RA Messages for September 5, 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 FILE ADJUSTMENTS FOR CLAIMS WHICH MAY HAVE BEEN INCORRECTLY PAID.

POLICY REMINDER FOR ALL DENTAL PROVIDERS

THE FOLLOWING IS AN UPDATE TO REMIND ALL DENTAL PROVIDERS OF SPECIFIC MEDICAID POLICIES, WHICH IF FOLLOWED, MAY RELEIVE THE PROVIDER OF POSSIBLE SANCTIONS WHEN THEIR RECORDS ARE REVIEWED. MEDICAID DENTAL PROGRAM POLICY STATES THAT A CLAIM FOR PAYMENT SHOULD NOT BE SUBMITTED BEFORE 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 SOLELY 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 AND 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 P.A. 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 TO 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 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.