVAL OF THE EXEMPTION, THE REQUESTING PHYSICIAN MAY SERVE AS THE CASE MANAGER UNTIL THE SPECIAL NEEDS CARE IS NO LONGER REQUIRED. THE WRITTEN REQUEST SHOULD CLEARLY IDENTIFY THAT THE REQUESTING PHYSICIAN WILL SERVE AS THE CASE MANAGER FOR THE RECIPIENT AND THE REQUEST SHOULD BE SUPPORTED BY MEDICAL DOCUMENTATION THAT SUPPORTS THE SPECIFIC DIAGNOSES OR MEDICAL PROBLEM. 

WHEN A MEDICALLY HIGH RISK ENROLLEES'S CONDITION IS EXPECTED TO IMPROVE, AND/OR CASE MANAGEMENT BY THE SPECIALIST IS NOT NECESSARY, THE PCP MAY ISSUE A LONG-TERM REFERRAL FOR UP TO ONE YEAR TO THE SPECIALIST IN LIEU OF THE RECIPIENT BEING EXEMPT, THEREFORE MAINTAINING PRIMARY CARE BY THE PCP. 

NOTICE TO PROVIDERS OF PROFESSIONAL SERVICES

THE CPT CODES WHICH WERE DISCONTINUED IN THE YEAR 2002 ISSUANCE OF THE CURRENT PROCEDURAL TERMINOLOGY WILL BE PLACED IN NON-PAY STATUS ON OUR FILES EFFECTIVE WITH DATE OF SERVICE OCTOBER 1, 2002. 

NOTICE TO ANESTHESIOLOGISTS AND CRNAS

ANESTHESIA PROVIDERS WHO ARE RECEIVING 106 DENIALS (BILLING PROVIDER NOT 
PCP OR SERVICE NOT AUTHORIZED BY PCP) ON THEIR CLAIMS FOR DELIVERY 
SHOULD RESUBMIT CLAIMS USING THE SAME PREGNANCY-RELATED DIAGNOSIS CODE 
AS THAT USED BY THE OBSTETRICIAN FOR THE DELIVERY. 

NOTICE TO ALL PROVIDERS

DUE TO REPORTS AND CONCERNS OF PROVIDER IDENTITY THEFT, THE PROVIDER ENROLLMENT UNIT IS NOT AUTHORIZED TO DISCLOSE ANY PROVIDER INFORMATION TO ANY THIRD PARTY. THIRD PARTIES INCLUDE BILLING COMPANIES AND/OR CLEARINGHOUSES, MANAGEMENT COMPANIES, AND CREDENTIALING COMPANIES OR OTHER ENTITIES NOT DIRECTLY ASSOCIATED WITH THE PROVIDER. REQUESTS FOR RELEASE OF PROVIDER INFORMATION TO A THIRD PARTY MUST BE SUBMITTED IN WRITING WITH THE PROVIDER'S ORIGINAL SIGNATURE (NO STAMPS OR INITIALS). 

ATTENTION COMMUNITYCARE PCPS

PLEASE BE ADVISED THAT THE SEPT 2002 CP-0-92 REPORTS LINKING COMMUNITYCARE RECIPIENTS TO PCPS ARE INCORRECT. CORRECTED REPORTS & LETTERS HAVE BEEN MAILED TO EACH PCP. CONTACT PROVIDER RELATIONS @ 800-473-2783 WITH QUESTIONS OR IF YOU DO NOT RECEIVE YOUR CORRECTED REPORT. WE APOLOGIZE FOR ANY INCONVENIENCE THIS MAY HAVE CAUSED YOU OR YOUR STAFF.