The Louisiana Department of Health and Hospitals Has Issues the Following Alert:
ATTENTION ALL LOUISIANA MEDICAID PROVIDERS - Important Information Concerning New Medicaid Requirements For Enrolling Ordering, Prescribing and Referring Providers (5/27/16)
OVERVIEW: The Affordable Care Act (ACA) requires physicians or other practitioners who order, prescribe, or refer items or services to Medicaid recipients to enroll in the Medicaid Program, even when they do not submit claims to Medicaid. The ACA requirements are designed to ensure items or services for Medicaid recipients originate from appropriately licensed providers who have not been excluded from Medicare or Medicaid.
Individuals who order, prescribe, or refer items or services for Medicaid recipients, but choose not to submit claims to Medicaid, are referred to throughout this notice as “OPR providers.”
Professional and Institutional Billing Providers should begin notifying any individuals who you report on fee-for-service claims as an Ordering, Prescribing or Referring provider that they must enroll with Louisiana (LA) Medicaid.
OPR Providers must understand the implications of failing to enroll in Medicaid. If you are an OPR provider, then the individuals and facilities who bill services for Medicaid recipients based on your order, prescription, or referral, will not be paid for those items or services unless you enroll in Medicaid.
Effective with claims using dates of service on or after September 1, 2016, LA Medicaid will deny fee for-service claims that use Referring providers who are not enrolled as of the date of service. Providers should monitor the Louisiana Medicaid website for future information specific to Ordering providers.
LA Medicaid has established edits for issues with prescribing providers. See below for more information:
IMPORTANT NOTE: These ACA requirements do not apply to providers listed on Medicare Crossover claims (Institutional or Professional). LA Medicaid will accept and process the Medicare claim with the understanding that Medicare has edited this information as the primary payer of the claim.
Message Below from MCNA for Dentists in Their Network Who Were Affected by a Recent Claims Review That Included a Request for X-rays on Some Restorations on Primary Teeth (5/13/16)
At MCNA, we are constantly engaged in quality improvement activities which include the routine analysis of patterns of utilization for various dental procedures. We do this to maintain program integrity and ensure high quality services are being rendered. Recently, we implemented a one-month review of providers who performed a filling on a tooth that is within 6 months of the AAPD shed age range. As part of the review, we asked providers to send radiographs showing the need for treatment. MCNA's clinical team sought to identify medically unnecessary fillings being placed on teeth that were about to be exfoliated or should have exfoliated already.
The primary concern of the clinical team with respect to this procedure is whether the tooth needed a filling, or would an extraction have been more appropriate given the prospect of natural exfoliation. These are some of the questions being answered through the review. In total, about 200 fillings were impacted by the request for radiographs. This is a very small number in comparison to the over 8,000 claims for fillings received during the time period of our study.
As you may know, MCNA has a Dental Advisory Committee made up of participating Louisiana providers and MCNA leadership that meets quarterly to discuss ways to improve our program. Last Wednesday, April 20th, Members of the Advisory Committee brought to our attention that the review could have inadvertently caused frustration for some dentists who had provided appropriate, quality care and properly submitted claims, but had legitimate difficulty submitting radiographs consistent with the request made by MCNA. Accordingly, the Committee suggested that notice of the study should have been given to MCNA providers. However, it is not customary to give notice that cases are being reviewed for potential waste, fraud, or abuse issues, because this would enable any problem providers to change their practices and avoid detection.
Having said that, MCNA does recognize the Committee’s concern for balancing the essential need to eliminate the detrimental activities of a relative few against the need to avoid overburdening the vast majority of well-intentioned providers. We do want to ensure a positive working relationship with all of the providers who participate in the program and do their best to provide excellent care. To this end, MCNA has taken the advice of the Dental Advisory Committee and has reprocessed these 200 claims for payment. Providers do not have to send in the requested radiographs at this time; provided, that any outlier providers we detected may receive a chart audit in the future.
Thank you for your participation. Should you have any questions, please contact MCNA’s Provider Hotline at (855) 701-6262.
UPDATE ON FILING REQUIREMENTS FROM 180 DAYS TO 365 DAYS (2/4/16)
Effective Aug. 1, 2015, Louisiana changed the timely filing requirements from 180 days to 365 days for all claims submitted for payment for a covered service rendered to a Medicaid enrollee. This change is a result of Act 21 of the 2015 Louisiana Legislative Regular Session which applies to claims directly submitted to the Department and claims submitted to specified entities contracted with the Department. See Act 21 for more details.
If you have any questions regarding timely filing requirements for members enrolled in MCNA, see the November 2015 issue of Dental Details on MCNA’s provider portal or call the Provider Hotline at 1-855-701-6262. For questions regarding timely filing requirements for Legacy Medicaid recipients, please contact the Molina Provider Relations Department at (800) 473-2783.
HOW TO CONTRACT WITH BAYOU HEALTH (Louisiana's medical Medicaid program managers, updated 1/7/16)
All five Bayou Health plans offer a limited dental benefit in addition to the current Medicaid Dental Benefit managed by MCNA.
Amerigroup, AmeriHealth Caritas of Louisiana (ACLA), and Aetna all contract with DentaQuest to manage the dental benefit. Information relative to credentialing and benefits offered can be found on the Dentist Page link at www.dentaquest.com/Louisiana or by contacting the credentialing hotline at 1-800-233-1468.
Louisiana Health Care Connections (LHC) only enroll FQHC/RHCs for the delivery dental services. Providers providing dental services via an FQHC/RHC should contact LHC for credentialing information at 1-866-595-8133.
United Healthcare Community Plan of Louisiana (UHC) ask interested dental providers to contact the United Healthcare Dental Provider Services line at 1-844-275-8751.
MCNA Dental Advisory Committee Meeting Update from 12-9-15
DHH announced a few weeks ago that Medicaid claims would now take an additional two weeks to be processed to increase “fraud detection.”Â The main reason, though, was allowing DHH to withhold a payment from third-party claims administrators (i.e., MCNA and the Bayou Health plans) until the next fiscal year.Â MCNA again confirmed to all present at the DAC meeting that there would be no change in MCNA’s handling of claims in spite of DHH pushing back its payment to MCNA.
The time allowed to request reconsideration of a claim rejected for administrative reasons has been extended from 60 to 90 days (dentist must provide an explanation of new information with the request).
When treating a referral from a G.D., pediatric dentists have been having to downcode D0150 to D0140.Â MCNA will henceforth pay specialists for a D0150 (when a comp exam is actually performed) provided there is an explanation regarding the referral etc. included with the claim. (Note: generally, any narrative included with a claim kicks it out of the automated system for review by a live person.)
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